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CORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1077-i House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
Thursday 11 May 2006 MR ANDREW FOSTER, MS DEBBIE MELLOR, MR KEITH DERBYSHIRE and DR JUDY CURSON Evidence heard in Public Questions 1-165
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 11 May 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Ronnie Campbell Jim Dowd Sandra Gidley Anne Milton Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor ________________ Witnesses: Mr Andrew Foster, Director of Workforce, Ms Debbie Mellor, Head of Workforce Capacity, Mr Keith Derbyshire, Economic Adviser, Department of Health and Dr Judy Curson, Head of Workforce Review Team, National Health Service, gave evidence. Q1 Chairman: May I say good morning and welcome you to the Committee? May I ask you to introduce yourselves and your positions for the record please? May I start with Dr Curson? Dr Curson: I am Dr Judy Curson. I lead the Workforce Review Team which is an expert group of NHS staff providing national analysis and modelling of workforce in the health professions. We work on behalf of and make recommendations to strategic health authorities. Ms Mellor: I am Debbie Mellor. I am head of Workforce Capacity in the Department of Health where my remit is ensuring that the workforce planning and the supply and demand are effective. Mr Foster: My name is Andrew Foster. For the last five years I have been the Director of Workforce at the Department of Health. As of last week, I have moved onto a new role, but I did not want to miss the pleasure of meeting you all just one more time before I went. If I could have the opportunity in a moment just to say a few opening remarks, I should be grateful. Mr Derbyshire: I am Keith Derbyshire. I am a Senior Economist Adviser in the Department of Health. I have worked on workforce issues in the past and am currently working on productivity. Q2 Chairman: May I welcome you all? This is the first session of our inquiry into workforce planning. Mr Foster, you said that you would like to say a few words first, by all means do. Mr Foster: I am actually particularly grateful to this Committee which in 1999 undertook a review of workforce planning which identified a series of weaknesses and failings and led to a major overhaul from a document produced internally by the Department called A Health Service of All the Talents and then to a restructuring of workforce planning which has become more robust year on year. I should not like to pretend by any means that we have a perfect workforce planning system now, but we have the closest thing to a balance between demand and supply for healthcare staff that we have ever had, as measured by the lowest vacancy rates for most of the main professions that we have ever had. I am very pleased that the Health Select Committee is going to focus on us yet again, because I am sure that we have further improvements to make, which we plan anyway, but it was the impetus from you in 1999 that pushed this much more to the forefront of the NHS planning systems and has been a real benefit. Q3 Chairman: Thank you very much. I wonder whether any of my colleagues here were actually on the Committee at that time; I was not. Mr Foster: Debbie Mellor was part of the team that provided help last time as well. Q4 Chairman: Let us pursue how that report and the subsequent actions got round. You have probably seen on the news this morning that we are being lobbied by NHS workers again today here in Parliament. I suppose many people out there, members of the public, would ask the obvious question. A few years ago we were told the NHS was short of staff, yet now we seem to be making people redundant. Why is this? Mr Foster: The headlines are a gross misrepresentation of what is really happening. For the last five years we certainly have had a remarkable increase in the number of staff. It is about 200,000 increase in staff in just the last four years and the last figure, the last year for which we have accurate records, is the year which finished September 2005, which showed that there was a further 34,000 increase in staff last year. This year, many organisations are having to make sure that their workforce plans are aligned with their financial plans and many are announcing intentions to reduce the number of posts in their organisations. However, when you plough beneath almost every single one of those headlines, they are reductions in numbers of posts, not making actual staff redundant. Typically, we did a poll of this when we had a HR conference in Birmingham the week before last, where about 1,000 HR managers were present and typically, the ratio of actual compulsory redundancies to the headlines is about 1:100; so in organisations making 300 post reductions, three compulsory redundancies. There are one or two exceptions to that, but for the very large part this is to be achieved through natural turnover rates, typically 10% in any organisation in a year, through reduction in reliance on agency and temporary staff and not through making actual staff redundant and particularly not clinical staff. Q5 Chairman: May I ask you about nurses in particular? The NHS Plan set the target of expanding the nursing workforce by 20,000 nurses between 1999 and 2004. Recent evidence shows that the nursing workforce in fact grew by 68,000 during that period. Why did this actual expansion so greatly exceed the target expansion? Mr Foster: Well, the NHS Plan target said at least 20,000 nurses and then it went on to roll that target forward in a series of two further documents which had a target going up to 2008. Yes, we have very significantly exceeded the targets that were set and that is really based on the needs of local organisations to meet the demands of the access targets, increasing the capacity necessary to reduce waiting times and to improve quality through delivering the national service frameworks. So the main reason is that the figures that were in the NHS Plan and the subsequent documents were minimum targets and they do explicitly say that. Q6 Chairman: I accept that they were minimum targets, but the plan in 2000 has been overshot, for want of a better expression, by 340% as far as nurses are concerned. It seems to me that when you talked earlier about this issue of workforce plans having to come into line with financial plans, most people would ask why workforce plans were not in line with financial plans, or the other way round, in the year 2000 when the NHS Plan was first published. Why do we wait while there is this perceived crisis? I accept, looking at these figures, I do not disagree for one minute, that the actual job losses are far below what has been grabbing the headlines in the media. What grabs the headlines in the media grabs the public as well. Why were we not having financial and workforce plans working alongside one another logically for the last six years? Mr Foster: For the last five years we have had workforce and financial plans which have worked alongside each other quite comfortably, as witnessed by the fact that the NHS has achieved its targets and stayed within financial balance until the last year, 2005-2006, when there were well-publicised significant difficulties. I accept that there was a degree of over-heating in the system just in this last year, where people clearly have taken on more than they could afford and there is some evidence of that, for example in North Staffordshire, which is one of the organisations with the biggest problems and has announced 1,000 job reductions, where it actually took on 300 extra staff in the first quarter of last year. The integration of financial and activity planning has not been as good as it might have been everywhere. For example, if you take last year's planning process, there is a challenge in the system that was created following the last HSC report so that organisations submit workforce plans at the beginning of the year and in April 2005 organisations submitted workforce plans which totalled an increase of approximately 6%. These were then challenged by the central workforce planning process and they were told that those did not really match up with the financial environment that they were entering. As a result of that, the plans were redrawn and predicted a 2% increase in the workforce in 2005-2006, which is in fact very similar to what was achieved when you look at the September 2005 census figures. It is a system which has worked relatively well for four or five years, but has just slightly over-heated in the last year. Q7 Chairman: Does this scenario of over-heating, as you call it, help to explain the current trend towards deficits and redundancies in parts of the NHS? Is that basically what you are saying? Mr Foster: Yes. The NHS does have deficits in 2005-2006. Two thirds of the money that we spend is on staff and therefore, in order to bring it back into balance, clearly staff numbers have a very significant part to play. Thanks to the very high turnover rate that happens naturally every year, we have the opportunity to do that with minimum redundancies. Q8 Anne Milton: Notwithstanding that the nursing workforce has expanded more quickly possibly than intended, the number of central administrative and management staff has grown more quickly still. In fact these figures in front of me show that nurses as a whole have gone from 30% of the workforce in 1999 to 29% of the workforce, whereas the support staff and senior management have grown quite substantially as a percentage of the total workforce. Can you justify that? Mr Foster: I can explain it and I can also point to what is likely to happen by the time that you get the next set of figures. Broadly speaking, what has happened over the last five years is that we have brought a level of management into primary care that was never there before. So the creation initially of primary care groups and then primary care trusts, each with their own management teams, is an attempt to introduce management into primary and community care that was never there before. If you look at the level of management in NHS acute trusts, you will see that there has been no growth at all, or only growth which is proportionate to the total increase in the size of organisation; so the significant growth has come in primary care. As part of the manifesto commitment last year, the Government announced their intention to reduce £250 million out of management costs, a process which is now working its way through with the reduction in numbers of strategic health authorities and primary care trusts so that by the time you get the next set of results, you should see a reduction in that figure which will bring it much more into line with the rest of the workforce. Q9 Anne Milton: I have to ask you, because I think the public would want to know, what the management in primary care has been managing? Mr Foster: It has been managing the change in the system which seeks to prepare for less care to be delivered in hospitals, more care to be delivered in primary care settings and in the patient's home. It is managing that pathway of the patients. Q10 Anne Milton: You are going to have to have another go Mr Foster, because I do not think that anybody reading this would be entirely clear what you mean by that. Mr Foster: What I would really like to do is ask you to ask that question again in the second half of our session when we have Dr David Colin-Thome present, who is the Tsar of national primary care and who will be able to give a better answer than I can. Q11 Anne Milton: It has been management for primary care, for practices and district nurses and ...? Mr Foster: It is also commissioning. It is also allowing GPs, on behalf of patients, to plan services and giving them the management support that they need to do so. Q12 Anne Milton: Right; so the managers have been helping the GPs. Mr Foster: Yes. Q13 Mr Amess: What you have just said is just barking mad. I am trying to reflect on it. We have more staff in the primary care trusts to sort things out because of the way the practices with the hospitals are changing and at the same time we are reorganising primary care trusts, we are going to cut down the numbers, we are going to streamline the numbers. This is an absolute shambles. This is not planning: this is just all over the place. I am sorry, but what you have just said to the Committee just does not make any sense whatsoever. You want us to leave it alone until 11.15am when the Tsar comes in and I realise you have moved on to another job, but you were the guy. You started off praising us for what we did in 1999, but honestly you could do a little bit better in trying to expand on what you said earlier, just to make sense. The general public are not idiots. Mr Foster: Okay. One thing I said was that we want a trend whereby people are treated less in hospitals and more in their homes and in the community; I do not think anybody would disagree with that. We said we have a trend where we want to have the patient experience in primary care better managed; I do not think anybody would disagree with that. We would say that we have reached a point where we recognise that this had resulted in a disproportionately high management cost going into primary care, so there is now a correction of the order of £250 million to concentrate that into a smaller number of larger organisations carrying out the same task; I do not think anybody would disagree with that. You have all of those three trends working at the same time which is a complex set of changes to manage but each of the three are things which I think people would agree with. Q14 Anne Milton: I just want to come back on one thing. The managers are for primary care and yet the number of GPs as a percentage of the workforce has gone down from 2.7% to 2.6%. The number of practice nurses, which I should say, if there is an increasing emphasis on primary care, you would expect to have gone up, but that has gone down. It is hard to understand this. Mr Foster: If you look at the community nursing figures, what you are seeing is a much greater flexibility here. Ms Mellor: The community nursing figures have been going up steadily year on year and we now have over 100,000 community nurses working in primary care. Q15 Anne Milton: It is not whether they go up or not, it is what they represent as a percentage of the total workforce. That is the crucial thing. The fact that they have gone up or down is not quite the point. It is the fact that as a percentage of the total workforce those numbers are going down. Ms Mellor: In community nursing, the numbers are going up. Anne Milton: No, you are not listening to what I am saying: as a percentage of the total workforce, not the actual numbers. Q16 Dr Naysmith: Are you saying there has been an expansion in primary care trust management staff or in primary care delivery in the primary care setting? Mr Foster: I am saying that there has been definitely an increase in the number of primary care trust management staff and the plan is to shift care from secondary care to primary care. Q17 Dr Naysmith: Not many people would disagree with that. What are the primary care trust managers doing for primary care that was not being done before? Mr Foster: Commissioning is the main answer to that. Q18 Dr Naysmith: Do you mean commission things at a primary care trust level? Mr Foster: Commissioning integrated care between secondary and primary care. The secondary care are provider organisations: they do not plan the whole patient pathways; they do commission the services; they do not decide what is delivered where, that is the role given to PCTs as advised by the experts, the GPs. Q19 Sandra Gidley: Let me get this straight. We have had an increase in primary care management over five years, the agenda you have just mentioned about moving care close to home and all of the other rhetoric, I would perhaps agree with, but I have seen little movement in that over the last five years. What I am struggling to understand is how services have been improved for patients; not the man on the Clapham omnibus, but the man in Clapham hospital's bed. There seems to have been no corresponding increase in workforce in primary care, which I could understand if this increased number of managers was delivering. So how has this actually improved for the patient? Can you give me a practical example, because I am struggling to get my head round this? Mr Foster: In answer to the two questions here, what you have seen in the last five years is slightly more growth occurring in the hospital sector than in the primary care sector and the benefits to patients you can demonstrate in terms of the dramatic reduction in waiting at every level of the system from A&E to outpatients to inpatients to cancer care, the improved clinical outcomes in terms of reduced death rates from coronary heart disease and cancer and the emphasis of shifting into primary care has been a plan for a while which is now really being given much more impetus by the White Paper, Our Health, Our Care, Our Say and through the creation of the new GMS contract which has a much better quality control of primary care. You can demonstrate the quality outcomes in primary care as measured through the quality and outcomes framework which is used to remunerate GP practices. So you can see demonstrable benefits there. The real stage of transfer from secondary to primary care is about to begin. Q20 Sandra Gidley: But the demonstrable benefits you talk about are because you are actually paying GPs to deliver certain services and they deliver if they are paid. I cannot see how that is linked to the increase in management. Mr Foster: No, but you asked me what the demonstrable benefits were of the increase. Q21 Sandra Gidley: The demonstrable benefits of the increase in management and actually most of what you said was related to secondary care, the reduced times for operations. Basically we welcome all that, but I cannot see the benefits in primary care. Mr Foster: You cannot just stop doing some practices in a hospital and start doing it in primary care. You need to manage the transition, you need to manage the patient flows and you need to manage the training of the staff who will apply the extra skills. So there is a management task in changing from something which is predominantly hospital oriented to something which is delivered much more in the home. Q22 Sandra Gidley: But you also said that there is a lot more impetus to this care close to home and we are now reducing the managers. What have they been doing for five years? Mr Foster: The managers have been changing to an environment where there is a greater level of management in primary care, but in response to the workforce statistics that we have seen about the disproportionate growth, what we have found is that the size of unit which is typically commissioning care in primary care, the PCT, has been too small. The big hospital trusts have been powerful organisations and have not been able to be sufficiently bossed around by the PCTs. The plan now is to have a smaller number of much more powerful PCTs, with greater powers of commissioning, building on the work which has been laid to shift from secondary to primary and strengthened by the direction set out in the White Paper. Q23 Sandra Gidley: So will the current changes mean a reduction or an increase in the number of managers working at primary care level? Mr Foster: It will mean a reduction. The next workforce figures you will see will show a reduction of managers working in primary care trusts. Q24 Sandra Gidley: I have never seen a single organisation that has resulted in large-scale management redundancies. Mr Foster: It is required. The £250 million manifesto commitment saving is disaggregated to each strategic health authority so that it has to be achieved at PCT level. The process of reducing from 300 PCTs to a number which has yet to be announced, but something of the order of half of that, will result in £250 million of management savings and that will show through in next year's figures. Mr Amess: Would you agree that it does not look very good? Nurses in 1999 30% fallen to 29.6%, bureaucrats 6.7% up to 7.7%, senior management 2.2% up to 2.9%. Chairman: I was going to put that question back to Debbie Mellor because what Anne Milton was pursuing and what you have just said there is that there is no contradiction. If some parts of the workforce are expanding by a few percent that does not really say there are not more people working in that particular area. That is basically what our witnesses are telling us about these differentials that there are in the tables we have seen. Q25 Dr Stoate: At the risk of being politically incorrect, I would have to say that the health service has been woefully under-managed for generations and in fact I have to say that some of the management increases in primary care have been very welcome. I am not talking about the number of administrators but the number of managers, and I really mean managers, is actually extremely welcome and has actually knocked some sense into what has been an extremely disparate sector of the health service for far too long. What I want to move on to is your memorandum which indicates that the focus over the last five years has largely been on expanding the workforce and the memorandum goes on to say that over the next five years, it is going to focus on the transformation of the workforce. Perhaps you would like to explain what that means? Mr Foster: The NHS Plan of 2001 produced by Alan Milburn started off with an analysis based on a variety of consultations but one of them was asking the public what they wanted to see. The number one thing that the public said that they wanted to see in 2001 was more staff better paid. What has really happened over the last five years is precisely that. More money has gone into pay, the numbers have increased by about 200,000 and we have introduced new systems of remuneration which are designed to increase the flexibility and productivity of the system. We have achieved the input targets. We are now shifting to looking at the output targets. Q26 Dr Stoate: That is my point. We are seeing the extension of numbers; now we want to see the transformation of the service. I want you to explain how that is going to happen. Mr Foster: Exactly. Mr Derbyshire on my left is our expert in productivity and I shall pass it on to him in a moment. Broadly speaking, there is a series of measures which have been well described by the former Modernisation Agency of high impact changes which require you to redesign the way services are delivered so that you reduce the length of stay in the hospital sector, you do as much work as day case procedures as you can, you adjust the skill mix of your team so that the work is done by the person who is safe to do the work but is most economically efficient. For example, some years ago you might have seen a doctor taking a blood sample from a patient, then we have had phlebotomists who have been trained to do it, then we have had nurses who have been trained to do it and now we have healthcare assistants who are trained to do it. So the same procedure can be carried out much more economically, effectively by somebody who is a member of the team and who can then be remunerated for taking on extra responsibilities. So that redesign of services and redesign of skill mix will enable us to get a higher output or productivity. Q27 Dr Stoate: Are you confident that will happen? All of that sounds lovely in theory and I am quite sure that is the intention, but are you convinced that is actually what is going to happen? Mr Foster: That is what is already happening and what we want to do is to accelerate it. Mr Derbyshire: If we go back to the NHS Plan in 2000-2001, then the decision was made to increase the inputs into the National Health Service by a significant and sustained amount and a lot of the increase in inputs was the increase in labour force which we have seen achieved. Over the past five years the output of the NHS has increased more or less in line with those inputs. What we should like to do is further increase the rate of improvement of the output of the NHS as fast as the increase in the input. Q28 Dr Stoate: Could it not be said though that it was somewhat reckless to expand the workforce massively without sorting out the outputs as a priority right from the beginning? All we are left with then are the charges, which we have heard from many members of the Committee today, of a massive explosion in management, but seemingly not enough to show for it yet. Is that not the charge that it is too easy to levy at you? Mr Derbyshire: There was a risk with the rapid expansion of the NHS that not all of the increased resources would be deployed on improving patient health. The question about managers is not what the increase in managers has been, but precisely what they have done to facilitate improved health outcomes. Q29 Dr Stoate: That is exactly the question. What have they done? It leaves open the question. We have seen the massive expansion, we can look at the huge input into the health service, but can you honestly say that enough has changed to justify that? Mr Derbyshire: In aggregate terms, we can, and working with the ONS and the Atkinson review of How to Measure Government Outputs, if you move away from crude measures of what the NHS produces in terms of patient treatments and begin to look at the quality and the health benefits those treatments deliver, then output has risen in line with inputs. Then there is a micro question about whether the mix of inputs is correct. Andrew made the point about PCT managers that maybe the organisations themselves were badly configured; they were perhaps too small for the role that they have gradually been evolved to do and we are putting that right for the future. One of the underlying reasons for their smallness to begin with was to work together in a community of GPs to organise services at primary care level as well as commission from secondary care. Mr Foster: On the point you made right at the start of your question about management, if you do patient surveys or if you even think anecdotally of the instances you know of where friends or relatives of yours have been using healthcare systems, by and large the time that they spend with the clinician is excellent; they have a fantastic service. It is their travel through the system that is often unsatisfactory and it is more management of the pathway that is needed and better management and that is really what we are trying to achieve in line with international best practice. We spend less than 3% of the NHS pay bill on managers and that compares well with anywhere else in the world. Q30 Chairman: May I just ask you about this issue of transformation? We are all very well aware of what the public's attitude was to the NHS Plan: more staff and better paid. In a recent interview that you gave to the British Journal of Healthcare Management, when you were talking about the workforce side of this, you said that we have to lose 1940s ways of working and need a more flexible workforce with more patient-centred care. Did you genuinely feel that there were still 1940s ways of working in the National Health Service? Not in whole, but in part or in whole? Mr Foster: Yes. I have given one example already, which was taking blood samples. Take another example, prescribing. We now have nearly 10% of the nursing workforce doing some form of prescribing. Several years ago only doctors prescribed. Now that is about really dramatically changing the division of labour within the workforce and allowing people with appropriate training to carry out tasks which they are perfectly skilled to do. Nearly 10% of the nursing workforce is a very large amount of transformation indeed, but that hides a plethora of exciting new roles. In any healthcare organisation you visit you will not only find these extended roles, people doing tasks that they did not do before, but you will find some completely new roles. We now, for example, have approximately 800 emergency care practitioners who are people who will deal with sick and elderly patients in their own home, avoiding them being admitted to hospital, which is not just an economic benefit to the system, it is infinitely preferable for the patients themselves. We could go on to give you countless examples of new roles in the therapies, in science, GPs with special interests, which are really about the transformation of the workforce away from the rather rigid silos of apples and pears, nurses, doctors and so on that there used to be. Q31 Anne Milton: Would you expect the pay to go with it? Doctors at one time prescribed and they were the only people who prescribed, then nurses extend their role and start prescribing. Would you expect, say, if you took nurses, that they would get increases in remuneration to reflect that? Mr Foster: Yes. Q32 Sandra Gidley: The accusation is that they become a cheap labour force. It is cheaper for nurses to prescribe than it is doctors. Mr Foster: No. It is cheaper for nurses to prescribe than doctors, and if you train a nurse to take on a significant amount of extra responsibility and pay them for taking on that extra responsibility, you have a win-win. You have a better opportunity for the nurses. Q33 Anne Milton: You would expect pay to increase with the extension of role. Mr Foster: That is exactly what Agenda for Change is designed to do. It is actually to incentivise people to take on added responsibilities and pay them more for it. If you look at the pay bands of Agenda for Change, band five is a newly qualified nurse, band six is probably a ward manager but then you see nurse endoscopists, cardiac theatre nurses and a whole range of extended roles at band seven and above reflecting the fact that they have taken on extra responsibilities. Q34 Anne Milton: There is some concern about that within some of the professions within the NHS. It is not so much an increase but equivalent pay scales that they are looking for. Mr Foster: The whole system is based on a very complex job evaluation scheme which took seven years to develop but working in partnership with the trade unions. It is probably the most thoroughly tested job evaluation scheme anywhere in the world and is widely regarded by the trade unions as a very successful joint development. Q35 Chairman: Are there any practical measures beyond Agenda for Change that workforce planners are using to get this transformation in terms of maybe skilling? Mr Foster: Yes. May I broadly say that we recognised that in workforce planning there is a degree of bottom-up: how many people are going to be retiring over the next few years? There is a degree of top-down: what are the major changes in demography, technology, international immigration? Then what we do is some skill specific analysis: what are the skills we need for cancer services of the future? Rather than saying we need to commission so many more nurses or so many more physiotherapists or whatever, we are looking at the competences that we require as an added input to workforce planning. Judy sits at the heart of this complex web, so may I perhaps ask her to answer that? Dr Curson: You are asking about what workforce planners can do to support transformation. Q36 Chairman: Yes, practical things beyond Agenda for Change. Dr Curson: One of the issues is that as workforce planners we can come up with plans. It is down to trusts and to service managers in the trusts to implement those and that can be an issue with new roles. For example, graduate mental health practitioners, where a new role was developed which crossed the boundary between social work, OT, nursing. Sometimes it can be difficult to convince service managers in trusts who are under a lot of pressure to take on new roles and to work in different ways, so one of the things is for workforce planners not to work in isolation and come up with great dreams of wonderful new roles that will make a difference, but to ensure that that is embedded in the way people work locally and that they actually want the roles and are going to know how to use them. A number of projects are going on nationally and at local level to try to support people to make those changes so that workforce planning does not take place ... We have talked about it not taking place separately from financial planning, but it is actually very important that it is not separate from service planning because otherwise there is a risk that workforce planners come up with new roles and then no-one wants to employ them. Q37 Jim Dowd: There has been a significant number of changes in workforce planning in the last five or six years. I just mention the National Workforce Development Board replaced by the Workforce Programme, the Workforce Numbers Advisory Board replaced by the Review Team. Why have there been so many changes and surely they are more disruptive than beneficial? Mr Foster: What you are describing are not fundamental changes, these are evolutions. So for example, you talked about the Workforce Programme Board and its predecessor the National Workforce Development Board, there was really a sort of modest adjustment of the membership of effectively the same body to make sure that we had better representation from strategic health authority management. There is no fundamental change going on there. Q38 Jim Dowd: Are you saying then that was because the SHAs developed over time and the relationship needed to change? Mr Foster: Yes; exactly. The original National Workforce Development Board was a stakeholder board which sat at the pinnacle of the workforce planning process and we recognised that we needed to get a better buy-in from the strategic health authority management. That is why that changed. Q39 Jim Dowd: Then of course the SHAs were reorganised. Mr Foster: And then the SHAs have been reorganised, but all that will mean is that there will be different individuals, but we will still have the SHAs represented within the process. Dr Curson: I would echo some of that; a lot of it has been evolution. My team used to make recommendations on medical workforce to a body called SWAG. It then made recommendations to the Workforce Advisory Board and now we go to the Workforce Programme Board. Basically the team has been doing very similar work with the same group of stakeholders over that five-year period, so it does feel more evolutionary than revolutionary in that sense, although I accept that there have been a number of changes. Q40 Jim Dowd: What about the disadvantages of this reorganisation? Dr Curson: Certainly in terms of the SHA reorganisation, there is a concern that there are very few workforce planning skills amongst SHAs and in the NHS generally and that is one of the reasons National Workforce Projects have actually set up the first training programme for workforce planners. There is a very real concern that these skills might be lost as people apply for jobs, even outside the NHS, while they are waiting to see whether they do have a future in the new health authorities. We are putting as much support in place as we can to ensure that people are retained and once the new people are appointed we shall be providing information packs for example and offers to help and advise them on where they can get information and so on if they are new to workforce planning. It is a concern, but one that everyone is actively addressing. Q41 Jim Dowd: Mr Foster, the Chairman mentioned your interview with the British Journal of Healthcare Management. In that you describe the closure of the Modernisation Agency as a terrible mistake. I should say in passing that, as the Director of Finance at Lewisham Hospital was poached specifically to work for the Modernisation Agency, it was a particular blow locally to learn that it was being closed. If it was such a mistake, what are you doing to redress that and why was it closed? Mr Foster: I should perhaps make it clear that I was giving an interview in a personal capacity and I have not actually seen this interview yet; I was not speaking officially on behalf of the Department, as you will probably appreciate. In my opinion, we set up the Modernisation Agency in order to give us really cutting edge, world best practice in terms of service and job design and it was beginning to do a fantastic job when it fell victim to the financial pressures of other priorities in the NHS. The work that was being done, indeed by some of the people who are advising this Committee, to accelerate, define and expand new roles, to develop a competence-based workforce, has lost some of the impetus behind it as a result of the disappearance of the Modernisation Agency. The new NHS Institute has taken over some of the former roles of the Modernisation Agency, but it is a smaller body, it does not have the same capacity to influence job redesign at ground level, so we are going to have to devolve the initiative to do that to NHS organisations themselves more. I personally feel we would have been able to do it better, if we still had the Modernisation Agency. Q42 Jim Dowd: What about the impact on programmes like the advanced practitioner programme? Mr Foster: Exactly. The programmes themselves remain, so out of the former work of the Modernisation Agency much has been retained and devolved to organisations like Skills for Health, the Sector Skills Council, to the NHS Employers or to some individual strategic health authorities. However, it has become rather more fragmented than it was and it will be more difficult therefore to coordinate as an overall pattern and there is less capacity behind it as well. Q43 Jim Dowd: In conclusion, are you saying that the benefits which it offered were clear but were just too expensive? Mr Foster: I am saying that the decision which was taken to remove the Modernisation Agency came just as the Modernisation Agency was really beginning to accelerate and deliver benefits. If we had waited another six or 12 months, we would never have removed the Modernisation Agency. Q44 Dr Taylor: I am afraid I cannot be terribly quick because I am just totally and utterly confused. We already know there have been something like 30 reorganisations of the NHS in the last 20 years. We are now getting organisation after organisation with acronyms, all differing, which come for a few months and disappear again; I am completely lost. We have got the National Workforce Development Board, the Workforce Numbers Advisory Board, the Modernisation Agency, NHS employers, none of which still exists. Then we go over the sheet of our brief and we have Workforce Development Confederation, we have them being made co-terminous with strategic health authorities, then them merging. How does anybody know what is happening and what is going on? It strikes me as utterly ridiculous. Mr Foster: May I separate those out? One is about structures of the NHS overall, so the move from PCGs to PCTs and then reducing the number of PCTs, the reduction in the number of strategic health authorities, previously directorates of health and social care, all of that is one set of things which I am happy to talk about if you like. In terms of workforce planning, the conclusion of your committee in 1999 was that we were not sufficiently sophisticated and it is hugely complicated. You will know as well as anybody how difficult it is to do medical workforce planning. Take an example like cardio-thoracic surgery where during the period of training of a cardio-thoracic surgeon the technology has changed so dramatically that we do not need what we started off the training with. So we need an ever more sophisticated set of arrangements which does mean setting up specific bodies with the right expertise. I apologise for the use of acronyms, it is because they tend to have such long names to represent the combination of expertise that they are representing, that we do reduce them to these acronyms. For each of those bodies and for the evolution of each of those bodies, there has been an extremely good reason, as outlined by Dr Curson, about getting the system ever better year on year, albeit that I fully accept that it will never be perfect. Q45 Dr Taylor: May I go back to the combination of the workforce development confederations and strategic health authorities? Is that not going to dilute the effectiveness of planning? How are you going to make sure that planning at strategic health authority level becomes really competent? Mr Foster: Again, I have expressed in that article that I regret the disappearance of the Modernisation Agency and I also regretted the disappearance of the separate workforce development confederations who were tasked very specifically with being responsible for workforce planning and commissioning of education and training. The reason for incorporating them into strategic health authorities goes back to some of the issues we were talking about earlier on, about better integration of workforce planning with finance and activity planning and the view which won the day, accepting that there are arguments on both sides, was that it would be better to locate the workforce planning and training commission functions absolutely inside the strategic health authority, so that what was a separate workforce development confederation now becomes an integral part of the strategic health authority to improve the integration of planning. That is the logic behind that. Q46 Dr Taylor: Do you think with the reduction of 28 to 10 that they will be able to cope? Mr Foster: Dr Curson has already outlined her concerns that there is a risk of loss of talent. On the face of it, we shall have more numbers of people than we need posts for, so there should be a surplus, but there is always a danger in reorganisations that the best people go quickly and therefore we may have some short-term problems. I am sure that Judy and her team will be doing their best to compensate for any short-term friction with a view to restoring a much stronger system under the ten new strategic health authorities. Dr Curson: From our perspective as the Workforce Review Team trying to work with the 28 health authorities, what appeared to happen was that when the WDCs were brought with the health authorities, and I can understand the rationale about integrating workforce and financial and service planning, although we regretted it at the time, when that happened what appeared was that some health authorities retained a much stronger workforce and workforce planning function than others. Our hope is that with the 28 coming down to 10 they will all have equally strong strategic workforce functions which have been set down as one of the functions of the new health authorities. Q47 Dr Taylor: And that is a hope? Dr Curson: That is a hope. Q48 Dr Taylor: Will it come true? What can you do to make sure it does? Mr Foster: We cannot say at this stage because the detailed arrangements of the structures of the new strategic health authorities are still being worked out. I should very much hope that this Committee in its conclusions on this process would have something to say on this, because you were very influential last time. Q49 Charlotte Atkins: Mr Foster, you were speaking earlier about redundancies and you seemed to be taking a somewhat blasé view about redundancies. I have to say that sitting in North Staffordshire - and you mentioned my local hospital - we take a less relaxed view about redundancies. You particularly mentioned my local hospital and you spoke about 300 extra staff being recruited in the first quarter. Can you elaborate a bit more about that? Mr Foster: First of all, I was by no means being blasé about redundancies. Everybody who works in human resources and workforce would say that they are the very last measure that any organisation should ever take and we have been very clear on a series of other things that can and should be done first before compulsory redundancies are even contemplated and far from being blasé, I was simply pointing out the contrast between the headline numbers that are being banded about as job cuts, which are in fact reductions in numbers of posts and not redundancies of individual people. So far from it. Q50 Charlotte Atkins: So you would expect in North Staffordshire we are still talking about over 500 redundancies? Mr Foster: Yes. I also said that there are two or three exceptions of which I am aware of organisations where the level of cut is so great that there will be more significant numbers and regretfully North Staffordshire is on of those two or three organisations. But, the example that I gave, which really follows the investigation that has been taking place into why North Staffordshire found itself in this situation that it is, did reveal that in the first quarter of last year there was this increase in workforce numbers which simply demonstrated the lack of integration in that instance between workforce planning and financial planning. Q51 Charlotte Atkins: What was the justification for taking on these extra 300 staff? Mr Foster: I do not know the answer to that, because I have not asked that question. I would imagine that it is because workforce planning is done in a separate place from financial planning. The workforce planners say what work they expect to have to do, they need more staff so they start recruiting them without actually reconciling that to the budget they have available. Q52 Charlotte Atkins: So who is responsible for linking up the issue of workforce planning with the financial resources available? Mr Foster: Following the last sitting of the Committee on this subject, the publication A Health Service of All the Talents made the point that there is a level of responsibility at every stage in the system. There is responsibility inside a provider organisation for integrating its planning, there is a responsibility at the level of the strategic health authority for challenging and ensuring that those figures are collected and then there is a responsibility nationally for us to aggregate the strategic health authority plans. I gave you the example of last year when we aggregated the first of the strategic health authority plans and it demonstrated a 6% increase in workforce planning which we said did not make sense in the financial environment. There is a challenge at the higher levels of the pyramidical structure, but the fundamental responsibility for planning lies at local level in each provider organisation. Q53 Charlotte Atkins: What worries me, and you have already spoken about the strategic health authorities and how of course they are going to be reduced in number, while even in the smaller scale, is when you have the Shropshire and Staffordshire Strategic Health Authority with a vast hospital, the University Hospital of North Staffordshire, in its patch, which did not pick up on the fact that workforce was being recruited not centrally by the University Hospital, but by each separate department and there was no central control, which you indicated, with that 300 extra staff just recruited with no reference to the financial implications. Mr Foster: Just as I have indicated that under the new structure there are responsibilities at every level of the NHS, when something goes badly wrong, as it has done in North Staffordshire, there is a degree of responsibility at every level. Q54 Charlotte Atkins: So the responsibility lies with the strategic health authority, it lies also with the management of the particular hospital. Mr Foster: Inevitably. Q55 Charlotte Atkins: But the reality is that the hospital management, in the case of the University Hospital of North Staffordshire, go off and get plum jobs whereas the staff, the very committed, dedicated staff of the hospital end up with their P45s. Mr Foster: Yes, and partly as a result of that and other stories, the system has been strengthened further this year. I do not know, Debbie, whether you want to outline the information we are now proposing to collect from each organisation? Ms Mellor: We started last year. There was a challenge process where we sat down with the SHAs and we looked at their workforce and their finance plans and on the back of that we decided we needed to collect a bit more data. So we started collecting some workforce data around the numbers of staff in post in various groups and across the total workforce and the pay bill and the agency costs that were associated with that. We are going to strengthen that system in the current financial year by making sure that we have a joint collection process which actually will bring together, within the financial information management system, FIMS, which previously has collected financial data only, a financial dataset alongside a workforce dataset, so that we can actually track these linkages and analyse them. Then we can feed that back and we can help both the strategic health authorities, in terms of the information that is available to them, and individual trusts by making sure that we have good benchmark information which they can then use. Q56 Charlotte Atkins: But if this process started last year, why was it the case, just before Christmas last year, well into the year, that it was still not clear in the University Hospital of North Staffordshire what the deficit was, what the financial situation was, just before in fact the whole board of the hospital resigned? Mr Foster: My understanding of that, and this is somewhat second-hand, is that the challenge process happened. The strategic health authority visited the trust board and asked it to explain how it proposed to deal with the financial situation that it faced, did not get a satisfactory response and that is why the board resigned. Q57 Charlotte Atkins: What worries me is whether the strategic health authority only visits the hospital once a year? Mr Foster: That is really what I was inviting Debbie to explain, how we are now going to be collecting information on a monthly basis so that capacity to challenge is served by an information dataset and you will have that information much earlier. Q58 Charlotte Atkins: Who will verify those figures? That is the other issue. There were conflicting figures washing around in North Staffordshire, none of which was verified. Who is responsible for verifying this? Ms Mellor: It will be the SHA who will be responsible for verifying the figures which come up from their patch. Q59 Charlotte Atkins: The very organisation that did not pick up on this problem last year. Mr Foster: Or, alternatively, the organisation which did pick up on the problem, but rather later than we would have hoped. Q60 Mr Campbell: What is the current formal role of NHS foundation trusts in the local workforce planning? It is in the nature of these trusts basically to integrate the workforce development through the local development plan. Has that been happening in the foundation trusts? Mr Foster: By and large, yes. They have a duty of cooperation, so there is a duty to contribute to workforce planning. Although they have many freedoms, they do not have the freedom to opt out of workforce planning. So by and large yes, they have been contributing well to the whole system. Q61 Mr Campbell: Are they actually working well within the health service economy? Are they contributing? Mr Foster: Yes. Q62 Mr Campbell: Does the workforce work in the same way as it works elsewhere in the hospital trusts? Mr Foster: Debbie may want to give you more detail, but the fundamental workforce information is a common set of workforce information which foundation trusts have to give us in exactly the same way as all other organisations, so that we can have integrated workforce planning for a whole strategic health authority. Q63 Mr Campbell: Are you telling the Committee that there is not much difference between the foundation trusts and a normal hospital which is not a trust? Mr Foster: In this specific respect, yes. Q64 Mr Campbell: In workforce planning, Mr Foster: Yes. Q65 Mr Campbell: May I ask you the same question in relation to the independent sector? We see the growth of the independent sector rising very fast in places. Is the same thing happening there? Are these people on board as well with the planning of the workforce? Mr Foster: Again, that was a change that was made following A Health Service of All the Talents where workforce development confederations were established with the explicit duty of setting up stakeholder boards which involved independent sector providers as well as NHS providers. I do now know whether Judy or Debbie want to comment on further strengthening which has taken place? Dr Curson: It does rely on cooperation. The independent sector is not required, for example, to participate in electronic staff records, which is only one of the ways that we collect data, but my contacts with them, both at national and at local level, have shown that they do want to cooperate because they are dependent on the same staff that we need and generally there is enthusiasm for cooperation, although recognising that they are in competition and that some issues are commercial in confidence. At this stage I am cautiously optimistic that we shall be able to continue to workforce plan. Clearly one sector where we have not had very good data has been the nursing home sector which is very disparate, which has been in the independent sector for many years and which does employ a large number of nurses; it has more beds than NHS hospitals. We are very hopeful that we shall continue to get reasonable data but it is not consistent and they are not bound by the same systems that the NHS is. Ms Mellor: In the recent White Paper it was recognised that we do need to have more integrated workforce planning across health and social care. One of the things that we committed to do was actually to work with local government to try to bring the workforce planning arrangements, particularly in social care and the independent sector, and particularly the independent sector nursing homes which have been more difficult, within the system. Q66 Mr Campbell: The danger with the independent sector, as we found out before, is that the training is not as good in the workforce as it is in the health service itself and it is a little sore which needs to be put right; their training methods or their training in general is not as good for the workforce. I do not think they plan it very well either. Ms Mellor: It is varied. It was particularly an issue in the first wave: how they were set up and how training was written into the contract. The people who were organising that have learned from that first experience and now training is included in the contracts. Again, it does need people to work together locally because often, if you take, for example, orthopaedic surgery, what is offered in the independent sector is a very important part of the routine joint replacement surgery, but it is not the full range of orthopaedic surgery and therefore a training programme both needs that independent sector provision in order to train staff, but equally the independent sector needs the NHS, so it is about cooperation, having rotational programmes across the two in order to do good training. Mr Campbell: As long as we have our finger on the button. Q67 Sandra Gidley: A lot of NHS workers have had new contracts and you have submitted information showing how much that has cost, but it is quite alarming to see an annual overspend of £250 million on the new GP contracts, £220 million on Agenda for Change and £90 million on the new consultant contract. Why does there seem to be a consistent pattern of significant overspend and what will be done to redress this? Mr Foster: The answer to that question differs for each of those three contracts so I shall try not to give an over-long answer. In relation to the GMS contract, that was created with a built-in ability to overspend if quality targets were exceeded and of the £250 million overspend £150 million is accounted for through over-achievement on quality. I do not want to make over-achievement on quality sound like a bad thing because obviously it is not. What this means is that by the objective criteria which are independently established as the best measures of what primary care could contribute to improved health outcomes, we have done better. For that overspend, we do have something in return. The rest of the GMS contract overspend principally relates to setting up the new out-of-hours scheme. It was very difficult to predict what number of GPs would retain an out-of-hours responsibility, how many would transfer them to cooperatives and what alternative arrangements could be put in hand in collaboration with secondary care providers, drop-in centres and so on. Obviously it is very important to have a fully comprehensive out-of-hours service and that is why that has over-spent. Do you want me to stop or go on to the other two? Q68 Sandra Gidley: It might be useful to just question something at that point. It seems to me that when GPs have been offered money for doing something, they usually try to maximise their salary; not just GPs let us be fair, anybody would do that. Certainly in conversations with my local primary care trust leads they said they knew that their local doctors would get their acts together and they all achieved just over 99% in my home town, which was much greater than anticipated. There is a little bit of a head-in-the-sand over that. How was the prediction made? What basis was used? Was it plucked out of the air? Was it based on previous changes? Why was it so out of kilter as a result? Mr Foster: Again, I was not directly party to that but I understand that it was a negotiated figure. There was evidence from the academic centres that were drawing up the criteria about what the current level of performance was and therefore what might be achieved. There was a desire by the GP negotiators to set the bar as low as possible. There was a desire by the Department negotiators to set the bar as high as possible and in the end there was a negotiated figure. Q69 Sandra Gidley: But how did they know what was going on? I find it difficult to find any baseline figure for what was actually being achieved. Mr Foster: I would prefer to transfer that more detailed question to Dr David Colin-Thome when he comes later on, but I understand that a university was allocated to collect the data and to ascertain the baselines. Mr Derbyshire: Could I just make a point on the GP contracts? There was a great deal of uncertainty about what GPs could achieve in these areas. The GPs may have known, and your GPs may have known, but the centre did not know. Having the contract out there which rewards the activities of GPs, we now know how effective that can be and we now know how relatively easy it is to achieve certain levels. We can recalibrate the GP contract using the incentive structure to achieve more outcomes in future. Q70 Sandra Gidley: I am not knocking the increased output; I welcome it. It is just a shame that we could not have set the bar a bit higher, as you said. If we get started on out-of-hours, we will be here all day, because I can go on about that forever, so perhaps we should move on to Agenda for Change. Mr Foster: The situation at present is that we do not know yet exactly what, if anything, Agenda for Change has cost over the estimate. We have a series of very important sources of information though and the most important one is that we did test Agenda for Change for a year in 12 early implementer organisations and, at the end of that, we were able to analyse 36,000 pay records which demonstrated that on average the cost of Agenda for Change had been accurately estimated. The second piece of information we have is a sample which took place partway through last year when roughly 40% of staff had been assimilated onto the new system, which was estimating an overspend of approximately £100 million and possibly some extra costs relating to replacing staff who had added holiday entitlements. This was an estimated study and our experience is that organisations which are asked to estimate costs tend to err on the cautious side so that when their financial year-end comes along, they cannot get criticised for having got it wrong. The third is that we are now getting a series of anecdotal reports from organisations which have analysed the introduction of Agenda for Change this year and they range, as reported in The Guardian last week, from Bedford Hospital Trust, which believes that it has over-spent by £1 million, to Leeds Hospital Trust, which is the biggest trust in the country, which has implemented within budget. If you put all of the available information together, it suggests that there may have been an overspend of the order of £100 million, which I deeply regret, but getting an overspend of £100 million on a pay bill of £30,000 million is about as close as you can get to landing on an aircraft carrier on a sixpence and is infinitely better than the last time we tried to do this on the nurse grading scheme where there was just a complete loss of control. Although there has been an overspend, it has been fantastically close to what was intended. Q71 Sandra Gidley: But with Agenda for Change a proportion of staff had a decrease in salary. Has that not been demotivating? Do you think that is acceptable? Mr Foster: In the early implementer sites 8.5% of staff required pay protection. Nobody has actually had a decrease in pay: some people's pay marks time until inflation catches up. On the early implementer sites it was 8.5%, but then, working with the Modernisation Agency and others, we found opportunities for those members of staff to take on extra responsibilities to move to a higher pay band. To give you an example of this, you could find a medical secretary whose job evaluation would allocate them to pay band three, which would mean that they would be moving to a lower pay rate than they had previously been on. So then there was a national project to design an advanced role for medical secretaries who would take on administrative work currently done by consultants, for example maintaining their clinical governance records or their records for revalidation. This enabled the post to take on extra roles and responsibilities to move it to band four, so that those staff did not have to face a pay reduction and again is beneficial to the whole system. It is still more economically efficient for the medical secretaries to do that work than for the much higher paid consultants to do the work. The figure that we now have for the 900,000 or so staff that have now gone fully onto Agenda for Change is that only 4.5% of staff have required pay protection and it has been a hugely complex system with 650 different jobs or grades. It would never have been possible to give everybody a pay increase, or if we had done, it would simply have cost a huge amount more. Getting it down to 4.5% requiring protection has been another very good achievement. Q72 Sandra Gidley: Could we then finally finish with the consultant contract overspend of £90 million? Mr Foster: The consultant contract overspend, on the basis of returns from individual organisations in the year 2004-2005, was £90 million and the principal reason for that was that a higher number of programmed activities was given to consultants than had been expected. The whole agreed negotiation with the BMA presumed that we would be able to reduce the average working week of a consultant to about 47 hours and thus they would get 10.7 programmed activities of four hours each. The actual outturn was just over 11.1 and that difference of half a programmed activity per consultant explains the vast proportion of the £90 million over-spent. Because of that overspend there was an adjustment to the tariff price which providers received in 2005-2006 which was actually higher than £90 million and therefore the consultant contract overspend, which we know has reduced in 2005-2006, because most organisations have negotiated a small reduction in programmed activity, is not part of the financial pressures that have been experienced in 2005-2006, because it was more than picked up in the tariff price. Q73 Sandra Gidley: The King's Fund Report yesterday was very critical of the implementation and you have talked about programmed activity, but there seems to be an opportunity missed to link pay to increased performance. Do you agree with that criticism? Mr Foster: It is fair to say that a lot of organisations put more effort into simply getting people onto the new system than generating the benefits from it and it was a difficult and complex task to negotiate. This is not something you do at a national level; you effectively have 30,000 individual local negotiations with individual consultants. It is fair to say that many organisations, at least in the first year, did not reap the benefits that we hoped for. They have then been supported in a process of job plan reviews which have been taking place this year, and are going to be given much better data, which Mr Derbyshire may want to talk about in a moment, which will enable us to use the mechanisms of the contract which is about transparent job planning, but also about setting objectives for individual consultants which would give us much greater optimism that these tools will be used more effectively in future years. Mr Derbyshire: Just to back that up, with the new tools and levers of the new consultant contract we want to give the NHS more benchmark information which can actually show at consultant level what the relative performance of their consultants is compared to their peer group in the same specialty. That actually will not only incentivise the managers to begin to ask questions but the consultants themselves will be interested to know where they are in the national distribution of productivity. Q74 Sandra Gidley: Is that not available now? Mr Derbyshire: No. It is going out this month.[1] Q75 Dr Naysmith: Mr Foster, you said that you ran pilots for the Agenda for Change people in a dozen or so different places. Mr Foster: Yes. Q76 Dr Naysmith: Did you think of running pilots for the GP contract and the contract for the consultants and if not, why not? Mr Foster: We would have liked to have run pilots for both the consultant and GP contract, but we were not able to agree that with the British Medical Association in each case. We did the closest thing we could do to that which was desktop exercises and dummy running in real organisations, to see in theory what this would mean. Inevitably that does not provide you with the same quality of data as when you actually practically test it. Q77 Dr Naysmith: So are you saying the GPs held out against doing a pilot? Mr Foster: I was not involved personally in the GPs' negotiations but in the consultants' negotiations I certainly wanted to have actual piloting and they would not accept that. Q78 Dr Taylor: It has been a great disappointment to me; I have missed out throughout my career. When units of medical time came in I was stopping being a junior doctor and stopped being a consultant long before these came in. Just going back to the GP contract very quickly, one of you said the GP contract rewards activity. Points have been made to me by GPs that the QOFs really were too easy and they were doing them in any case and all this has meant is that they have ticked boxes to show they are doing it. Have you any proof that they are doing things now that they were not doing before? Mr Foster: I should really prefer to have Dr Colin-Thome answer that because he will be better able to do it. In relation to the first portion of you question, Debbie Mellor is also responsible for the return-to-practice scheme where retired practitioners can receive suitable training and rejoin. Q79 Dr Taylor: No, I am not tempted at all. Just going back to the consultant contract and job plans, in a previous inquiry not all that long ago we were horrified to discover that a relatively small proportion of consultants actually had job plans even though they had been in existence for years, long before this new contract. Are all consultants now fitted up with job plans and does their pay depend on that? Mr Foster: Yes, all consultants now have job plans and it is a condition of agreeing a job plan to be able to go onto the new consultant contract in the first place, so in that sense, yes, it is linked to their pay. The other piece of leverage inside the consultant contract which has generally not been used as well as it might is the ability to agree annual personal objectives with each consultant, for those objectives to be reviewed at the end of the year because pay progression through the scale, which sadly you were not able to enjoy when you were a consultant, is dependent on meeting the job plan and delivering the agreed personal objectives. Q80 Dr Taylor: Could you give us some examples? What would these personal objectives be? To do more operations, see more patients in outpatients? What are they? Mr Foster: They could be quantitative objectives, they could be related to the data that Mr Derbyshire has described will be available on productivity information, they could be related to service improvement and quality improvement, they could be related to redesigning, multi-disciplinary working. The real objective, what we really want to do here, is to ask each NHS organisation what they are trying to achieve, probably the best resource available to them to achieve that is their consultant, so let us put into their job plans what their contribution is to what the organisation is trying to achieve. Q81 Dr Taylor: Would it not have been easier just to go for a fee-for-service contract and why was that not done? Mr Foster: As I am sure you know, that is a very big question and fee-for-service is generally out of favour throughout the world where it is being used because fee-for-service tends to incentivise inappropriate behaviours and tends to lead to loss of control of the finances of the system. Q82 Dr Taylor: Was it seriously considered or was it discarded right at the beginning? Mr Foster: In the initial stages, over all of the contracts, we looked at the possible reward systems which were available throughout the world and in the case of the GMS contract what we have come up with is something which is a world leader in linking pay to system quality and what we come up with in Agenda for Change is another world leader which rewards people for developing their personal skills in line with what the organisation is trying to achieve. Q83 Dr Taylor: Will the new contract encourage people who do a lot of day surgery? Mr Foster: That is an example that you could put in. If we know that the national average day case rate for some particular procedure is 85% and we know that a particular consultant is doing 70%, you can put into a personal objective an agreement that that should rise to 85%. Q84 Dr Taylor: Could that extend to lengths of stay? Mr Foster: Another really, really good example of precisely what you should do, yes. Q85 Dr Taylor: Finally on changing roles, has there been any evaluation of any possible disadvantage of changing roles? I am thinking really of junior doctors no longer having to take blood, which was one of the best ways of making sure that you could always get a needle into a vein. Now they are losing out on that practice. Has there been any evaluation of any disadvantages of these sorts of changes? Mr Foster: I am not aware of any evaluation of disadvantage, although the Hospital at Night project, which has looked at the reorganisation of services and roles at night and weekends, seems to have demonstrated very, very large benefits indeed in terms of quality of patient experience, allowing junior doctors' training to be better delivered because they spend less of their time working at night and a reduction in the procession of faces that you have if you are sadly admitted to a hospital at night. Anecdotally one hears of the type of problem that you hear, but I am not aware of a whole-scale evaluation. Q86 Chairman: You talked about the pay bands in Agenda for Change. Is it your knowledge that any pay bands for nurses have been moved to a lower rate of pay through Agenda for Change? Mr Foster: I do not know personally of that, but given that there are 400,000 nurses, it is possible. Q87 Chairman: It is quite possible that that would have happened and the scene you described earlier may not be the case in some instances. Mr Foster: I certainly know that where protection has had to occur, the more common areas where this has happened have been in administrative and clerical and managerial jobs. Q88 Chairman: Not in nursing staff? Mr Foster: I am not saying that there are not any, because I do not want to give you the wrong impression, but I certainly have not heard of many instances of nurses being banded lower than their current pay. Q89 Jim Dowd: Briefly, after that tale of woe of Dr Taylor's thwarted clinical career, may I just ask you one question on productivity? There is a problem with productivity right across the British economy, public sector, private sector et cetera. The ONS recently brought out a report showing six different indicators of productivity in the NHS. You chose to adopt one of those six which coincidentally or incidentally was the one which showed the highest figure. (a) Why did you choose that? (b) Is it not important to have a durable and broadly accepted measure of productivity within NHS staff at all levels? Mr Foster: I am in the fortunate position of having the best expert in the Department next to me, so I shall pass it over. Mr Derbyshire: The answer to (b) is easier than the answer to (a). The obvious answer to (b) is that we do need a better measure of what the NHS produces, not just in terms of the number of treatments but the health benefit which accrues from those treatments and also the patient experience of going through the system. Waiting times of six months have gone down significantly and that is of value to people. The physical facilities in which they are treated has value for people, as does the amount of time they get to speak to the consultant. We need to bring all those things into the measure of output before we can actually have a proper debate about whether productivity is rising in the NHS or not and the ONS, under Sir Ron Atkinson, did work with the Department of Health to improve the measure of output that we had previously which was about the cost of the number of treatments. Over the long run, that has been increasing by about 0.5% to 1% per annum in terms of productivity. When we put more money into the NHS with the NHS Plan investment, we expected productivity would not actually rise. We did not anticipate that we could put all those new resources into the system and get productivity as well. What we do have is a significant increase in output and outcomes and the ONS measure does give a range of the level of output growth over the NHS over the last five years. Yes, the Department published the high one as being the best available, but they also included the others and explained the different methodology to make it transparent. Q90 Dr Naysmith: Mr Foster again. We have had a number of submissions from education providers indicating that they do not think they are sufficiently involved in workforce planning; sometimes they say they are involved too late or not at all. What do you think we can do about that? Do you agree with that and do you think there is a plan to address it? Mr Foster: This was one of the identified weaknesses in 1999 and again, when workforce development confederations were established and required to set up their stakeholder boards, they were required to have representatives of education on those boards to address that issue. I am interested that that is what the educational institutions have submitted to you in evidence. In my five years in the Department I have had no complaints from educational institutions to me that they do not feel they have been adequately involved. It may be that there are some local instances where relationships have not been as good as they might be, but, again, it seems to me that that is another opportunity for this Committee to recommend to us that we identify any shortcomings and look to strengthen them. Q91 Dr Naysmith: Perhaps we will pursue that a bit more with the people who have said that to us. Do you think there is any role for the independent sector as far as education and training are concerned? Mr Foster: Definitely; yes. Mr Campbell asked some questions. When you say the independent sector ...? Q92 Dr Naysmith: I do not necessarily mean providing --- Mr Foster: There are the existing private hospitals. There are nursing and residential homes, which is a very large sector. There is the first wave of independent sector treatment centres that the Government commissioned where we are not explicit about training and then there is the second wave where we are explicit about training. Yes, it will be absolutely clear that they must provide that. Q93 Dr Naysmith: You see it only in terms of the second wave. Mr Foster: We are requiring it in the second wave. Q94 Dr Naysmith: Is there a chance you will be extending it more widely? Mr Foster: Yes. For each of those sections of the independent sector we have different levers available to us and the strongest lever available to us is where it is our money which is commissioning the services, thus we can require it in the wave two contracts. We should also like initially to encourage it to be introduced into the wave one contract and then when they are up for renewal at the end of their five years, we shall obviously have the opportunity to extend to them as well. Q95 Mr Amess: Witnesses, we are anxious to wrap up this session because we have had enough. So very, very quickly, recruitment from overseas. We all know what went on, we have lots of doctors and nurses and others, marvellously handled, very, very successful and now we have people here, educated here, who cannot get jobs or are losing their job et cetera. First of all, from one of you a comment on that approach and has the Department done any work to see whether taking staff from the developing world has in any sense damaged those countries? If you do have some work on it, is the Department trying to cover up releasing that information? Try to say something to make it more interesting at the end. Mr Foster: I shall hand over to Debbie in a moment because she has led in this area, but if I go back to 2001-2002 when we were tasked with these massive increases in the NHS workforce, we knew how many people we had already commissioned to come out of training, we knew approximately what the average retirement rate was and we knew approximately what the average return rate was, in other words people who have had a career break. When we put all those things together, we knew that we did not have enough input of nurses and doctors to deliver the capacity that was required to achieve the main objectives of improving access. Thus we set up the international recruitment programme with the international code of practice which still remains, as I understand it, the best in the world, which means that we only recruit actively from countries where their governments agree for us to do so and that has been the biggest single contribution to achieving the workforce capacity that we have needed over the last few years. Now we face a situation where funding growth begins to reduce, where a balance between supply and demand is much closer. The numbers coming out of domestic training, because we have been investing in that year on year, are increasing. We are becoming less and less reliant year on year on staff from overseas and many of them came over here with fixed-term contracts of two to three years which are now not being renewed for that very reason. We have to balance the obligation we have to our home grown-students, the workforce planning needs of having the capacity to meet the demand in the system, and the international duty you have in the countries from which these staff have come. As we said earlier in response to questions, workforce planning is a very difficult art to get right, but as of where we are now, we have the nearest to a balance than we have ever had. Ms Mellor: You asked two questions, one was about unemployment. There certainly have been problems with doctors, a lot of them from the Indian sub-continent, who have come here, who have taken the exams, got their GMC registration and have not then been able to get into the NHS. What happened was that, on the back of the NHS Plan and the work that we were doing around international recruitment in the medical side, which was focused very much at consultant level and for GPs, a sort of message got out that England was expanding and needed doctors. Although we have worked very hard with the British Council, with our High Commissions in the Indian sub-continent and with the GMC to get out some very clear messages that there were limited recruitment opportunities in the NHS, there has been a large number of doctors who have come over here over recent years speculatively hoping that they would get in and I am afraid a lot of them have been disappointed. One of the things that we have done, apart from trying to get these messages out, is that we have actually looked at the system that we have got in place with the Home Office around work permits. We recently changed the permit-free training arrangements so that we have brought into line with the way that all other professions and staff groups are treated the way in which we operate work permit arrangements for the medical profession. That has been very helpful in sending out a very final and clear signal that actually it is sensible to check on what the job opportunities are before you go through the difficult and expensive process of getting onto the register and coming over here to find jobs. We are introducing, to support the Modernising Medical Careers, the MMC process, and the new arrangement for training doctors, a new centralised web-based recruitment system which will give us a much simpler and more cost-effective way and more sensible way of getting doctors into the various training programmes. It will also help us manage the flow and the routes into the NHS for international medical graduates and it will make sure that there is a sensible, clear, open route which does not have them coming over here speculatively. I am hoping that we have made improvements there. The second question you asked was about the ethics of what we are doing and what the impact had been in developing countries. We are the only developed country which has actually developed policies and practices and an ethical recruitment code of practice to try to manage international recruitment. We have certainly made clear that, within the NHS to start with, we did not want to see active recruitment from developing countries with vulnerable healthcare systems and we worked hard with the independent sector and with the recruitment industry to revise, improve and extend that code so that it covered our partners in the independent sector and was also supported by the Recruitment and Employment Confederation. You asked what we are doing in terms of having an understanding of the way in which this is having an impact in developing countries. I have to say we have built up a very close working partnership now with DFID and we are also working with the World Health Organisation - you will have seen their recent report which flags what we are doing around ethical recruitment - and with organisations like the International Labour Organisation and the IOM. There are several programmes which are being taken forward to look at the impact in various, particularly sub-Saharan, African countries to see what the impact is and what can be done to help those local healthcare systems address some of the push factors which are fuelling the emigration from their countries. I am not quite sure that we have any secret information that we have not published anywhere. We do have a Memorandum of Understanding with South Africa and we have a lot of discussions and debates with them. Mr Amess: So no cover-up. Thank you very much indeed for your comprehensive reply. Q96 Chairman: My colleague wants to ask you a specific question in relation to EEA doctors. May I first ask you about this issue of working within the code of practice with the independent sector? My understanding is, and correct me if I am wrong on this, that if somebody came in from a country that we would not directly recruit from because of the weakness of their healthcare system, it does not mean to say that they could not work within the independent sector for a length of time and then be recruited by the National Health Service. That length of time is six months. Is that correct? Ms Mellor: It has certainly happened and we do know that within the independent sector there has been quite a level of recruitment and some of that is from the developing countries that we would not like to see and some of that indeed has been the basis of our discussions with countries like South Africa. Q97 Chairman: But there is no statutory regulation which could stop them doing this, so if they do not volunteer to cooperate, then it does not get done. Is that correct? Ms Mellor: Yes, but, as I say, we have worked with the Independent Healthcare Federation and with the Recruitment and Employment Confederation to try to extend our code of practice. What will actually really help us to address this issue is that the Nursing and Midwifery Council have brought in new arrangements for the training of nursing recruits from overseas and what that requires is that they have to go through a period of training within a higher education institute. That is quite a costly process and it is going to be a very difficult process to do if you do not have an employer fully backing you and being prepared to fund it. That will make the kind of opportunistic individual immigration a little bit more difficult for the individuals because it will be more difficult to organise and it will be more costly to do. The real answer to this is that we have supply and demand matched far more, particularly in nursing, so I would hope that even those bits of the independent sector that are not aware of and are not complying with the code of practice would find that they can actually recruit far more easily from within the UK or indeed from within Europe without the additional expense and difficulty of going to the Philippines or South Africa or Ghana or Kenya. Q98 Chairman: Do you have regular meetings with DFID about these issues? Ms Mellor: Yes. Q99 Dr Stoate: It is obviously very good news that we are now producing more medical students of our own and more medical graduates; that is obviously very welcome. Nevertheless, we have relied on the NHS for generations, on the good will and the hard work of huge numbers of doctors and others from the Indian sub-continent who come here and work tirelessly for the NHS for a long time. I have been contacted by a significant number of doctors who now have recently found out, for whatever reason, and these are non EEA graduates, that they either will not be able to get a job, they are not eligible for a job and that the current job when it finishes will not be renewed, that they will not be allowed to complete their training and, obviously for good reasons, they are pretty upset. How has this been allowed to happen? Why was there not a much more planned and orderly transfer once we knew that we were beginning to produce our own graduates in sufficient numbers? Ms Mellor: We started looking at the work permit arrangements and the need to have another look at that last July, when we started to talk to the Home Office and also to the deans about how the whole regime --- Q100 Dr Stoate: But that was last July, that is less than a year ago and now these people have received letters from their trusts saying they cannot complete their training, they can finish their current post, they are not going to be allowed to apply for posts which come up. That is a very short timescale for someone to rearrange their entire life. Ms Mellor: There may be some lack of awareness of the way the changes have been implemented and we are trying to make sure that the guidance which NHS employers have issued on this actually gets to the parts of the organisations that really need to understand it. We are very clear that in introducing this change we needed to have some transition arrangements, so we worked very carefully with the Home Office, who were very helpful and who agreed that we would have transitional arrangements. So anybody who is in training will be able to switch into a work permit from the permit-free arrangements, so that they will be able to complete their training. Q101 Dr Stoate: May I just clarify that. Are you saying that they can not just complete the current posts that they are employed for in the trusts, but they can complete their entire training? This is not what I am getting from many of these groups. Ms Mellor: This is a very complex area. Medical recruitment is complex and the work permit rules and the immigration rules are equally complex. Rather than me trying to give you an answer now in a couple of minutes, perhaps I might write to you and set out the exact transitional arrangements. If I may just confirm, yes, the arrangements that we put in place are that there will be transitional arrangements so that people who are in training programmes will be able to complete those training programmes and international medical graduates will be able to apply for posts, but, in common with everyone else in the UK economy, we shall in future have what is called a resident labour market test, which means that we have to check that we cannot fill that post already with somebody who is a UK doctor or, if they are suitable, a doctor from the EEA. Q102 Dr Stoate: I should like this clarified because it is causing a significant amount of upset to a lot of highly motivated people who have based their lives and their careers on what they thought was their prospect and now it is not. I should very much like proper clarification on that. Ms Mellor: Yes; certainly. Q103 Chairman: We should be very grateful for that, but just tell us in your written answer whether or not somebody who is actually in training is different from somebody who is actually in the country looking for training. This might be an area that you could give us a few views on as well. Ms Mellor: Yes. Chairman: Okay? May I thank you all very much indeed for coming along and helping us in our first session in what is going to be quite a long inquiry? Thank you very much indeed; you have certainly been very helpful. Jim Dowd: Could we just add our very best wishes to Mr Foster who has been a regular attender over the past few years? Q104 Chairman: Absolutely. I understand you are joining us in the North West. Mr Foster: Indeed; the best part of the country. Chairman: Thank you very much. Witnesses: Professor Sue Hill, Chief Scientific Officer, Sir Liam Donaldson, Chief Medical Officer, Dr David Colin-Thome, National Clinical Director, Professor Bob Fryer, National Director for Widening Participation in Learning and Mr Andrew Foster, Director of Workforce, Department of Health, gave evidence. Q105 Chairman: Good morning. May I welcome you all to the first session of our inquiry into workforce planning? May I ask you for the record just to introduce yourselves? Professor Fryer: My name is Professor Bob Fryer. I am the National Director for Widening Participation in Learning, that is I look after the learning of the non-professionally qualified staff in the NHS. Dr Colin-Thome: Dr David Colin-Thome, National Clinical Director of primary care and a GP for some 35 years. Professor Hill: Professor Sue Hill, Chief Scientific Officer of the Department of Health with lead responsibility for healthcare scientists. Mr Foster: Andrew Foster, until recently Director of Workforce. Sir Liam Donaldson: Liam Donaldson, Chief Medical Officer for England and the UK Government's Chief Medical Adviser. Q106 Chairman: I hope Andrew that you now have a copy of your interview. I asked that you be given a copy of it. There will not be any questions in this half which directly relate to it. I am sorry about that; we assumed you would have seen it. May I start by asking the first question to Sir Liam Donaldson? May I also say I am very pleased to have you back here in your role as Chief Medical Officer? The last time you gave evidence to this Committee you made some impact in relation to the subject matter that you were championing. I just hope that this Committee's report and any subsequent actions were helpful in championing your cause and I am very pleased indeed at the way things are progressing. Sir Liam Donaldson: Thank you Chairman. I do not intend to make any impact today. Q107 Chairman: In 1999 this Committee was advised that an oversupply of doctors was highly unlikely before the year 2020. We have received evidence from the NHS Employers that there is currently a 7% oversupply of doctors and that this will rise to 12% by 2009.[2] How did this occur and is this a desirable scenario? Sir Liam Donaldson: My own view is that I do not really accept the assessment that there is an oversupply of doctors. Even if you look forward to those distant time spans that you have mentioned, we shall still be lower than the OECD average. When I came into post in 1998, we were above Turkey, but otherwise we were the lowest OECD country for doctors per head of population. We are still behind and I do not see ourselves as producing an excess of doctors at all, indeed with demographic trends, with the fact that we shall have a 70% female medical workforce in the next few years, with changes in technology, with greater specialisation, we are still going to need a lot of doctors. Q108 Chairman: You heard the last couple of questions we had in the previous session. It is very difficult to relate to OECD levels and ratios about doctors to population as opposed to the actual needs of doctors within the system. Clearly this inquiry is going to be looking at the needs of different levels of clinical and others caring in the healthcare system. Is there no sort of optimum level within our system as opposed to saying that, if it is different to the OECD level or it is still lower than the OECD level, then there is still a need for doctors? Is that not quite the way we should be looking at it? Sir Liam Donaldson: There are several benchmarks that you can choose. The most difficult benchmark is to predict future need which has always been unpredictable in the past. I have a fair amount, through representing the UK on the World Health Organisation, of insight into other healthcare systems and even at an impressionistic level, it is clear that many other healthcare systems are able to provide faster care than we do at the moment with a skilled competent doctor. We do pretty well and we are improving but the basic infrastructure of care in this country, which includes the number of doctors and nurses, is still expanding and it needs to expand further. Q109 Chairman: You do not think with the expansion of medical schools that medical unemployment is inevitable? Sir Liam Donaldson: No, I do not think so at all. Q110 Chairman: Presumably at other grades as well, in terms of nursing and things like that. Sir Liam Donaldson: I do not know so much about nursing, but as far as medicine is concerned, I do not think we shall see that. We have never seen it so far. Q111 Chairman: Do you think that anybody who goes to medical school in this country and after very many years becomes a doctor, at whatever level, has a right to have a job within the system? Sir Liam Donaldson: Yes, they do in the first instance and then, after that, it depends on how well they do their job and how well they perform and so on. But yes, the aim is to give every graduate a post to go into at the time of their qualification. Q112 Chairman: Should that be under all circumstances? Sir Liam Donaldson: Well, unless there are concerns about somebody's competence, health, conduct and provided that they want to have a job. As you know there is a small number of medical students who, having graduated, go into other professions. Obviously there is a small proportion like that, but as far, for example, as this forthcoming summer is concerned, we expect to be able to put all our medical graduates into the first year of what is now called a foundation programme, which will take them through two years uninterrupted of basic medical education, which will be of a more educationally based nature than has been the case in previous years. Q113 Chairman: If it was the case in this more transparent health service that the Government and the general population desire to know the costs of the National Health Service, as opposed to what it spent, if we are moving to payment by results, if I were running a trust and I had an option of either setting on two doctors directly from medical school, in their next phase of training as it were, and spending money from my budget to do that, as opposed to saying that I have a target to meet from my budget, maybe for elective surgery or something, and under those circumstances I have to spend the money on the patient and not on the doctor, would that be unacceptable? Sir Liam Donaldson: There is a lot wrapped up in that question. Obviously, we want patients to be seen by skilled, competent doctors, but at the same time most chief executive officers of hospitals would know that if they do not invest in the future, then they will not have high quality doctors in the future. You do need both. These fears of expediency on the part of hospital chief executives are often talked about, but I have yet to meet one who would dilute the quality of training in their hospital, the quality of research and all the other things which eventually contribute to high quality patient care. Mr Foster: I just wanted to talk about medical unemployment and to link it to the previous session where Debbie Mellor was talking about overseas graduates. In so far as there is medical unemployment in this country, that is where it is; it is for the several thousand who came here on spec without specific jobs hoping that they could find ones easily. That is where the medical unemployment lies. Because there were several stories last year about unemployment of UK graduates, the GMC conducted a study of the last three cohorts which found that the problem is absolutely tiny. Of the 2005 graduate cohort, there were six unemployed and four of those were not actually looking for jobs. Of the 2004 and 2003 graduate cohorts, there are about 20 and 30 in each case who are currently unemployed but generally that is because they are looking for a job that geographically suits them and have not been able to find it. Those numbers are absolutely tiny. So UK graduate medical unemployment is not really an issue. Q114 Dr Stoate: The Royal College of Physicians have told us that the number of doctors receiving specialist training under Modernising Medical Careers is likely to exceed the number of posts ultimately available. Is that true or not? Sir Liam Donaldson: We do not know what the number of specialist posts will be in 10 or 12 years' time. The Royal College of Physicians have been very supportive of the Modernising Medical Careers programme, they are helping us in the planning, but, as you well know, there are great changes in medicine occurring all the time. For example, it takes 12 years to train a cardiac surgeon. Within the last five years, the developments in treatment of heart conditions, with the possibility of minimally invasive treatment, has meant that we are probably now going to have heart surgeons in excess of the numbers that we shall need. So a 12-year training programme and a five-year change in technology which has transformed the position for that particular specialty and I could give other examples. You have to keep these things constantly under review. If you settle on a figure now that you are definitely going to need in 12 years' time, then we shall see problems in the planning of the specialist workforce. Q115 Dr Stoate: Do you see a contradiction though between that and the answer you last gave. You could not see any realistic chance of unemployment in medical graduates and now you are saying that as we cannot possibly predict what we are going to need, then we may not need these graduates which we are currently training. Sir Liam Donaldson: No, I am talking about the balance between specialties. There are 59 specialties. If we have 59 rigid boxes all with a number in them for 10 years' time and then we sit back and do something else until the clock ticks round, then we shall have problems. We have to evaluate the need specialty by specialty, but on the whole, given the position internationally, the trends in the burden of disease, the growth of technology, the feminisation of the workforce, I think we shall need more doctors. Q116 Dr Stoate: That is true, but if someone has done a specialist training programme, then that trains them to be a specialist in a particular area or field. If that is no longer required, then we may have an overall matching number of doctors, but if people with very specific higher training cannot then get a job in that specialty because it does not exist anymore, for example, then that is unemployment surely. Sir Liam Donaldson: I do not think so. We need to take a more flexible approach. I cannot believe that the excess of cardiac surgeons that we would have, if we just simply sat back and waited, would mean all of those doctors were made redundant. They will be able to adapt the skills that they have gained in surgery and in the diagnosis of heart disease and treatment of heart disease into other specialties. For example, vascular surgery, operations on blood vessels, is a specialty which is going towards, not exactly disappearance but almost so. Now radiologists can push wires and tubes into those same blood vessels and do the treatment that would in the past have required a full-blown operation. We have to keep all of these things under review. Q117 Dr Stoate: Just to go back to my first question, so the Royal College of Physicians is wrong, there will not be these specialist trained doctors who are going to have no jobs to go to. That is what they are saying to us and you are saying they are wrong. Sir Liam Donaldson: If they are saying it in such black and white terms, then that is not right. If they are expressing a general concern that we need to get the specialty training right for the future, and they themselves have had ideas about redefining some of the specialties within the medicine, it is something that we need to work with them on and we do work with them. I do not mind them making provocative statements from time to time because that keeps us all on our toes. Q118 Dr Stoate: They keep us amused as well. Just a final point. What will the impact of Modernising Medical Careers be on the non-training service posts, which the Royal College of Anaesthetists have called the so-called "failed doctor" grade? That was not my expression that was theirs. What do you see happening in that situation? Sir Liam Donaldson: We shall probably see fewer of these posts which are really designed within local organisations to meet a service need because we are going to see an expansion of training posts following on from the medical school expansion. I do not like that description, and neither do you by the way you asked the question, but we do have to remember that there are many doctors today, for family reasons or work/life balance attitudes, who do not necessarily want to go on to become principals in general practice or consultants. For example, some of the most talented doctors in the country are in such posts in very specialised areas of practice. For example, I know of a radiologist who is very expert in the ultrasound diagnosis of certain conditions, who, although a staff grade, has cases referred to her from consultants because they regard her as the best opinion in a particular field. We must not regard these posts as posts which are not valuable and do not have a future; they do and they are very important. Q119 Dr Taylor: Can we come on to the European Working Time Directive? Can you bring us up to date: In 2004 the aim was 58 hours. I cannot remember what happened about those European cases and time on-call counting within those hours. What is the state with that? Mr Foster: In 2004 there was a reduction to 58 hours but the main impact of 2004 was that the rest aspects of the directive came into play, as interpreted by the SiMAP/Jaeger judgments, which are the two that you are referring to, which effectively meant that we could no longer staff hospitals with doctors who were resident on-call. Instead we had to move to a pattern of shift working. What has happened since is that there have been many, many attempts within the European Union to revise the Working Time Directive laws as they apply to rest and at this stage no agreement has yet been reached. There is a lot of consensus that SiMAP/Jaeger are having an unhelpful effect in some medical specialties and there is a common desire to overturn it, but it is intertwined with several other issues of the opt-out and so on. The next stage is a meeting in June under the current Austrian presidency which is going to hammer out yet another attempt to produce a compromise solution to it. At the moment we are still stuck with it. The next phase of the Working Time Directive is in 2009, when we have to reduce doctors' and trainees' working to 48 hours a week. That in itself will be a very, very big challenge, even more so if we still have not resolved the SiMAP/Jaeger issue. It underpins some of the comments that Sir Liam was making about workforce planning. Clearly, if you currently get 56 hours from a junior doctor and in future you get 48 hours, that drives a need for greater numbers. Q120 Dr Taylor: Is there still the concern among some junior doctors about the lack of training even at the 48-hour level? Mr Foster: Yes, we have received concerns from various specialties that because of the change to shift working, they have to spend an increasing proportion of their work at nights and weekends when they are not typically being trained by consultants. Some of the logbooks from surgeons and anaesthetists in particular show that they are getting less direct training than under the previous system. We have a project called Hospital at Night which is designed to correct this and the best examples show that by cross-cover between medical specialties and by enhancing the roles of non-medical staff, we can go back to having most of the trainees available during the daytime and we can improve their training. Sir Liam Donaldson: There are also some very innovative new teaching methods in some specialties. For example, in radiology we now have three academies around the country, one in Norwich, which I visited last Friday, which train the young doctors on digital x-ray images in a databank. Rather than sitting as an apprentice in hospital looking at one x-ray at a time, they are able to have a databank which includes abnormalities and findings from images all over the world and they are taught specifically and they are given feedback on their competency. In some of the skill-based specialities, it is possible to use techniques of simulation to fill in that gap which, as you rightly point out, because of the lower hours of exposure in a conventional training, mean that people do not see as many patients as they would have in the old days. Q121 Dr Taylor: Is there any answer for junior surgeons and the worries that by the time they become consultants they will probably have done relatively few of the sorts of operations they will then have to go on to do? Sir Liam Donaldson: Probably the main solution would be to look at those technologies of simulation which, as you know, in minimally invasive surgery are now quite advanced. Mr Foster: In addition to that, what the Hospital at Night project tells us is that there is very little, almost no, actual surgery which needs to be done or should be done at night in hospitals and yet we have a lot of surgical trainees on-call at night. By providing suitable cross-cover arrangements, you can return to the situation where the high proportion of their time is available during the day where they can get those experiences of operations. Q122 Dr Taylor: Can you forecast whether the aim is going to be, to cover the 2009 problem, to employ more doctors or to shift the work that doctors do more onto other staff like the nurses? Mr Foster: This will vary according to the geography of an organisation. There are certain critical masses for some specialties that you have to maintain, so in some cases, in rural and remote hospitals, you can only resolve this by increasing the number of doctors. The best practice in large hospitals is to do exactly what you say, to have better cross-cover arrangements between the medical specialties and to enhance the roles of non-medical staff. Q123 Dr Taylor: Does the affordability of this by 2009 worry you? Mr Foster: Yes, it will be part of our spending review bid for next year to recognise the costs that are applied by it. Q124 Jim Dowd: I just want to come back to Sir Liam on this question of training. I saw a release from the BMA a year or so ago saying that medicine is the most socially exclusive of all higher education or degree courses. The only one that was more socially exclusive was veterinary medicine. If you are from a manual household background, you are 200 times less likely to get a course in medicine than you are if you come from a professional or A-B group background. Given the fact that it is so divisive and exclusive, given the fact that the technology is changing the nature of the training, one of the reasons that it is as divided as it is, is because very few people, other than from a relatively prosperous background, could contemplate training for seven years, ten years, 12 years. Are you taking the opportunity to change the courses, obviously in concert with the great gatekeepers of the royal colleges, to ensure that you can reduce courses as technology changes, which, at the same time, will encourage people from non-traditional backgrounds to come into medicine? One of the big problems we have with the health service is that it is actually almost entirely middle class practitioners and almost entirely working class patients. Sir Liam Donaldson: It is a very, very important area and it is one which has always concerned me. There has been a change towards a more balanced entry of medical students to medical school. We are certainly well represented now in some ethnic minority groups, although not the Afro-Caribbean community where the entry levels are very, very low. The social class differences are still quite marked as you have pointed out. We have done a lot of work with medical school deans, particularly in the new medical schools which have been established over the last few years, and I chaired the committee which established them, to lay down criteria so that for them to be successful in being awarded more places they had to improve access to disadvantaged groups. It is very important, it is important for doctors to have insight into the communities that they are serving. We are trying to do as much as we can, but to some extent it means going back into the education system earlier on to make sure that those students have the opportunity to get the right qualifications at GCSE and A-levels to get in. It is possible to get into medical school with other sorts of qualification now as well and certainly the new medical schools, Peninsula would be an example, University of East Anglia another example, they do have a much more diverse range of students than they have had in the past. Mr Foster: There has been some research carried out which demonstrates that one of the biggest problems is that students from poorer backgrounds or from certain ethnic minorities, not all ethnic minorities, do not perceive that they have the chance to become a doctor; they really think they are excluded. Some of these more modern medical schools that Sir Liam has described are doing out-reach activities where existing working class medical students go out to schools and say "You can do it. I have done it" and that has been demonstrated to be one of the most articulate ways of breaking down that particular problem. Professor Fryer: There is evidence that the real issue is not simply the level of the A-levels that students from non-traditional backgrounds get, but the wrong ones too. For example, chemistry is often a lack. Some medical schools around the country are now working with local further education colleges and with local schools to put in, at no cost to the student let me say, that additional training so that they can get the qualifications in the relevant areas. It has been very responsibly done because they are very keen not to take students from disadvantaged backgrounds and then get them into a system where they fail. There has been a scheme, for example, with London FE colleges working with the University of Southampton specifically to target Afro-Caribbean students where the FE college plays a key role in preparing them for entry into medical school. We could give you some data on that. Q125 Chairman: Are you aware, not the new schools, that the Sheffield Medical School has links with comprehensive schools in South Yorkshire, one in my constituency in Dinnington, where they actually visit and chat to the head about the brighter pupils in there who may have no links at all with the medical profession on a family basis at it were, but are taken out and encouraged to go into medical school through our current education system. That seems a very sensible approach in terms of this issue of the social class and medical education. Professor Fryer: There are many examples of that around the country and I want to say that the medical profession themselves have been very good in doing mentoring and coaching and indeed it would be good to see this as part and parcel of NHS organisations, seeing themselves as exemplary employers, reaching back into the education system to raise aspirations, to provide information and to work alongside the young students. That has been happening and where it happens it is extremely effective. Q126 Jim Dowd: The note I saw from the BMA did admit that this was an area where they were just not doing well enough. That was the tone of it rather than anything else. Professor Fryer: There is still a long way to go. Q127 Dr Naysmith: We have spent a lot of time this morning, as we usually do, talking about doctors and nurses and allied professionals, but actually the section of the workforce which is growing fastest of all is the scientific workforce. I have one or two questions for Professor Hill to answer in that area. What are these staff doing and do you think the numbers are going to continue to grow? Professor Hill: We now know more about the composition and the roles which are undertaken by the scientific workforce than we did. For example, we now classify the healthcare science workforce into 51 disciplines and they are grouped into three broad-brush divisions: life sciences, which include genetics; physiological sciences are those that work predominantly in clinically facing specialties like cardiology, respiratory medicine; and those in physical sciences and engineering, from the medical physicists supporting imaging and cancer treatments for example, through to clinical engineers, who are engineers who design equipment or work and develop rehabilitation-type solutions, to maxillo-facial prosthetists. In terms of the numbers employed within the workforce, there has been an increase of 5,814 over the 2001 baseline. We have done a lot of work to collect more detailed information on the scientific workforce through the introduction, for example, of the T-matrix which is the scientists' specific part of the Department of Health census which is collecting information on 18 disciplines in six employment grades as well as the rest of the disciplines in the more aggregated data. To provide us with more information in terms of the age, profile of the workforce, the future planning arrangements for the scientific workforce, we are working with three strategic health authorities on a more detailed workforce project, that is Trent Strategic Health Authority, North Central London and Greater Manchester. That is giving us a greater insight across the totality of the workforce. Q128 Dr Naysmith: So they are clearly a key section of the workforce and you think they are going to increase in numbers in the future. Professor Hill: They are a key section. The recognition of their contribution to healthcare is growing and the importance, for example, of many of the scientific disciplines in delivering the 18-week access target by better diagnostic service provision, is obviously driving some of the changes. In terms of the workforce profile for the future, we shall need to increase the workforce but not necessarily more of the same. There needs to be a greater focus on the scientific workforce skills which are required to deliver service functions as opposed to the old traditional routes and associated with that will be more assistants and associates, which will reflect the increasing automation in some parts of the workforce, the demand for higher types of low clinical risk activities. Equally, there will be the requirement for more advanced and consultant practitioners to support the advances in science and technology and the need for more specialist advice and interpretation. Q129 Dr Naysmith: Just before we go into that in a little bit more detail, I used to teach scientists in that category before I became an MP. One of the things that they always used to tell me was that they were not paid nearly enough money. Mr Foster, you were talking in the previous session about Agenda for Change. Have they significantly improved under Agenda for Change? Mr Foster: As Professor Hill has said, there is no simple answer to that because there are 51 different specialties. However, the job evaluation scheme is designed to recognise the complex range of skills, knowledge and environmental difficulties that people have to face. Yes, their skills are properly recognised in the new job evaluation scheme and many of them have benefited considerably, particularly in terms of the starting salaries for laboratory staff. Q130 Dr Naysmith: I am glad to hear that. When talking about this group of staff, is the increase a result of the development of new roles or is this just employing more people in existing roles? Professor Hill: There is a combination. There is no doubt some of the work that we have done to introduce a new career framework for healthcare scientists has focused the scientific workforce on the development of new roles, that is both from a national perspective in some of the work that we have been doing, but also locally to meet local service requirements. The bulk of the increase we have seen to date has probably been in more traditional roles, but we are seeing a change in the profile towards more new roles being commissioned and funded. Q131 Dr Naysmith: One of the things that we have frequently heard in this Committee in the past is that the NHS is pretty slow at taking advantage of new technology and, even when it comes in one bit of the National Health Service, it often does not spread very quickly to other parts of the NHS. Could that be partly due to not taking advantage of new technologies because of workforce shortages? Is that a possibility? You may not agree with what I said in the first place, but it has certainly been said in this Committee often enough. Professor Hill: The evidence we got from the functions which are undertaken by the Healthcare Science Workforce is that they are adopting new technology. For example, they have been our key drivers in the adoption of new in vitro diagnostics for example and some new diagnostics which support, for example, cardiac physiology interventions or indeed more handheld portable-type investigations in respiratory physiology. So this workforce has been a leader in terms of adoption of new technology. Our challenge is actually how we can use the skills and talents of the Healthcare Science Workforce to help the rest of the workforce adopt new technology. Indeed, we are working on a competence framework, based on the healthcare science competences which might be applicable across the wider healthcare team, around adoption of new technologies. Q132 Dr Naysmith: One of the things which has been said to us by some of the companies who manufacture some of this new equipment is that they would like perhaps to get involved in training National Health Service staff. One can understand from their point of view why it would be a good idea, but it is also possible that they could bring about change more quickly, if this happened. What do you think of that idea? Professor Hill: Yesterday I was just out at the Medtronic Training Centre in Switzerland looking at the type of simulated training that they are providing for interventional cardiac devices as well as training some of the cardiac physiologists, for example in interpreting echo-cardiography. There has been quite a substantial uptake in England by both the medically qualified staff and the scientific workforce in accessing training solutions provided by the independent sector and that is quite common across a number of the different healthcare science disciplines. Q133 Dr Naysmith: So that sort of thing is something that you would be happy to encourage. Professor Hill: Yes. In terms of the future and the way in which technology is advancing, there will be a need both for us to reflect the ability to respond to that technology in both pre- and post-registration education and training programmes, but also in solutions with the independent sector and other providers of such training on highly specialised pieces of equipment. Q134 Dr Naysmith: I have one final question to do with the fact that biomedical sciences are a key diagnostic group within the National Health Service but the training of them is not within the control of the Department of Health. Is that something which is a problem, or is it something which worries you? Professor Hill: We are modernising pre-registration education and training for both of the two currently regulated healthcare scientist groups, the clinical scientists and the biomedical scientists, to make them more fit for NHS purpose. That is being done in conjunction with educational providers and in a separate stream of work we have discussions ongoing with the Department for Education and Skills on how we might drive changes in the funding and the arrangements for the delivery of these new NHS fit-for-purpose programmes in the future. Mr Foster: This is an inevitable difficulty when you have graduate professions which contribute employees to many different industries. It would be difficult for the NHS to say they insist on monopolising it. It is the collaborative arrangements which Professor Hill described which really are our best bet. Q135 Mr Amess: Professor Fryer, it is your job apparently to devise and implement a strategy to improve access to learning across the NHS. How are you doing? Please do not be immodest. Professor Fryer: The first thing we are going to do is build on the success which is there already. By comparison with the rest of the British workforce, this is the most highly qualified and highly skilled workforce in the country. Just to give you an example, there is a big concern in the country about the numbers of people qualified at what is called level two or above, about the equivalent of five GCSEs. 80% of the NHS workforce is already qualified at that level or above. So the first thing is to build on success. The successes also include a very innovative scheme which was introduced as part of the NHS Plan to provide dedicated money year on year for unqualified staff either to acquire NVQs or to use what was called an individual learning account to get other money. This is not year zero. This is not the Pol-Pot regime, we are starting and the NHS has much higher aspirations for the qualifications of its staff than does the rest of British industry because it wants to get a very, very professional staff. Specifically what this means is also attending to things which do need improving. One of the areas needing improvement is around literacy and numeracy levels. We know that this is a problem across the British economy and indeed in health and social care generally we more or less match the challenges which are faced in the rest of the British economy, that is that about one fifth of all adults have some problems with literacy and almost 50% have some problems with numeracy. How we have been tackling that is to work very closely with the Department for Education and Skills and with local education providers to put in place specific programmes which are aimed at healthcare staff. All the evidence around the world shows that if you actually build literacy and numeracy into the local work and personal circumstances of people, it is much more effective, so we have started in that direction. Secondly, there are possibilities for progression. For example, we are currently already recruiting about one fifth of our nurses from healthcare assistants. Healthcare assistants form one of the largest sections and one of the fastest growing sections of the workforce and we have provision in place whereby healthcare assistants can get financial support to undertake their training so that they can progress into nursing. In fact we have set an ambitious target of systematically moving that up to 25%. That would be a second area in which we are doing some work. A third area in which we are doing some work is that we are trying to reach back into the labour market, both amongst young people and in socially-deprived communities, to get training levels up so that when people enter the workforce they have higher levels of training, in very close collaboration with the Department for Work and Pensions and with Jobcentre Plus so people do not lose their benefit while we bring them up to a threshold of qualification. Those are just three examples of how we are doing this. Mr Amess: You have already answered the second half of my question, so I am going to give you A++. Q136 Dr Taylor: That is encouraging. I am delighted to hear that you are encouraging healthcare assistants to go on to become fully qualified nurses. We have been given some figures. We have been told that £4 billion is going into the Multi-Professional Education and Training Levy and that more than half of that is spent on medical training when doctors only account for 9% of the workforce. Is that right? Professor Fryer: It is not quite accurate. Q137 Dr Taylor: Please correct the figures we have been given. Mr Foster: The figures you have been given are correct, but this is really about how we fund doctors in training. A large part of that actually pays their salaries. Rather than paying their salaries through their employers, because they are doctors in training their salaries come through these training budgets. Professor Fryer: If you take the length of time a doctor needs to be trained, part of that training has to be covered by them still earning some money. Q138 Dr Taylor: That is why it is such a very large proportion, because it is training. I am with you. On the surface it looks very unfair, but in fact ... Professor Fryer: No-one would argue that it is yet as fair as it might be, but there have been considerable improvements and the gains have been year on year and we want to see that continue to make sure that the appropriate levels of funding are made available at each level of the career framework of Agenda for Change. Sir Liam was talking earlier, for example, about Modernising Medical Careers. That means smarter and newer ways of spending the money we have so that there is more money to be spent across the board. We do not see any decline in standards in training doctors and other clinical staff, but things like the digital learning and the e-learning have allowed us to release resource so that other people can then have additional training. Most of the training at the lower end of these scales does not take so long, but there is still the issue, if you want to remove people from the workforce so they can do this training, of backup costs. What we are trying to do there is develop a systematic approach to work-based learning and to e-learning so that you do not have the double cost of both the education and the backup. Q139 Dr Taylor: May I ask about these conferences which are advertised so widely? The Health Service Journal every week has three or four glossies and for a day conference the typical cost is £440.63. Who pays for that? Are you paying for that? Are you getting value for money out of it or are these conferences an entire waste of time and making money for somebody else? Professor Fryer: I am not going to generalise about conferences. First of all, the conference world is a market world and education is a very big and growing market; in fact probably now the fastest growing market for conferences. Q140 Dr Taylor: Who pays that £440.63? Professor Fryer: It is a combination. Very often it is local organisations which pay and local NHS organisations will have policies on what sorts of conferences and what sorts of benefits they expect to derive for their organisations and their patients. So they might pay. Sometimes individuals pay. Very rarely does any payment come from the centre or from the money we reserve for training for the staff that we have been talking about. Q141 Dr Taylor: It is all a local decision. Professor Fryer: It is largely a local decision. Q142 Dr Taylor: Would anybody keep an eye on value for money for that? Who should it be? Professor Fryer: It should be the local managers who sanction the attendance. There should be reports back from conferences and the benefits should be spread. There is a bit of a culture in the country - and this is nothing to do with the NHS - of people seeing conferences as an individual benefit and not as a corporate benefit. We need to ensure that we are much choosier about who goes to what conference and be clear what the benefit is. You cannot generalise: some are extraordinarily valuable; some, quite frankly, I would not spend the time of day on. Q143 Dr Taylor: Any comments? Am I alone in being worried about these? Mr Foster: We have worried about them in the Department of Health from time to time. You occasionally see an overseas conference which has a very large number of UK delegates going to it and you wonder why it should be beneficial that so many go. There are waves from time to time of carrying out exactly what Professor Fryer described: much tighter local arrangements to make sure the value for money is being achieved. There is no doubt that the conferences have the potential to supply good training on the issues of the day from the experts who know what they are talking about and are much appreciated. There was a conference yesterday addressed by Sir Liam on MRSA, which I think in fact was free of charge to delegates but which was extremely well received. Q144 Dr Taylor: Free of charge? That is excellent. How did they manage that? Sir Liam Donaldson: I did not actually speak at it. I do speak at most conferences, indeed it is probably years since I sat in the audience at a conference and it would be the greatest pleasure if I could have the opportunity not to be the speaker for once. Q145 Chairman: In view of what you said earlier about the issue of numeracy and literacy of the workforce, do you feel that the proposals for extended vocational training from 14 to 19 in secondary education and in further education, potentially higher education, have any implications for the NHS? Professor Fryer: Very, very important implications. In fact I have been talking to Lord Leitch precisely about this. As the largest employer nationally and locally we have a great interest in what goes on in schools. Indeed it is very difficult for any employer to correct what does not happen in schools. That is a national issue. It is extraordinarily difficult and it is much harder for us to correct it. We are very keen to see the development of the combined routes both academic and vocational; indeed some would argue that healthcare is par excellence an area where you need both academic and vocational aspects of work. The healthcare scientists would be a very good example and I would argue indeed that surgery does; it needs certain of the skills which are much more associated with vocationalism. We are very keen to work very closely, very keen to see the new vocational certificates being very much geared towards the NHS. We have our Sector Skills Council, Skills for Health, which takes an active interest in that and no doubt they will talk to you about that when they come. I work very closely with the Sector Skills Council. Q146 Chairman: Could you tell us what will be the role of the knowledge and skills framework in improving education and learning in the NHS? Professor Fryer: The particular advantage of this is that it affords an opportunity. Every year there is an entitlement in the NHS and, again, that makes it almost unique amongst British employers. There is an entitlement to an annual appraisal and interview and discussion on your personal development with your manager. Out of that can come a personal and learning development plan. The huge advantage of the knowledge and skills framework is that you can look at what you need to do, where you need to develop and be trained and if necessary get additional credit qualifications in order to progress through that career ladder. The knowledge and skills framework, with this built-in entitlement is a tremendous opportunity for building and growing our own workforce and that has huge advantages. Some of the issues we discussed in the first half in terms of recruitment can be counteracted. There is evidence that it actually reduces labour turnover and absenteeism and raises the morale of staff, in particular what this does is actually hold out the prospect to somebody who comes in at a relatively modest level to improve their professional skills and competences and indeed their life expectancy, because higher qualifications in education are closely associated not only with material life chances in the way of money, but mental health, wellbeing, participation in the community and so on. The knowledge and skills framework is a tremendous tool. What we want to do is to support local managers in getting the most out of it. Year on year we can see improvement, but there is some way to go. Q147 Chairman: Is it likely to be hampered by other areas of the Agenda for Change like the job-matching process and things like that? Professor Fryer: It is not necessarily likely to be hindered by other processes. What it does require is that in that dialogue between local managers and their staff, which goes on annually, those managers themselves have a very clear understanding of the service delivery and the service improvement that the body as a whole is trying to achieve and therefore what their future needs may be. It cannot be done in isolation. It needs those people to have a clear understanding about the priorities and the challenges which their healthcare organisation is facing. Q148 Chairman: Do you believe that the constituent parts of the National Health Service, including representative bodies of the workforce, have endorsed the knowledge and skills framework? Professor Fryer: They were involved in designing and testing it and developing it. I should say that the representative bodies, the trade unions and the professional bodies, including the royal colleges - do not exclude them - have been very, very positive about the whole notion of widening participation and progression. What we need to do now is year on year show the improvements. They have been very supportive of it and Andrew can no doubt talk about how they helped to design and build it and test it. Mr Foster: The knowledge and skills framework really is the centrepiece of the pay system. As I said earlier on, it really is quite a unique pay system which rewards personal development with pay development which aligns the two. The knowledge and skills framework was designed over a period of a five-year negotiation, working with the trade unions and professional bodies in the NHS and you would not find a single one of those bodies which would come here and say anything negative about it except that it must be implemented properly. If you analyse somebody's learning needs and fit them into their knowledge and skills framework then you have to be sure you can follow through delivering the learning and training which is required by it. For the last 12 months we have been getting people onto the Agenda for Change and as of March we had 99% of the non-medical English workforce being paid under Agenda for Change, but that is only the start of it. Now we have to get all the benefits out of the knowledge and skills framework and align the learning needs of individuals with the service needs of the organisations. Q149 Charlotte Atkins: Earlier on Mr Foster you passed the baton to your colleague Dr Colin-Thome on primary care. Maybe we ought to ask the question first of all which Mr Foster was having some difficulty answering. What exactly do managers in the primary care sector do? That was one of the questions with which Mr Foster was having some difficulty. Dr Colin-Thome: It depends at what level. There are two levels. There is one at the primary care trust level, which is not really primary care; it is the organisation which funds the whole health service. They have a key role there in making certain that resources are allocated and so on. There has also been a growth in management at general practice level. One of the tests for us in general practice is to have our practice better organised. Sometimes, although the doctors and nurses can be good at their clinical work, they are not effective at running an organisation and making it more effective. For instance, if you look at one of the drivers in the new GP contract the quality and outcomes framework, it is about getting systems in place for people with long-term conditions, chronic care. That takes a different mindset than is often around amongst clinicians. At PCT level they have a significant function and, as you know, we are halving the number, which I know in your area has caused some issues. We are halving the number so there will be a smaller number of PCTs because you can have a critical mass of people working together for one organisation. At practice level there is a significant need not to grow a lot more, but to have better quality managers and in some practices they did not have much management at all. Perversely, the quality and outcomes framework, which will give better clinical quality to patients, needed better management. Q150 Charlotte Atkins: I think you are right in saying that PCTs are going to be halved as opposed to reduced by two thirds, if the feedback I am getting is correct. There is a move by the Government, rightly in my view, because I think my primary care trust does an excellent job, to shift from secondary to primary care. However, what we are seeing in terms of workforce is that it does not seem to be paralleled by an increase ... Obviously there is an increase in staffing at primary care level, but there seemed to me to be more of an increase in hospitals. For instance, if you look at nurses, there is an increase in nurses in hospitals but not as large an increase in practice nurses. Similarly, if you look at the increase in consultants, there seems to be a disproportionate increase in consultants as compared with GPs. Why is that? Dr Colin-Thome: That is historic. I do not want to criticise previous ideas, but there basically has not been enough investment in primary care. It has taken a long time to recognise that primary care is the biggest provider of clinical care; we do about 85% of all the consultations. International evidence has also been gathered by people such as Barbara Starfield and locally by Brian Jarman that increasing the number of primary care professionals, including doctors, makes a difference not only to the satisfaction of people with the health service but makes it more cost effective and now there is some actual connection with better outcomes. In one sense it is probably our fault by being, so-called, independent contractors. The health service has focused on the salaried end of organisations such as community nurses and staff in the hospitals and left primary care independent contractors a bit adrift. What I welcome about the policies which really have happened in the last 15 years is the greater focus on primary care, but the investment has not followed. That is maybe the reason for the lurid headlines about how much we are paid in primary care now. It does seem to have worked, because there has been a huge growth in doctors in general practice; an increase of about 1,000 a year in the last three years. That is head count rather than whole-time equivalents. In the last four or five years there has also been a growth of something like 18,000 nurses, of which only 3,000 or so are practice nurses. Q151 Charlotte Atkins: That is the point, the proportion, in terms of the percentage increase in practice nurses, is far less than nurses overall and that is a concern. You focused on GPs, but clearly the work of primary care is heavily carried out not just by GPs but by practice nurses, by health visitors, by community matrons, people like that who are making a vast difference in the quality of primary care and the experience of the patient. Dr Colin-Thome: That is where the biggest growth has been, in community nurses who are not employed by GPs; they are community-based staff. The issue for us then, and sometimes we have not been good at working with organisations outwith the people we employ, is how does the registered population, which is quite unique in British general practice, be the population base to look after communities, rather than just about general practice and its own organisation. If you look at the general growth of community nurses, it has been about 12,000 in the last five years. These are community-based staff that will do some of the work. It is not all going to be done by general practice. The other issue about more care out of hospital is that will not all be done by primary care workers. What we are arguing about is that we need our hospital-trained staff, but working in different ways nearer the community. For instance, some of the community matrons will traverse primary and secondary care and work with social care to get a better package of care. It is not just "Let's shut the hospital and give it to primary care", it is increasingly about where the care takes place and some of that will be our secondary care colleagues, including especially nurses rather than consultants, doing some of that work. Q152 Charlotte Atkins: Obviously in terms of the increased role that nurses are taking on that makes a lot of sense. Can you just answer one question about the redundancies in the secondary care sector, in the hospitals? Would you put that down at all to the increase in resources going to the primary care sector or would you see it more as a function of the primary care trust holding their acute hospitals to account and in fact defining where their residents, their patients, will be treated? Dr Colin-Thome: It is a consequence of the realisation that in Britain, compared with a lot of equivalent healthcare systems, we put people in hospital, which modern medical care and healthcare do not lend themselves well to. For instance, because of the work of community matrons, these are case managers who are nurse trained --- Q153 Charlotte Atkins: Managing emergency admissions much better? Dr Colin-Thome: No, they are actually managing people with complex long-term conditions, with co-morbidity, the group of people, not that many, who often have more than one chronic illness. The crude figures are that about 5% of our population account for 42% of all the bed days. The international evidence on case management is that you can often reduce emergency admissions, though the evidence is sometimes not clear. The biggest difference they make is shortening lengths of stay, because people can go home early and that will have a big impact. If a lot of patients with chronic long-term conditions are the biggest inhabiters of hospital beds and we can shorten their lengths of stay without affecting, in fact improving, their wellbeing and their life quality, then we do not need as many beds as we have traditionally had. It is often where care is taking place. The issue which is going to be interesting is that out of the redundancies not many were fully directly employed nurses. What will happen is that there will be more growth in primary care, because more care will be done and things like practice-based commissioning will be driving some of that. It is where care takes place. Some of the more lurid headlines about sacking are really just saying that we are using resources not very appropriately by keeping people in hospital unnecessarily when their care could be done better in community settings. Just as a very practical example, I am doing some work with the teaching hospital in Manchester where they have asked me to be their lead primary care adviser for the hospital. I can do it part time along with my other commitments. What we have come up with is that the hospital and the PCT, without getting in the way of contestability and choice and all that and being transparent, are saying they want a joint venture around urgent care and long-term conditions so we can rationalise where the care takes place and have fewer headlines. You will find more and more growth of that much more imaginative working. If you look at the acute hospitals project, of which I was a member, about reshaping the future hospital, there is a move to say that care could be done in different ways. That is a generally accepted view now. Q154 Charlotte Atkins: How do we make sure that the education facilities of the NHS follow the staff? The impression we get is that a lot of the education and training takes place in the secondary area. How do we make sure that the innovative things which are happening in primary care are backed up by education resources? I should be interested to know how much clinical training is available in the primary care sector and what the proportions are, how much per head someone in the primary care sector gets in terms of training as compared with the acute sector. Dr Colin-Thome: I cannot help you there. Mr Foster: I do not have that information available. Q155 Charlotte Atkins: Could you let us have it? Mr Foster: What I can say is that the post-registration training monies are held by the strategic health authorities. They are not held by the trusts or the PCTs. The strategic health authorities can direct those monies to support what is generally trying to be achieved. In this case what is generally trying to be achieved is a transfer of work from hospital settings to primary and community care settings and there are plentiful examples of where staff are being trained to do that. I went to Epping Forest a few weeks ago and saw a team of staff who had previously been nurses working in the hospital who are now providing step-down arrangements in the community for the people Dr Colin-Thome identified, the over-75s who have the most frequent admissions to hospital. They were now being looked after by a case manager, either in their own homes or in a community hospital. This was a much better service from the patient's point of view and was much more efficient from the whole health economy point of view and was an example of where posts will be transferred from secondary settings to primary and community care settings. Dr Colin-Thome: Also our community nurses are trained in community settings; we have a post-graduate degree. Practice nurse training is within the gift of general practice and I have to admit that sometimes that varies. The drivers of the contract which looks not just at clinical care, and therefore they have to have an expertise to do this well, but also at the organisational standards we are setting about having work plans and so on for our staff on which we have to be measured, will drive better training in general practice as well. Many practices do excellent training, but there are accusations of variation, though of course all our community nursing services are trained. Some of the community matrons are nurses coming from hospitals who might have emergency knowledge and can work well across, but they still need some training and we do have some training programmes for our community matrons and we have produced a competency framework and so on to get that training. Q156 Charlotte Atkins: Who is making sure that the health authorities are performing equally well across the country? There has been a huge variation in the ability of strategic health authorities to perform. Sir Liam Donaldson: On medicine it is pretty standardised. There has been a major shift at both the undergraduate and postgraduate level to introduce more time in general practice and that is determined by national curricula. I do think there has been a massive change over the last ten years in medicine. As far as nursing is concerned I guess it would be more determined by local practice. Dr Colin-Thome: Yes. Q157 Charlotte Atkins: To be honest, I am not quite so interested in doctors and nurses; I am actually more interested in the overall workforce in the NHS because very often it is these people, certainly community nurses, but other staff as well within the NHS, the carers, people like that, who are the ones who have the most contact with the patient. Dr Colin-Thome: The training which some of the work people like allied health professionals, physiotherapists, have in hospitals is relevant to what we want in community settings. In the White Paper we have made quite a significant commitment to training programmes for carers, which we focused on earlier. I actually lead on the long-term conditions programme for the Department of Health and that is a significant part of our strategy because we recognise that most care is informal or self-care and both the patient who has the condition needs to be given more training programmes, which we are doing with things like the expert patient programmes and the diabetes programme, but also we need to be committed to carers. Professor Fryer: You are quite right that there is a whole range of people within the team and healthcare assistants form a very large group, a fast-growing group in the workforce --- Dr Colin-Thome: Including in primary care. Professor Fryer: As longevity increases and we know that not only is there a small proportion of the population which makes huge demands on the service, but actually it is age-related too in those last 10 years of life, healthcare assistants become very important and if you want evidence of what happens when you do not get it right, have a look at the research which was done on the Paris heat wave and the Chicago heat wave. Very often it was this level of skill and expertise and training that was lacking. I spoke early on very positively and I am feeling very positive about what the NHS is doing, but there is a lot more to do. The White Paper was extraordinarily honest. There is a sentence which the Secretary of State put in her recent White Paper, Our Health, Our Care, Our Say which said that sometimes we find that the least well-served communities in terms of healthcare are served by the least well-trained staff. We do need to do more. The obverse of me saying that 80% of the staff in the service are at level two or above - if I put it the other way round - is that we find that 28% are on level two or below. When the NHS staff survey, which is a very important source of information, suggests that up to one fifth of staff claim they receive no training at all, we all in this room know who they are without having to ask. We are doing well, there is this shift, healthcare assistants are an important component of that change and we need to do much more. Anything your Committee suggests that we need to do more for those staff will have me throwing my hat in the air. Dr Colin-Thome: If you are looking at chronic diseases, it is unfortunate more of us are getting these, but it is a vehicle for working better together, one of the things we are going to work on with not just with our secondary care colleagues but social care colleagues who have many of those skills we lack. This is not about a healthcare system on its own and long-term conditions management is the practical way that that can be demonstrated. Some of the most effective ways of not needing to admit people to hospital include having social care input. Q158 Sandra Gidley: You mentioned lurid headlines about wages and I want to bring you back to those. Whilst the press will always pick on the sensational, you cannot get away from the fact that there is a £250 million overspend on the GP contracts and they are figures supplied by the Department. Why did it go so wrong? Dr Colin-Thome: I do not know that it went wrong. Q159 Sandra Gidley: From the GPs' point of view it probably went exactly right. Dr Colin-Thome: The trouble is that the contract is quite unique, because it is the world's largest quality-based contract that anybody has attempted. What our trade union, the BMA, the Department and also our expert panel estimated - because we had no baseline data - was that we would hit about 75% of the quality points. Some people might say that we did better because it was too easy, but actually there has been quite a significant investment in people such as healthcare assistants and nurses. It is actually quite hard to get to 91%. There was enough money, given that PCTs have had a huge increase in their allocation. So they did have money to compensate for that, but we did overachieve and that is to our credit. If you look at things like chronic disease, which amounts to 50% of the points, we know that better care systems for people with chronic conditions will increase longevity as well as quality of life. There is a drive to do that. The other issue which is interesting is that it was not uniformly spread. Some PCTs actually balanced. Maybe they had made a better assessment, maybe they had baseline knowledge of what their GPs were doing but some managed to balance their books and not overspend. It is a global sum. The other interesting thing is that the overspend or underspend or whatever bore no correlation to the QOF scores. It was not as though the biggest overspenders were where the practices had the highest QOF scores. It is interesting that one of the issues we are trying to look at is how local health organisations, who are much more knowledgeable about local conditions, can make an assessment of both the needs of their communities, but also the capability and capacity in their local organisations. That is what the new PCTs will have to do in spades to have that knowledge. Wrong maybe, because it is hard often to allocate and to know exactly the monies you require, and you could equally argue that about out of hours care, but again there was huge variation in PCTs about how they spent their money, so in a global sense you might say we got it wrong, but it is local organisations which obviously have to have a better assessment. What is fantastic now is that the GP contract has given us that baseline and now that we are doing it with all that effort, we are going to try to make it a bit tougher so that it is about continuous improvement. Q160 Sandra Gidley: You say there is a baseline, but it is quite difficult to assess what more is being delivered because I have seen reports which say that what has actually happened is that the good GPs are just getting paid more for what they delivered anyway and with the GPs who perhaps needed the biggest kick the improvement has not been quite so great. Hospital episode statistics have been collected since 1987, but there are no parallel statistics for GP activity. Is anything being done to address this imbalance? Dr Colin-Thome: The quality and outcomes framework now does that. All we had were patient contacts, but now two things have come from the contract. One is that it is much easier to put this information on the computer, because it is really hard to track patients if you have paper-based records. One of the side benefits is that we have a fantastically better database of what patients have got wrong with them. That is number one to build up for the future. Two, we do have quite key markers now about the effectiveness of care. What the QOF people did, quality outcomes framework people did, including our expert panel, was look at process measures which were easy to measure because they would fit a contract, but which you know will lead to outcomes. That is why a lot of the clinical points were for things like diabetes and heart disease and stroke because we have better evidence that those measurements lead to better health outcomes. That is what they did. It was not that good doctors were not doing good things; it was that we managed to raise the level of all our patients rather than the variation because there was a more systematic --- Q161 Sandra Gidley: Would it not have been better to have had a year of base-lining to find out what was actually happening in practice so that you could actually see whether you were getting better value for money in the end? Dr Colin-Thome: In a scientific sense yes, but the real issue for us was that we were desperate to get more investment into primary care because the number of GPs' had remained flat for years and the number of consultants was growing. One of the negotiation points was how to get more money into primary care to make it a much more attractive career and that seems to be working in the early days and that certainly ought to work if you look at the same sort of event which happened in 1966 with the contract. The second thing is what we were determined not just to give lots of money but at least to try to link it with a quality based contract. In an ideal sense it would have been better, but on the other hand there is some urgency to invest more in primary care and that seems to be benefiting. It would not have been ideal, but often a negotiation contains a lot of different issues which you are trying to address and that was what we came up with. At least now we have this baseline. What we are going to do is introduce new facets and we do not have a baseline for that, but at least it is a start. Often people collect better data when they have some incentives to do so and that means that the database will be much tougher and more accurate. After all, we do get reviewed at practice level by our PCTs to check that we are not doing things correctly. In an ideal sense I would agree, but there was a whole package of reasons why we were investing more into general practice, not least the fact that since we have better outcomes and better effects for the health service from primary care we needed more people in primary care. Q162 Dr Naysmith: May I comment on something you said? You said that some PCTs in some parts of the country came in on budget and therefore they maybe estimated better what the cost of the contracts was going to be for PCTs, but actually what happened in the PCTs where that happened was that they postponed development and investment plans that they had planned for that year and they have now had to postpone them or give them up so they could come in on budget. That is what they tell me. Dr Colin-Thome: That is the job of a manager really: to manage that resource and set priorities. Q163 Dr Naysmith: Of course. All I am saying is that it was not because they estimated better what the contract was going to cost. Dr Colin-Thome: Some might have done, because they may have had a better shot at assessment. If you look at some of the personal medical services, PMS, 40% of GPs, the PCTs had a clear view, as a sort of exemplar, of what practices could achieve, because they had local contracts. You are right in some senses: you manage a budget by setting out the priorities and one of the biggest priorities for the best hit for your pound is actually investing in primary care. There is an international evidence base to back that. Q164 Dr Naysmith: I am not disagreeing with anything else you have said, that is the only bit you said that I disagree with. Dr Colin-Thome: That is what a manager does. If there are some issues you have to prioritise, you may have to delay others. Q165 Dr Naysmith: They had carefully budgeted for developments they intended to put in place this year and they could not do them because the contracts came in at slightly more than they expected. Dr Colin-Thome: Right; yes. Chairman: May I thank you all very much indeed. May I also thank you and some other organisations for contributing to our written evidence which has now been published and will be available for people to look at. We have had quite a long session this morning and thank you Andrew Foster particularly for being involved. Thank you all. This is the first public session of a very long inquiry which I hope will come out in a few months' time with some guidance in terms of where workforce planning should be going in healthcare in general; not just in terms of the National Health Service but where we all often need to have different forms of healthcare. Thanks again very much. Sorry about the lateness of the hour; these are becoming far too predictable now. [1] Note by witness: The consultant productivity data may be released later than May in order to be issued with other benchmark information currently in preparation [2] NHS Employers have subsequently submitted a correction to its written evidence on this point. The evidence should have stated that there are currently 12% more Foundation level medical training posts available than there are medical students graduating in the UK each year. If current trends continue, this figure will fall to 7% by 2008-09, increasing the risk of an overall oversupply of medical graduates. |