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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1077-iii House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
Thursday 8 June 2006 DR JONATHAN FIELDEN, MS KAREN JENNINGS and MR ALASTAIR HENDERSON PROFESSOR DAME CAROL BLACK, MR GEORGE BLAIR and DR KAREN BLOOR Evidence heard in Public Questions 271 - 391
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 8 June 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Anne Milton Dr Doug Naysmith Mike Penning Dr Howard Stoate Dr Richard Taylor ________________ Witnesses: Dr Jonathan Fielden, Deputy Chair of Consultants; Committee, British Medical Association, Ms Karen Jennings, Head of Health, Unison, and Mr Alastair Henderson, Deputy Director, NHS Employers, gave evidence. Q271 Chairman: Good morning. Could I welcome you to our third session in relation to our inquiry into workforce planning and ask you to introduce yourselves and your organisations for the record. Ms Jennings: Good morning everybody. My name is Karen Jennings and I am the National Secretary for Health in Unison. Unison is the largest trade union in the Health Service, representing over 450 staff right across the piece, other than doctors and dentists. Mr Henderson: I am Alastair Henderson. I am Deputy Director of NHS Employers, the employers' organisation for NHS Trusts. I am particularly responsible for pay and negotiations. Dr Fielden: I am Dr Jonathan Fielden, a consultant anaesthetist with an interest in intensive care medicine. I am Deputy Chairman of the Consultants' Committee of the BMA and also the Chairman of Negotiators. Q272 Chairman: Thank you for coming along. Mr Fielden, we are now paying our consultants a lot more as a result of the 2003 contract. Why have we not seen more improvements in return for this extra pay? Dr Fielden: I think you have seen improvements in return for the extra pay. The hours that consultants are doing are now properly rewarded and recognised. There are tools available within the contract to ensure that job planning allows consultant time to be focused for the best benefit of patients, and you have the tools to engage consultants at trust level in the objectives and direction that trusts need to go. There are other tools there. Some trusts - my own, for example, and there are many others around the country - are using it very well and very successfully. Others - and in an organisation as big as the NHS I suppose you would expect this - are not using those tools as well as appropriate. Those tools are there to be used and we are there to help them. Q273 Chairman: We were told by the Academy of Medical Royal Colleges that the short-term impact of the new consultant contract has been to reduce the productivity of the consultant workforce. You are saying, Mr Fielden, that that has not happened, certainly in some areas. Do you agree with that statement? Dr Fielden: I would not agree with the statement. Having said that, we would have to ask what you mean by productivity. You asked the Department what they meant and they came back with a whole range of productivity measures. I think the Department has to decide what measure of productivity it is talking about and then we can come back to answering that question. The contract was about recognising the workload that consultants did, appropriately remunerating it and giving the tools for engagement between employers and employees, and I think that is what the contract has done and will allow that relationship to develop. Q274 Chairman: Mr Henderson, do you have any comments on this? Mr Henderson: Yes, indeed. I think it is important, both with the consultant contract and the Agenda for Change, to recognise what they can and cannot deliver. The consultant contract is a contract of employment; Agenda for Change is a pay system. By themselves they do not result in improvements to services; they are tools to be used. As such, I think they can be tools that can either be a hindrance or a help to organisations making changes. I am pretty clear, both with the consultant contract and Agenda for Change, that compared to what we had before they are huge aids to organisations making changes. Specifically on the consultant contract, my colleague David Amos, who came to you a couple of weeks ago, described in what I think was quite a nice way that we now have a currency and a method for engaging with consultants that we did not have before, a currency with which we can talk about how their work is planned, how their work is delivered, and we can talk about how work needs to be changed, if it does. I think that is now beginning to happen in the NHS. Q275 Chairman: Andrew Foster, who I know has left the post, came here and he said to us that he believed a lot of organisations put more effort into simply getting people onto the new system than generating the benefits from it. Do you think, Mr Henderson, that the implementation of the contract was rushed? Mr Henderson: I do not know about being rushed. I think just on 90% of consultants are now on the new contract - and remember it was their choice to do that. I think it is important to recognise that it was not implemented in a uniform rate or manner across the NHS - and that is probably not surprising. I think it is true that to start with there was probably as much attention paid on the process of putting it in and the process of job planning rather than the content - and, again, that is not necessarily surprising. There was a huge amount of activity going on and the transactional job of getting the new contract in of itself was a major task and organisations did understandably concentrate on that to start with. In the second/third round of job planning, we are seeing organisations, now that the structure and the machinery is in place, concentrating on how you use the job plans, how you develop them. I think we are seeing more and more of that. Q276 Chairman: Are you saying, basically, that we are seeing more benefits from it now than we were with the initial implications? Mr Henderson: Absolutely. I think that is happening all the time. I think there is a range of examples of benefits and of ways that it has been used. There are a number of examples one can find of job plans that now have team job planning which provides cross-cover across various specialities. That has happened in anaesthesia, in paediatrics, in radiology. In Plymouth Hospital, I know they have introduced, through a contract, annualised hours and team job plans in their colorectal team. That has meant that they have now not had any cancellations of clinics due to consultants' annual leave (which was something that used to happen) and they have 100% utilisation of sessions. Bart's would tell you that their team job planning has helped them deliver their A&E targets. Hampshire Partnership Trust, as well, developed evening services there for consultants. That developed, over time, through better job planning, through better dialogue between consultants and managers to sit down and work out how they do that best. That is going to develop over time. Q277 Dr Naysmith: Dr Fielden, could I ask you a question to do with the negotiation stage of the contract. Andrew Foster told us last week that he wanted to run a pilot scheme but the BMA refused even to consider it. Is that true? Dr Fielden: My recollection is different: that the piloting was refused at higher level. Q278 Dr Naysmith: Higher level in the Department of Health? Dr Fielden: Yes, at either ministerial level or higher. Q279 Dr Naysmith: Why would Andrew Foster say that when he was in charge of the negotiation? Dr Fielden: I am not sure on that. From our position, we felt that there may or may not have been some benefit of piloting, but actually it was better to bring out the contracts across the board. To our recollection, we did not refuse piloting. Q280 Dr Naysmith: Would it be true to say you were not enthusiastic about having a pilot? Dr Fielden: I do not think we felt, on this particular aspect, that it was going to be the best way of bringing in this contract. There was a choice aspect, where the consultants went across to it, but job planning should have been done from 1991, so it was not a radical change. The increased clarity that was brought in with the contract was going to bring that in and then reward and recognise the hours and work the consultants were doing. Q281 Dr Naysmith: You are probably aware that there were job plans long before this new contract was agreed. Dr Fielden: Yes. Q282 Dr Naysmith: And we have had evidence before this Committee on many occasions that hospital administrators did not take up the question of job plans with consultants because they would know that they would be told where to go. That sort of thing has been said two or three times before the Committee. Might it not have been a good idea to see what effect the new contract would have on job planning before we actually agreed it? Dr Fielden: As I say, we did not feel there would be a substantial benefit of piloting in this particular example. Our recollection from the time is that piloting was also not something that was pushed centrally. I believe the issue of piloting ideas with doctors goes back even as far as Ken Clarke. It was felt that you would not pilot things because doctors would wreck things, and therefore you pushed things in. I would not agree with that, but we believe the pressure to pilot came from other sides. Mr Henderson: I was involved with Andrew in the consultant contract negotiations through both stages - an assortment of delightful BMI negotiations, phase 1 and phase 2 of them. We were keen to talk about piloting and it was something that we were not able to progress. It is not the easiest thing to do to get a pure pilot. That is a slight difference in some of the Agenda for Change piloting of new pay systems, with some of what was proposed there, but I think it was something that we did wish to explore. Q283 Dr Naysmith: Do you regret it not having happened? Mr Henderson: It might have been nice to have some sort of pilots, yes, though one of the important things about the contract that I think is most important is the potential cultural change that the contract implies. That takes place over time. That is always quite difficult to get in a three-month pilot. It might tell you something about how x payment system works, but you are probably unlikely to get information on what the cultural changes mean with the workforce. Q284 Dr Stoate: We are talking about very large sums of public money and we cannot even agree on who did and did not want a pilot. I am very concerned about what I am hearing. I would like to explore further Mr Henderson's statement earlier on in the session about gradually getting improvements and things sorted out with the new consultant contract and things gradually coming into place and seeing improvements over time, but we were told quite clearly by David Amos that rigorous job planning and objective setting are crucial to the end benefits of the contract. Should this not have been sorted out before the contract rather than hoping it would all come right a year or two afterwards? Mr Henderson: As was said, there should have been job planning in the NHS before. Frankly, I think it was very patchy. I do not think it is surprising that having a good and rigorous system of job planning and appraisal is something that develops. I do not think it does land fully formed in one go. It is something that you do on an annual basis and hopefully you get better at. I am not saying that you do not want it as good as possible first time round, but you do get better at it. Both managers and the doctors involved in the process will begin to understand the process better and will be given to understand how to get more benefits out of it. The fact that it is an improving process is unsurprising. Q285 Dr Stoate: I think the taxpayer has a right to know why, for example, a 49.4% pay rise between 2001 and 2005 for consultants was not backed with rigorous improvements in productivity and job planning before that very large sum of money was spent. Mr Henderson: As Jonathan has said, there is a whole series of measures on the success. I think that introducing what I have talked about - this new currency, this new dialogue for consultant - is a benefit that has been worthwhile. I think we have seen improvements in service and I think we have seen improvements in the management of consultants and the way that consultant time is managed, and that is going to take some time. Q286 Dr Stoate: But we cannot even agree on what productivity is. Sir Alan Craft has told us that he thought productivity would go down; Dr Fielden has told us he thinks productivity has gone up. All I do know for certain is that there are huge amounts of public money being spent. We do not seem to be getting very far in terms of even deciding what has happened and why. Mr Henderson: By what you measure productivity, yes, there is a whole series of things. There is, of course, straightforward output of consultants, which is a subject of considerable debate on which I know your advisers have some keen views as well. I was talking to Jonathan Michael, the Chief Executive at Guys and Thomas's, saying that the way he has been viewing that as an organisation is not just productivity in terms of throughput of operations, important though that is, and contact with patient time, but it is about also the use of consultants in their teaching, in their research, in their clinical audit and clinical governance. It is ensuring that the contract is used for full and getting all the benefits of that as well. That single productivity measure is then quite difficult to work out what you want. Q287 Dr Stoate: It is a very long answer but it does not really reassure me. Let me put a more straightforward question. When will job planning and objective setting be fully operational to improve productivity? Mr Henderson: I think it is. Job planning is fully in. It will continue, year on year, to continue more benefits. Q288 Dr Stoate: I am still not convinced that we have got very far. The money has gone in, job planning seems to have partly gone in and productivity possibly is improving - but we cannot even agree on that. I simply want to know when taxpayers can say, "We've got our value for money." Mr Henderson: Job planning is in. Job planning and objective setting is happening in every organisation. It is happening to different degrees of success, but it is getting better each year. I think the public can say they are seeing improvements from the consultant contract. Dr Stoate: Thank you. Q289 Anne Milton: Mr Henderson, I wonder if I could ask you to do the "man in the pub" test. Anybody reading this transcript - and I have some sympathy for what Dr Stoate was saying - would not understand a lot of the words you use. I wonder if you could explain what "currency and method for engaging consultants" means to the man in the pub. Is it surprising that it was not there before, really? Mr Henderson: Yes, it is surprising that it was not there before, but it has not been. The way that organisations engaged with consultants over the past has not been terribly ----- Q290 Anne Milton: Man in the pub, who does not talk about engaging. Mr Henderson: Fair enough. Q291 Anne Milton: I think it means something physical rather than intellectual. Mr Henderson: There has to be a proper way that trusts manage the work of their doctors, like they manage the work for all their other staff. That did not always happen in the past. This contract provides a better way of planning the use of consultants' time, so that what they do can tie in with what the local organisation wants, so it can deliver the best form of services for local patients that is most appropriate, so that we are using the consultants time most effectively and the best way to deliver services for patients. Q292 Anne Milton: So a management tool for encouraging - forcing if necessary, and I know you do not like that word - consultants to do what management wants them to do to produce better outcomes - I mean, I do not mean to be prejudicial - to produce better outcomes for patient care. Mr Henderson: Yes, indeed. Dr Fielden: It gives you the tools so they can have that discussion. Q293 Anne Milton: Tools, meaning? Dr Fielden: The framework. You have to sit down on at least an annual basis. You have the blocks of time, you have the objectives for supporting resources, the aspects to a discussion that you must go through to ensure that what a consultant is doing and when they are doing it is appropriately focused on what the trust needs for patients and what the current doctors feel they need for patients. One of the reasons that did not happen before is that the trusts were concerned that the closer they look, the more they realise consultants are doing. As we shared with you in previous sessions here, the hours that consultants were doing were substantially in excess of the old contract. They continue to be in excess of the new contract. The closer you look and the harder you try to force people to do things, the more they are likely to react and say, "Okay, you do not get this bit for free if you are not going to treat me like a professional." I think one of the reasons the trusts avoided it for so long is that they realised what a huge amount was going on - and the closer you look you reveal even more. Anne Milton: Thank you. Q294 Dr Taylor: Back to productivity. We have really only talked about activity, which is the easy part of productivity to measure. We can easily measure FCEs, the outpatient scene, but what about health outcomes? What measures are there to include a measure of health outcomes in these contracts? Dr Fielden: I think it varies a lot between trusts and the amount of data they are actually using. We would certainly advocate, and we are advocating in the information we put out to consultants and into the public domain, "You should be including all aspects of how best to improve care for patients as part of the information that informs your job planning process." Let me take an example of myself in intensive care. There is clear evidence of the benefit of patient outcome of having more consultant time on the floor in the intensive care unit throughout the day and into the evening and night. That presence improves the quality of care and outcome for patients in intensive care. My job plan now allows us to focus more consultant time in intensive care for those patients and we are seeing benefits in the improved care of patients going through our unit. Similarly, in A&E. Q295 Dr Taylor: What are your measures of outcome coming out of the ITU? Dr Fielden: Survival. In intensive care terms, survival. Q296 Dr Taylor: So that is easy. Dr Fielden: You can then map it in. You can then, if you like, look at quality of care outcome as well. We have managed to ensure that our follow-up clinic in intensive care is properly focused within a job plan, so that we can make sure the morbidity aspects related to intensive care are also looked into. We have examples around the country, in obstetrics and paediatrics in Plymouth, where they focus their emergency work into a week. That allows separation of the emergency/elective workload, which, as Alastair has already mentioned, means you get less cancellation of elective work but also a greater fully-trained presence, like consultants, in for emergencies, which improves outcome. There are multiple examples of that. If you are measuring just fixed consultant episodes going through in cardiac surgery, for example, they are going to go down because our radiologists have got particularly clever at boring out arteries, so the number going through is going to go down. If I am a cardiologist, the more patients that I put on beta-blockers, ACE inhibitors and otherwise, the fewer should be coming back to my clinic, so my productivity is going down but my health outcomes are going up. I think you have to throw the productivity question back to them. If I may come back to Howard State's comment about a 49% increase, I think that is an interesting figure to quote because the hours in the contract went up from 35 to 40 for the base hours and there was a small rise associated with that. The majority of the increase in that period of time was because you are paying for the extra hours that are being worked. Most consultants are being paid now for about 44/45 hours of work, which means that trusts can guarantee and decide on which hours they want to be done and focus that for patients, rather than it not being paid for and then maybe or maybe not being done. So the majority of that increase is, if you like, paid-for overtime. Q297 Dr Stoate: This was in a report from the King's Fund. They said consultants' basic pay rose by 49.4% between 2001 and 2005. That is not from us, it is not from Government. That is from the King's Fund. Dr Fielden: The King's Fund report was limited to five trusts in London. Everyone pretty much recognises it is a very limited report. Those figures focused on the early years. The biggest pay rise in the contract was for consultants in the first few years. That is partly a recruitment measure and partly a factor that junior doctors' salaries had increased and therefore there was a need to increase consultants' salaries, otherwise you would have juniors taking a drop in salary before they went in to taking much more responsibility. That was an appropriate increase. If that increase was high, the increase at the end, to retain doctors, was higher. In the middle, it was about 4.5% or 5%, if you look at it, until you add on the additional paid overtime. The King's Fund report was fairly choosy with how it picked its figures because I think it gave them the headline to give them the publicity they wanted. Chairman: We are going to move on to the Agenda for Change. Q298 Mike Penning: I will speak to my friends from Unison, who must have felt a bit left out for the last ten minutes or so. The Committee has heard that about 4.5% of staff so far have moved on to Agenda for Change contracts on protected pay. Is that a figure which you understand is correct? Ms Jennings: That is a figure which we would support. It has been produced through partnership with the Department of Health. It is a figure which is rather supported - in terms of, we were expecting a larger number to be on protected pay. As a result of developing better job profiles, we have been able to reduce that figure down to 4.5%. Q299 Mike Penning: Which are the areas of professional expertise which have been most affected by this? Many of us have been written to, in my case by the pharmacy profession and senior nurses. Are there other areas which have been affected dramatically by this? Ms Jennings: I think the group that has been affected most by this is the admin and clerical sector, medical secretaries and so on. I think they have begun to improve in the bandings that they have achieved as a result of looking at better job development programmes and the profiling of them. Q300 Mike Penning: Is that because of the difficulty in looking at their job descriptions and fitting into certain bands, or is it just because of the way that admin in the NHS has expanded so much over the years and we do not quite know what pay they should be on? Ms Jennings: I think it is a combination. Also I think the panels that were implementing and assimilating the staff needed additional advice and information about where to place those staff, so that they were not demonstrating any bias towards clinical staff and therefore not fully understanding the role of the admin and clerical staff. Q301 Mike Penning: Are Unison happy with the way the appeals procedure is working for those who have suffered? I have had correspondence from constituents whose pay has dropped. Is the appeals procedure working well or are there teething problems there as well? Ms Jennings: It appears to be working well at the moment. We are not getting complaints through. Because it is done in partnership, I certainly think that the mechanisms for appeal are much better than they were under the previous pay and grading system, the clinical trading structure. I think we have learned a great deal about how to work in partnership and to ensure that there is a fairer process in place. Q302 Mike Penning: Mr Henderson, from the employers' side. Mr Henderson: The protection is less than was first thought. It is important to remember that protection does ensure that nobody's pay drops at all. I mean, it may stand still but it does not drop. I think Karen is right, our view is that probably the majority where protection is, is in admin and clerical roles. Q303 Mike Penning: And a 4.5% is something that you see as well? We have heard slightly higher figures, so I am interesting in confirming what you think. Mr Henderson: Yes, I think that is about the figures that I am picking up. The estimation was that it could be up to 9%, but I think it is less than that. It is running at around 4.5%. Q304 Dr Taylor: The people who have been in touch with me have been people in the more senior grades. Is it fair to say that they would mostly, if we are talking about nursing, be in the RCN rather than in Unison. I am talking about nurse consultants, nurse specialists. A large number of those I think are on standstill, which is quite hard. I know it is not as bad as a pay reduction but it is quite hard when your pay suddenly sticks and other people, who are probably doing not much more than you, are on an increasing range. Ms Jennings: Unison represents a broad family, including senior nursing staff. We have 240,000 members. I think the important thing to remember is that Agenda for Change is about an equal value pay system and it has a rigorous process of determining where individuals are assimilated to. Our evidence is not necessarily that senior nurses are suffering more than other groups of staff. Q305 Dr Taylor: Those who are being made to standstill were probably being paid too much before, is that what you are saying? Ms Jennings: No, I have not said that. I think if they are standing still then they have been properly evaluated and are being paid what they should have been paid. Q306 Dr Taylor: Do you have physios and occupational therapists? Ms Jennings: We have occupational therapists. Q307 Dr Taylor: Have they been affected? Ms Jennings: Occupational therapists have, indeed, been affected. In our submission to the Pay Review Body evidence, we are concerned that the recruitment and retention of occupational therapists is very worrying - in fact, I think they are the second largest occupational group that continue to have major shortages. There are some concerns for highly skilled technical staff to go on to gain access to education and training on occupational therapy. We believe it would be helpful, in that case ,if recruitment and retention premia were utilised to enable better recruitment of occupational therapists, because they do not feel they have done as well out of Agenda for Change as other comparable groups. Q308 Dr Taylor: Is it, again, the more senior occupational therapists who feel hardly done by? Ms Jennings: I think it is across. Q309 Dr Taylor: I think Mike mentioned pharmacy. What about pathology, the path lab technicians - the medical laboratory scientific staff? Ms Jennings: I think there is still a lot of work to be done on their job profiles. It is a continuing process, looking at the job evaluation scheme and developing profiles for those particular schemes. We are trying to look at a family of job descriptions and profiles which will enable a better career development and better career structure for those groups. Q310 Chairman: Is there any evidence at all, both Karen Jennings and Alastair Henderson, that Agenda for Change has been used for cutting costs in any trusts that may not have spending problems? Mr Henderson: Not that I have seen at all. I am not sure how, particularly, it might be. There has been a rigorous process of job evaluation, of putting people on to new schemes. I have not heard that as a complaint. Ms Jennings: I think it is a very interesting question and it is certainly something that was used in previous pay systems to depress the grades that existed. Generally speaking, that has not been the case. However, I think there has been some industrial strife in the ambulance service, in particular, where it has been felt that a blanket grading of certain staff has been brought in to depress costs and we are trying to look at mechanisms to overcome that. I think that is a claim that could be made there. Q311 Chairman: Mr Henderson, do you want to add to that. Mr Henderson: I think there have been some anxieties for ambulance staff to have. It is slightly ironic that ambulance staff overall have done particularly well out of Agenda for Change. Often in a pay reform it is a comparative evaluation, that you may have done well but you perhaps did less well than you thought you ought to have done. With the allied health professionals, it is an average £3,500 gain that people were making, and, with nurses, over £4,000 around each of the grades was the average gain that was being made. Q312 Chairman: On the issue of Foundation Trusts, I think in theory they do not have to endorse or take on board Agenda for Change. Do you feel there is any threat that that may happen at some stage in the future? Ms Jennings: When the Foundation Trusts first came into being, clearly Alan Milburn was making promises that in the Foundation Trusts' five-year business plan they would have to include Agenda for Change. It is not clear that that has to be the case with subsequent secretaries of state. It certainly is not a requirement within the legislation. Of course the regulatory body for Foundation Trusts does not have a mandate over pay and terms and conditions of service. We do have concerns about the future of the continuing of Agenda for Change in national bargaining as the roll-out of Foundation Trust Hospitals takes hold. We have tried to have meetings with the Foundation Trusts' network, to no avail because they do not want to meet on a collective basis. That sends early alarm bells in our collective heads around the future of collective responsibility around pay and negotiations, and we have examples of some trusts which are departing already from pay and terms and conditions of service, particularly, for example, around admin and clerical staff. That is happening in London in some Foundation Trust Hospitals where they are having some difficulty recruiting and retaining their staff. Q313 Dr Stoate: If we are moving towards all hospitals being Foundation Hospitals by 2008, which is the Government's stated aim, then surely Agenda for Change is theoretically dead, so why bother with it? If all hospitals become Foundation Hospitals and Foundation Hospitals do not have to stick to Agenda for Change, then what is the point of Agenda for Change? Ms Jennings: The experience under the Thatcher years was that when trusts were legally allowed to set their own pay and terms and conditions of service, the vast majority did stick with the national terms and conditions of service because it made huge sense not to replicate that negotiating at a local level. But I do think we did see at that time some maverick trusts and renegade trusts which did move away. If that begins to happen, particularly as it becomes more and more competitive, we are going to see, I think, more industrial relations problems and differences between staff and how they are trained. Mr Henderson: I think Foundation Trusts but all other organisations have the right to do different terms and conditions and they are legally allowed to. I think Karen is right, Agenda for Change does provide a framework, and an attractive framework, but it does provide an awful lot of flexibilities as well. That was all part of the purpose. I do not see at the moment much due from foundation or other trusts to want to do it because they have a system that they can use. Also, it is not the best use of everybody's time to reinvent wheels if there is a good framework there. Q314 Charlotte Atkins: Moving on to the new Knowledge and Skills Framework provided by Agenda for Change, we have had glowing reports from various witnesses. Is it really as good as it seems? I see from the Unison evidence that you are calling for the ring-fencing of learning and skills budgets, so clearly you do have some concerns about the whole training agenda. Ms Jennings: Thank you for that question. The Knowledge and Skills Framework is like the jewel in the crown of Agenda for Change. It is inspirational, in the sense that, for the first time, all staff in the NHS - from porter right through to consultant and chief executive - have the right to access to education and training. Alarmingly, in the Healthcare Commission's report it indicated that less people this year had professional development plans than last year, so something is going wrong in terms of that access assessments in relation to their education and training. Also, because of the trust debt situation, I know we have had alarming headlines about redundancies and job cuts, but, when a trust does that, it goes through the whole system of what you can cut elsewhere. So there is a whole range of other mechanisms to save money before you then announce, as well as that, staff redundancies, and the big chop is in education and training, without a doubt. We are seeing that right across the country. In fact, we have a letter from I think the South West Strategic Health Authority that has written to all trusts saying there will be no money for NVQ training, there will be no money for seconding healthcare assistants, there will be no money for post-registration training - and we are talking about a large number of trusts. In fact I have the letter here, so you are very welcome to see that, but it is saying that there will be no cash allocation to trusts, there will be no new healthcare assistant secondments, there will be no new full-time AHP secondments, there will be no funding for seconding registration students, there will be no funding for EN conversion, there will be no NVQ funding. If you look at where staff are being developed at the moment, where the biggest growth is, where the richest pool for recruitment into professional education and training is, it is healthcare assistants. Unison's own healthcare assistants' surveys have repeatedly shown that 80-90% of healthcare assistants want to gain access to education and training, want to develop themselves to a high level, and want to go on to do nursing, occupational therapy, or whatever it is, ambulance paramedic training. We are going to cut that source of potential recruitment which is key to the modernisation of the NHS - absolutely key - if we have nurses that are shifting up and up-skilling and therefore needing more hands-on staff. Could I mention, on this skill-mix element, that the commissioners of education and training are very tunnelled in their vision about where to access education and training from. There are no universities that provide part-time registration training. Now, do you not think that is bonkers? In a time when the average age of a student nurse is 29 years of age, has children, how on earth can they last on a course that is full-time? We would like to see - which is something Unison has developed with the Open University and NHS Professionals - a true skills' escalator, where you are providing education and training to healthcare assistants, enabling them to gain access to pre-registration programmes and going on part-time courses - and you find that the attrition rate is way in excess in full-time courses than part-time courses. We have to ask Strategic Health Authorities, who commission the education and training, to start to open up their eyes to better opportunities for that. It is much more cost-effective. Just think about the money you are losing all the time. Q315 Charlotte Atkins: Presumably you have put this to the Department of Health, have you? Ms Jennings: We have put this to the Department of Health. Q316 Charlotte Atkins: What sort of response have you had? Ms Jennings: I wrote to Patricia Hewitt earlier in the year expressing my concerns about the potential lack of money for education and training and the answer that I had to that was that they had not set the budget yet. We have made numerous approaches to the Department of Health about looking at widening the opportunity and the access for pre-registration training and to look to develop part-time courses. There is a bit of a stranglehold, I think, between the Commission in this and the higher education institutions. Q317 Charlotte Atkins: Are the NHS Employers very much in favour of the Unison approach here? Presumably it would increase productivity if you can train the existing workforce to take on more responsible roles, as encouraged by Agenda for Change, rather than taking people in who might decide health is not really their thing and they will leave and hence you waste all that time. Mr Henderson: Absolutely. That is a core part of Agenda for Change since we started. That is a core part of the KSF and there are good examples of that. In Dartford and Gravesham there is an example of a ward administrator who has taken on more roles, in terms of admission of patients, and is doing that. Developing those people - and Karen is absolutely right, those people who work in the NHS normally want to get on and move on - is an entirely sensible thing to do. I think KSF will be a real benefit in doing that. Q318 Charlotte Atkins: One thing that the Committee is a bit concerned about is that the Knowledge and Skills Framework has not been implemented until after the job evaluation. Were there any other approaches considered rather than just doing that process whereby job evaluation happens first and then the Skills Framework? Surely, the Skills Framework and the training element of it should have been put in much earlier. Mr Henderson: I think it is. I think we now have about 85% of KSF outlines, about 55% of full KSF. My understanding is that it was really just in part practical terms that you could not have done that before. There is a cycle for the KSF which starts coming in from this October. The task of implementing the whole new job evaluation pay system was pretty hard. I am not sure whether it would have been possible to do it altogether, but it is now coming in. Q319 Charlotte Atkins: Clearly, this is key to productivity. Mr Henderson: Absolutely. Q320 Charlotte Atkins: The idea that somehow this is constrained by budget seems to me a false economy. Mr Henderson: As you will know, there are a number of organisations who have severe financial difficulties. I am not sure that in those positions there is necessarily any one particular bit of the budget that has to be per se immune if there are savings to be made. But I would quite agree with you, and I think most trusts would agree, that it is clearly short-sighted in the long term to take money out of the training, but that is not going to happen with the KSF. Q321 Charlotte Atkins: Have we not heard earlier that huge amounts of money have gone into staffing, and, whatever level of staff, we are fearful that we are just not getting the productivity gains that we should be getting out of the vast sums of money that have been rightly invested in staff. Surely it is a very, short-term expedient then to start cutting the training, which is absolutely vital if we are going to get the true productivity gains out of our investment. Mr Henderson: One trust, I think Central Cheshire Primary Care Trust, has told us that one of the things, interestingly, the KSF has allowed them to do is to make better use of their training resource budget. Perhaps in the past it was slightly random and training went to some of those who maybe put their hand up and seemed very keen on it rather than necessarily those at whom it was most directed. The KSF, this PCT tells us, has allowed them to work out where the best need is and they have said it has made better use of their training budgets there. Q322 Charlotte Atkins: But are they also cutting the overall budget? Mr Henderson: I have no idea about that particular organisation. Q323 Charlotte Atkins: The important thing is - and I would hope the employers are going to make very strong representations to acute trusts and to PCTs - that training should be absolutely key here. We are going to get the productivity gains that the Government and we as consumers of the Health Service have a right to expect. Mr Henderson: I think that is right. Remember, the NHS's training budget is absolutely vast and still huge sums are being put into that. We are just saying that I am not sure individual organisations would support ring-fencing budget A or budget B, because there are equal calls for a particular cancer budget or whatever. There has to be then some flexibility, and clearly no trust is going to want to cut off its nose to spite its face by cutting back training, but, if you are making financial savings, you have to have flexibilities of where to use them. Q324 Charlotte Atkins: Training is just seen as an easy pot, is it not, to cut? Mr Henderson: Not just in the Health Service but across organisations, that has been the case. I am not sure that is the case in every organisation. I think there is increasing recognition of the importance of that, but I am saying that there are organisations that would not want, if they are having to balance their books, their hands tied precisely about where they do that. Ms Jennings: I wonder if I may introduce that there are major, major reforms. It is a continuous process in the NHS, as we know, but with our health, our care, our say and the migration of the workforce from secondary care into primary care, we are going to need to see a step up in the investment in education and training. Also, with the demographics that face us, we are going to have to make sure that we have enough staff in the NHS to keep going. We have a third of the nursing workforce due to retire in the next five to ten years and where are we going to get them from if we do not start to grow our own. As I said earlier, we need to make sure that we do not disillusion those healthcare assistants, those who cannot get any access to education and training. They have that glass ceiling at NVQ Level 2, and yet there are all these amazing developments that they are getting involved in now. And it is not just healthcare assistants who support nurses: you have physiotherapy support workers, occupational therapy support workers and speech therapy support workers - all of them working in the community to get older people out of hospital - who require education and training. They can go on to assist those professionals, such as the occupational therapists that we spoke about earlier, going on to grow that workforce. It is absolutely crucial, if we are going to have that world-class healthcare service that we keep talking about. Q325 Chairman: Would you leave us that letter that you have there. Ms Jennings: Yes. Absolutely. Q326 Dr Taylor: I would like to congratulate Karen on her tremendous defence of the healthcare assistants and the training, and to wonder if this sudden cut in the training budget is anything due to the Government's deficits and its attempt to minimise the deficits. Ms Jennings: Dr Taylor, I think it is to do with that. Q327 Dr Taylor: That is where they found the money. Ms Jennings: We have one third of trusts which are in debt. One third of NHS Trusts that we know are in debt. As I believe I said earlier, when you make cuts and announce redundancies, that is the last measure. There will have been a whole raft of other measures put in place to save money. Under education budgets - we know from hearing that from our members - KSF is becoming an almost impossibility. Q328 Mr Amess: Let us not quote my namesake any more. Unison said that Agenda for Change "... has fostered a partnership between Health Service managers and employees" and everyone thinks this new partnership is wonderful. I would be delighted if someone would quickly tell me when I have finished what we mean by "this partnership". Obviously when people are given more money they are absolutely delighted. Look at Members of Parliament: we are all delighted when we get our extra little bit of money, so we are all bound to say this is fantastic. But, in reality, it would appear that the Government now feels that this has been rather an expensive arrangement in hindsight. What do the Panel think about that? Ms Jennings: I think there are some extraordinary examples of partnership - from even before Agenda for Change came into being. If I may give you an example of the London Ambulance Service. That was a service that was on its knees and it was about to be disaggregated, disbanded and reorganised elsewhere. A visionary chief executive and a visionary branch secretary came together and provided the solutions for the London Ambulance Service. They were then at the cutting edge of how an ambulance service should model itself. They introduced appropriate responses; in other words, technicians, paramedics, going out on bicycles, motorbikes, cars and, indeed, helicopters - you did not need to go out in an ambulance truck every time - and also a range of different skill mixes, so you do have the ambulance technicians, you do have the paramedics, you do have the researchers. The benefit realisation is that there are good industrial relations - because it was appalling before that - and response times were improved upon and came in under what the response time targets were. You now have the reconfiguration of the ambulance service based on that incredible model of partnership. Again, this is an ambulance service that has worked through Agenda for Change fairly peacefully as well. There are many, many other examples of partnership that I can give you. Clearly, when you come up against a situation where there are deficits and difficulties, I think it is incumbent upon the chief executives and the board to work with the trade unions to ensure that they find joint solutions to it. What is unacceptable is when there are announcements about redundancies and job freezes and they have not spoken to the branch about it. I think the Department of Health did not demonstrate itself very well as a role model for partnership last year when it parachuted in the reconfiguration of Primary Care Trusts and Strategic Health Authorities. I think they have recognised and apologised for that and have attempted to move on to make sure that there is closer collaboration and information. We want to see a lot more consultation out of the Department of Health before decisions are taken and we hope that we will move on from that position. Mr Henderson: If you think that introducing a pay reform unit brings benefits, brings everybody rushing out in gratitude, please let me put you right on that. What I think we mean by the partnership that really has worked well for Agenda for Change, and I think, in large places, with the consultant contract implementation as well, is with management and staff representatives genuinely tackling problems and the issue together, and finding that it is in their benefit to seek a solution together rather than have what may have been rather more adversarial approaches before. In another example from the example Karen used of the Ambulance Service, the National Blood Service, the Blood Authority, which had a history of pretty poor relations, has introduced Agenda for Change on a joint basis that has improved things for the staff and has improved the service enormously. When we talk about that, I think it is about cooperation, behaving as grown-ups, to address problems together. I think you are right, that it is easier to do that when you are doing something nice. It is more of a challenge when you are doing something less nice, like potential workforce reductions. I think that will be a test, but I am confident that in a number of places relations that have developed will mean that those are addressed on a "nobody wants to do that" basis but will be dealt with jointly and on a grown-up basis. Behaving as a grown-up, I think, is what partnership is about. Q329 Mr Amess: Some vicious attacks have been made upon the consultants. They are not all playing golf on the golf course, are they, Richard? That is an unfair caricature, so can we have your version. Dr Fielden: I think it has always been an unfair caricature. Without a doubt, there is clear evidence of the huge amount of work consultants deliver for patients within the NHS. Partnership, I think, has been aided by the consultant contract substantially. The tools are there for that adult and often difficult discussion. I think we are seeing the number of programmed activities for consultants now being focused down, the overall numbers coming down, so that they really are focused on the hours that are needed for patient care. In trusts where the trust management are working in partnership with their consultants, you see dramatic improvement. My own trust has gone from deficit last year to predicted surplus this year. That is because we worked very closely with our senior managers and the consultant body, through improving our A&E to deliver all the A&E targets 98% of the time; bringing in a clinical decision unit that has dramatically changed emergency medicine; improving intensive care; separating the elective and emergency workloads - so that we can really focus the skills that we have to where the patients need it. That works where you have partnership. Unfortunately, that partnership is often put under stress by often centrally driven, short-term financial measures. Where that partnership is then fractured, you have organisations that continue to fail and they cannot address those difficult decisions. The consultant contract, in particular, does give you the tools to do that, but very often centrally driven short-term measures mean that that partnership is fractured. Ms Jennings: As we increasingly move into situations where there are retrenchment measures taking place within trusts, some of our branches are telling us that they are starting to lose their facility time and time off to be able to do the necessary trade union activities to participate fully in partnership. I think it would be helpful for the Committee to think about that and to make comment on that, because if we want to continue with an NHS that celebrates the partnership that it has and the relative industrial peace that it has, we need to make sure that there is proper trade union time and facility time for them to participate in the activity. Q330 Mr Amess: Although it is tempting, I must not prolong this session. I think the answer was that you think the money that you have is reasonable. As you know, we are having an inquiry into deficits and these things can be teased out there. Specifically to Unison, given that you welcome this spirit of partnership: Do you think what is happening at the moment with jobs being lost is going to sell this? Ms Jennings: Thank you for the opportunity to come back in again. Since the NHS ten-year plan, the NHS has made great strides on investing in the workforce, on the human resources agenda, on very valuable equal pay system. I think it has set the standard for all others to follow. I think the more recent reforms are very worrying in terms of the unravelling of that cohesion of the NHS. I do believe that the trust debt situation is going to impact badly, but I think the trust reforms more than the existing debts at the moment are going to have a great impact. On the outsourcing of services, the supply of services, the outsourcing of community services, although we have had a retraction of the statement from the Department of Health that all PCTs will divest themselves, it is quite clear that the direction of travel remains the same and there appears to be a favouring of the private sector, influencing the development of the private sector. It is that which concerns us in relation to the harmony of the NHS, the solidarity across the NHS, and also we do not think it is cost-effective or cost-efficient. I think a lot will be undone in terms of the national bargaining and the human resources agenda in relation to that. Q331 Mr Amess: Finally you got the money, you got it quickly, but there is the impression that the changes which the Government wanted to working practices has not been entirely secured. Is that unfair? Mr Henderson: No, I do not think it is unfair. As you described, it is changes to working practices and culture, and changes to working practices and culture do not happen overnight, nor can we expect them to. There are more and more examples of these benefits coming through. That tap is going to come more and more on stream, to mix a few metaphors. Ms Jennings: There are more changes than are being reported and I do not think enough is being done to measure the benefits of those changes. Alastair mentioned earlier, for example, the NHS Blood Service which has made huge changes in terms of benefits realisation. It is now a 24 hour, seven day a week service. It has improved its recruitment of transport services to such an extent that the service no longer has to rely on couriers and that has saved them £2 million. Who is talking about that? Who is talking about those savings that are going on? If you look at what Primary Care Trusts are doing in relation to developing skill mixes, bringing in support staff to work with district nurses, occupational therapists, and so on, they are keeping people out of hospital longer and those benefits are not being measured in terms of costs. That really does need to offset some of the other concerns we have around productivity and the overspends in some Trusts. Q332 Mr Amess: Are the consultants going to do what the Government want them to do? Dr Fielden: The consultants are focused on what they need to do for patients. If what the Government wishes to do is in line with what patients need, and that increasingly is focused on a local level, then those two visions are aligned. Coming back to the contract, I think that does give the tools to ensure that at local level the Trusts and consultants can ensure they deliver for patients in the most appropriate and value for money way. Unfortunately sometimes Government whim and short-term policy changes mean we cannot do that and it gets in the way. Mr Amess: We have three splendid advocates for their cases. Chairman: Could I thank all of you for coming along this morning and helping us with this particular session. We are now going to move on. Witnesses: Professor Dame Carol Black, President, Royal College of Physicians; Mr George Blair, Managing Consultant, Shared Solutions Consulting; and Dr Karen Bloor, Senior Research Fellow, University of York, gave evidence. Q333 Chairman: First of all, could I thank you for coming along and helping us with this inquiry. This is our third session today and I know some of you have caught the flavour of the last session we have just finished. Could I ask, for the sake of the record, that you introduce yourselves and your organisations. Professor Dame Carol Black: I am Carol Black, currently President of the Royal College of Physicians. I am also a rheumatologist and work at the Royal Free Hospital. Dr Bloor: I am Karen Bloor, a Senior Research Fellow at the University of York in the Department of Health Sciences. I am also a non-executive director on Selby and York Primary Care Trust. Mr Blair: I am George Blair, Managing Consultant at Shared Solutions Consulting. I am also a director of the HR Society, which is an interest group with special interest in workforce planning where I have spent much of my working career. Q334 Chairman: Once again, thank you for coming along and helping us. Could I begin by asking a question to all of you. The think tank Reform has argued that if the NHS focuses on improving productivity then it will be able to the reduce the size of its workforce by 10%, describing this as a realistic medium-term outcome. Is this a credible or desirable scenario? Professor Dame Carol Black: Thank you for that interesting question. Could we reduce the workforce? If we did increase productivity, and it depends how you define productivity and I would put into that not just efficiency but quality which is very important, then you may certainly be able to reduce it a little. If you bear in mind the other counter-factors, for example the European Working Time Directive, you are going to have people working a shorter time, consultants and well as doctors in training, so you are going to need a workforce to cope with that. Patients' needs are increasing so you have to balance that. We have an ageing population. We seem to be also increasing the diseases which come from our own behaviour, such as obesity, poor sexual health, and excessive alcohol consumption. If you balance these things, if you factor in that you would like to improve quality and you wish to meet the needs of patients, I am not at all convinced that you are going to reduce the workforce requirement spread across the different health care professionals by a great amount. Dr Bloor: I looked at the Reform Report and it was an interesting report and had some useful points to make, but at times it lacked a really clear evidence base. Q335 Chairman: It was more theoretical. Dr Bloor: Yes, I think so. That 10% seems to be a rather ambitious target. The NHS, and healthcare in general, is a labour-intensive industry; it is about caring, and it is always going to be difficult to make the level of productivity improvements that would generate that kind of staff saving, particularly in the context of some of the demand factors that Carol mentioned. Mr Blair: Across the board 10% to me sounds very much like the approach that everybody has to make 10% across the board savings this year, when there are certain areas that can make substantially more than 10% savings with the right sort of investment and other areas where there is much, much less scope for doing so. I think a more interesting question would be what is the scope to increase productivity and what timescale and what sort of investment is needed. In some areas there is considerable scope, particularly where technology changes. If technological changes are properly anticipated and planned for, and organisational structures are changed, then you can make much more in those areas. There are some good points made about other areas which are inherently labour intensive. For instance, a district nurse visiting an old person in their home perhaps a 10% saving in their time may not be a good idea. Q336 Anne Milton: To come on to what you said that this is just about saving money, it is a rather theoretical look at different ways of treating the workforce. The idea that you put more investment in fewer people, I would be interested to hear your views. What we are talking about is working smarter. You are right, Dr Bloor, that the NHS is about caring but that is not just about numbers. There is a sense that we all run around doing lots of activity but not necessarily achieving very much, therefore if you invest in your workforce and get them to work smarter maybe you could reduce the workforce. Mr Blair: Let us be specific. If we look at pathology, there are huge changes there with capital investment. The non-urgent work could go to big centralised automated laboratories and save a huge amount, so that is an area where much more could be achieved and that is an example of working smarter. I am very keen on that notion of working smarter in those sort of specific areas. The other thing about working smarter, the NHS drowns in data but it has very little information. By information I mean information, and particularly for clinicians, which is there in one document which pulls things together. I would argue the most useful thing, if we are talking about productivity, is to involve clinicians in it. The earlier discussions were about you have had the money, have you delivered. I think there is another question, how do we encourage you. Clinicians are very keen to improve the quality of care. Let us have quality of care indices included, and that would involve clinicians a lot more. Quality can also impact on costs through hospital acquired infections. In order to support your view about working smarter, I would say it is crucial that information needs to be presented very much better, and its for clinicians because they are the ones who effectively will deliver productivity. If it is other organisations pointing out to naughty boys and girls, perhaps that is needed to some extent but that is not going to motivate anybody. I am very much in favour of what is called elsewhere a dashboard of key indicators, so that in one document a whole range things to do with throughput, quality of care and quality of patient experience are there on the wall for clinicians and they monitor it themselves. That would be the sign of success. That is what, for instance, in terms of working smarter, Toyota have been brilliant at. They are the world leader in terms of improving productivity because they get their staff to monitor what they do over a wide range of activities and drive down waste. We need to present this in a way which is meaningful for clinicians not just meaningful for management consultants. Dr Bloor: I think your question was more investment in fewer people. Q337 Anne Milton: That is right, but feel free to expand. Dr Bloor: That statement lacks a real evidence base. As George says, there are some areas of the Health Service where that might be the case. There is some quite interesting research evidence from the States that looks at the appropriate level of training of nurses and whether a more highly trained nurse gets clear patient outcomes, reduced mortality, reduced readmissions, reduced unnecessary complications, that kind of thing, so there is some evidence that better trained people, even fewer better trained people, can be more effective than increasing the number of people. There is some evidence that contributes to that, but in general to say more investment in fewer people across the Health Service is a bit of a sweeping generalisation. Q338 Anne Milton: It is a very big statement, but what you would suggest, if I summarise, is more work needs to be done and there is early evidence to say that might be worth it. Dr Bloor: I am a researcher or I would say that. Professor Dame Carol Black: I will restrict myself to talking about doctors working smarter if that is what you ask. It would be difficult to think how you would change, at the moment, the hours they are working. If you are saying we will have fewer doctors but make them work longer hours, certainly for physicians they are already working about 59 hours a week so you could not really have fewer of them working longer. The things that would be extremely helpful, for example, would be if we could separate more appropriately acute admissions and our more elective work because most of us are schizophrenically trying to do two things. We try to look after the ever increasing acute medical take, and we are trying to do out-patient work, endoscopies, et cetera. That means you are trying to do two jobs so you are probably not terribly smart at either. If we do develop this speciality of acute medicine appropriately, then that would help us be smarter. We would be smarter in our work if we had our diagnostics better arranged, if we did not have to stop at 5 o'clock being able to get a CT scan, for example. It would also be an enormous help if there had been some systems reform before we did all the other things like introduce a consultant contract. In fact, the system had not been reformed so consultants were paid more money but in a system which would not support more efficient working. The final point I would like to make is about data, which has been brought out before. Doctors are really interested in data that relates to outcome and are not interested in data for data's sake. If you want us to work smarter and you want to engage us, then it is to be can we see it to patients' benefit. It has to have relevance. Q339 Anne Milton: Loaded at the front end, as you say. Could you be more specific on systems reform? Professor Dame Carol Black: Perhaps I could use my own speciality as an example. I am a rheumatologist and the flow of patients through the rheumatology department in which I have worked for many years could be greatly enhanced. We bring people back to do all sorts of investigations, we send them upstairs to get their blood tests and they wait an hour and a half up there, they come down and might need a knee X-ray so they come back with that. They come to me in a clinic that is already ongoing and already working behind time. If you go to some hospitals in other countries, they have worked out how patients flow around systems. They have made it possible for us to work more efficiently. I am sure you could take any speciality, often the X-rays are missing, the notes are often missing and then you scrabble around for that, so it is all about how you provide the actual environment in which you could make us work smarter. Q340 Anne Milton: I find it enormously frustrating listening to what you have to say. It is a continuing theme of a lot of these evidence sessions that I listen to something that has been going on for 20 years. It seems so utterly simple, does it not, to work out how to move patients around a hospital, be it an acute admission or an elected admission, or out-patients or in-patients. Why do you think it has not happened? With all your experience, why has nobody ever got to grips with it? Professor Dame Carol Black: I am probably giving you a fairly local feel and I could be quite wrong but it is rather about living in silos. The consultants have lived in their silos, put their heads down and done their clinical work but we have not communicated well. A huge amount of this has been about communication with doctors, managers, other health care professionals, the clinic clerk. We have just not had the right environment, and perhaps the right drivers, to get us together to say this is what would be so much better for patient care. We have managed to do it, for example, much better now in acute care, the A&E end of the hospital. There is a much better throughput. It requires local doing, because I do not think this is something the centre can actually do. It will vary with geography and with the people who work in an environment. As president of the College I have travelled a huge amount to many hospitals in the country and I see some hospitals that do it extremely well. There are very good examples out there of where this has been looked at and tackled but spreading good practice in the NHS seems to be remarkably difficult. Q341 Anne Milton: Something we all want to happen, for 10, 20, 30 years, is just not happening even though we all want it to happen. Professor Dame Carol Black: There are examples of where it has happened but it is how do we get that. It is about getting people to actually be singing to the same hymn sheet. Q342 Dr Naysmith: Before we go into my questions I will pick up on what has been said. There are some really good examples of the flow improving. There are a couple of good examples in my own constituency relating to breast cancer in women where they come in the morning, have a biopsy, and by the evening they have had the results of the biopsy and, if necessary, counselling. That all used to take days before. It can be done and it ought to be done, but, as you say, it is more often in the acute sector that it gets done like that. I wanted to talk about what you were talking about before but in the context of the large increase in staffing that has taken place in the National Health Service since 1999. I want to start with the quotation from Dr Bloor's written evidence to us that "before planning to increase the stock of human resources it is essential to establish that the existing workforce is working effectively". From some of the things that have been said already, and maybe you could expand a little bit, did the NHS do this prior to this rapid growth? You have indicated that maybe you think it did not, but why did it not do it? Dr Bloor: No, I do not think it did do that, and it is contemplating further increases without doing that now as well. We have some evidence of that. There are huge variations in activity rates between hospitals, general practices and individual doctors. There are huge variations in activity. Admittedly some of these measures are quite crude and do not pick up overall productivity, including the quality measures that Carol has mentioned and that are obviously desirable, but there are some substantial variations, and largely unexplained variations, in what people are doing and what different organisations are doing. I do not think we really did address the effectiveness of the workforce enough before we expanded it. Q343 Dr Naysmith: Why not? Dr Bloor: I guess it comes back to the discussions we were having on the last point about lack of communication between different organisations and between different teams within an organisation. There were some interesting points made in the Reform Report about the difference between primary care and secondary care on this kind of responsiveness issue. They were saying there was a different mix of staff in primary care compared to secondary care, but it was also a difference in the responsiveness of those staff to different situations as well. It is a small example, but as a non-executive I visit local general practices to look at their patient satisfaction questionnaires. By the time I go, they have the results of the questionnaire. In one of my local general practices there was a point about a children's play area and where the letter box was. The GP I was discussing this with said they had had that comment on one questionnaire and they had re-organised the children's play area and moved the letter box. I thought in a hospital or a PCT, or even the University of York, that small change would take months of deliberation and sub-committees. It is sometimes easier for small organisations to move and respond faster than bigger organisations where there are the silos that Carol mentioned. In terms of why we have not made sure that the workforce was working more effectively before expanding it, I do not know. Perhaps we should ask the Department of Health about that. Q344 Dr Naysmith: I am using Carol's example of a rheumatology clinic and going off for tests and coming back. With the expanding workforce, you could either, find a cleverer way of doing that and get more patients through faster in a better way or you could just run another clinic if you have more staff in the same old-fashioned way. Why do we not do the first thing I mentioned and try to look at more intelligent, cleverer ways of doing the same sort of thing without getting more staff to do more of what has gone on before? Dr Bloor: I do not have good evidence for this but I wonder whether it might be about empowering teams within organisations to make those kind of changes. I cannot believe that the rheumatology service that Carol describes could not sort that kind of thing out if they were given the freedom to do that. I wonder whether there is a role for saying what a team is and empowering them to make small changes, sometimes small changes at the margins, to improve effectiveness. Some hospitals do that and some do not. Q345 Dr Naysmith: The problem with this is the increases in pay, and all that sort of thing, have followed behind the increase in the workforce. It would have been better the other way around, as already mentioned. Do you think that is the case? We should have looked at all of this before introducing Agenda for Change, or is it part of Agenda for Change? Dr Bloor: Some of the variations that we have seen are emerging as a result of the contract changes and we will get better information in the future because of some of the changes that have been introduced. Perhaps we did not know, and could not have known, some of those issues earlier. Mr Blair: I think there are other issues to do with bottlenecks. The NHS has so many different staff groups, some of who are key for diagnostics. Professor Black has already made a crucial point about the use of scanners which are crucial for this. Whilst overall you can see big increases in staff, we have had additional standards, but we do not have enough staff to use them. That has a negative effect on productivity, spending more on capital but not getting commensurate output from it. There are quite fundamental strategic issues if you want to look at productivity and improve it and say where are the bottlenecks in the NHS now, in five years time, and how can we plan for them. Diagnostics is a crucial area. How do we incentivise people to introduce skill mix faster? There are system practitioners being introduced, an excellent role, very useful, and yet I would argue that the pace of innovation is too slow for our needs. It is predictably slow because that is what happens when something new is introduced. I would argue that we need to think what is important, what do we need to happen, and what can we do to incentivise those service managers who do new and difficult things. Q346 Dr Naysmith: Do you think what is missing are incentives to do it? Mr Blair: In that particular example, yes, because it was very well project-managed that assistant radiographer programme nationally and there was money invested in education and training. I would argue that for a busy service manager it might be interesting to wait and see what their colleagues down the road do and how successful it is. Why should somebody dive in straight away if they are very busy. We should reward them by some means of additional monies for training, development, or to spend on the staff appropriately to attend conferences so that people see some rewards if we want to get people to do more. I do not necessary mean money in their pockets, I mean money for their clinical areas. Professor Dame Carol Black: It is always easier to do what you normally do. It is easier to put another doctor or another nurse into a clinic than to take the much more difficult, both mental and cultural, things that are needed to really sit down all together and say how on earth do we change this for patient benefit. That requires much more planning. It requires that you put much more intellectual effort into this. People are so busy trying to meet the workload they have that it seems the easiest thing, I suspect, to say if we employ another person we will calculate we will send another X patients through the system. Of course that is not the best way to think about it. When the European Working Time Directive came upon us, what people did was employ more doctors because that is what we had to do, but that did not give much time for constructive thinking about anything else. Q347 Dr Naysmith: That leads on to what was going to be my next question. Have there been other changes since 1999 which have had an effect on productivity? The European Working Time Directive could have had the effect of making the existing workforce work shorter hours but more effectively but you say we just employed more doctors. Professor Dame Carol Black: We simply had to. Our doctors in training really deliver a huge amount of service. When you did the calculations if we literally did not employ more pairs of hands you would not have been able to fill the rotas. You would not have had human beings to do 24 hours a day. It was not a question of those people working smarter. Q348 Dr Naysmith: With the existing workforce and the additional ones that you needed, the numbers overall could have been reduced if we had the existing ones to work smarter. Professor Dame Carol Black: You still have to cover. Maybe what they do within the hours they are there we could say could they work smarter, but it is a fact of life that to keep patients safe you are going to have to have an adequate level of cover. We are just about down to the bare bones now. We could not really reduce night cover medically any further. Q349 Dr Naysmith: There has to be a minimum. Professor Dame Carol Black: Most hospitals have worked very hard to try and meet the European Working Time Directive and have pared down their night cover to a considerable degree. Q350 Dr Naysmith: My final question was going to be something slightly different but it comes in now quite well. When we were in California we had a session with Bob Brook, one of the directors of RAND Health, a thinking out of the box organisation, coming up with lots of interesting suggestions which I could put to you now. He suggested where some things could be done more cost effectively. For example, not everybody who was performing cataract surgery had to be a fully qualified surgeon, and you could do this kind of thing using highly trained technicians but not necessarily people who had gone through full medical and surgical training, and probably ophthalmological training as well. That is very much out of the mainstream thinking but it is a possibility. It is a very routine thing and you can learn to do it. Things like reading mammograms which do not require full medical training, could some of the things that radiologists currently do be outsourced to areas in different parts of the world where they do a mechanical read and send back the reports? Obviously this is looking very much into the future, but are things like that not considered rather than just employing more doctors? Professor Dame Carol Black: I hesitate to comment about surgery so I am not going to offer you a comment on cataract surgery, but if I took into a world I know much better, physicianly medicine, there are many things that people other than doctors could do. We know that and we are fully supportive of extended roles of medical care practitioners. In fact, our College, along with the general practitioners at the University of Birmingham, has written the curriculum for the medical care practitioners for the Department of Health so we do not have a problem with that. People can work to protocols, so if this is a protocol driven exercise, which you are implying surgery is, that is fine, but when you train a doctor you do have excess knowledge. You have that knowledge which you only use may be 10% to 15% of your time but my goodness is that valuable when the difficult cataract comes up or the difficult mammogram. I would suspect your family, as much as for mine, would like to know that the person looking at that mammogram would be able to cope with the 15% when you need the extra knowledge. It is a way to go to a certain extent but you have to be very sure that you do not disadvantage a patient by that extra knowledge which, in any profession, you get but you do not use all the time. You should not underestimate the value of that. Q351 Dr Naysmith: Dr Brook was advocating it, not necessarily me. How about the other two in the context of what has happened since 1999? Dr Bloor: Professor Brook has some fascinating ideas. There is evidence that some of these tasks can be done by other individuals. There has been a recent large trial of nurse endoscopy which demonstrates that nurses can do most of the endoscopies that are within their protocol. There are complicated ones and that is where you need a doctor, and there are also training issues which Dame Carol can comment on in a more informed way. There are some tasks that can be done by people other than doctors. The American evidence is quite contradictory on this. A lot of the time what they call non-physician clinicians, people who are not doctors, are brought in and can do tasks, can see patients and do it well but they tend to operate as complements to doctors rather than as substitutes. We are not always saving money or reducing the workforce but what we are doing is adding in another level of care. If that is improving patient care, that is fine, but it is important to note that certainly from research evidence they are often operating as complements and not necessarily as substitutes. Q352 Dr Naysmith: They could theoretically increase the throughput if what they are doing is hanging around waiting for the occasional emergency. Dr Bloor: I am sure they could. Mr Blair: I very much like your international approach rather than saying certain things are happening very dramatically how can we respond. There are sometimes changes in response to crisis measures. It is fascinating looking at the States where nurse anaesthetists have had a much more advanced role than they have had in England for something like 25 or 30 years, and the question is would that be useful to introduce here. I am surprised that that sort of thinking does not take place a lot more often. I know when German operating teams came to Britain there was real consternation that they have fewer roles. Quite often it was the consultant, another skill mix, that had a wider role which meant that you had fewer workers. They had expensive people, fewer of them, but doing more things. I would see more the point about there is lots we can learn from other countries, they have done certain things that we have not for 20 or 30 years, let us evaluate to see to what extent we can bring that to Britain. Professor Dame Carol Black: Could I make one correction? We have nurse anaesthetists. Mr Blair: But to the sort of standards that the Americans work, which is virtually on a par with consultant anaesthetists. It is very much more advanced practice. I did not make that point well enough. We do have them but in Britain it is a much more junior role compared to America. Thank you for that correction. Dr Bloor: It is important to target your most expensive resources, and in the NHS that is our doctors, our consultants and our GPs. It is important to target those resources where they are needed most, and if there are some of these tasks that can be done by other people then that might be more efficient but it is not necessarily going to save money. Q353 Dr Naysmith: Do you think the Royal Colleges are obstructing developments in this kind of area? Professor Dame Carol Black: Emphatically no, certainly not in the last four years. If you think about our workforce unit and the work that we have done, we have provided figures, and very useful figures, to the Department for many years. We have worked in very close collaboration with them on the workforce requirements within our 28 specialities. We have always tried to be reasonable there and to work it out and we now have a very good relationship. The fact that they use our figures would indicate that they do have faith in them and believe in them. We have, over the years, had an increasingly more efficient workforce unit. As far as medical care practitioners or extended roles, the interest really started in the Royal College of Physicians under my predecessor, Sir George Alberti, because it was during his time that we had our first Working Party on skill mix. We have been very supportive of skill mix. What we are not supportive of, and I would indeed hope you would not be supportive of, is having a lot of additional practitioners who do not work to national standards. You require that your doctors are all trained to national standards, that we have competencies which are assessed and then we have continuing professional development. The only caveat we would put to extended roles is that it ought to be on a national basis so you can move anywhere in the country with those qualifications. You would like a medically qualified person to have competencies against which you would be assessed, and presumably in some ways you would be revalidated. That is just one more example that there has been a change. I would not like to tell you that 25 years ago perhaps there would have been such an open door to these changes, but I think we have been very welcoming. All our specialities, for example endoscopy and gastroenterologists, have worked very constructively with nurse-led endoscopy. Certainly in my own speciality we have physiotherapy-led spinal clinics and nurse-led clinics. If you look at any of the medical Royal Colleges they have all been endeavouring to embrace this. Q354 Dr Naysmith: Some people would suggest some of your fellow college presidents have been less progressive in this area than you have. I am sure you will not want to comment on that. Professor Dame Carol Black: Of course it is variable, and some people find it more difficult to change than others and somehow memberships and fellowships whose views they have to consider. We have all been moving down a road, some of us faster than others. Dr Naysmith: We now have thoracic surgeons results on the internet. Q355 Chairman: There has been a debate around areas like the limitation of types of surgery in treatment centres in terms if you only have one or two joints, as opposed to three, four, five, six or seven joints. The profession has had comments about that. Not that every surgeon has to be all singing all dancing, but I know in terms of the potential changes for training there has been a heavy debate that should not happen and we should not restrict. Would you agree with that in general terms, I do not mean in any specific area? Professor Dame Carol Black: You mean the work that could be done within an ISTC? Q356 Chairman: Yes, in the sense that some colleges have commented that it is restrictive in terms of what they can and cannot do because you are looking at probably one or perhaps two knee joints and that is it, whereas in quite a lot of orthopaedic surgery you have a wider choice than what is in treatment centres. Do you think that has been an issue? Professor Dame Carol Black: I do not honestly think I have enough information to give you a considered answer. It has not been something that has been in the forefront of my own college. What we would feel about Independent Treatment Centres is we would like the people who work in them to be appropriately qualified and perhaps rotate through the units in the NHS. As physicians if we develop ISTCs for gastroenterology or diabetology, it would be to everybody's advantage, especially if they are going to be teaching ISTCs, that those people working in the ISTCs could rotate through the NHS hospital. It would better collaboration and very reassuring to the doctors who work within the NHS. It would be a possible way to go that might improve some of the fears and worries that are around. Chairman: That is probably for another inquiry. I will move on to the David. Q357 Mr Amess: I am not going to ask Mr Blair if you are comfortable with your name, or if you are the result of a glorious union between George Bush and Tony Blair, and ask you about the collection and use of information about productivity. You said it needs to be improved, could you expand on that and tell us what it is you want to collect? Mr Blair: My perspective on a national level is that we must improve quality indicators to fully engage consultants. For it to work, it has to be real for clinicians at different levels. For instance, a radiologist would have some different indicators or measures for him or her than there would be for a surgeon. All that sort of thing needs to be thought through. The other thing that needs to support that information, information is only useful if people use it. What I was wondering is at what point does a nurse, a doctor or a physiotherapist enter a discussion like this about working practices and working smarter. There are all sorts of tools and techniques that can be used. Where do they learn that? When do they learn that? I am not at all clear how that happens, I would argue that for information to be really effective that needs to be underpinned. Q358 Mr Amess: Do NHS organisations tend to measure activity rather than productivity? Is there any evidence of this trend? Mr Blair: he honest answer is it varies enormously. The NHS has suffered very badly from old information systems that do not talk to each, produced by different functions at different timescales. The information side is not well resourced, so if there is any time for economies because they are clinically phased in, those are the sort of areas that are very vulnerable. Perhaps that is an issue to put to you. Some analytical skills could easily be called men in suits, or women, but they could be easily those people first for the chop because they are hands-on. Giving you a metaphor, in the Battle of Britain radar was crucial so that the scarce resources were most effectively deployed. There was no clamouring for scrapping the radar and having more pilots. We need to have a debate where there is more local investment in making information work for the clinicians and give them information, less data, less frequently, but something which they have been involved in, their colleges have been involved in the various measures, because they will differ. Q359 Mr Amess: We will certainly reflect on the advice you are giving us. Finally, Hospital Episode Statistics, how useful are they in measuring productivity or is it all a waste of time? Dr Bloor: Hospital Episode Statistics are an administrative data set. They are a routinely collected data set about patient episodes. They were not designed to measure doctor productivity or productivity of the health workforce at all. They are far from ideal as a measure of productivity but I think that they do have a role. You asked earlier about whether the NHS is an organisation prone to measuring activity rather than productivity. I would argue that until quite recently they tended to ignore both. We can get very tied up in quality measures and in trying to find an ideal measure of productivity that adequately takes into account patient case notes and quality of care. We can get paralysed by that. I would argue that there is a role, and we have done some of this recently at York for the Department of Health, to share information about crude activity levels adjusted where we can for differences in patient case mix. Despite its inadequacies, and there are many, it can act as a catalyst for developing those better indicators. Until we share information, until we use information, there is not the incentive to make it better. I would argue that Hospital Episodes Statistics does have a role in producing something that is better than nothing. I will expand on that if there is more time. Professor Dame Carol Black: I would say that as far as HES data is concerned one of the things we have tried to do for clinicians through our empyreumatics unit, which is in Swansea, is to encourage them to use that data. They can come and we will help them burrow down into their own data. We do bear in mind that it does not do out-patient work, it does not tell you anything about the telephone calls a doctor makes, anything about management, anything about all our other activities, but I think clinicians do need to learn how to use what we have got. We have had increasingly better uptake. People have learnt quite a lot about themselves when they have burrowed down into this data. It is what we have at the moment but we would like to see it made much more sophisticated and that is what is needed. Dr Bloor: The out-patient data is developing and it is in process. I think Dame Carol's college has been leading this question of clinicians looking at their own data, validating their own data and beginning to use it. That can only be a benefit. Q360 Dr Naysmith: Following up on this Hospital Episode Statistics, no matter how crude it is if you use it to measure consultant activity you find huge variations between the amount of "work" that is reported by using that statistic between different consultants. Why does that happen? If it is as crude as that and not of any use, then we should not use. It must be telling us something. Dr Bloor: Yes, it does, but it is a very partial picture. At the moment the distributions that we have produced have been on in-patient episodes not including out-patients and not including any real measures of quality or outcome. That is where we really need to focus our efforts in developing better patient outcome measures. There is huge variation. Some of that can be explained, some of that can explained by differences in patients and case mix. Severity of patients differs and I do not think that is always adequately adjusted for. The only adjustment we could make was by HRG and tariffs which is an imperfect adjustment for case mix. There are differences in the consultants, their age, their gender, their contracts, their other interests, their other responsibilities, they might be medical directors, they might be clinical leads, they might be teachers and trainers, they might be researchers. There are differences at consultant levels and there are differences between Trusts, and perhaps the access to operating theatres might create differences in productivity. Q361 Dr Naysmith: Do you think it is misleading? Dr Bloor: No, it is a basis for discussion. Q362 Dr Naysmith: Between whom? Dr Bloor: I would not use it as a performance measure, but I would use it if I was a medical director of a Trust. I would use it to have a conversation with my consultants around job planning and appraisal. If there are bottlenecks that are being created that limit consultant productivity in some area, then that would be discussed and hopefully resolved. I would use it if I was involved in job plans and appraisals in that way. I might even use it in clinical excellence awards. Q363 Dr Naysmith: You could use it to measure and theoretically increase productivity as a partial measure? Dr Bloor: You could use it as a basis for discussion. I do not think it is an overall measure of performance. It is a very partial picture but it does give some transparency. Q364 Dr Naysmith: How do the discussions you are talking about begin? "Dr So-and-so, it looks as if you are not doing as many episodes of activity as someone further along. Can you explain to me why?" Dr Bloor: Yes. There may well be good reasons why Dr So-and-so is not doing as many episodes and it might be that he is a clinical lead or medical director or something like that. Q365 Dr Naysmith: Presumably the management would know that? Dr Bloor: Yes. If, for example, you have a group of ophthalmologists and they are all doing a relatively similar amount of episodes per year. If you are then faced with a national distribution that puts all of those in the lower quartile and says that in other hospitals other consultants are doing twice as many episodes per year, that is a reasonable question for a manager or a medical director to ask what is creating these episodes. Q366 Dr Naysmith: It is probably useful for that purpose as well, comparing between Trusts. Dr Bloor: Yes. Professor Dame Carol Black: To add to that and give you a very practical example, if in a Trust where you have surgeons who do transplant surgery or highly complicated surgery where there may be quite a lot of complications post-surgery, the people who look after those complications, because they are usually metabolic, will be the physicians. You might in a hospital like that find although it is never recorded your physicians spend all day keeping Mr Smith alive and well post-surgery from medical complications but that is never recorded anywhere. That person has actually spent that day interacting with and on behalf of their surgical colleagues. You have to know what is the hospital case mix. What is it doing? What might its doctors be asked to do that is not recorded through the data that we do collect? It is about using this data intelligently. Q367 Dr Naysmith: Is that why the impression has got around in some quarters that the medical profession is resisting this kind of productivity measure? Professor Dame Carol Black: The medical profession does not resist data collected appropriately, in which let us hope they have had some say in what is being collected, if it is related to outcome. Doctors are quite hungry for that sort of data and they certainly are prepared to look at that. They have been quite resistant in some cases to look at HES data, but it depends how you are going to use this HES data. You have to use it intelligently and appropriately and know what its limitations are. Q368 Dr Naysmith: Is there any indication that this resistance is likely to increase? Is the situation getting better, in other words? Professor Dame Carol Black: I think if we improved our quality of data, it would certainly get better. What frustrates a lot of doctors at the moment is this hoped-for improvement in IT. We would like to get there and we would like to be able to have this data as that would make a difference to what we could look at and what we could do. Q369 Chairman: I have a question for Mr Blair. In your submission, you commented on the "complete lack of clarity regarding who is responsible for trying to improve productivity", and you recommend that the NHS trusts should have a dedicated lead for productivity. How would you see this role working and is not productivity, if not a matter for all the workforce in any institution, certainly a matter for the managers of the workforce? Mr Blair: Certainly it is a matter for managers, but I think it has not had an adequate focus and I think many of your questions really point to that, that some organisations were historically well resourced, others were poorly resourced and resource in the past was purely incremental, so there were no rewards for improving productivity historically. I think there needs to be more focus on it. I think it is for all organisations to try and answer that question and come up with their own solution. You are quite right that it would vary locally, but my sense is that productivity does not just include financial measures, "How are we doing financially?", but there is a whole wider range of issues and going on to things like hearts and minds, that brings in working practices, it brings in human resources. I think it goes back to what we were hearing earlier about silo mentality and I think there needs to be a productivity group. I think that would be a better way to develop that idea which somebody convenes and is responsible for with all the various inputs. I do not see examples of that, although admittedly some trusts perform very well. When I circulated my paper, one wrote back to me saying, "Oh, we've done this, George", so I do not want to imply that there are not examples of very good practice, but I think a lot more could be done to pull together a whole range of people to look at this in a more consistent way across an organisation. Q370 Chairman: Perhaps I could ask the other two witnesses, do you think we should have dedicated people in NHS organisations looking at productivity or should it be managers having time to do this, as it were? Professor Dame Carol Black: My personal view is that you have got the people there who should be deeply involved with this. You have got clinical directors, you have got clinical leads, you will have senior nurses and you will have managers, and really if you put another person in there, you take the responsibility away, I think, from the people who should be deeply concerned about productivity, so I would like it to be the people who are delivering the care. Of course that does require time and that might be a factor, but again if we had better data, if Connecting for Health was working well, then that would again help. Dr Bloor: I am inclined to agree with Dame Carol on this. I think if you have a person who is director of productivity or whatever, it might feel like it is their job to deal with productivity and not everybody else's. I would be inclined to give it to the medical director. Q371 Chairman: We have been taking evidence sort of in this area and a number of written submissions we have had to the inquiry commented on the lack of integration between financial activity and workforce planning in the NHS. Indeed in one of the earlier sessions we had about this was this issue about what has effectively been the over-recruitment certainly beyond targets that were set and now there are the problems that we have in some areas of NHS organisations with over-expending, as it were. Whether these are related or not, we will be looking into at a later stage. Do you think that improving productivity really should be a way of helping to integrate this sort of planning process of workforce planning and the economic activity in institutions as well? Dr Bloor: Yes, I think it should actually. I think it should certainly be integrated into the workforce planning, that productivity should be an integral part of workforce planning. I guess it is particularly obvious now that workforce planning and forecasting and financial planning and forecasting have not necessarily been done together when we have got a finance squeeze and also people coming out of medical school and business school and those expansions in the workforce have been substantial, so it has perhaps focused the mind on that mismatch, but yes, I think more attention to productivity, more integration of productivity into workforce planning should help to address that. Professor Dame Carol Black: I think had we taken it from the point of view of a pathway of care for a patient and said, "If you have a certain condition, what sort of health intervention do you need? What kind of workforce do you need to create? Do you need a nurse, a physiotherapist, a doctor? What do you need", we might then have been able to start to think together about the shape of the workforce. Rather, we have increased nurses, physiotherapists and doctors, but we never said, "What do you require along a pathway of care?" and I think that would have been a much better way to have approached it. Then we could have employed the workforce that, as far as we can see, and it is always difficult to see what you are going to need ten years down the road, but we could have surely made it more appropriate to what the pathway indicated. I think we did not do any of that thinking in any of that planning. Mr Blair: I would like to come in about the planning process, my experience of previous local delivery planning processes. We get central guidance from the Department, there is a finance bit, an activity bit and a workforce bit and there is this sense that they are experts producing their needs. Then it comes at strategic health authority level and they think, "How can we pull this together? How can we make this meaningful and easier for our trusts to contribute to?" and then each of them will try to come up with some sort of approach and some produce quite good spreadsheets and then they cascade that down. Then you get somebody in finance usually, somebody looking on the service side and somebody in the workforce all with their own spreadsheets, all trying to communicate. I have had quite a lot of experience of budgets now being cut for whatever reason, so finance reduce their figures, but the message has not gone through to HR because it is done in such a fragmented way that that particular trust passes on to the strategic health authority and the Department the demand for staff that even then it cannot afford, so that whole planning process lacks integration all the way through. I know that there have been attempts to change it, but I think we need a lot smarter thinking. It is very easy to write software nowadays where you can feed information in, and I think what is necessary is for them to be planning software where, if you have got this money, you reduce the budget and, therefore, you have got to reduce the staff accordingly and you cannot just send effectively three different submissions stapled together. Q372 Chairman: We had one submission to this inquiry which said that the alignment between workforce and financial planning was "woeful". I assume from what you have said, Mr Blair, that you would agree with that? Mr Blair: Yes. Q373 Chairman: Not in all cases obviously. Mr Blair: That is right, but there are too many cases of that, yes. Q374 Dr Taylor: Going back to improving productivity, Carol, you said that the people on the ground who do this are the clinical directors and the clinical leads. How well do you think they are prepared for this job? Professor Dame Carol Black: I would have hoped that somebody who takes on the role now of the clinical director, a medical director or a clinical lead would certainly have got some of the necessary training to be able to think and do this. I think it is about sitting down together. I do not think there is magic in this. If you think of productivity as quality as well as just efficiency, then I think you will engage doctors, so I think it is about getting people ---- Q375 Dr Taylor: One thing, I think, some of us were quite impressed with in California where we have been is that they pick out what they call 'emerging medical leaders' early on and actually train them. Are we actually doing any formal training in medical management because, I quite agree with you, in my day you picked it up as you were going along, but I am not sure that is the best way to do it? Professor Dame Carol Black: That is an exceedingly good question and it is something that we have all been very aware has been missing in the training of the average doctor. I think, for example, BAMM has done a very good job of training at the level of people who are committed ----- Q376 Dr Taylor: The British Association of ----- Professor Dame Carol Black: Yes, the British Association of Medical Managers, when people have committed to becoming a medical director or a clinical director and they are already down that road, but what we have not been good at, and it is now changing, is how you get into both undergraduate and postgraduate education the skills that will allow you to be a clinical leader and to have medical management skills so that this is spread much more across, I would not say all consultants, but that you are getting this ability into the consultant body. There is the emerging leaders network which has just been set up in the Department of Health which is now seeking to identify such people and we have all been asked to offer names, so there is a young emerging leaders network, there is work from the NHS Institute for Improvement and Innovation with the Academy of Royal Colleges to really now start getting programmes out there. It is perhaps a bit late in the day and we should have done it earlier, but it is ---- Q377 Dr Taylor: But it is coming. Professor Dame Carol Black: We have had a very good programme with middle managers and young consultants going for the last year in which they have done problem-solving together. They have come from the same trust, the clinician has identified the manager and together they have had to bring a problem that needed a solution, so they had to do some systems reform. That has been actually riveting in the way it has shown how people can work together and they will increase productivity in each of those projects. There was, almost without exception, increased productivity if you put quality into that, so I think a lot is happening now. Q378 Dr Taylor: Will this help to cut down the barriers between the silos because this is one of the awful things, that there are so many barriers? Professor Dame Carol Black: Yes. Q379 Dr Taylor: Obviously clinical directors and doctors in management have got to work very closely with managers. Do you think central targets have driven a split between managers and doctors where they contrast? I think it was Dr Fielden who said that doctors and managers would work well together as long as the aims were the same. Have government targets tended to drive these apart? Professor Dame Carol Black: Well, quite a few of those targets would be things that a lot of doctors would think were not unreasonable. We might not have designed them in quite the same way and we might have wished to modify them, but I think managers and doctors do have the same aims which are to improve the care for the patients in their institutions. I think managers are under quite different constraints from the centre and I think it adds attention, but one would hope it might enable doctors and managers to understand each other better and perhaps to be able to work together more effectively. Q380 Dr Taylor: Coming back to quality, which is what we all desperately need, how should data relating to quality and to outcomes be collected? Have any of you any ideas? Professor Dame Carol Black: Could I just give you two examples of perhaps the way it has been collected through the Royal College in the national stroke audit and the myocardial infarction audit, both of which were national audits set up by the Royal College's Evaluation Unit. The important thing about those audits was that they involved clinicians right from the beginning. They helped design the programme, they fed their own data in, they knew the data were safe and they were going to be compared with each other, but you had managerial buy-in because 100% of the acute hospitals in this country participate, so you had hospital buy-in, you had doctor buy-in, they could see where they were and nobody wants to be bottom of the list. Therefore, I think you can do it effectively as long as you plan it properly and it is on a topic that people think to be important. Improving door-to-needle time improves mortality, so no doctor is not going to want to do an audit that actually does that, but it is getting it aligned to appropriate patient outcomes. Dr Bloor: I think there are some really interesting developments in this kind of outcome measurement within individual specialties, so, as Dame Carol mentioned the myocardial infarction audit, there are also joint registers and that kind of thing and cancer registers that are developing lots of quite detailed information about patient outcome, but within clinical specialties. What I would like to see in addition to that is something generic that we can use across specialties, something like EQ5D or SF36, one of these measures ---- Q381 Dr Taylor: Help! You are going to have to expand on that. Dr Bloor: I am sorry, it is a generic measure of quality of life. EQ5D is a simple five-question scale basically asking how you are with five very simple questions and it has a kind of thermometer where you can locate your own state of health on one day. It has been used across clinical trials in all kinds of different areas, but it has not been used to routinely measure how patients are doing in the NHS. A different quality-of-life measure, SF36, is one developed by the RAND Corporation, and I believe you visited them recently, and that has been used in BUPA as part of their everyday routine data collection in patients, so they give patients these questionnaires before they are admitted and then again six months later and they see whether there is a difference; they see essentially whether patients are feeling better six months after their operations. It is not rocket science. I think we could add that level. I think the bottom-up development of real detailed clinical measures is essential, but I would quite like to see that generic measure of simple health, how is a patient feeling, on top of that. Q382 Dr Taylor: So the best measure of outcome is to ask somebody how they are? Dr Bloor: Yes. Mr Blair: I do not have anything to add to that. There were some good answers there. Q383 Charlotte Atkins: We have heard that workforce planning in the NHS has traditionally focused just on measuring and controlling staff numbers, and that is what everyone tends to focus on whether they are going up or going down, so how do we get the NHS instead to focus on the whole issue of productivity and closer links between the workforce and financial planning because it seems to be woefully lacking at the moment? Mr Blair: I think there is quite a trick with regard to finance people. I think there would be real value in getting finance people to have a great understanding of the workforce issues. I have been involved a huge amount in workforce planning training and training HR people and some of them are not sufficiently networked in with finance people and what I thought was that we have not been thinking, I would say, widely enough, so broadening finance thinking with regards to the workforce, because that is where most of the money is, would be incredibly useful, so that would be one thing I would suggest, a key target audience. Q384 Charlotte Atkins: It seems amazing to me that it has not happened already. Given that the NHS spending is largely about employing staff, I would have thought that the two were so intimately involved and connected that you could not do financial planning without knowing exactly what the workforce implications were. Mr Blair: Well, if that were so, how come there is the issue I have presented with the scanners, that you have scanners which are switched off at five o'clock and the finance director is quite happy to sign off, "Yes, we need more"? I am not saying that they are not needed further down the track, I am not saying that we are doing well nationally compared with other countries, but clearly there is a lack of think-through and particularly an understanding of where the bottlenecks are in the hospital. I think it goes back to this silo thinking and I think that probably is one of the issues which is again coming up and hitting us in the face. Q385 Charlotte Atkins: Does it not say something about the quality of our financial planning within the NHS when they are just turning off a scanner at five o'clock and then thinking about needing more scanners because they have got several which they have turned off at five o'clock? Mr Blair: I am wondering whether that is further down the system and that the people in finance are quite removed and will not really know much about clinical things, so I think the NHS is really like a sort of vast old clock with lots of different cogs which do not always mesh in with each other and what are sensible decisions at one point. For instance, if you are the manager of a radiography department and all of a sudden you are offered a new piece of equipment and you know that next year it will not be on offer, you are going to say yes, so that is a sensible decision for that manager, but it is not necessarily sensible for the whole NHS or perhaps for the finance of that hospital to do so, so what we are left with are people in a fragmented system making what, in their individual cases, are sensible decisions, but collectively they do not add up. It is that collectivity, how to make the NHS, even within trusts, a more holistic sort of organisation which is key. Q386 Charlotte Atkins: So is this happening anywhere? Are there changes anywhere which are approximating to what you are saying needs to be done? Mr Blair: Please, with something as large as the NHS there are all sorts of areas of excellence. I have come across a few, but I cannot sit here and tell you the scale of what the good practice is and where it is. Q387 Charlotte Atkins: Maybe you could let us know because I think we obviously ought to be looking at good practice and, from what you are saying, it does not seem to be hugely prevalent. Mr Blair: Let us say, there are too many examples where it is clearly not there. I think that might be a better way of putting it. Dr Bloor: Just to go back to your question about the disjointedness of financial and workforce planning, I think it is partly just timescale. We make a decision to increase medical school intake in October and we are making a decision to increase the medical workforce in ten or 12 years' time and the financial plans are not that long, so there is a problem there. I think that Dame Carol's earlier example about looking at pathways of care and integrating workforce planning, not looking at the medical workforce on its own, not looking at the nursing workforce on its own, that really needs to happen and there are examples of this. The Australian Medical Workforce Advisory Committee and I believe the Canadian systems as well have made much more of an effort to integrate their overall workforce planning techniques, although sometimes they still take out medics as a separate case which I think we probably need to stop doing. Q388 Charlotte Atkins: Well, that is one of the issues, is it not, Dame Carol, that the medics often are taken out as a special case and do not see themselves as part of the overall workforce in the NHS? Would they be willing to embrace this more inclusive change? Professor Dame Carol Black: I think that you now do see examples and I think you can see it in some of the Royal Colleges in the sense that they are embracing medical care practitioners and they are bringing into their colleges either through associateships or affiliateships non-medically qualified colleagues. I think just one other thing perhaps to put into the equation somewhere is that we are feminising certainly the medical workforce and that does have an effect on numbers and how it is going to pan out in the future. Remember, even though you may have numbers, they are not all whole-time equivalents, so you see a large increase in the number of GPs, but how many are whole-time equivalents? There are lots of different factors and perhaps the one thing we have really been thinking about recently is how flexible we could make the physician workforce. I cannot talk for other specialties, but we really have to try and make it as flexible as possible because we do not know really what the needs necessarily are going to be. We can say we are all going to live longer, we are going to have more chronic disease, we think it is going to look like this and we need to work with colleagues in the community, but we somehow have got to build much more flexibility into the workforce to be able to move laterally, and that is quite a challenge, but one I think we have got to face. Q389 Charlotte Atkins: Do you think that the medical profession is likely to embrace this flexibility? It has not always been known for its flexibility. Professor Dame Carol Black: I think you have got to start very early on with the young and try and get them to see the world in perhaps a different way. If you just take planning in the 65 specialties which we have in this country, it is, I think, fairly obvious now that, even if you qualify in medicine and you are guaranteed perhaps your foundation course, you may have to be flexible about doing a specialty that was not your first choice. Years ago you were going to be a neurologist and that is what you went for absolutely 100% and you wanted to work in London. Well, it is quite possible that now you might have to think about perhaps being a geriatrician or a clinical geneticist and you might go and work in Manchester. I think it is that sort of flexibility ---- Q390 Charlotte Atkins: Or indeed having more than one specialism. I was talking to a consultant in my own local hospital, North Staffordshire University Hospital, who was pointing out that when you have consultants who are just pure specialists in one field, therefore, you overnight have to employ several consultants to ensure that everything is covered. It seems to me that you are talking about flexibility, but how about the medical profession looking at a range of specialisms rather than just one pure specialism? Professor Dame Carol Black: Well, we are doing that, for example, with the College of Anaesthetists, the College of Emergency Medicine and the intencivists in how they could devise much more sort of composite training and then the opportunity to work either in the emergency room or you may want to spend some time in the acute admissions ward, you might even wish, as a physician, to be able to spend time on the intensive care ward. Now, that is their four specialties and it is quite reasonable and easy to start with and we obviously need to extend that idea and perhaps you might see yourself acquiring an additional competency, so, if you were a respiratory physician, but your trust required a special skill akin to your specialty so you were not way out, perhaps in the future we will devise competencies that you can acquire post-CCT and that would be another way of extending your skill base and being more flexible. Q391 Dr Naysmith: A general physician maybe! Dr Bloor: Well, there are two conflicting trends here, are there not, because you have got this need for flexibility, but you also at the same time have the drive towards sub-specialisation and more and more sub-specialisation where we have two or more orthopaedic surgeons who do not focus on the ankle, and that kind of thing is happening more. I think the sub-specialisation is perhaps limiting the flexibility, and perhaps there is a difference between surgery and medicine, but there seem to be kind of conflicting trends here. Mr Blair: Picking up the point about the 65 specialties and given the need to plan for that many, without doubt some of those plans will be proved wrong by events. I think the issue is not so much to be surprised by it, but to try to identify that early on. I heard in 2003 about cardiothoracic surgeons and that was just a workforce planner, not somebody involved in medicine, so the word was on the street that that was a problem area and I think we all ought to have a recipe of what we do if there is a specialty with substantial over-supply, what the process is for rapidly retraining people, some sort of accelerator scheme so that it is not as if, "Oh dear! We got it wrong". Well, life is like that for something with so many changes and with the planning over such a long timescale, so I think there is much greater scope needed for contingency planning and also looking at scenarios, looking at the impact of technological change much more widely and advertising that on the Net, "These are the views of changing technology". That would be very useful to share to involve people like surgical manufacturers of equipment because what they are designing, in three or four years' time people will be using, so there is a great deal of value to be picked up from intelligence from that source as well, so we need a great deal of flexibility and not to regard it as, "Oh, we've got too many of these people. Oh, we've got it wrong. Let's start splitting people up". We need to have the flexibility to sort them. Chairman: Well, could I thank all three of you very much indeed for this session. I suspect it will be next year before you see the outcome of this inquiry, but thank you very much. |