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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1077-iv House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
WORKFORCE PLANNING
THURSday 15 JUNE 2006 PROFESSOR BONNIE SIBBALD, DR HUGO MASCIE-TAYLOR, ALISON NORMAN and DEBORAH O'DEA
MR BILL O'NEILL, MR ROB DARRACOT and DR SALLY PIDD MR MARC SEALE, MR FINLAY SCOTT and SARAH THEWLIS Evidence heard in Public Questions 392 - 544
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 15 June 2006 Members present Mr Kevin Barron, in the Chair Charlotte Atkins Mr Ronnie Campbell Sandra Gidley Dr Doug Naysmith Mike Penning Dr Richard Taylor ________________ Witnesses: Professor Bonnie Sibbald, Deputy Director, National Primary Care Research and Development Centre, University of Manchester, Ms Deborah O'Dea, Director of Human Resources, St Mary's NHS Trust, Dr Hugo Mascie-Taylor, Medical Director, Leeds Teaching Hospitals NHS Trust, and Ms Alison Norman, Director of Nursing and Operations, Christie Hospital NHS Trust, gave evidence. Q392 Chairman: Good afternoon. Would you like to introduce yourselves? Ms Norman: I am Alison Norman. I am here as a member of the Board of NHS Employers, but I am also Director of Nursing at Christie Hospital in Manchester. Dr Mascie-Taylor: I am Hugo Mascie-Taylor; I am also on the Policy Board of NHS Employers. My day job is Medical Director at Leeds Teaching Hospital trust. Professor Sibbald: I am Professor Bonnie Sibbald, a professor of health services research with the National Primary Care Research and Development Centre in the University of Manchester. Ms O'Dea: I am Deborah O'Dea. I am Director of Human Resources and Organisational Development at St Mary's Hospital in Paddington, and I am also President Elect of the HPMA (Healthcare People Management Association). Q393 Chairman: Once again, welcome. Can I ask a general question to all of you, but I hasten to add that if what you want to say has been said, you do not have to repeat it. Changes to skill mix and the development of new and extended clinical roles such as specialist nurses is currently very fashionable in the National Health Service. Can you tell us why this has happened, and what is the evidence base for these types of changes? Professor Sibbald: I am happy to comment on this, at least from the perspective of primary care. There are three main drivers of this change. The first is the presumption that one can save costs by using nurses as opposed to physicians. The second is that one can enhance the quality of healthcare by adding specialist nurses and others to physician teams. The third driver is medical workforce shortages, either nationally, regionally or locally. Ms Norman: I agree with Bonnie, but would add to that. The liberation from the nursing point of view in terms of what nurses traditionally did and what they are now doing came in 1992 when the regulatory body introduced scope of practice which basically enabled nurses to build on the basis of their professional training and education and to go into other roles. Over that period of time there has been a tremendous development, both in terms of specific specialist roles; but also generically, for example the nurse practitioner - those in primary care and those in acute hospitals - who can enable first contact with patients and speed up the process of care and support. Some medical shortfall has driven some change, but, equally, it has been the need to enable patients to get early and efficient access to care, and to ensure that patients get continuity. One of our problems is that in relying on doctors in training to provide much service contribution, you do get discontinuity. A specialist or advanced practitioner nurse within the team can provide sometimes the one bit of consistency that a patient with an illness over a long period of time will get. Q394 Chairman: Andrew Foster gave evidence to us on 11 May, and he said that redesigning the skill mix will enable us to get higher output or productivity. Do you agree with this, and is there evidence that these changes are cost-effective? I know that Professor Sibbald has a view about that. Do you agree that it is going to get higher output or productivity? Dr Mascie-Taylor: I would absolutely agree with the drivers that have been set out to you. Given the drivers, which essentially are the existence of various facts, then they predict the answer to your question, because if it is the only or the best way of doing it, it would have the effect that you are talking about. The danger would be if one undertook skill redesign for less good reason, and then it might not have the desired output. I suppose my point would be that if the employer takes the view that that is the optimum way of achieving a desirable, then it will work. If it is done for other reasons - and there are various other reasons why it might be done - then the outcome is less certain. Q395 Chairman: Can you give us an example of the reasons - just one? Dr Mascie-Taylor: Certainly. There is a mix here of employer ambition and professional ambition, and it is necessary, if you want to achieve changes in the skill mix, to have both of those; but sometimes the balance is in favour of professional ambition as opposed to the needs of employers; and the appropriate and correct balance needs to be put into that if the desired effects on productivity and quality are to be had. Professor Sibbald: The research that we have reviewed in primary care suggests that on most occasions you will not get gains in productivity or reductions in cost. The reason for this is that at least in the research setting, when you substitute a nurse for a doctor, nurses tend to consume more resources than physicians but generate the same high quality of care output; but as they consume more resources, that eats into the savings you get in their salaries, so the overall effect tends to be cost-neutral. We also know that without very tough management strategies, when you add a specialised nurse to a physician team in the expectation that the doctor will delegate away elements of that care to the nurse, physicians tend to continue with their previous activities, so the nurse is then as it were doubling the volume of service but not enhancing the efficiency of the service. Ms Norman: There are other elements obviously around patient quality and patient safety, for example protecting junior doctors particularly from being thrown into the front line in the way that traditionally they were, often in areas where they may not have had the opportunity to gain expertise - and I would cite particularly out-of-hours use of experienced nurses who are often the first port of call for dealing with patient care. In my own hospital, which is a specialist cancer hospital, our out-of-hours nurse practitioners probably are in a significantly better place for the specific cancer problems for patients than the doctors in training who may also be part of that night-time team. Although efficiency and cost-effectiveness has to be important to us, the issues of patient safety and ensuring that people who are not fit for purpose in dealing with those patients' needs are not put in a position where they have to, must equally be important to a concerned employer. Q396 Sandra Gidley: Is there a flip side to that? As a patient, I would probably want the most experienced person, but it has also been put to us that the situation you are describing actually reduced training opportunities for junior doctors. How do we make sure that doctors have access to training and make sure that there is expertise and safety for the patient? Ms Norman: You make an important point. In my own place of work we have to undertake a lot of invasive procedures with patients and give them drugs. One of my concerns is that, to be honest, nurses have almost entirely colonised that area of work and do it very well; and it is important that we have to remember that doctors have to be able to understand that too. This is essentially around the practical skills that doctors have. There may be a need to balance the learning needs and protective learning time for doctors in training and their exposure to practice, but in a way that does not expose patients to being practised on, and supported. There may be particular times when that balance is not quite right. I think that within individual hospitals and in discussions with medical trainers you need to ensure that doctors get that exposure as well. Dr Mascie-Taylor: I agree with that and support it. It goes back to the point I was making, that one needs to decide at the outside what the objective is. Is it quality; is it quantity; is it cost reduction; is it improved training; what exactly is the purpose? The employer needs to drive that and drive it effectively, and then good things can be achieved in a number of those areas although not necessarily all of them. It is perfectly possible, and should be the case, that competent nurses, trained doctors - there is absolutely no reason why doctors cannot learn from people other than doctors. If it is set up in that way it works well. If the training of doctors and indeed any other professional is ignored, it will not work well. It comes from the same point: what is the purpose of this, and how do we set it up in such a way to make it work? Ms O'Dea: The experience in our trust is that where you involve the clinical professionals, doctors and nurses, senior doctors and nurses, at the coalface, in the redesign of these roles, it works extremely well. If you hand them down and tell them how things are going to change, it tends not to. They take into account that the juniors will need training. I can give you a couple of very good examples. Currently, we have nurse practitioners that take the place of SHOs on the rota. Professor Lesley Regan, who was involved in the design of this, tells me that not only does this vastly improve patient care because of the continuity, but also it assists in teaching the juniors that are still coming through. She is very keen to continue with that practice. Equally, we have nurse practitioners working alongside doctors in the care of TB patients, and the studies have shown that those patients comply with the drug regimes far more when they are seeing the nurse practitioners. It is very difficult to put a cost on that or a saving, in terms of productivity; but there is a very clear benefit in terms of patient care. Q397 Chairman: The think tank Reform gave evidence to this Committee and they said that the NHS should have more investment in fewer people - and they were talking about a percentage reduction in the workforce; that with the right investment there could be a better National Health Service. Do you think there is a risk that skill mix changes means that we are dumbing down the NHS workforce? Ms Norman: This is the point that Hugo has made. Dependent on the motivation and the big picture that you are looking at of skill-mix change, it can be enormously enabling as well. It can enable somebody with more advanced or developed skills to be able to devote time to that. Often, those criticisms of the NHS in terms of the people who are non-clinical, who are clerical administrative staff - I see little purpose in one of my highly qualified nursing colleagues doing work that one of our clerical colleagues could do better, in order to enable that nursing colleague to spend time with patients, and managing his or her team of colleagues. Equally, at the other end of the scale, properly trained and qualified assistant practitioners, who can undertake very important aspects of the fundamental care of patients, for example ensuring patients who need assistance with eating are provided with that assistance, are fundamentally important. It is all about the quality of management and the way that you deploy the art and science of skill mixing. Q398 Mike Penning: Can we develop a little more the effectiveness of changes. How well do the current workforce planning structures in the NHS encourage work on skill mix and role redesign? The leading part of this is, how could it be improved? Nothing is perfect, so how do we move on from here? Ms Norman: The way that it can be improved is building on what has worked very well in the past, for example the work of the Modernisation Agency previously, and increasing the new Institute for Innovation and Skills, in supporting good initiatives and enabling other organisations to follow on. That is a key role for NHS employers as well. One of the major criticisms of the NHS is that you have a very good idea in Shrewsbury but do you do it in Stafford? Q399 Mike Penning: Everybody is re-inventing the wheel, all around the NHS? Ms Norman: Yes, or, rather more worryingly re-inventing the flat tyre, which can also happen. Often we learn more from people's mistakes than we do from their successes. It is about giving people the tools to undertake the work within their own context and environment, and sometimes the use of drivers. There is no doubt that bringing down access times for patients has been a real driver for change. Sometimes it has felt like quite hard work, but it has been a very good thing in liberating our thinking and our ideas about what essentially is a team endeavour in healthcare. You do need to work with a team to get these ideas into place and working properly. Q400 Mike Penning: Individual teams in different parts of the NHS, even though they may be doing exactly the same job, are not developing at the same speed; they may be doing very well but there is no continuity throughout the NHS. Ms Norman: I think there is more than there was because of the work that has gone on, for example, through collaborative projects, in cancer care for example. The cancer collaborative has provided us with a really clear framework, and indeed in terms of measuring our performance in cancer you jolly well need to respond to that toolkit if you are not actually delivering. There is no doubt that there is still work to do. Within organisations you will find some things that are day-to-day working practice, and other teams might be less open to it, so you need to do your own internal work on that. Dr Mascie-Taylor: Locally, to encourage employers very strongly to look at the most effective way of performing their functions, so support from the centre for local employers, taking on these issues and working with the professions locally. As has already been said, that produces far more ownership and far more likelihood of success than some imposed directive. The difficulty with that is that it produces lack of symmetry, and one has to accept a degree of lack of symmetry if you want to empower local people. The balance is, I think, with empowerment rather than looking for symmetry, which hopefully addresses ----- Q401 Mike Penning: Is not the problem with that though that if you do not have symmetry, you increase the postcode lottery in healthcare? Dr Mascie-Taylor: Yes, there is an absolute balance to be struck - I agree with you. You cannot necessarily always have both. You have to have some of both. I would go for empowering local employers to work with local people, but set a balance, because there is a national role which seems to me about offering examples of good practice to employers and helping them learn from them and providing evidence that they work, that is they achieve that which they set out to achieve, and they do not achieve other things - so to be clear about that. I think that nationally it would be useful for more departmental support explicitly for employers; and, again in that balance, slightly less engagement with individual colleges, which have a vital role in training, education and good-quality service delivery; but they also have another role, which is about the interests of their members. Q402 Mike Penning: The drivers that Alison was referring to, so a sympathetic driver rather than a target-driven driver. Dr Mascie-Taylor: Yes, but these are all balances, are they not? I agree with you that we should avoid postcode lotteries when we can, but you have to do this at a local level if it is to work. The trick is to have a fairly light touch from the centre about specifics, and a strong drive from the centre about supporting and enabling employers as opposed to dealing with endless professional bodies and, if you like, picking up too strongly on their vested interests. Q403 Mike Penning: Is there a light touch coming from the centre? Dr Mascie-Taylor: It varies. Q404 Mike Penning: That is a politician's answer! Dr Mascie-Taylor: This would be the last place for me to blame politicians! Professor Sibbald: The situation in general practice and primary care outside the acute sector is much more challenging. There is a need to have a clarity of objective as to why you are changing skill mix. This has been said before. It is a solution to a problem, so you need to analyse your problem carefully to know whether a particular skill mix change is right for your organisation - and it may not be. That goes to your point that there needs to be local variation. The second point has to do with good human resources, skills and management, which are not think on the ground in primary care. They are small self-employed businesses generally speaking, and they do not have the kind of input that enables them to make complex skill mix changes to support the process of change very easily. It is difficult for me to see how that can be altered. It needs to be addressed. The third thing that is different about primary care is that often changes in skill mix happen much more rapidly than in the acute sector, partly because they are small organisations and are less tightly managed and regulated; and that often means that you have employers, employees - nurses in particular - taking on new and expanded roles, without yet having an educational infrastructure to support that change. That is where there needs to be a much more responsive educational system to keep pace, as it were, with the changes going on in that. Ms O'Dea: I would agree with Dr Matthew Taylor that the important balance here is between the local ownership - without that these things just do not work - and central regulation, I suppose, of how we consider whether these things have worked or not. I have seen some very good practice. South Tees in particular has a very good practice around deciding that things have not worked and stopping them; and I would like to see some more of that. There is good practice from the employers' organisations, their large-scale workforce team, sharing best practice. Within that also we need to ensure that people implement that best practice in the way it was intended, and do not over-egg the jobs that people are not qualified to do. I think that I would recommend that the Institute of Innovation and Improvement and the Employers' Organisation need to set a framework for us around the testing of these jobs, and ensuring the safety of these jobs and that they work. That is where the centre comes in; it is in setting frameworks and doing some education. Q405 Mike Penning: That is very interesting because it sounds very ad hoc as to what best practice is being shared at the moment; so would you say that the NHS is good at piloting these sorts of projects, and are they pulling together the information well enough and distributing it throughout the NHS so that everybody does not re-invent the wheel every five minutes, and so that you can share the best practice in a more sympathetic way rather than moving on, as we discussed, with a postcode lottery system? Ms O'Dea: It is the "not invented here" syndrome that tends to be the problem, rather than the centre saying, "let us pull this together". It is a need for local ownership, and that is the balance that we have to get right. Q406 Mike Penning: Where you have got local ownership and somebody is doing it quite well, with best practice and so on - is that being drawn into the centre and then distributed back out correctly, with the correct amount of information; or is it done ad hoc throughout the organisation? Ms O'Dea: I think it is a mixture. In the large-scale workforce team, for example, the alternative support worker has proved very popular and has been a very successful initiative. It has been taken up by NHS employers, and they are supporting local employers in implementing this new role. Those initiatives are excellent. We have to make sure that the others are tried and tested and really do achieve what they set out to achieve in the organisations that are testing them, before we get over-enthusiastic about sharing that practice. We often share it before we have really tested it. Q407 Mike Penning: Is the funding there to do this, or are you robbing Peter to pay Paul to get this funding? Is the funding coming down from central government to allow you to do that? Ms O'Dea: There are some national workforce projects that are fully funded to go out and pilot, for example, what we ought to be doing around team-working; what we ought to be doing around the European Working Time Directive. However, local employers will see their own needs and will invest in improvements that they believe benefit their patients and their staff. Q408 Mike Penning: Many local employers in the NHS are in deficit, so there is quite a difficult decision to be made here, surely, as to whether there is a funding need or not; and if it is left completely up to the individual trust or individual strategic health authority and they are in deficit, it is not going to happen, is it? Ms O'Dea: As I said, there is a mixture. There are some central initiatives, but there are also local people who want to make changes for the better within their own organisations, and they will continue to find the money to do that if they believe that will improve ----- Q409 Mike Penning: I wish they could find it in my part of the world! Professor Sibbald: You asked about the evidence base for change. As a researcher, my evaluation is that there is a wholly inadequate evidence base to support most skill-mix change - that people for example believe that nurses would save money when substituting general practice; and the evidence base is that that does not happen. My view is- as I would say, as a researcher - that we need more research! Q410 Mike Penning: More research, more money, of course! Professor Sibbald: Also more money for the research. Dr Mascie-Taylor: In terms of mechanisms by which people learn, some of it can usefully be through a national centre, but a great deal of it is horizontal, and some of it is international. There are a number of mechanisms, all of which work in different ways. In terms of evidence base, it is crucially important if we are to convince various groups of professionals of the need to change. Finally on resources, there is resource, but if one were to compare the amount of resource to the resource that drives clinical change, it would be far less. Less resource goes into service change than into clinical change. Ms Norman: What we need is the opportunity for there to be a framework whereby good practice could be disseminated, and an ability within the organisation to have organisational development resource to bed it in. That is something that traditionally NHS organisations have not been terribly good at. It is something that often gets squeezed first in times of difficulty. Where it does work, if I could give an illustration - the emphasis that was driven to some degree politically some years ago, around enabling non-medical people to prescribe, which is now coming into play - if you like it was a political idea that was enabled through the NHS system and the strategic health authority. However, it is down to individual organisations to make sure that they have planned how that will be implemented and that they are careful about who goes to do the course, and that they are then able to work in practice. An illustration of how well that can work: we have a consultant in palliative care, a nurse in my organisation, who works closely with the Macmillan community specialist nurses in Manchester. We believe we are getting evidence (a) that because of the prescription of opiates, pain-controlling drugs, by that nurse prescriber fewer patients are having emergency admissions, and less use is being made of our out-of-hours GP locum or on-call systems. That has got to be better for patients. What I would love to be able to do is to have Bonnie come and research this because I do think there is a dearth of research into some of the changes that we are making, and it would be good to be able to demonstrate that. Q411 Mike Penning: It is quite interesting that you use the analogy of palliative care, which is outside the NHS in most cases. We draw down on them enormously - the Macmillan nurses and the hospice movement in general. It would probably be great to see Bonnie come in and do some analysis on that, to show what is going on. Ms Norman: The NHS of course does fund it. In terms of Macmillan, they give their name and their money for three years. The name stays but the NHS often, or the individual hospice, picks that up. Q412 Mr Campbell: When we talk about spreading innovation within the National Health Service, because we have heard in evidence that it is always a bit slow on the take-up when it comes to that sort of line, can we learn anything from the independent sector on innovation? Can they teach you anything? Is there anything there? We are told in evidence that the private sector is better than the NHS at innovation. Do you have any evidence of that? Dr Mascie-Taylor: I am absolutely not familiar with the evidence that it is better than, but absolutely open to the idea that the private sector innovates well. I would argue that in certain areas the NHS innovates well. I do not see a lot of point in which is better at it. I think they do it differently. What might be really helpful would be for me to look at the freedoms the private sector has to innovate. If one accepts, for the sake of argument, that the private sector innovates well and maybe better, what is it that allows it to do that? I think it is about the fact that it is often in limited areas of business as opposed to global business. It therefore can direct its workforce more appropriately. It is often less constrained. It has a limited area of activity, and far greater managerial freedom. It is less heavily directed, less heavily regulated, and less heavily target-driven. If you accept your thesis that it is good at it or better at it, you have to look at what are the factors that allow it to be good at it or better at it. My view would be that it is about limited rates of activity, greater managerial freedom, and probably less power amongst individual professions and unions. Ms Norman: We can also learn lessons from the "not-for-profit" sector. If you look at organisations like the Marie Curie Cancer Care and Macmillan, those organisations are very close to what people want and how people are feeling; hence they come forward with services that meet those needs. The fourth point to add to Hugo's very excellent list would be being close to the patient and to the community; and perhaps the NHS has not always been as good at that as it needed to be. Dr Mascie-Taylor: That is because they often in a necessary but limited area. Professor Sibbald: I would say that NHS general practices - and the important thing here is that they are independent contractors into the NHS - are some of the best innovators in the world, and they adapt to change extremely quickly. I am thinking here of general practice-based counsellors as an example - mental health counsellors. There were about 12 in the country in 1980; by 1992 a third of general practices had one on site; and by the late 1990s more than 50% of general practices had them on site. The other point I would make is that the extended multi-disciplinary teams in general practice in this country are thought to be the best model by other Western developed countries around the world - so the United States, Australia, Canada, France and New Zealand. They are all looking to our model of care as to the way they want to move in their country. Q413 Mr Campbell: Will payments by results make it better to get innovation from the Health Service - or is that a tricky question? Dr Mascie-Taylor: A really tricky question! Ms Norman: It will if it works. Dr Mascie-Taylor: You could construct it in such a way that it might. If you are going to use a quasi market system to drive change, the changes which it produces will depend absolutely on the ability of the market-makers to drive change. I do not think any of us know, on this side of the table, quite how that market will be constructed, and therefore in what way it will drive us. We await with interest. Professor Sibbald: I would say again the difference between the acute and the primary care sector is that payment by results will reward the acute sector for activity and volume, so it is a volume-driven thing. People have an interest in doing more, which is a desirable thing in some respects. In general practice however the payment system there is paid for performance and is about quality of care produced; and that is only a segment of income that is balanced by capitation and other basic fees. That blended payments system, as it is often known, is thought by most academics at least to be the best possible balance in terms of achieving high‑volume and high-quality care. Q414 Dr Naysmith: The Modernisation Agency was scrapped a couple of years ago. We had some evidence here that that might have been a loss. Andrew Foster, for instance, said that the skill mix projects had become more fragmented as a result of the loss of the Modernisation Agency. Do you agree with that? Ms O'Dea: I think there is a gap that needs to be taken up by organisations like NHS Employers. We have to use the infrastructure that we have now to co-ordinate it in the absence of the Modernisation Agency. Q415 Dr Naysmith: Do you think it was doing a good job in this area? Ms O'Dea: I think it raised the profile of these sorts of things across the sector in a way that that profile had not been raised before. Q416 Dr Naysmith: Do you think you will have to find some other organisation to fill its place, or to do the role that ----- Ms O'Dea: I think the needs may be slightly different now, but I think there is still a need for some central framework around some of this, as we have been talking about this morning. Q417 Dr Naysmith: What has been the impact on the National Practitioner Programme? Do you think it gave the wrong message, that it was not really a priority? Ms O'Dea: I think that where these innovations were started they have continued. What is really important was that people locally started to think about what was the best way to deliver care. We have a plethora of examples to show that where that continued, it continued very well. It served its purpose extremely well in getting local people to change the way they were practising. Q418 Dr Naysmith: Dr Mascie-Taylor, do you think it has meant fragmentation and giving the wrong messages - scrapping it? Dr Mascie-Taylor: I think the Modernisation Agency played a useful role. As I indicated earlier, there are many ways in which people learn, and one of those ways is through a central body, and the Modernisation Agency in part was that. I do not think that is the only way of doing it. I cannot see a great deal of point in getting into a debate about whether it was the right or wrong decision; more important is the need to look to the future and recognise that the centre, the national body, has a role, not the only role, in producing useful change and innovation, and also in producing the research that would support it. How you want to badge that is a secondary question that I would be happy to talk about, although I do not consider myself particularly expert. If, as often appears to be the case, there is a perceived need to change a national organisation, it is sometimes easier for the service if what it does changes, whilst its name does not. What is particularly disruptive is when its name changes and what it does does not! Ms Norman: The Modernisation Agency was a turn-around team for practice, to help practice be fit for purpose and be able to meet different challenges. We continue to need that kind of supporting service. Q419 Dr Naysmith: Where is it coming from now? Ms Norman: As Deborah said, I think NHS employers can help fill that gap. There has been space left, and we need to find ways of filling it. If we need finance turn-around teams, as is happening quite a lot in the service, we also need that kind of support to help us turn around services and to get that spread of good practice. I do believe - I probably would say this, would I not - that NHS employers can help with that, along with some other organisations. Q420 Dr Naysmith: They have got lots of other NHS employers who have lots of other things to do as well; how can it be made a priority, if it should be a priority? Ms Norman: I think its priority would be brought about because unless we get service delivery right, we will not manage our finances properly within the Health Service; we will not manage quality properly and we will not manage access properly. Really, it is about modernising the way we do things and ensuring that people are being employed appropriately, both for patient care and also for their own job satisfaction. Sometimes organisations need something outside themselves to assist them with dealing with those issues. Interestingly, we are just spending money on bringing somebody who has got their training in the Modernisation Agency and is now working independently, to come and help us with our radiology waits in our organisation. In times gone by, I suspect that we might have got that service free! Q421 Dr Naysmith: We also had evidence suggesting that the Modernisation Agency's approach was sometimes too simplistic, and also that it did not involve clinicians enough. Were those two criticisms fair? We are talking about an agency that has now been scrapped, and that is fair enough, but we are learning lessons for the future as well. Ms O'Dea: We are, but a great deal of good came out of the Modernisation Agency. You have just heard that we are still employing people who were trained by them and a lot of us have received a lot of training and a lot of excellent tools, and took that out into the field. Most of the work that I have ever been involved with, with the Modernisation Agency, gave me tools and attributes to take out and work with our clinicians. At the coalface, I think clinicians have always been involved where projects have been successful. When they are not involved, projects are not. Q422 Dr Naysmith: Do you agree with that, Ms Norman? Ms Norman: Yes, I do. Sometimes it is difficult to engage clinicians of any discipline, in something that feels theoretical and abstract. If you can show people it makes a difference to the lives of their patients and their working lives, that is when you really get hearts and minds. Q423 Dr Naysmith: So you think that if the agency trained enough evangelists to go out there and spread the word ..... Ms Norman: There can never be enough evangelists. Q424 Chairman: Is there any contradiction between national evangelists and local ownership? Ms Norman: I think it is about a really good franchise, is it not? You sometimes need help outside of yourself, and that is what the external resource can give you. However, you have to have the capability, confidence and desire to drive that locally. You cannot just take a solution from one place and apply it without customising it. Q425 Chairman: You do not think there has been a reluctance to listen to evangelists, on the basis that "your model does not fit here"? It seems to me that there is no great national plan, although we might have a National Health Service, about how we should run GP practices, because the needs of different communities are so divergent in many instances. Dr Mascie-Taylor: I do not think I would take the view that all general practices should be run in the same way, because, as you point out, the needs of their populations are very different. Importantly though, general practices, just like secondary services, should be run in a way which benefits the patient as opposed to benefiting the people providing the service. If there is an area here that should be tested, it is what is the function of the organisation, not the need for symmetry, but a need for an absolute focus on the function. Then the form follows that function. Q426 Dr Taylor: Can I go back to some areas of concern, some of which has been touched on, the first of which is the training of doctors. With the almost universal use of lobotamists at the moment do medical students get practice with taking blood during their training? Dr Mascie-Taylor: They do. Q427 Dr Taylor: Enough? Dr Mascie-Taylor: Well, is it ever enough? They do get that practice, and indeed doctors in training get that practice. I have to say that the amount of practice that I had as a junior doctor far exceeded my requirements. There is a difference here between that which is necessary for training and that which is necessary to provide a service. The important point is, let us discriminate between the two and let us not use people for service where it is inappropriate, but equally let us recognise that they have to be trained. If you are clear about the purpose, you come to the right answer. Q428 Dr Taylor: As far as putting up drips, do they still get enough practice with that, even though the nurses are doing most of that now? Dr Mascie-Taylor: In part, the answer to your question is that nurses are doing most of it. The difficulty I think is that with the particular patient where the nurse practitioner may fail - what was then inappropriate is to let the doctors do it when they are less skilled at it. I have absolutely no difficulty with nurses or indeed any other group of people becoming skilled in areas where traditionally doctors were skilled. My view is that if it is a particularly difficult access problem then you might need to call on the skills of a particularly skilled doctor, for example an anaesthetist, rather than making the assumption that any doctor can do it simply because they happen to be a doctor. Q429 Dr Taylor: That is absolutely right. One of the first examples of skills mix, which was absolutely crucial, was the introduction of ward clerks, which took away paperwork from both doctors and nurses. With deficits will there be a threat to this sort of post? Ms Norman: One can never predict what pressure might do to people's common sense, but I would certainly resist that in my organisation, should it be the case. I would hope NHS employers can assist organisations that are in difficulty, and that we could manage what may, I hope, be a short-term financial difficulty well, so that we do not throw babies out with the bathwater or do things that cost the organisation more money or cause dysfunction. Q430 Dr Taylor: You would also be protecting nursing assistants, the people who feed the patients who need to be fed. Ms Norman: I think what one has to have at the heart of the whole thing is where the patient experience comes in and the degree to which organisations can be as concerned about evidence of good patient experience as they are about the financial bottom line. That has always been a hard balance to achieve. For organisations which aspire to be successful foundation trusts, for example, they will not prosper if the evidence about patient experience - and we have national surveys now that can tell us if people do well or not - if those surveys suggest people are doing badly, one of the questions in the national survey is, for example, whether you got the help you needed with being fed. If you find yourself falling to the bottom 20%, I would hope the commissioners of your services would take an interest, and, more importantly, that you would be interested in dealing with that. Q431 Dr Taylor: Can you expand a little bit about nurse practitioners improving continuity of care? One of the complaints I get consistently, particularly about in-patients, is because of shift systems and continuity of care goes by the board. Are nurse practitioners in a position in hospitals to assist continuity of care? Ms Norman: I think they are. We have a system which is very common in many hospitals, where you have a group of colleagues who work out of hours, supporting the medical teams, forming the first line of support. They will be on duty for a period of time during the week, and some patients will see them quite frequently. Sometimes you may consider the patient gets discontinuity because they may get a different person. I suspect what is important to that patient is that the nurse on the ward gives a proper brief and hand-over; and if that patient is in pain or requires the siting of a cannula or they require the commencement of treatment, my view is that what the patient wants more than anything else is that that happens quickly and competently. We obviously have to be concerned about not fragmenting the care that patients get, but often it is efficiency, speed and quick response to the need. If I can give you an illustration of where this works well; we have colleagues working with teams, largely in the out-patient setting, called nurse commissioners, who effectively do the work that registrars used to do. So we now have a colleague working in a firm or practice who has her own out-patients' clinic; she works alongside the professorial team; she undertakes quite invasive procedures for patients; and she is somebody who, particularly for patients who have survived the treatment but may require further intervention - she is the continuity that has been there for a decade. That is what nurses can very often add to the party for the patient, if you like. Q432 Dr Taylor: The point that Professor Sibbald made was that in some cases where nurses are taking over work, doctors are not giving this up. Can you give us some examples of that? What sorts of things were you thinking of? Professor Sibbald: Nurses and doctors both dealing with minor and self-limiting illness in patients who are on same-day appointments in general practice - coughs, cold and flu. Instead of surgeries being arranged with some sort of triage for those patients that are directed to the nurse, both the nurse and the doctor will continue seeing those patients. Those types of problems are almost limitless in the population. If you offer the places, the patients will fill them up! Dr Mascie-Taylor: On continuity of patient care, we can no longer rely on a particular staff working very long hours. We have not yet fully replaced that. We have to look at single sets of notes - multi-disciplinary team working and IT solutions. It is a real problem. Q433 Dr Taylor: Single sets of notes between nurses and doctors and all professionals, including psychiatrists? Dr Mascie-Taylor: If appropriate, yes. There may be some difficulty at the margins. Mike Penning: They would have to be handwriting experts! Q434 Dr Taylor: So, single sets of notes. Are we really coming towards that, whereby nursing and medical notes are being combined? Dr Mascie-Taylor: We are undoubtedly moving in that direction. We need to move more quickly. More importantly, it reflects an attitude of mind that what matters is not which profession you are in, but that we are caring for the same patient and the information can be shared. That is the challenge. The challenge is not a physical set of notes; it is the attitude that underlines multiple sets of notes. You can drive that through IT solutions as well as in a number of other ways, which we can discuss if you wish. Q435 Dr Taylor: How are improvements in technology affecting skill mix? Ms O'Dea: Sadly, a number of my staff find themselves jobless this week because of NHS jobs, which was absolutely marvellous. We have saved hundreds of thousands of pounds by having jobs on the Net rather than having to advertise them, and by linking our workforce systems directly into the NHS jobs network, so that we do not have to re-key. Nobody has to photocopy bits of paper or run round the hospital handing them out. I will end up with a group of staff that are more senior, and more professional staff and less junior staff. We are having to redeploy those staff, but that one action will have saved the NHS hundreds and hundreds of thousands of pounds through technology. Q436 Dr Taylor: Can you think of any clinical technological advances that have reduced ---- Ms O'Dea: PACS. It is fabulous in what it does. Not only has that reduced the need for hundreds of people in dungeons in hospitals to run around and try to find films, and then try to get them to the right place at the right time; but it also means that doctors have access to those images immediately the patient is there, and anywhere for teaching. It is fantastic! Q437 Dr Taylor: How generalised is PACS now? Ms O'Dea: It is increasing. Dr Mascie-Taylor: It is becoming more generalised. It is an expensive system to put in, and I think one of the difficulties with PACS is that ----- Q438 Mike Penning: Where there are deficits. Where there are financial problems, it is not coming through. Dr Mascie-Taylor: It is not simply deficit; it is about the cost of ----- Q439 Mike Penning: But it is a real problem. Dr Mascie-Taylor: It is a problem, but then in medicine in its broader sense you will spend whatever money is available. The skill of management is to make the best use of resource. PACS drives through quality of care. What is less clear about PACS is that it will cut cost, so again we need to be clear about the objective. If you are looking to improve quality of care, PACS will do it; if you want to reduce costs, it will not. It is the same discussion about skill mix: what are you trying to achieve? Q440 Sandra Gidley: We heard from some people that there is a feeling that specialist nurses and particularly nursing specialist roles are becoming increasingly specialised and narrow in focus. Is this a good thing generally? The other thing that has been put to us is that they often do not like having to perform the basic nursing skills. The phrase has been used before, but are nurses too posh to wash these days? Ms Norman: The challenge for nursing is that they have got to be able to wash and they have also got to be able to perform specialist roles in terms of role substitution for doctors and the needs of patients in the service. I do not think we can do one or the other; we have to be able to do both. I would say that it would probably not be the best use of nurses in developed roles to have them washing patients as well. For example, I told you about the example of our nurse clinician. I do not think it would be a good use of her skills to have her looking after the personal care needs of one of our in-patients. However, I think that personal care needs in patients are as important. The trick that we have to pull off is to ensure that within the nursing workforce you have a proper spectrum and that you value all the component parts of that. In terms of the point at the heart of your question, we often get very seduced into discussions about specialist roles, when we also need to be very concerned about the support and training for the unqualified staff who are working alongside the professionally qualified nurse, and maximising the contribution and the ability of the band 5-starred nurse. You need those people to be good at managing resources and be optimal in the range of clinical skills they have got. Q441 Sandra Gidley: I would like to challenge your use of the word "unqualified". I think people working alongside nurses in those roles would feel they have a qualification of some sort. It may not be a nursing qualification, but I do not think the word "unqualified" is fair. Ms Norman: I apologise; I should have used the word "unregistered"; but equally we are very fortunate in \Manchester; we have benefited from the work of the strategic health authority in setting up a very excellent practitioner programme. The key thing for organisations is that you do not invest in colleagues and train them and support them to a qualification which is a foundation degree in fact, for those colleagues in Manchester, and then have them coming back and doing exactly the same job. You have to enable them to develop that. Q442 Sandra Gidley: Professor Sibbald said when talking about the change in skill mix that it was very difficult to see that any cost-savings had been achieved because of the different ways that nurses consumed resources, and that the evidence base is not there to show cost-saving. With the new clinical roles, such as medical and surgical care practitioners, is cost the only option? Are we improving productivity or improving the service we give to the patient? Has any work been done to show that it is not just cost, but that we can provide a better service through skill mix? Professor Sibbald: In general practice nurses can add quality to the care, so it is cost-neutral and they are adding quality. For example, patients tended to rate their satisfaction with their practitioner more highly when that practitioner was a nurse as compared to a doctor. Part of the reason for that, we think, is because nurses were less productive in offering longer consultations with patients and they were seeing them more frequently; but that was something that was very much valued by patients. We also know that nurses tend to give more information and advice to patients, which is again something they very much appreciate. We know too that nurses working for example managing chronic disease clinics in general practice - that that is a model of care that improves the quality of care for those patients, compared with the situation where the physician tried to do that with a routine consultation. Adding quality to care is something that nurses can do. Dr Mascie-Taylor: Looking at the question slightly differently, if you look at the targets that the NHS has now broadly achieved, if you look at the A&E target, where the targets that we now have largely met would be the envy of many Western countries - they have been met because of changes in the skill mix in part. A bit depends on what you regard as evidence, but the NHS would not have responded in the way it has and increased its capacity to deal with things more rapidly if it had not entertained many changes in skill mix and many changes in systems. There is pretty good sense of increased productivity in that sense. A lot depends on the nature of the evidence you are looking for. Professor Sibbald: A pre-requisite for a skill mix is that you have a large population to serve of relatively undifferentiated conditions, or at least there is a high volume of a particular thing; because that is the only situation in which you can sustain this ever-increasing specialisation and role differentiation, both among physicians and between physicians and nurses. That model of care then drives the system towards having larger, more complex teams, and that means that if you are not going to expand the volume of care, you are getting fewer general practices because they have to be bigger and more complex; and that model of working is not necessarily efficient, let alone cost-effective for example in rural settings, with low population densities. The question of whether skill mix can improve productivity goes inherently to the nature of the patient population you are serving. I would also add that there are costs that we have not talked about yet clearly here today, of having larger and more complex teams. If before you had one, say, general practitioner that managed all the problems in his or her presenting patients; and now you have to have the physicians, the receptionists and three nurses each dealing with a particular kind of chronic disease - cardiovascular, muscular-skeletal - then you get a problem with the co-ordination of care. There is a management cost to having larger and more complex teams that also needs to be considered. Q443 Sandra Gidley: Do teams need to be doctor-led? Some of the submissions from doctor organisations have said that is very important to retain. Are they just defending their own interests or are they really necessary? Ms Norman: Where you have a consultant physician-led service I do not think it is inappropriate for the doctor to be the team captain. Preferably they do not need to play any roles, and many people do not have much problem with that, but there may be issues where you are spear-heading new services where there may not be physician involvement and that is where that kind of approach and attitude can stymie it. In years gone by in some of the primary care developments, nurse practitioners for homeless people and things like that, that kind of attitude did create barriers to those developments. Dr Mascie-Taylor: This may not be popular with my colleagues but in a multi-disciplinary team people should bring to that team their expertise. Somebody in that team needs to have expertise in leadership but it may or may not be the doctor. Sandra Gidley: That is very refreshing. Q444 Dr Taylor: The European Working Time Directive, could we have met it without the extended roles of nurses? Ms Norman: Absolutely not. Q445 Dr Taylor: How will we cope with the 2009 requirements? Ms Norman: We will have to become even more clever in terms of the point made by your colleague about ensuring that as nurses colonise roles previously undertaken by medical personnel that we do not abandon the important things that nurses do. Q446 Dr Taylor: What scope is there for extending the roles of other people, such as physios, OTs and MLSOs? Ms O'Dea: I am fortunate enough at St Mary's Hospital to be chairing a group with about 15 consultant medical staff, a group of nurses and some others, to look at how we are going to maintain the quality and safety of patient care 24 hours a day, 7 days a week, 365 days a year, with all of the changes that we are going to face in modernising medical careers, modernising nursing careers, with my own Trust loosing 3,000 hours of junior doctor time a week by 2009. I would like to agree with Dr Mascie-Taylor that our local consultants are actually telling me we are not being radical enough on your thinking. They are very keen indeed to do this in a multi-disciplinary team-led way rather than a doctor-led way, and these are consultant themselves. We are going to ask Professor Michael West, who has done a lot of the work around the links between multi-disciplinary team working and reduction in patient mortality, to come along and work with that group so we understand exactly how to design a workforce that enhances the use of the multi-disciplinary team. That is a physician-led request. We have supported those doctors with a leadership programme to ensure that they had the skills and access to the work that has been previously done around the creation of new roles, including the work previously done by the Modernisation Agency, so that they can define what the need is as a multi-disciplinary group of very senior professions and they have the skills and the knowledge to look at what other people have done and say is that going to fit here or is it not. Dr Mascie-Taylor: Could you give us an idea of the sort of extra things physios, for example, could take on? Ms O'Dea: In our own Trust we have some physiotherapy-led clinics and out-patients rather than having people constantly see orthopaedic surgeons. Those sorts of things prove very popular. We are beginning to understand the skills and knowledge that are going to be needed to bridge that 3,000 hours gap, and only after we have done that will we define from where those skills and knowledge should come, from which of the professions. Something that both Alison and Hugo said earlier is you start by looking at what you need to treat the patient. You put it into a block and say these are the knowledge and skills we need at this time of the day to ensure we have quality and safe patient care. You then redesign the roles around those looking at what other people have done, looking at what the nursing profession, the physiotherapy profession and the medical profession brings, and then decide where those roles can only be done by professionals and where those professionals need some additions to their current role in order to take this forward. Professor Sibbald: If the problem you are trying to address is a medical workforce shortage, then the obvious solution is to have more doctors. There are other strategies for doing that and I know this committee has, and will, consider those things. The reason for me making that point is as we change skill mix and develop very new roles for nurses and other health professions, they are not going to go away in the future when we have an adequate supply of physicians. You need to think in the long-term about whether the effectiveness, efficiency and quality added through these changes that we might make for a short-term need will be sustained into the future. I do not see a lot of evidence one way or the other about that. Q447 Dr Taylor: Thank you for that warning. Dr Mascie-Taylor: When asking what is the work to be done, too often there is an assumption it is work that needs to be done by a specialised doctor, which is usually not the case. What is the work to be done and who do we have available to do it, that will drive some change in skill mix. Finally, a point you made, sometimes for highly complex services where you do require large teams of technically driven people you have to be prepared to take hard decisions about centralising services. Q448 Chairman: A number of Accident and Emergency Departments have changed their process so patients are now seen by a consultant as soon as they arrive in order to speed up the decision making, and the quality of decision making is a lot better for that. Does this not show that one of the important things is where we deploy skills as well as what skills we have? Would you agree with that? Would any of you think this could go beyond A&E and into other areas, certainly in the acute sector? Dr Mascie-Taylor: I think the crucial thing in A&E is to recognise that doctors in training should be providing less of the care and be receiving more training. They are not fully trained and the rate of decision making is probably too slow. If a decision needs to be made by a doctor, the consultant is the one best equipped to do it. The specific of your question is who sees the patient at point of entry to the department. There are two ways of doing it: either a very experienced triage nurse or a very experienced doctor. Either of those will work and neither is right nor wrong. What does not work is lack of experience or lack of a system which triages patients. You need the right person in the right system but you do not have to be dogmatic about what is their background. Q449 Chairman: Could you extend that into other areas within your hospital in terms of people with more experience seeing patients earlier or quicker? Dr Mascie-Taylor: I do not have the evidence but my intuition is the more quickly patients are seen by an experienced member of staff, whatever their background including doctors, the quicker will be their treatment, the more appropriate, the better the quality of care, and the more productive it will be. That is not surprising as it is the same as in any other walk of life: the experienced professional will do better quicker. Q450 Chairman: What might be surprising is we are actually having this conversation. As far as patients are concerned, most of them would think they would see the top people when they are taken into A&E. In some instances they do, where it is an obvious situation coming out of a motor car accident or something like that. Otherwise, is this deemed to be a part of training of doctors as opposed to other things? You do not see a consultant when you first go into A&E so why is that? Dr Mascie-Taylor: It is in part because of the very varied nature of problems that present at A&E, many of which can be dealt with by people other than a consultant, and part by a relative lack of consultants. If we had the financial and human resource capacity to have every single patient seen by a consultant as they arrived in A&E, I suspect what we would see is some increase in quality of care, some increase in rapidity of care, and a very substantial increase in cost. Q451 Charlotte Atkins: Professor Sibbald, we have already heard from you that your research has shown that using nurses in place of doctors is cost neutral. You were saying it improved the quality in terms of patient care, but your research showed that nurses are more likely to refer patients to hospital. Why is that, and does that mean that patients are less likely to receive appropriate care if seen by a nurse? Professor Sibbald: They were not universally more likely to refer but there were, in a sufficient numbers of studies, that you got a small effect in that direction. The short answer to your question is the appropriateness of those referrals was not investigated so I cannot directly answer your question. I can indirectly answer it by saying that the health outcomes for those patients were not altered, either more favourably or the reverse, through that referral, and the cost of that referral was taken into consideration in this overall determination that nurses were cost neutral. Q452 Charlotte Atkins: Do you think there will be any impact by GP commissioning on this process? Professor Sibbald: The most likely effect of GP commissioning, as it was with fund holding, is some marginal change in where they direct patients in the acute section and a big effect in terms of moving services out of hospitals and into the community, and in particular into their own general practices where they can provide a wider range of care. Generally speaking, the way they have expanded service, the range of service provision and practices, is to hire more specialised nurses to undertake that work. Q453 Charlotte Atkins: What proportion of current primary care work is done by GPs? This is obviously in view of the fact that their contract has meant fairly substantial pay rises for GPs. Are they doing less and getting more? Professor Sibbald: Yes. Q454 Charlotte Atkins: Do you think that is justified? Professor Sibbald: No. Q455 Charlotte Atkins: I am very sorry that we do not have on of our members on the committee here today because he is a GP and I am sure he would have wanted to come in there. Professor Sibbald: I can say on what basis I give that answer. We conduct national surveys of general practitioners in this country, about 1,000 GPs. We surveyed the same panel immediately before and immediately after the contract. We asked them to report their hours of work and their pay. On average doctors were reporting a £15,000 increase in pay and a four hour reduction in their working week. We have a panel of 45 practices where we do detailed investigations of quality of care and we have been following this panel since 1998. What we can see is there has been an increase in the quality of care steadily over this period of time, and the new contract seems to have added further value to that, so we are getting something for our money. Q456 Charlotte Atkins: This extra four hours they have to play with, I assume they were not donating that to the work of the local Primary Care Trust? Professor Sibbald: I do not have an answer to that. Q457 Charlotte Atkins: When was your research done? Professor Sibbald: The after survey was conducted in the autumn of last year, and the before in the spring of 2004. Q458 Charlotte Atkins: You were saying you think that with GP commissioning there is going to be more activity within the community, if not within GP surgeries themselves. What changes to skill mixes are required when that happens? Obviously it is emerging, it is happening now, but what are the changes in skill mix we need to do now to meet that challenge? Professor Sibbald: This, and the most recent White Paper reforms as well as the new contract, will reinforce a trend that has been evident very strongly in general practice from at least 1990, which is that you are going to get larger more diverse teams of health professionals. In particular, you will see greater role differentiation amongst GPs within a practice, so partners become more specialist in particular areas at the expense of being generalist in all areas. You will have more nurses employed in practices, and those nurses will have more specialised roles than they have had in the past. Pharmacists are another health profession which plays an increasingly prominent role in primary care delivery in minor illness management, to medication review and in repeat prescribing, among other things. Q459 Charlotte Atkins: Will this be at the cost of patients not being able to see their GP, which some patients value? Professor Sibbald: Yes. That trend has been evident for a very long time. As the size of the team increases, the opportunity for patients to see the doctor of their choice, or indeed the nurse of their choice, declines. That is widely known to be true and has been shown across Europe in studies. We know too that patients value continuity of care, so they do not like that change, but the question is what are they willing to trade-off for that. Many patients are quite happy, as was suggested earlier, to see any professional who is competent to deal with their problem quickly and simply, but the most vulnerable patients are the ones who most often value continuity. People with serious and ongoing problems, particularly of a psychological or distressing nature to them, prefer to see the individual with whom they have built a relationship. What I cannot say is globally what impact that will have on the quality of their care, as the evidence base for that, although extensive, is divided as to whether loss of continuity has a negative and damaging affect or not. Q460 Charlotte Atkins: Hopefully if we have this one set of notes in primary care as well as in acute care we might overcome that problem. Given that a number of nurses are likely to be made redundant in some acute settings in hospitals, what scope do you see for these nurses going into primary care from hospital settings? Professor Sibbald: There is considerable scope. The tradition has been for general practice to be staffed by nurses who first worked in hospitals and later in their careers moved out into the community for a wide variety of reasons. I would say there is every opportunity for them to do so. Q461 Charlotte Atkins: Lastly, do you think that primary care generally has had enough of a priority in terms of role redesign? The whole of the medical system seems to be geared up for hospitals and not so much primary care. Is that changing or are we still seeing that the focus, in terms of innovation and role design, is at the hospital level? Professor Sibbald: I would say two things. Where general practice loses out is in access to good human resource management expertise and skills which are much more available in acute trusts. On the other hand, I think that their degree of distance on the innovation front has been an asset to general practice. They are small businesses. They are usually quick on their feet in terms of making skill mix changes, often leading them in the country. I do not think that they suffered in terms of innovating in terms of roles within practices but they could do with more HR skills. Chairman: Could I thank you all very much for coming along this morning. I am sure your evidence will be invaluable when we come to draw up an inquiry at some stage, very likely at the end of this year or the beginning of next year. Thank you for your evidence this morning.
Memoranda submitted by the London Ambulance Service and the Royal College of Physicians
Examination of Witnesses
Witnesses: Dr Sally Pidd, Chair of the Recruitment and Retention Working Group, Royal College of Psychiatrists, Mr Rob Darracot, Director of Corporate Strategic Development, Royal Pharmaceutical Society of Great Britain and Mr Bill O'Neill, Head of Education and Development, London Ambulance Service, gave evidence. Q462 Chairman: Thank you very much for coming along. Could you, for the sake of the record, give us your name and the organisation you represent? Dr Pidd: I am Dr Sally Pidd, Associate Dean for Workforce at the Royal College of Psychiatrists. I am also a practising clinician in the North West of England. Mr Darracot: I am Robert Darracot, Director of Corporate Development at the Royal Pharmaceutical Society of Great Britain, the professional regulatory body for pharmacists. Mr O'Neill: I am Bill O'Neill, Head of Education and Development for the London Ambulance Service. Q463 Chairman: Thank you very much for coming along. This is our fourth evidence session on Workforce Planning. Your organisations have all recently been involved with changes to skill mix and the development of new and extended clinical roles. How effective are current workforce planning systems in helping to make these changes? Dr Pidd: The mental health professions as a whole have worked very hard over the last few years to look at new ways of working in mental health. This was led initially by concerns about psychiatrists and their roles. People were finding increasingly that consultant psychiatrist roles were becoming over-extended and they could not deliver an adequate service, and because of those concerns a national steering group was set up to look at new ways of working for psychiatrists which has moved into now looking at new ways of working in other mental health professions as a whole. That work went alongside the work of the Mental Health Care Group Workforce Team which has now been disbanded. That is of some significance because that Group had an overarching remit to look at the mental health workforce as a whole and make recommendations, for example for increasing commissions for clinical psychologists or training numbers for psychiatrists. With that joint remit of looking both at the numbers needed and then at the changing roles not only of psychiatrists but other mental health professionals, the Mental Health Care Group Workforce Team was able to tie together quite well the planning aspect for the service as a whole. With the demise of the Mental Health Care Workforce that has been lost to some extent. To balance that, the changing remit of the Workforce Review Team to cover not only doctors, which it initially did, but all other relevant professions, it remains to be seen how that works out. In a time when we have seen a huge development of new roles in mental health, particularly in response to the NHS plan and the working out of the National Service framework for mental health, it is a critically important time to get the workforce planning right, both from the top down and from the grass roots up, when so many roles are changing, in order to deliver a service. There are some things where central control has its place, but in looking at changing skills mix you have to start down at the service level. Mr Darracot: We very much welcome this opportunity to come and talk here today because workforce is a particular issue for us at the moment and we have spent time looking at that. Pharmacy is a little bit complicated because the majority of pharmacists delivering service on behalf of the NHS, or to NHS patients, are employed in the private sector which makes workforce management a little more complicated. You are right to highlight the fact that we have, in both secondary care roles and in primary care now increasingly, pharmacists moving into more clinical activities and, therefore, extending their roles into those areas. We have been working with the Department of Health and the Welsh Assembly government on developing a workforce planning model which covers both the NHS and the private or community sector, which, rather than providing any answers, supported the need for some of the changes which have been proposed in recent legislation, particularly with regard to skill mix within the pharmacy workforce. The planning model, which hopefully we will be launching to the world at some point very shortly when we have dotted the "i"s and crossed the "t"s, highlights the gap that currently exists, which everybody felt was there in the first place but we now have some evidence and a rather robust model for that. The workforce team have also made some recommendations as to how pharmacy needs to adapt to resolve some of those issues. It is fair to say that while it has highlighted the gap there as well, some of the recommendations we have already seen starting to happen. For instance, the move from an essentially manipulative activity in the supply and provision of medicines into working more closely with patients about medicine as utilisation. What we are seeing now is the start of automation, and the greater involvement of automation both in the secondary and also primary care sector. One of the suggestions that comes out of the workforce model is we need to look at different ways of doing existing tasks, and we welcome the opportunity to talk to you about it. Mr O'Neill: We are in a slightly unique position in some respects in so far as the major impact for us has been the introduction of the role of ECP. Q464 Chairman: We will go into some detail about that. It is about this overall workforce planning system that we have at national level and the helpfulness that has been. Mr O'Neill: The reason I mention that is because that has been, in many respects, the catalyst which has led to us look at the rest of our workforce. To be honest, we are still in a "what about the rest of the workforce" situation at the moment, and it is hard to describe it without bringing the ECP into it. Q465 Chairman: Maybe that would be a good way of doing it. What I was trying to probe was whether the workforce planning systems inside the NHS particularly how well funded or should be better funded or better allocated in terms of where funding goes to which body. I do not know if you have any firm views in that area, or maybe you could pick it up later on. Let us move on. Q466 Mike Penning: If you feel you want to answer that question later on, that is fine. How can we encourage individual organisations and managers to do more work of this type to move this on? Dr Pidd: This is where there is a need for national work to filter down, and to filter down effectively, to local organisations. If I give some examples from mental health, the New Ways of Working group, which produced its final report last year, demonstrated that it is possible to pilot different ways of working and then to evaluate those pilots, but then you need a mechanism for disseminating the results of those pilots, of changing roles, for example changing the role of pharmacists to be involved in clinical activities within mental health. For that work to be overseen by a national body, in this case the National Institute of Mental Health, you then need a mechanism for disseminating that out to areas and then encouraging that down to local level. Q467 Mike Penning: Are you saying those mechanisms are not in place at the moment? Dr Pidd: They are in place at the moment through the regional development centres, but I think often to take those results and implement them locally there often needs relatively small pump priming monies, for facilitators for example, if you are looking at changing the skill mix within a team. If I give another example, one of the outputs of the New Ways of Working Group has been the development of a creating capable teams toolkit which enables local teams of any sort, be it in children's services or community mental health teams, to examine the local needs, the local skills, and the local skill mix to see if the service could be redesigned to produce better outcomes for patients. Service users are a part of implementing that. The work has been done at a national level to produce this toolkit, but in order to implement it locally you may need some skilled facilitation and some time. Q468 Mike Penning: Would money be the driver for this to happen? Dr Pidd: I do not think it is a lot of money; it is often a small amount of money. Q469 Mike Penning: Clearly it is not coming through now? Dr Pidd: It is not coming through in the way it perhaps needs to. I think a lot of learning from the national pilot sites in New Ways of Working both for psychiatrists, advanced practitioner nurses, and so on, is not getting down quickly enough. Mr Darracot: I think we are in the process at the moment where there are some key building blocks in place. If you look at the community pharmacy side for a moment, there are proposals in the Health Bill which will enable some of these skill mix things that may be need to happen in the community to take place. We need some legislative change. There are some long-standing provisions by which pharmacist's responsibilities in community pharmacies require them to be present, there is a physical presence aspect, and some of the proposals in the Health Bill take us a little bit further forward on that. We welcome the opportunity to talk about flexibility because as pharmacists do get into more clinical roles, either spending more time with individual patients within the pharmacy itself or outside the pharmacy location, then you need some flexibility to sort out the problem of the physical presence which has been a feature of the law for some years. We are really looking forward to discussing the regulations that may fall out of that. We are in the process of actually doing something about it, which means sorting out some of the legislative aspects. There then comes a point at which we need to really highlight to the profession at large what those new possibilities are, how people who start to take those opportunities can use them and how that improves services for patients. It is incumbent upon us all to highlight that to the profession. With all of these things you are looking at people working a particular way for a long time. Some of these opportunities are quite different ways of working and we need to highlight that. I am not saying it is necessarily a matter of funding. We have a new pharmacy contract in the community which is bringing about some of these new roles anyway, but there is a legislative issue there. In the secondary care sector we are still coming out of the finishing of the completion of the Agenda for Change programme. That has left us with some issues that still need to be resolved and I can discuss those at some length. We are waiting to see how that all falls in place. There are one or two key things coming up which I would highlight at this stage which are pinch points in the system, and they are rather further back in the generation of a pharmacist than the actual service delivery, in the sort of training programme. Pharmacists currently are trained as scientists so the funding stream for pharmacists is through HEFKE, so science funding as opposed to clinical funding. As pharmacists get into more clinical roles, there is a question mark about how that training is funded, particularly the exposure of pharmacy students and pharmacy at the pre-registration level to patients and how that is facilitated. If you just have a science funding stream, there is little provision within that for clinically based training. Q470 Mike Penning: It is a very tight gateway, is it not? Mr Darracot: The higher education institutions have a range of ways of dealing with that but it would help if some of that was looked into. Q471 Mike Penning: Perhaps we can come back to that. What about the ambulance service? Mr O'Neill: That comes into the issue for us as well. We had the publication last June of the Ambulance Service Review from the Department of Health. That, alongside with the work that has been conducted by the Ambulance Service Association employers and the British Paramedic Association, is giving us far more of an idea of where we are going in terms of our skill mix and the way that we implement some of that. I am trying not to touch on ECPs yet, but for us the issue is about how we get that funding. We traditionally provide our training in-house so it has not been associated with higher education which has been gradually coming in over the last decade I would suggest. Certainly now with the standards of education that are set by the Health Professions Counsel, with the curriculum guidance published by the British Paramedic Association, we see ourselves in a far more higher education direction, which is right. We do not want to throw the baby out with the bath water and move away from the in-house apprentice route, but we are scratching our heads, to some extent, how we are going to fund this because nothing seems to be coming to light. No matter which way we turn, we seem to be getting some blank faces in terms of how to make this transition. Q472 Mike Penning: You get that from politicians sometimes. Have these new workers in these new in extended roles replaced existing workers or have we put a whole new tier in? Have we kept the existing workers and put in a whole new tier of skilled workers. Dr Pidd: In mental health they have largely come in alongside existing practitioners, so within community mental health teams there has always been a mix of social workers, community nurses, doctors and occupational therapists. New workers coming in, for example working more on the primary care/secondary care interface, is a new layer if we are talking about gateway workers or graduate workers. Q473 Mike Penning: They have not replaced but there is a whole new layer. Dr Pidd: They have not replaced them in function, but one of the workforce issues has been that as new roles have been identified the existing workforce have moved into them which has sometimes left gaps. Q474 Mike Penning: Have people then come in to fill those places so there is an increase in provision? Dr Pidd: Certainly within mental health services the new roles have enhanced the service. For example, there is no shortage of psychology graduates interested in moving into clinical work. There have never been enough training places for clinical psychologists which has left a gap in the service. We have now created a new role for psychology graduates to come into the mental health workforce in a primary care setting gaining skills, and doing this at a time when the notion of the skills escalator within the NHS means that people are coming in and can progress along different career pathways than used to be the case. Q475 Mike Penning: We will go on to ECP quickly, but I do not know if it affects you. Mr O'Neill: It is too early to say because we are not sure the extent to which the introduction of this new role is going to impact on numbers of other roles we have. Q476 Mike Penning: Your main problem will be funding, as you just discussed. Mr O'Neill: Yes. Mr Darracot: In pharmacy, as an example of the secondary care sector, some of the new roles pharmacists have gone into have followed a recognition that medicines are important parts of the health care system. There is a lot money spent on them, and the appropriate use of the pharmacy skills around use, and the use of the medicines, if you invest more time and energy in that as part of the clinical team, then you end up with better outcomes for patients. In terms of what the pharmacist does there, the additional parts of those roles really have taken over some of the roles that might be elsewhere in the team. They are carving out a role in independent prescribing and this will save time elsewhere in the system. As to what the pharmacists were doing which now allows them to do these new roles, that has largely been delegated to more technical staff. Q477 Mike Penning: It does not look as if you have increased your workforce but have delegated skills around so the skill base has increased within the existing staff. Mr Darracot: The roles around the supply of medicines have been largely delegated to technical staff, yes. Q478 Charlotte Atkins: You have been incredibly patient but you can now tell us about emergency care practitioners, what they do and how they fit into the emergency care workforce. Mr O'Neill: I think it would be fair to say that I can only really tell you how they work within London. It would be fair to say how they work in other areas of the country is not necessarily the same as the way they work in London. One of the issues that we do have is there does not seem to be a consistency in what is understood as an ECP across the country. In terms of what they do in London, they effectively support both our operational response to 999 calls and are given the opportunity to work with other local health care providers to be able to help with some of the out-of-hours work, et cetera. The way it is working at the moment is we do not have anybody who has come through the ECP programme fully trained and out the other end; they are all in what you might call a development stage. Q479 Charlotte Atkins: How long have you had these? Mr O'Neill: The current cohort are in their second year. They will end up with a diploma working through St George's at Kingston University. I have to be somewhat vague about some of this because some of it is quite vague in terms of why it has been planned the way it has been planned. If that sounds like I do not know what I am talking about, to an extent this whole thing grew up outside of the auspices certainly of my department and my remit within the organisation. It was kept in this vacuum and developed there and we are now picking up some of what may have been mistakes that were made along the way in trying to develop this role. We do have a situation where, at the moment, there is a lot of development time with our ECPs and not a great deal of operational time. That is something we are trying to address and pull that back around. We are not seeing the effectiveness we might have expected to see at this stage, but it would also be fair to say that the evidence is not telling us anything other than they are being as effective as could have been projected at this point. Q480 Charlotte Atkins: It always amazes me that within the Ambulance Service nationally there is loads of innovation going on in particular areas and it is not taken up by other ambulance services. What is the overall rating of your ambulance trust in terms of stars? Mr O'Neill: Two. Q481 Charlotte Atkins: You are hoping that these ECPs will help increase your overall performance. Mr O'Neill: Yes. Q482 Charlotte Atkins: Can you tell me, at this stage, what sort of percentage of emergency admissions your ECPs are enabling you not to take to hospital? Mr O'Neill: Of the calls that they attend, the non-conveyance rate is about 50% as opposed to about 25% for a traditional ambulance response. Q483 Charlotte Atkins: Michael was asking earlier about funding, so presumably there would be an overall saving to the Health Service because you are not taking them to hospital because it would cost you much more per patient to do that. Presumably that is where some of the savings will come to develop this particular role. Mr O'Neill: I believe it costs about half of what it costs for a patient to go through the Emergency Department; the range is between £24 and £29 per patient visit by an ECP as opposed to around £55. Q484 Charlotte Atkins: £55 seems a bit low to me. Mr O'Neill: Those are the figures I have seen in the research. Q485 Charlotte Atkins: You say in your evidence that ambulance staff do not have medical advice routinely available, but in some ambulance trusts they do have medical advice routinely available, do they not? Mr O'Neill: There are varying forms of advice. I think every operational ambulance person would be able to pick up a phone or radio and get medical advice. We have someone on duty 24 hours a day who is able to pick up on the kind of calls that crews call in and say "I need help with this." Q486 Charlotte Atkins: Do you have a team centrally to which your ambulance crews can ring who are experienced in the whole area of emergency service? They ring in and will get the advice so there is routine medical advice available? Mr O'Neill: It is not used routinely but used for those situations where the crews feel themselves stumped and do not know how to proceed. Q487 Charlotte Atkins: You do not use a Telemedicine system? Mr O'Neill: No. Q488 Charlotte Atkins: I know some ambulance services do use that and are able to get from the patient the status of the patient and feed that straight back to the medical team, so they work on that very effectively. I am surprised, given the challenges faced by the London Ambulance Service, that that is not routinely done in London. Mr O'Neill: It is done for certain conditions. For example, the new policy we have for direct admission into cath labs for people who have confirmed heart attacks, there is that back and forth communication going on, but for the majority of calls, unless the crew make a decision that this is something they need advice on, then it is not done routinely. Q489 Charlotte Atkins: You do not use the technology available to give information to the medical team back at base? Mr O'Neill: The medical team as such is going to be one person who is an on-call medical adviser. Q490 Charlotte Atkins: We have already spoken about the 25% decrease in the number of people taken to hospital, but in the meantime A&E departments are having increasing numbers of patients going to A&E. What do you think the potential is for this particular development to reduce A&E admissions? Mr O'Neill: The target for our service is to reduce the number of patients we take to A&E by 200,000 per year within the next five years. Q491 Charlotte Atkins: What percentage is that of your present admissions? Mr O'Neill: About a quarter. Q492 Charlotte Atkins: What plans do you have, given we have had the review of the Ambulance Service, to learn from other innovative practices in other services? Mr O'Neill: Now that we have got fewer services with the amalgamation of ambulance services across the country, that should be easier to achieve. It would be fair to say traditionally it has been very difficult to share practice among ambulance services. That has increased with the publication, several years ago, of the new joint Royal Colleges' Ambulance Liaison Committee Practice Guidelines. We saw people coming together from ambulance services, more so than we saw before, to share good practice and set a national standard. We have started to do that a great deal more than we did 10 or 15 years ago and I can see it continuing to do that. Q493 Charlotte Atkins: I am quite surprised by that response because you had this star rating system, which presumably is in place to ensure that excellence is recorded and presumably learnt from. At the moment, apart from that Committee you are talking about, there is no way of improving on the performance which exists in individual ambulance services. Mr O'Neill: I think the Ambulance Service Association is a means by which we do share some other good practice, and certainly in terms of what we are looking at around skill mix and what the shape of the workforce needs to look like in the future, that kind of area is something we do quite well. In terms of ambulance education, we have improved a great deal in terms of sharing the way we do things amongst ambulance services. In the past there were enormous differences between what we do in London and what other services did, even just around the length of the training courses. That has improved a great deal so despite my focusing on the development of the practice guidelines there are other areas that we have shared good practice. Q494 Jim Dowd: You said that with ECPs, what you described as the non-conveyance rate went up from 25% to 50%. The savings thus indicated do not go to the LAS, do they? Mr O'Neill: No, not necessarily. Q495 Jim Dowd: In fact, it might cost you more to have that rate. Mr O'Neill: In some respects yes, and in some respects no. As far as it will cost us more to train these advanced practitioners, but then we are only sending one person as opposed to sending a double-crewed ambulance. At the moment we are unable to say. Q496 Jim Dowd: I readily accept it is far better in terms of service, and far better for the tax payer who pays the bills for all of them, but within the labyrinthian complexities of the NHS finances you also have this target of 200,000 over five years. Was that self-imposed or was that agreed with the acute trusts? Mr O'Neill: It was self-imposed to an extent in so far as it was based on us looking at outcomes for patients who we take to A&E and being able to safely judge that those patients could have actually got definitive care or been as safely left at home rather than being taken to A&E. It is based on the actual outcomes of our patients. Q497 Jim Dowd: To follow up Charlotte's point about why the increased non-conveyance rate has not reduced attendances at A&E, I realise you are only speaking for London but can you give us an indication normally what proportion of A&E attendees are brought by ambulance? Mr O'Neill: I do not know. Q498 Dr Taylor: I am a bit confused about the training of ECPs. You start with paramedics and then you give them extra training. Is this standardised throughout the country or does it vary from ambulance service to ambulance service? Mr O'Neill: It varies, in some cases hugely. Q499 Dr Taylor: Certainly that is the impression. You said this was a three-year training. Mr O'Neill: Two-year university based training. Q500 Dr Taylor: Is that day release or night release? Mr O'Neill: Basically they are full-time ECPs. Q501 Dr Taylor: You lose them for two years full time. Mr O'Neill: The programme is two years long. We get between one and two days operationally out of them depending on the student themselves. There is a lot of flexibility. Q502 Dr Taylor: How does this fit with regulation? Your paramedics are regulated by the Health Professions Council. We believe there are nurses in training as ECPs as well. Mr O'Neill: Yes, some. Q503 Dr Taylor: Surely the training should be regulated by somebody. Mr O'Neill: It will be, I believe, but at the moment it is not. The British Paramedic Association would like to see the regulation brought in under the respective regulation for each different profession who is involved in this programme. Q504 Dr Taylor: A separate bit in the nursing to do that. Mr O'Neill: Nursing for nurses, and paramedic for paramedics. I know there are other opinions that there should be separate regulation for ECPs, and to the best of my knowledge that has not been decided on yet. Q505 Dr Taylor: Your people in training are not yet out on the road as ECPs? Mr O'Neill: No, but they are regulated as paramedics. Q506 Dr Taylor: On the medical back-up that you think they should have, your paramedics who are giving thrombolysis presumably are connected to a cardiologist? Mr O'Neill: We do not use thrombolysis in London. Q507 Dr Taylor: Because you are able to get them to a centre to consider re-vascularization quickly enough. Mr O'Neill: Yes. Q508 Sandra Gidley: Before I move on to the questions I was expecting to ask, can I just pick up on that. If you have different bodies regulating the same role, could you not end up with differences between the regulation depending on whether they were ultimately regulated by the nursing body or the paramedics? Mr O'Neill: This is not a specific area in which I am involved. Q509 Sandra Gidley: I have some questions for Rob Darracot, and I need to put on record that I am a member of the Royal Pharmaceutical Society. The written evidence commented that the role of pharmacy technicians and assistants has been extended in recent years. You alluded to this earlier but I would like some clarification. Has extending the roles of non-professional staff made the overall pharmacy workforce more productive or differently productive? Mr Darracot: In so far as I think that extending the roles of technical staff allows the pharmacist to do different things, I think it has extended the overall activity of the pharmacy profession as a whole. Q510 Sandra Gidley: The submission also says that there is a predicted gap between supply and demand of pharmacists. Does that mean it would become more important to have more technicians or other pharmacy staff that are not actually pharmacists? Mr Darracot: That would be one way of plugging the gap, because a significant part of the role of the pharmacy profession is the supply of medicines and you could see that could be fulfilled in some way by various forms of automation. That is one way of dealing with that. Automation in itself is not the answer because machines are only as good as the people who are operating them. It does change the balance of what is required but also the productivity goes up in terms of the actual handling of the medicines themselves. With 700 or 800 medical prescriptions a year being generated in the NHS, that is a continuing growing burden of purely technical activity outside of the cognitive activity that goes alongside it. Q511 Sandra Gidley: The submission seemed a little bit cautious about extending the roles of junior staff and I wondered why that was. Is it a sort of doctor/nurse situation where sometimes you get doctors wanting to hang on to their traditional roles? Do you have pharmacists feeling threatened by pharmacy technicians taking on extra roles? Mr Darracot: I am sure there is an element of that within the profession. The submission is a little cautious because we are in a period of change. We are regulating technicians at the moment only a voluntary basis and we are expecting to have the statutory authority to do that shortly. We are in a process of change anyway, and before we get to the point where we have statutory regulation of pharmacy technicians I think it is right to be cautious as to what we will do. The other thing we have embarked upon in the last six months is a major review of our education policy in how we regulate the education of pharmacists and the education of pharmacy technicians. The statutory regulation of technicians really means that we need to take a fresh look at how we regulate the education of technicians. Something may then fall out of that. The key to all of this is to identify the sort of scopes of practice. You have the scope of practice of pharmacists changing as they explore and go to new areas, something which has been supported by policy documents from the Government here but also in the devolved administrations. There will be a knock-on effect into exactly how we define what actually is the technician's scope of practice. Q512 Sandra Gidley: You mentioned legislative change earlier and the Health Bill has provisions for changing the way that the community pharmacy particularly is supervised, so instead of the current situation we have the pharmacists continually on the premises. That could actually change. Does that not mean that there is a greater need for regulation of technicians? What are pharmacists going to be doing if they are not on the premises? Mr Darracot: First of all, I think the regulation of technicians is an important part of that because any of the changes which are suggested may come about as a result of the Health Bill will, if the pharmacist is going to do other activities, either on the premises, which means they are not in a position to directly supervise the supply of medicines, it will require that activity, if that activity is going to carry on without their direct and personal supervision, to be done by somebody who is trained to do that. I would expect the pharmacist not to leave patients in that position without that being the case, but I think having regulated technicians is part of that package. So whilst we welcome the flexibility that the Health Bill offers and we look forward to the discussion on the regulations, I think there are two other things which we will be very mindful of. First of all, that any new system ensures that patients' safety is not compromised; secondly, that one of the things we have talked about often in office, that pharmacists are readily accessible health officials. I think what you have alluded to is that if we are allowing the flexibility for pharmacists to undertake activities outside of the pharmacy then there is a question, therefore, about how access to that service is going to be maintained. So in developing those regulations I think we need to be very mindful of both of those points: that patients' safety will not be compromised if pharmacists are undertaking other activities, which I think fundamentally requires the regulation of other practitioners within the pharmacy setting, and secondly that we do not throw the baby out with the bathwater and lose the access to the pharmacy service which is currently available out there now, right now, walk-in off the street and there it is. Q513 Sandra Gidley: You mentioned earlier that the role of pharmacy was changing and one of the suggested questions, which I thought was rather unkind - I will read it out, and I do not expect you to answer it - "Are not most pharmacists over qualified for many of the tasks which they actually perform given that prescribing is mostly done by doctors and the majority of drugs are pre-packaged?" I think that displays a lack of knowledge, personally, about what pharmacists do do. I just wanted to put that on the record. Would it be fair to say that the new contract gives pharmacists a lot of opportunities to provide different services, but how is that actually benefiting the patient when a lot of those services are just extensions of what is happening maybe in a GP's surgery or could also be provided by nurses? Mr Darracot: I would answer your initial question by maybe saying I notice that the NHS workforce survey says that there is a 65% increase in the pharmacy staff in the last ten years in hospitals, and I say about time too. I think what is very important is that what we are starting to use now for the first time is the very expensive training that pharmacists get in the use of medicines, and pharmacists are uniquely qualified to deliver that service. Frankly, my view is that if those services are delivered by anybody else because of the complexity of modern medicines then actually we are not doing right by the patients, and that the extended role begins to use for the first time, in a fuller sense, the very training that pharmacists spend five years acquiring. Q514 Sandra Gidley: I have to say, if I felt that my training had been used I probably would not be sitting here today, I would probably still be a pharmacist; so I have to concur with that. Finally, practice-based commissioning: will pharmacists get a look in? Is there an opportunity for pharmacy or will it be dominated by GPs? Mr Darracot: It should be but the earlier signs are not good. I think that is partly just the way things are but also partly because of the pressures within the service generally. But I think there is scope there and if other health professions do not recognise and help that along, then I think they are also missing a trick actually. Q515 Dr Naysmith: Dr Pidd, I want to explore what this role extension and substitution that we have been talking about has meant and potentially could mean in the future for mental health services. You have already mentioned - and you have also written in evidence that you have submitted to the Committee - that there is a shortage of psychiatrists in the UK. So to what extent have mental health services compensated for this shortage by extending the roles of other groups? Again, you have already mentioned clinical psychologists this morning, and the New Ways of Working Report, which I think you yourself authored. Dr Pidd: Undoubtedly one of the drivers for new ways of working for psychiatrists was the chronic shortage; we have historically had vacancy rates of 15%-ish for psychiatrists, which remains stubbornly stuck almost whatever we do, and it seems that we have so far failed to bridge that gap. That has meant pressure on psychiatrists and their working practices. So I think some of the driver for looking at how mental health services as a whole can be provided does come from that starting point. But I think there is also recognition that psychiatrists have not always been doing things that only psychiatrists, only people with medical training could do within the mental health workforce; and also a recognition that we work within multi-disciplinary and multi-agency teams. Therefore, looking at the skills at each of those members of the team and how they can be enhanced to provide a better use for the service users and carers I think has underpinned all the work on new ways of working. Because alongside that we were disappointed with the demise of the Modernisation Agency because the Changing Workforce Programme was a big driver for looking at developing new roles and extended roles and supplementary roles to enhance the overall mental health workforce. So I suppose it has partly been to make up for the lack of fully trained psychiatrists, but I think it has also enabled us to think more critically about what it is that each member of the al health workforce can bring to the care pathways of patients. Q516 Dr Naysmith: It is interesting, is it not, that when talking about the Choice Agenda - and we are not here to talk about the Choice Agenda today - people do suggest that one of the things that people using mental health services would like would be the ability to chose their main worker, whether it is the psychiatrist or clinical psychologist or a social worker or a psychiatric nurse, and that ought to be a driver too, ought it not? Dr Pidd: Yes, I think it certainly is. I think one of the problems about changing roles is that patients' expectations sometimes do not match the workforce changes that take place because often people say that they would like to spend more time with their psychiatrist, whereas in fact under the CPA arrangements the person they are probably likely to see most of is their care coordinator, who may be from a number of different disciplines but is unlikely to be a doctor. So I think there is something about respecting patients' choice but also trying to provide them with a rationale for why seeing a psychiatrist is not perhaps what is needed on a weekly or a more regular basis, and seeing somebody from another discipline can meet their mental health needs in a better way. Q517 Dr Naysmith: Have psychiatrists been reluctant to give up tasks that have normally or traditionally been allotted to them, to other staff groups? Has there been a reluctance in the profession at all? Dr Pidd: It is always very difficult to generalise because psychiatrists are not known for being like sheep, which are all of a same mind. There is undoubtedly a hard core of psychiatrists, probably of an older generation, who have a very clear idea what their role is and do not wish it to change. I do not think that is true of the majority of psychiatrists. We have all trained in multi-disciplinary settings and very much see our role as to be part of a team, whether it is an inpatient team, a community team, an Assertive Outreach team. So certainly amongst the younger generation of psychiatrists there is an expectation that their role is very different from that of a psychiatrist who had their own huge caseload which did not really interact with anybody's caseload at all. Q518 Dr Naysmith: We have been told that the new role of Graduate Mental Health Practitioner has not been particularly successful in the sense that few local services have made use of them. Is that true in your experience? Dr Pidd: I am surprised that that is what you have heard. Q519 Dr Naysmith: It was the head of the National Health Service Workforce Review, Judy Curson, said that. Dr Pidd: It is a relatively young role and so I think it is perhaps unfair to make judgments at this stage about it. I would guess most services have only had the experience of graduate workers over the past two or three years. Also, I think when graduate workers were first introduced there was not a robust framework within which they could work, so I think some graduate workers were placed into primary care as a sole practitioner, and really with quite a limited remit, without perhaps enough backup from other services. But I think with the development of primary care mental health services, which I think is going to continue apace in the coming years, the graduate workers will be working alongside clinical psychologists or nurse specialists with CVT skills; they will be working alongside counsellors, they will be working alongside community psychiatric nurses who are doing rapid screening and triaging of patients, as well as offering short-term intervention. So I think the graduate workers will find their place, and I think it is one of the problems of workforce planning and workforce changes that sometimes not enough time is given for new roles and new services to bed down before a judgment is made as to whether they are going to be effective or not. Q520 Dr Naysmith: That is very helpful. How do the STR workers - and for the audience and for the note taker I had better say what that stands for, "support, time and recovery" workers - fit into this? Dr Pidd: I think they are fitting in extremely well. The idea of support, time and recovery workers came very much from service users and carers identifying that what they needed more of were people who could given them hands-on time helping them in activities of daily living, negotiating their way through the benefits system, perhaps facilitating their use of occupational activities and therapeutic activities. We have always had within the healthcare system a huge number - they used to be called unqualified staff - of non-professionally qualified staff, who have had a variety names, and care assistants and support workers have been part of the mental health service for as long as I can remember. I think the introduction of the STR workers has added a professional dimension to what they do; they are not just the people who run around doing the odd jobs to support people. But for many users of mental health services they are their first port of call and their main support, their main advocate. So I think STR workers - although I think the numbers that were suggested in the NHS plan were fairly artificial - in fact is one of the groups that has been quite enthusiastically embraced because there was a ready pool of people already working as OT assistants. Q521 Dr Naysmith: So would you say that they have improved productivity in the service? Dr Pidd: I think it is difficult to define what productivity is in these terms. I think if we are talking about the quality of patients' lives then undoubtedly STR workers have enhanced the quality of patients' lives, their ability to access facilities that everybody else does. Certainly in terms of social inclusion agenda, for example, I think STR workers may not recognise that is what they are doing, but think effectively that is what they are doing - that they are acting as a bridge between the world, which many people with severe and enduring mental health problems find quite a frightening place to negotiate, and they are facilitating their re-entry. Q522 Dr Naysmith: It is certainly something that you would want to encourage? Dr Pidd: Yes, I certainly think so because the role of medication, for example, in the treatment of mental health services is only a relatively small part for people - it is a vital part - but making sure that they can access housing benefits and recreational activities certainly promotes the recovery model and that is absolutely vital. Q523 Dr Naysmith: Finally to round all this up, we started off talking about the shortage of psychiatrists and you mentioned all those other people who make up the team, but there must be variation in availability from one part of the country to another in how these teams are made up. Dr Pidd: Yes. Q524 Dr Naysmith: Do you think that people adopting new roles is sustainable into the future in order to compensate for the shortage of psychiatrists? We will probably need more psychiatrists in the future rather than fewer, given what is going on. Dr Pidd: I think we probably need at least the number that we have at the moment, if we were fully recruited to them, partly because of the changing demands. For example, when the new Mental Health Bill finally surfaces that will undoubtedly place more demands not just on psychiatrists but on other mental health professionals as well. But I think in terms of the sustainability of new teams, from a workforce-planning point of view one of the difficulties has been that a lot of the top down instructions about the composition of teams and how many functional teams you need for areas was predicated on urban areas. So I come from, relatively speaking, a rural area and it does not match very well. So I think there is a need to ensure that there could be local variation to meet the local services, but also making sure that areas which are struggling, either for financial reasons or for recruitment reasons, are having difficulty; that there is some mechanism in terms of the oversight of the Strategic Health Authorities or the reformed PCTs, the larger PCTs, to ensure that services are still commissioned with an equality of access to all these different professionals rather than areas that already have those services continuing to have them and other areas struggling. Chairman: Could I thank you all very much indeed? Could I just say to Mr Darracot that one of the roles we do play around this table is being the devil's advocate on occasions - we do not expect witnesses to take everything personally? Thank you very much indeed for coming along and helping this morning. Memoranda submitted by Health Professions Council, General Medical Council and Nursing and Midwifery Council
Examination of Witnesses
Witnesses: Mr Marc Seale, Chief Executive, Health Professions Council, Mr Finlay Scott, Chief Executive, General Medical Council and Ms Sarah Thewlis, Chief Executive, Nursing and Midwifery Council, gave evidence. Q525 Chairman: Good afternoon, I am sorry we have started a few minutes later. Could I ask you, for the sake of the record, to introduce yourselves and the organisation that you come from? Ms Thewlis: I am Sarah Thewlis, Chief Executive at the Nursing and Midwifery Council. Mr Scott: I am Finlay Scott, I am the Chief Executive at the General Medical Council. Mr Seale: I am Marc Seale and I am the Chief Executive at the Health Professions Council. Q526 Chairman: Thank you very much for coming along and to help us. Could I declare my interest, as I am currently a lay member of the General Medical Council? Could I ask an opening question to all of you? How are regulators helping to develop a workforce that is fit for purpose for the 21st century, as opposed to just developing more of the same? Ms Thewlis: You have three regulators here and one of the things as a team - and I think we do work collaboratively across it - is very much looking at seeing regulation in its broadest context and not just seeing it dealing with unfitness to practise issues. So very much looking at the individual registers we keep and making sure that people who come on to those registers are capable of what we call safe and effective practice. We all do that in very different ways because obviously we have different professions that we work with, but I think very much when you are working at workforce planning it is about making sure that people that come on to the register are competent - but that is obviously something that the individuals themselves have responsibility for - and also to work with employers. At the Nursing and Midwifery Council as a new body we have worked very hard with employers about making sure that we can provide a flexible workforce. I am sure we will go on to some more detail, but just for the record there was some conversation about the emergency care practitioners and I think it would be helpful to say what our position on that is, and I am sure that Marc will come in and do some of the detail. Some of those people who are nurses, who have gone into emergency care practitioners, one of the important things to say is that if people are on a professional register then obviously they have signed up to a professional set of standards and a Code of Conduct by which they are regulated. So I think the argument about who regulates them is probably a secondary point. The important thing is that somebody regulates them, and I think one of the discussions that we are going to have for the review of non-medical regulation is looking at some of these emerging roles that come out and how those get managed. But I would very much want to put it on the record, I would not want you to think that there are people out there doing things and nobody is actually controlling that. Mr Scott: Good afternoon. To answer your question, to recall that we have four statutory functions, although to read the Press and listen to the radio and television you would often think it was only one, namely dealing with doctors who are impaired. The other three functions, that is Standards, Ethics, Education and Registration, all help us to contribute to the shaping of the workforce through influencing not only undergraduate medical education and training, but also the attitudes, the ethics and principles that doctors take to their work day by day and, as with the Nursing and Midwifery Council and other regulators, the very direct control over who joins our register from outside the UK and the EEA. In addition we ensure that we always consult widely on any proposals that we wish to make. For example, when we laid down new guidance in 1992 on the undergraduate medical curriculum that was the result of extensive work involving others, and as we are revising that at the moment again we are ensuring that we fully involve representatives of the public, employers, and of course representatives of the profession, to try to ensure that the public's expectations of doctors can be reflected in the way that the doctors of today are educated. Mr Seale: In addition to the points that Sarah and Finlay have raised, I think one of our roles is very much to ensure that regulation is not a constraint for development of the healthcare system in terms of what individual practitioners can do. The Health Professions Council also has a specific role in advising the Secretary of State of which new professions should become statutorily regulated, and that, I think, is vital in terms of protection of the public. I think the last thing is that all three of us have participated in the Foster and Donaldson Review and we are eagerly awaiting the outcome of that because I think that will that enable the regulators to be fit for purpose as we move forward into the existing century. Q527 Chairman: Could you tell us, as well as setting professional standards - and it probably relates to what you have just said, Marc - should regulators be involved with regulating the activity levels and clinical outcomes of professional staff? Is it more than just setting standards? Mr Scott: Volume levels, I am absolutely convinced, are no concern of the regulator; the regulator is clearly concerned with the quality of outcome. I think that is a different dimension. First of all, can I explain that we have found it helpful to think of regulation in terms of a four-layer model, the four layers being personal regulation, which reflects the set of values, ethics and principles that every professional - not just doctors - should take into their work; a team-based regulation, reflecting the fact that, in our case, doctors increasingly work as part of teams and not on their own; workplace regulation provided by employers and other healthcare providers; and finally national regulation is provided by us and by, say, the medical Royal Colleges. Our role in terms of the quality of outcome is to lay down broad principles through our core guidance, Good Medical Practice, which influences how doctors approach their interaction with patients and their relationships with colleagues. The definition of specific standards in relation to outcomes is best left to those with specialist knowledge, and that is generally not the province of the GMC in our case but of the medical Royal College and faculties. So our job is to work with the medical Royal Colleges to ensure that those standards are available and understood by the profession, and in the event that allegations are made by doctors on the lowest of the standards, to draw in appropriate expert help in making a decision as to whether that is true or not. Ms Thewlis: I think building on from that it is the whole issue of what evidence individual practitioners will produce as far as when they are coming to re-register. At the Nursing and Midwifery Council, building on our successor body, the UK CC, we have something called PREP, which means that every three years people have to produce whatever evidence they have done to make sure they have kept themselves up to practice. We accept that we have to do some work on that and it is not as robust as it should be, but I think that there is an important philosophical point that people recognise that they do not just get on to the register and stay there for life and are only taken off if there is some sort of misconduct or lack of competence within that, and I think very much what we are looking to do - looking at some of the work that the GMC have done - is looking at how we can accept the four-layer model that Finlay talks about, and recognising that we, as the regulator, have a part in that along with things such as are happening on a local basis and also with individual teams, rather than actually just producing something and expecting somebody to do that completely independent of what is happening within the workforce. One area that I think is quite a good example is some of the work that we have done with the Royal Pharmaceutical Society around extended prescribing, where very much if you are looking at that spreading across a wide range of professions, looking at what are some of the core standards that we should all work together around, how you can train people to actually take on the extra responsibility as far as prescribing is concerned, and I think that is a good example of where you can see regulation working across the regulators, seeing how we are looking to improve patient care. Mr Seale: The only other point I would like to add is that while we are a regulator of health professionals and not the environment those individuals work in, under our standards of conduct and performance ethics our registrants are also required to only undertake action if it is safe and effective, and therefore we would not expect a registrant to be working in an environment that they thought was unsafe, whether it was to do with, let us say, infection control, or indeed the workload was so heavy that they could not deliver appropriate healthcare. So in a sense we do indirectly have an influence on the working environment of those registrants. Q528 Charlotte Atkins: Sarah, your evidence stated that the involvement of regulators in workforce planning is "vital but frequently overlooked". Can you give us some examples of that happening, please? Ms Thewlis: I think a good example would be the whole area of international recruitment. I joined the Nursing and Midwifery Council in 2002 and obviously I think there had been a policy direction about looking to increase capacity within the whole of the NHS, but I do not think anybody had a discussion with the regulators about what that was going to mean about people coming on to the register. So just to give you some figures, in 2000 we were looking at about 5000 people coming on to the register, and then at the peak in 2002 it was up to 15,000 that were looking to come on to the register. The system - and I think this is partly a responsibility for us as regulators - is really looking at some of the trend analyses and how really we could have looked at a different way of how we were going to handle some of those applications; and what we wanted to do was to make sure, as the regulator, that we could actually say, "Yes, safe and effective practice," and I think some early discussions would have been quite helpful around that. That is the first point. The second point would have been around some of the treatment centres that people were looking to build in. We are driven by legislation - that is what you do when you are a regulator - and one of the things we are not able to do is to actually offer temporary registration, and I think part of the thing with the overseas teams that were coming over was that that was one of the things that they were looking to do. But I think if they had had a conversation with us at the beginning then we could have said, "We cannot deliver on that, we are not able to do that. We actually have core European standards where people have to have met some minimum competences and unless they have done those it is no good you telling us that this is a fantastic nurse. If they have not delivered around the core European directive we are really sorry, we cannot help." So those were two examples I would give you. Q529 Charlotte Atkins: Thank you for that. It sounds a bit as if you are poor wilting flowers, waiting to be asked. I have to say that you are regulators and you do not look the sort of person to me that is a wilting flower. Ms Thewlis: I think you are right, and that is one of the things where, in fairness, individually we have all worked with the respective Departments of Health at a much earlier stage. But you are quite right, I think sometimes regulation did see itself as rather isolationist and maybe did not get involved, but I think all three of us now recognise that we do need to work more closely with employers and actually get there at the beginning. Around some of the new roles' work, what I saw happening was the regulator was dragged in at the end and said, "Would you approve this?" which really is not terribly helpful because I think regulation needs to be there at the beginning and work with employers; and also what the policy direction is that you are looking to drive forward. The third bit in that is really looking at where education fits within that because I think that at the NMC we have responsibility for quality assuring education, which our predecessor did not. So I think it is important that there is a very active dialogue because to actually change educational programmes takes quite some time. So I think from the policy direction it is important that the regulator does have responsibility for education in the way that they do at the GMC, but that was new for us. You are right, we cannot afford to be wilting flowers and I would not say we are. Q530 Charlotte Atkins: Finlay and Marc, are you punching your weight as regulators or are you sitting back and wilting? Mr Scott: We are certainly not a wilting flower; where I come from you do not survive if you are a wilting flower! In fact our experience, perhaps because we are a longer established body, contains really good examples of cooperative working with the Departments of Health, and I can particularly mention the Department of Health programme for recruitments of specialists internationally. We were involved in that from the outset and very successfully so. Also, when the ISTC programme was first launched we were involved in that from the outset to ensure that registration was not an impediment and that those who were proposing to tender for ISTCs understood our requirements. So there have been quite good examples. On the other hand, I think that some of the current controversy around international medical graduates who have been unable to find jobs might have been avoided if there had been a clearer national picture of workforce requirements which could have been communicated to IMGs who were thinking of coming to this country. So I would say that it was more of a mixed picture with some success but some work still to be done. Q531 Charlotte Atkins: So the GMC are getting their slice of the action. How about the health professionals? Mr Seale: I think it is very important as a regulator we work with all our stakeholders, I think particularly in healthcare where in fact you are beginning to get a very different Scottish NHS and also I think Wales is beginning to go in a slight direction. So it is important that we have good contacts with the four different administrations. I think also that some of our professions, for example chiropodists and pharmacists, over 60% of them do not work in the NHS but work in the private sector, so it is important that we influence that process. To give you an example, with a new profession coming on stream, emergency practitioners, I think it is vital that when those individuals are trained they can work anywhere in the NHS, and one of the roles as a regulator that we must do is ensure that those skills are transferable throughout the UK and you do not end up with a situation that somebody who trains in Kingston finds that they cannot work in Cardiff because their training has been very different. So it is very important that we are brought in at an appropriate time, but at the same time we are not seen as a blot on the system. Q532 Charlotte Atkins: It just seems a bit odd from the evidence we had earlier - and I think you were in the audience to hear the evidence. Mr Seale: Yes. Q533 Charlotte Atkins: On the emergency care practitioners it did seem somewhat vague. It has been developed in London and I know it has been developed elsewhere within the country, and that must be a concern for regulators, is it not? Mr Seale: Yes. I listened to the discussion that you had a few minutes ago on this particular subject and maybe I can give you some background information that might be of some assistance? In essence it is a new emerging profession, there are very few people currently on courses and there are a number of courses that have now been set up. What essentially is happening is that the people who are going on those courses are already regulated because they are either nurses or indeed they are paramedics. So in a sense we can wait for a short period of time because those individuals will be regulated when they go back into the workforce because we regulate by protection of title, and the principle is that as long as you are educated and you are working within your scope of practice your Code of Practice comes into play. The issue coming down the road is that at some point these new courses will want to recruit people who are not necessarily nurses or paramedics and therefore if they are not statutorily regulated when they finish their courses there will be nobody to regulate them, there will be nobody setting standards of training, conduct and ethics, et cetera, and, more importantly, we will not be able to protect the public because of the outside regulation. Again, if we go back to Foster and Donaldson, certainly in the Foster review, coupled with the themes that we discussed, there is an issue about how do we regulate these new professions and how do we set standards, et cetera? Hence the desire to see the results of those two reviews as soon as possible. Dr Taylor: Going on with that, I am a bit alarmed because I was under the impression that there were emergency care practitioners actually working in my area and I think in Charlotte's as well. Charlotte Atkins: They are not called that; it is a slightly different role - certainly not the university training in Staffordshire. Q534 Dr Taylor: No, there is certainly no university training in my part. So should you not already be involved in the regulation of the training of these people who are seen as absolutely crucial with loss of emergency services across the country? Should you not, and the NMC as well, as nurses are going to be in this role too? Mr Seale: How we currently treat a group like this is that we would regard it as a post-registration qualification in those individuals who have already qualified as a paramedic or a nurse, have gone through their training and in very small numbers are now going out into the workforce. But the ideal situation is that they should be regulated at the post-registration level and that we should set the standards of that level. It is one of those issues that we want to move ahead but currently we are working for developments within the Department of Health on these other two reviews. Ms Thewlis: I would concur with what Marc says. I think one of the things that we talk about being on a professional register is about ensuring that people work within what we call their scope of practice. So obviously people do not extend into areas where they are not competent, so I think that is the first bit. But as Marc said, one of the bits that we are waiting for is obviously what is going to come out from the Foster Review, because these emerging roles will have some clarity around the system that we are going to need to take this forward. Q535 Dr Taylor: In your evidence you make a distinction between extension of existing roles and the establishment of new roles. Ms Thewlis: Yes. Q536 Dr Taylor: Will the ECPs will be new roles or extended roles? Ms Thewlis: I think that is one of the things where it is talking about not tying things down so tightly that you do not have a flexible workforce, and I think that is one of the things where we are very conscious that sometimes regulation is seen as a barrier to progress rather than actually something about where you can manage it going forward. I have given you two answers on that one really, Dr Taylor, because I think some of it you will see where it is just an extension of role, whereas some of it you will actually say, "No, this is a significant jump that you are talking about, it is something different." What we are very keen on at the Nursing and Midwifery Council - we are having discussions with the Department of Health at the moment - is actually having what we call an advance practice part of the register because I think there is that step change where you are saying, "What you initially trained for is more that you are doing now." I think some of the roles that we are talking about, particularly if you have responsibility for total patient care, that that is very different from doing the normal nursing that you would do. So we are having very fruitful discussions, I hope, with the Department of Health about having this level. Almost in the same way that the GMC has the Specialist Register, then we are looking at something along those lines. What we would be doing would be having a set of broad competencies where we would work with some of the specialist areas around particular clinical areas where obviously we would need to take their input because it is not our responsibility to set up the detailed clinical standards, but we are responsible for the competencies. Q537 Dr Taylor: So nurse consultants, nurse practitioners, nurse specialists would all be in this? Ms Thewlis: They could, and one of the things from a public protection point of view is that none of those titles that you have just mentioned are regulated or protected, so anybody could call themselves one of those where they have perhaps done a two-week course or they may have done a Masters level of education. But the difficulty is, if you say, "I am a nurse consultant" or "I am a nurse practitioner" a member of public would think that must mean that you have some sort of training. That is why, from a public protection point of view, the NMC feels very strongly that there should be a regulated part of the register where you could only use that title if you got to a certain level of competence. We have a little bit of a joke about this as to what is the longest name you can get for a title for a job that you are doing, will it fit on the name badge? Q538 Dr Taylor: I find that surprising. So some people who are labelled as nurse consultants probably are not? Ms Thewlis: It depends how you define what a nurse consultant is. Q539 Dr Taylor: How do you define it? Ms Thewlis: We actually talk about nurse practitioners and we have worked with the Royal College of Nursing, we have worked internationally - because obviously nursing is a very global profession - looking at setting a series of what we would call competences, that when you have reached that level there should be some protected title that comes with that to allow yourself to call yourself that. I think from a public protection point of view, when people use the word "doctor" of whatever they have a kind of understanding that that means you have done some sort of training, that you are safe, and "We think it is okay, we trust you." Q540 Dr Taylor: I have to declare an interest, one of my daughters claims to be a nurse consultant! I shall have to chase her up on this! Thank you very much. You have already covered the point about regulation not being a constraint and rather being a facilitator. The last question is to Finlay. Is it right to say that the medical profession has become more regulated than other professions recently? Mr Scott: I think if you ask most doctors they almost certainly would say so. I think the serious point is to recognise, as we have tried to do through our four-layer model, that doctors are not only regulated by the GMC but regulation takes different forms, including regulation of where they work or their employer. I think the aim has to be, whether it is in the context of revalidation or any other initiative by the GMC, to ensure that we can achieve the desired impact with the minimum burden. I think some of the thinking that has been emerging over the last 12 or 15 months around risk-based regulation from the Hampton Report, is extremely helpful, and it will enable us in developing revalidation, once Ministers have made their decisions, to approach revalidation on a basis that allows us to target much more closely the effort required to be confident that a doctor is up to date and fit to practise. That is why, as part of our ongoing programme of reform and modernisation, we are proposing to collect scope of practice data about doctors who hold a licence to practise so that that data can both be made available to employers in the context of workforce planning and to members of the public, and will also inform our approach to regulating individuals and groups of doctors. Q541 Dr Taylor: Sorry to backtrack, can I just go back to the emergency care practitioners for one moment because I am still not clear? Are Marc and Sarah saying that you would keep nurse emergency care practitioners under your regulation and ambulance trained ones under your regulation? Mr Seale: I think the issue of who regulates them is completely irrelevant. I do not think that regulators should be having turf warfare between who regulates. What is important is that they are regulated, and whether you put them all in the nurses - or indeed if the dental regulator was to regulate them - it does not matter, as long as they are regulated. Q542 Dr Taylor: So somebody will do it? Ms Thewlis: Yes. Q543 Dr Taylor: Who? Ms Thewlis: Without wishing to second guess what is coming out of the Foster Review, they have talked about this concept of almost having a host regulator. I would see the emergency care practitioners, Marc would have responsibility around the education and the quality side of it, and there may be some nurses who take the decision that they want to actually not be regulated by the Nursing and Midwifery Council now, but they would rather be regulated by the Health Professions Council. If they did not make that decision and we had a fitness to practise issue that came up where somebody had concerns about the standard of care, then obviously within our legislation we are able to bring in what we would call an expert witness of due regard for somebody saying, "Is this appropriate care that is being given?" So I think that is the sense we want to get across - that, as Marc says, it is not who does it; it just needs to be done. I think one of the things that has been very helpful, I hope we have given a sense that we do actually collaborate and we do not have turf wars around this, because I think the public need to know that there is an effective system of regulation in there and we have part responsibility for that - the individual profession does - but, as Finlay said, there are other groups as well. Mr Scott: The same issue arises in relation to other groups such as surgical care practitioners and medical care practitioners. Essentially there are two models that have been on the table. One is where you would have a single regulator responsible for any one of those groups and then individuals who were already registered with another regulator would have a choice of double registration or of switching their registration. The second model, which is the one that Sarah has just touched on, is where you have a lead regulator but those who are already regulated, i.e. registered with another regulator, could remain regulated in that way, and then their existing regulator would take the standards from the lead regulator. It is not a very easy concept to describe, but I think it is fair to say on balance that it is the one that the community of regulators thinks would work most effectively. Q544 Chairman: By implication that would mean that probably the statute that covers all your three areas of regulation may have to be a bit more flexible at the moment. Mr Scott: Perhaps it would help if I tried to illustrate what I was clumsily trying to explain? If you take, not emergency care practitioners but, say, surgical care practitioners, as has already emerged from the evidence both from us and others, there are essentially two sub populations - those who qualify perhaps as nurses or some other healthcare profession and those who, from the outset, seek to qualify as a surgical care practitioner. One model is that, say, the GMC would be the lead regulator for surgical care practitioners, but nurses who went on to qualify as surgical care practitioners could choose to remain regulated by the NMC. We would lay down the appropriate standards under that model. In that the event that the nurse, now surgical care practitioner, had her or his competence challenged the NMC would handle that in accordance with the standards that we had laid down. Mr Seale: It might be useful to link this debate back to workforce planning. What is going on - and it is beginning to accelerate this change - is the traditional model of doctors, nurses and physiotherapists is beginning not to work, because I think what is happening is that new skills, new technology, new drugs, et cetera, start off in a very small group of individuals who are skilled in doing that and gradually that skill goes down through the workforce. At the same time you can actually now come into the workforce at a particular level with that new set of skills and what the regulators have to do is to capture those new individuals with the new skills as it trickles down through the system. Currently it is not quite working correctly but I think all the regulators want to see it work effectively. That will mean that as demands are put on the workforce those skills could then flow through the individuals. Chairman: Thank you very much for that. We are likely to have this inquiry running to later this year if not into next year, so if you have any further thoughts in this area please do not hesitate to contact us and we will be more than happy to receive them. Can I thank all three of you for coming along, and I am sorry about the delay. |