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UNCORRECTED TRANSCRIPT OF ORAL EVIDENCE To be published as HC 1077-v House of COMMONS MINUTES OF EVIDENCE TAKEN BEFORE HEALTH COMMITTEE
Thursday 29 June 2006 MR PAUL STREETS, PROFESSOR ELISABETH PAICE, MR BERNARD RIBEIRO and PROFESSOR DAVID GORDON
PROFESSOR DAME JILL MACLEOD CLARK, PROFESSOR SIR ANDREW HAINES and PROFESSOR TONY BUTTERWORTH DR DAVID McKINLAY, DR GRAHAM ARCHARD, PROFESSOR SELENA GRAY and MR PAUL HOLMES Evidence heard in Public Questions 545 - 675
USE OF THE TRANSCRIPT
Oral Evidence Taken before the Health Committee on Thursday 29 June 2006 Members present Mr Kevin Barron, in the Chair Mr David Amess Charlotte Atkins Mr Ronnie Campbell Sandra Gidley Dr Doug Naysmith Dr Howard Stoate Dr Richard Taylor ________________ Witnesses: Mr Paul Streets, Chief Executive, Postgraduate Medical Education and Training Board, Professor Elisabeth Paice, Chair, Conference of Postgraduate Medical Deans, Mr Bernard Ribeiro, President, Royal College of Surgeons, and Professor David Gordon, Chair, Council of Heads of Medical Schools, Medical Education, gave evidence. Q545 Chairman: Good morning. I am sorry; we are a few minutes late. Could I ask you, for the record, to give us your name and the organisation that you are from? Professor Paice: My name is Elisabeth Paice. I am the Dean Director of London Deanery and the Chair of COPMD, the Conference of Postgraduate Medical Deans. Professor Gordon: I am David Gordon. I am the Dean of the Faculty of Medical and Human Sciences in the University of Manchester and I am here in my capacity as the Chair of the Council of Heads of Medical Schools. Mr Streets: I am Paul Streets. I am the Chief Executive of the Postgraduate Medical Education and Training Board. Q546 Chairman: I understand our other witness, Bernard Ribeiro from the Royal College of Surgeons, is presently in a cab shortly to be with us. Could I, first of all, thank you very much for coming along to give evidence to us today on what is our fifth day of our evidence taken in the inquiry into workforce planning. A question for Mr Streets and Professor Paice: the new system of specialist medical training begins in the summer 2007. Nine thousand five hundred specialist training posts will be available, but the BMA estimate that 21,000 doctors will compete for these posts. Why is there such an apparent shortage of specialist posts and what will happen to those who cannot get a training place? Professor Paice: At the moment the September 2005 census shows that there are 21,000 people in SHO (Senior House Officer) level posts. Those posts are funded one way or another. Many of them are educationally approved SHO posts, some of them are locally funded, trust doctor posts, which are not educationally approved, and the census is not able to distinguish between the two; but do we know that there were 21,000 people in posts at that time. If you like, that is the stock. Five thousand of those have been reconfigured into Foundation Year Two posts, which start in August this year and will continue, so actually the 21,000 is now reduced by 5,000 to 16,000. Of those 16,000 posts, as I say, it is not totally clear exactly what proportion are locally funded, but the majority of those 16,000 are educationally approved SHO posts, which would fit very nicely into the specialty training programmes of the future at three levels: the first year, the second year and the third year. It would, therefore, be possible, with the existing resources, to fit all of those 21,000 people into all of those four years of posts. The question then is whether or not you have the specialist training opportunities and, indeed, the requirement for all of those people in those posts to go through to complete training, either to be a GP or to be a consultant, and that is a decision which has to be made for the long-term because you certainly cannot start people down a training pathway if you cannot complete it. The likelihood is that the capacity to train is there. It is a decision to be made whether the commitment is there to take people through. Q547 Chairman: Have you anything to add to that, Mr Street? Mr Streets: It might be helpful for the Committee to understand that it is PMETB's responsibility to set standards, maintain standards and promote and develop. We have no due restriction over numbers, but in terms of this debate we can work with the deans in order to ensure that people can fit into training beyond the first year, and that is one of the things that Professor Paice has referred to. Q548 Chairman: Basically, are you saying, Professor Paice, that UK-trained doctors do not face a genuine threat of unemployment? Professor Paice: I do not believe that there is any need for the output of the UK medical schools to face unemployment and not be able to complete their training. We have moved from a phase where we encouraged a great deal of international recruitment, and I do not think that is sustainable. Of that 21,000, we know that more than half were not UK graduates, so there is a balance to be struck there. Q549 Chairman: You have mentioned the issue about the new Foundation Training Programme. Will doctors in all Senior House Officer posts have equal access to specialist training posts or will it be reserved just for the new foundation training programme? Professor Paice: No, the idea is that that body of people who are in the SHO posts will have the opportunity to compete for the training as GPs and training as specialists, not just the Foundation Two people. Q550 Chairman: Could I just welcome Bernard Ribeiro. We understand you have been spending some time in a cab? Mr Ribeiro: Thank you very much, Chairman. My apologies for being late. Chairman: No problem. Q551 Dr Stoate: I would like to explore one final point. The BMA is saying, openly, that there will be significant unemployment amongst doctors because of these new changes and they are predicting that vast numbers will emigrate to other countries. Is this realistic or simply crying wolf? Professor Paice: It depends how you describe "doctors". At the moment there is unemployment amongst doctors in the UK, and it is something which is very concerning. A lot of the unemployed doctors are doctors who have come to this country to train, have taken PLAB and are unemployed, and that is a situation which I do not think anyone finds acceptable. It would be quite wrong to say there is not unemployment amongst doctors in the UK, there is, but that may be a different thing from saying that looking to the future, with the changes which have already been put into place about access to permit free training, there is a plan in the future to organise things so that there are unemployed UK graduates, which there is not. Q552 Dr Stoate: I still do not feel much happier, because the BMA are saying that there will be large numbers of unemployed doctors as a result of these changes. Are you saying that this is not going to make much difference or is going to make much difference? Professor Paice: As I say, I think that it is important to say what you mean by "doctors". There is not enough training capacity and, indeed, need in the UK to train every doctor who has come and taken PLAB and has come to this country looking for training to offer training to everyone. It just is not there. If you are saying, is there going to be unemployment amongst doctors? The answer is, no, there is no intention to train every doctor that comes to the country seeking training, but I am having to make a distinction between plans for the output of UK medical schools and plans for the very, very intense interest there is in coming from various parts of the world to seek training in the UK, and there is not the capacity to meet that demand. Q553 Dr Stoate: So you are saying that UK trained doctors coming out of our medical schools in this country will not face unemployment but many people who are coming into the country who are given training might? Is that a better way of putting it? Professor Paice: I would have to say that those people who are unable to compete in that market, those UK graduates who find themselves unable to enter into open competition successfully, as the vast majority of UK graduates would, will not be unemployed. Nobody could guarantee that every UK graduate will be offered a training programme - that is not possible - but the plans are being based on the intention to offer an appropriate number of training programmes for the UK output. Is that a reasonable way of putting it? Dr Stoate: That is much clearer. Thank you. Q554 Sandra Gidley: You seem to be saying that it is unacceptable that a doctor would do a degree course and then not be able to access further training. Professor Paice: No. I guess what I am saying is it would be wrong to plan to produce medical graduates and to say, "The plan is we will have a cull and we are not planning for a third of them to progress." After a six-year undergraduate training programme, which is broad and deep and expensive, it would be wrong to plan for people not to be able to train further in the postgraduate field and make themselves useful. Q555 Sandra Gidley: So we actually need fewer university places? Professor Paice: No, I do not think so. I think we need all the doctors that we are currently training. There has been a recent review of this looking at the projections over the next ten, 20, 30 years, looking at the demographics of the doctors being produced, looking at the participation rates that are predicted, looking at the skill mix for the future and the needs of the country for the future, and careful discussion as to whether we needed more medical schools or fewer medical schools, and the conclusion was actually at looks as if we have probably got it about right at the moment. Q556 Dr Naysmith: I am going to turn to another aspect of this training. There has been a recent survey in which 62% of doctors who were surveyed (and it was a large survey, more than a thousand doctors of all different grades and skills and so on) felt that patient safety had worsened as a result of the recent changes to postgraduate training. What are your comments on that? Do you agree that is a valid judgment? Mr Ribeiro: We presented evidence last time on the basis of what we had surveyed following the European working time directive, and it really is a combination of the impact of what the EWTD has done since 2004. What we found for our survey was that 83% of the respondents felt there had been a reduction in the continuity of care and, as a consequence, in the quality of care which they felt they were able to provide to their patients, and that was our college survey. When you talk about patient safety, doctors in a professional sense have a real desire to see the job done and not to leave a case until they are satisfied it is properly done. The restriction imposed by time-based working, which what the European working time directive does, leaves many doctors with the unsatisfactory situation of having to hand over to somebody else to manage the case, and I think it is this sense that gives rise to the question of patient safety. In terms of risk to patients per se, I suspect that that would be subjective in terms of how that is reported. Professor Paice: I think it is very difficult in a period of change for people to see how things can work in a new world. People are very used to what they do and change seems risky. My own personal view is that the reforms, particularly the reforms around the Working Time Directive, which will hopefully put an end to sleep deprived doctors, will do nothing but good for patient safety. I strongly believe that doctors do not learn well when sleep deprived, nobody else learns well when sleep deprived, and there is good evidence to show that what you do learn at night when sleep deprived following that learning experience is not retained. So, the first thing I would say, putting an end to sleep deprivation can do nothing but good for patient safety. The second thing I would say is making sure that the training is structured, that competency is assessed, that supervision is in place before people are allowed to do things unsupervised can do nothing but good for patient safety. What is absolutely critical is that people get the experience that they need, and one of the things I think that we have to do with the new reforms is to make sure that that happens, because there is no doubt about it, surgeons cannot learn unless they are able to practice and see what needs to be seen, and that means moving away from a system in which trainees have been seen perhaps as deliverers of service that you have to train in order to get them to come and work for you and into a system where trainees are there to learn, where the learning is available, at the times when it makes sense for them and in the centres where the clinical cases are there for them to learn on, so that when their learning is done in a streamlined way and a little bit quicker than we do it now, they come out as specialists and general practitioners who are competent, experienced and able. Q557 Dr Naysmith: I am not sure whether you are saying that the judgment expressed by these doctors was correct and you are doing something about it or whether you disagree with that judgment? Professor Paice: We are talking about reforms which are still in the pipeline, and so I am saying I think they are wrong, I am sure they are wrong, that patient safety will suffer in the future if we get the training right, but if left to serendipity and opportunism, I have absolutely no doubt that there will be problems. Mr Ribeiro: Can I come back on that. I entirely take that aspect. I think where we have been concerned in our projections is over the time that will be available. Currently trainees are clocking up something of the order of about 17,500 hours in the current Calman system of training that they have towards the end of the training. Our calculations were that with the onset of the EWTD (48 hours by 2009) that will lead to a reduction down to something like 6,000 hours of training time. As a consequence of that, our college has actually extended the period of training with this new arrangement to anything between--- Q558 Dr Naysmith: That aspect has been sorted out? Mr Ribeiro: Part of that aspect has been sorted out by virtue of the fact we have extended the training from six years of specialty training to about seven to eight years, but it is important to realise that a lot of practice and experience that we have is going to be based on competences, and those competences will determine that somebody is competent to practice, but it actually needs a lot of experience before somebody can practice independently and in a professional and safe way. Q559 Dr Naysmith: So there is a danger that people will not get that experience unless you make absolutely sure? Mr Ribeiro: While I accept everything that Professor Paice has said about working at night and the problems, and we have looked at that, and perhaps I could return to that later and the work that we are doing in the college on the separation of emergency elective, what I would say is that, recognising that problem, we have extended the period of training to take account of that. We are also, within our college, developing courses for our current trainees which will look at some of the problems that come in delivering care. Trainees as well as consultants need to have training in the effective handover of the skills that they have acquired, and these are part of the things that we are doing, and we are developing courses to make sure that they are fully aware of this. Mr Streets: Clearly, we cannot bury our heads in the sand. The Working Time Directive is with us and it will have an impact on training, and you can juxtaposition, as Professor Paice has, the past, where people worked 120-hour shifts, with the future where they will be not be able to that and question whether actually that was safe for patient safety too. The key for us is that we must make more explicit some of the things that have been implicit in training, and that is about standards for curricula, standards for assessment and the standards in which training is taking place, and PMETB is a part of that working alongside MMC and the colleges and the deaneries. The danger is that if we do not do that, we will just need to continually extend the length of time that people train, and that will probably lead to less flexibility, and, as this Committee has considered previously, one of the things that we need to more towards is more flexibility. We think there needs to be a move towards much more explicit standards for the situation in which training takes place, and PMETB is a part of that. Q560 Dr Naysmith: The same survey found that, as a result of Modernising Medical Careers, 63% of junior doctors felt that the quality of training had worsened. Is that something that you are prepared to address? What do you think of that? The junior doctors themselves felt that training had worsened? Professor Paice: Yet, Modernising Medical Careers is not yet implemented. The Foundation Two programmes start in August, the new run-through grades start in August 2007. Q561 Dr Naysmith: So what we are talking about is really things that have happened that have got nothing to do with changing medical careers? Professor Paice: I am not sure what they were referring to. Q562 Sandra Gidley: My question is to Mr Streets. There has been a change in the way doctors train, and you now have the two-year foundation course split into the F1 and the F2 year, F1 controlled by the GMC and F2 under PMETB. Would it be more sensible to have the whole lot organised by one organisation? Mr Streets: You could take that view. There is a logic behind what has been proposed, because the GMC is responsible for the registration of doctors and doctors are registered at the end of F1 (Foundation Programme One). PMETB is responsible for all specialist training that takes place after that, and that is where the cut takes place. What is important is that we work closely with the GMC, and we have a joint group working with the GMC, for example, looking at how we get a quality-assured foundation programme. We also have a joint group which is looking at how the outcomes of foundation will be looked as a whole. I would like to reassure you that we are working very closely with the GMC. It might be better if it was one or other of us, but there are reasons why, from a statutory perspective, the GMC needs to be responsible for the first year of foundation programmes where people are signed off. Q563 Sandra Gidley: Could you clarify why the GMC does need to be involved at that stage? Mr Streets: It is about the registration process for doctors. Doctors are registered at the end of their first year post medical school. Q564 Sandra Gidley: Why does that mean that they have to completely oversee? Why can they not just assess what has gone on, or is it just easier to do the two alongside? Mr Streets: Professor Gordon may want to come in on this because it is very much his territory in terms of what happens after medical school. Professor Gordon: The position is that the Medical Act defines the responsibilities of the GMC and then the PMETB takes over thereafter, but the delivery of medical education up to qualification, normally five years from admission to medical school, is directly what we do, but we remain responsible for our students to ensure that they are getting good experience and training and education for that next year until they are fully registered. We are very happy to have that responsibility, because we believe very strongly that there needs to be a continuum in the medical education process from admission to medical school right through to higher training and, indeed, to continuous professional development. I think it is a pity that we have divisions at any point, but obviously one body cannot deal with everything right the way through. There is another important point in there, and that is that in the development of the foundation programme and the later stages of MMC there has been a lot of thought put into the educational content of the curriculum, but some of our students have commented that maybe that has not been as joined up as it might have been. They have found themselves in the first foundation year being taught about things that they felt had adequately been covered in medical school. So, I think, yes, there needs to be much better "joinedupness". Mr Streets: It might help the Committee to know that the Chair of the GMC Education Committee, which is responsible for this, is also the Chair of PMETB, and that is Professor Ruben, so in that sense it does help in terms of coordination between the two bodies. Q565 Sandra Gidley: Does he get paid twice? Mr Streets: You would have to ask him that. Q566 Sandra Gidley: Mr Ribeiro, there has been some comment that the additional training requirements of the new foundation programmes actually put a further strain on consultant time. Is this a justified comment? Mr Ribeiro: I was actually in the north-east yesterday talking to some consultants, and I asked them that very question because they had got some foundation trainees with them, and I got two different answers, which was that there were some consultants who felt that they put an inordinate amount of strain on them in terms of the extra time to do the assessments, and so forth, and others, who clearly have had some training in this, who were able to organise their work in such a way that they felt that they could accommodate it in the time that is available. That is a foundation programme. Once you add the Modernising Medical Careers group, which will start in 2007, to it, I think Professor Paice actually has the figures of what it actually means in terms of time, but we do anticipate that for the assessments that will need to be done, and there are a series of work-placed assessments that do need to be done, it will add extra time to a consultant's working. What we have been trying to do, working with the deans, is to develop a framework that will allow to us have regional schools of surgery for us and for medicine and for the other specialties, and within these frameworks we will actually define the responsibility of the various people who are going to undertake training, and it may be that not every single consultant will have a responsibility for training per se. I think all consultants have an obligation to train, but in terms of responsibility for supervising and organising the training and the assessment of trainees, this may have to be done by consultants who have been selected, trained and picked to do it. I do not think it is just a matter of every consultant having to have that responsibility; that is one of supervision. Q567 Sandra Gidley: You have just mentioned in terms of assessment as to how much extra time it would be. Are you able to quantify that? Mr Ribeiro: This is what I hope the Postgraduate Medical Deans will be able to tell you, because they did actually do that sum before they made the bid for extra monies for the foundation programme. Professor Paice: We certainly did look at how much it would cost or at least how much time it would take to do the various assessments, and I will apologise, I do not have the figures in my head but I am happy to send them along. I would actually say the trouble is when you think about the future in terms of the now, you some time get things wrong. Yesterday I went to a presentation by the National E-learning Alliance, which really opened my eyes to what modernising education should look like and already does look like for radiology, where you join an on-line learning management system, where the things that you need to learn, the films, et cetera, are brought up to your own laptop in the comfort of your own home. You do a lot of the training in your own time and the outcome so far appears to be that trainees who have this available to them are volunteering to take the exams a year early, passing them, moving ahead at a far greater rate and also going into the clinical environment (and this is the important bit) to meet with their consultant already well prepared, well informed, having had the opportunity to do some virtual learning and are then able to benefit from that expertise, and that is very expensive specialist time, rather than the old apprenticeship model. What we need to do is modernise, not just medical careers but modernise the content and the delivery of education, and that is expensive, but by no means unaffordable, as an overall vision for the way we train specialists in the future without just simply doing one-to-one teaching. Q568 Sandra Gidley: Is the consultant as trainer model slightly outmoded then, because it seems we are expecting them to be trainers, managers and clinicians and you cannot necessarily expect everybody to have all three of those qualities? Professor Paice: Not only that, but you need huge opportunities for people to practice skills which are not everyday skills. The high fidelity simulator environment where you have everything which looks jolly like the real thing and you are faced with emergencies, five emergencies in one day that might take you five years to experience in real life and have someone observe how you carry out everything from the procedures, to the thinking, to the team working, to the resource management, to the human factors. That is the kind of learning which is available, and I think patients would be surprised to discover that it is not available for every trainee on a regular basis. Mr Streets: Professor Ribeiro is probably right that not all consultants in the future will train, and it is interesting perhaps for the Committee to juxtaposition general practice training where GPs are selected as trainers and remunerated as trainers compared to hospital training where that is not the case. Clearly, there is an issue here about how trainers are incentivised to be trainers and, indeed, how trusts are incentivised to provide training. This Committee previously has looked at ISTCs, for example. The first wave of ISTCs were not in any rewarded for training, the second wave will be, and that is very important from our perspective; but what is more important in all of this is that there is a cultural training and education embedded in the NHS. That is actually pretty important to us because that is the only way that consultants will be released from this work, and that means chief executives being measured just as much on their ability to provide a workforce for the future as delivery today, and that is one of the central problems that we have to address as we move forward in preventing MMC. Professor Gordon: Just a small point to your expression of surprise at this degree of multi-skilling amongst the consultant workforce. Q569 Sandra Gidley: It is not just surprise, it is disbelief. Professor Gordon: You have to have to remember that 7% of all hospital doctors are actually clinical academic staff employed by universities and they, in addition to doing clinical work, and at the top and, of course, patient safety is paramount, also teach and do research, and we expect their research to be of international quality as well, so there are a lot of people working very hard. Mr Ribeiro: One of the issues in the workforce is this question of consultant expansion, and one of the reasons we have been very keen to drive that is because we felt that we would be moving towards a consultant base rather than a consultant-led service. So, we will inevitably end up with many more consultants than trainees, and we have estimated that the ratio would be something like five consultants to every one trainee in the future. So, with that sort of ratio, it is inevitable that consultants will have to develop different skills. Some will develop skills as managers, some will develop skills as educators and trainers, some will develop research and academic skills, some will have technical skills that actually determine their future and the trust will appoint people on the skills that they actually present. On the question of the interaction between trainer and trainee, one of the things that our colleges have been doing, with support from the Department of Health, is to develop a new web-based curriculum, and as regards the work on this our college, which is an intercollegiate surgical work base, I think is a first, and in fact there has been a lot of interest from countries outside the United Kingdom in what we are doing. The intention with this is actually to have a conversation, as Professor Paice has said, through the web-base with your trainee to actually set them objectives, see whether they will be able to meet those objectives and then to critique it and decide how they are progressing. It is not all about necessarily a face to face, and we must be aware of technology. One of the things that we criticise as a profession is that we are obstructers of change. Actually the medical profession has been one of the greatest innovators of change, and we have actually undertaken this in the development of this new curriculum. Q570 Dr Taylor: Going on with the content of medical training, it is obvious that undergraduates have got to have the scientific and the clinical training. Some of you have mentioned other aspects of the NHS. How important is it at student level (and really to Professor Gordon, I think, first) that they are taught about the NHS itself, about relationships with managers, with other professionals? Professor Gordon: You have to remember that we are educating medical students for a lifetime career rather than just training them for a job, and that career for most of our graduates, of course, will be in the UK but many of them will work abroad, some of them will be overseas students who, once they are fully trained, will return home. Education for a lifetime career, potentially worldwide, means that the NHS is a very important element, but it is not the sole element that they need to understand. Nevertheless, it is very important that, certainly before qualification, our students understand how the NHS works and how they can interact with the service, more importantly, how they interact with their professional colleagues in other disciplines and learn to work together in a team. I think most undergraduate medical curricula are quite well advanced in making sure that that understanding is in place. The GMC Education Committee would be on our backs if we did not. Q571 Dr Taylor: So at undergraduate level that happens. As one moves up the scale, on one of our visits recently when we went to visit Kaiser Permanenti, we learnt that fairly early on they pick out what they call "emerging medical leaders". At what stage does that happen in a career? Is it left until somebody becomes a consultant or are there steps before then? Professor Gordon: It is a subject of great interest to us, for a number of reasons, not least, for example, that it is surprising that more people do not put themselves forward to become deans of medical schools, and we are particularly concerned that more women do not put themselves forward to become deans of medical schools, and we are working with the leadership foundation and higher education on that problem. We see it as something that extends much earlier in people's careers and, indeed, we are looking into ways in which, right down to medical student level, there will be some people who will be interested in developing their leadership skills, and there is some work being done at the University of Leeds Medical School on this. Q572 Dr Taylor: More and more doctors have to be medical managers. What is the college doing about that? Mr Ribeiro: Again, in the submission that was given by both Professor Dame Carol Black and Sir Alan Croft, reference was made to young emerging consultants, as you have said, and also reference was made to the fact that the Academy and the colleges are working very closely with the Institute for Improvement and Innovation, because we see that one of the major deficiencies, which I am sure you experienced when you became a consultant, is that you were trained to be a physician and a surgeon, and I was plainly trained to be a surgeon, you were not trained to manage, and we picked that up during our early consulting years. I remember having a three-day refresher course on how to deal with managers and how to deal with management in the early days. We would hope that that would be part of the curriculum, and one of the things that has come in our curriculum is adopting the GMC's seven principles, one of which does involve the acquisition skills of management. So, within the training programme, we will actually be teaching this and training those skills. Q573 Dr Taylor: You are talking about the future. Is it there now? Mr Ribeiro: Currently, it is there in the curriculum that we have developed now. We would hope, and we are encouraging our trainees, that all trainees in the current Calman programme would be encouraged and move to the new curriculum. We would certainly expect those Calman trainees who are in year one to four to adopt the new curriculum. We cannot force them to do so, they were appointed under different terms, but we would certainly expect them to adopt those principles. Q574 Dr Taylor: Would there be any to move pick out people who show promise in this and push them forward? Mr Ribeiro: In what way? Q575 Dr Taylor: To push them forward to take on more of the management, more of the leadership role if they looked to be the sort of people who would do that. Mr Ribeiro: The model I was suggesting to people is that to be employable as consultants it is not good enough just to have the skills of a doctor, they will have to, at a point, demonstrate that they have added value to that trust, because I think in the future what we as colleges have done is produced a cohort of trainees with a certificate that says, "You are accredited to practice as a consultant." We have not armed them with anything else. What I think we now have to be cognisant of is that we are in a market place now, and trusts are going to function on the basis of contracts, commissioning, PBR, all those things which will determine that they have a workforce to deliver the agenda that they have been given, and I think we have a responsibility as colleges now to develop that workforce. Mr Streets: Your question was broad on content but you fell specifically on medical management. PMETB has said it will look at what the content and outcomes of all curricular should be in order that we can look at the core content, and one of the aspects that we will look at is medical management. We have specifically indicated this. We think there are three levels at which this needs to take place. There needs to be a compulsory component medical management which is within the CCT itself for everyone, but also there needs to be the opportunity for people to pursue medical management as a speciality post CCT, and, as previous people giving evidence to this Committee have said, we have encouraged the work of the National Institute for Innovation to took at this specifically, and also potentially the opportunity for doctors to take time out to do, for example, an MBA. Having just come from the NHS Confederation Conference, there is great deal of talk about the need for clinical engagement and clearly to date one of the issues has been clinical engagement; but I think it is interesting that the Committee has not looked, which for me is one of the major drivers of content in the future of medical education, at the different kinds of relationships between patients and professionals as held by things like a patient-led NHS, and if one looks at moves towards the recoverability of patients in the future, older patients requiring a very different kind of relationship with their doctors, I would suggest to the Committee that that is perhaps the major change that we need to look at in medical education and how we get that right. Q576 Dr Taylor: "A different relationship with their doctors"? Mr Streets: If I can use diabetes, which is the example I know very well, good diabetes physicians were moving to a model very much where it is a partnership between patient and professional making joint decisions around on care. Dr Taylor: Thank you. Q577 Dr Stoate: According to Mr Ribeiro, Modernising Medical Careers is going to introduce for, the first time, this idea of competences in the currency of medical training. Do you think this will help to improve flexibility of a consultant's career? Mr Ribeiro: I think there have been some who have felt that a trainee who has been proved to be competent in one particular area, for example taking gall bladders out, might be able to provide a service to the NHS by doing a service list of gall bladders. I think you have to see it in context. The training is the training in the whole, and just ticking a box to say, "I am competent to do gall bladders", is not what we are about. Certainly in general surgery we would expect our trainees to end being more than just competent to manage the emergencies; they must be able to be competent in their own speciality, plus the ability to manage the general emergencies, and that is a big task because it involves expertise in all the sub-specialties within general surgery. Q578 Dr Stoate: I have got an even bigger question. Given that the role of surgeons if likely to change very radically over the next ten, 20 years, are we training the surgeons now with the right competence to be flexible in the future, given that their role is going to change enormously? Mr Ribeiro: I have used the expression that one has to learn to be light on one's feet, and I think that we all know the dangers that came from Tagermat, the drug that got rid of ulcer surgery, you will no doubt ask me questions about cardiac surgery and drugs that get rid of the need for cardiac surgery. You have got to be light on your feet. If you do not have a good, broad base to your training, you will be never be able to reposition yourself into another specialty. Q579 Dr Stoate: Is the current training under MMC going to do that or not? Mr Ribeiro: This is one of the things that we have done. We have started from a premise that we were here to try and shorten training and improve training educationally, and we felt that we could do that and the time-frame for that was suggested that this could be done in six years, indicative years. However, the confounding factors of the European Working Time Directive and all those things made it absolutely clear that this was not achievable in that time frame, and what we have in surgery done is insisted that we have a core two years, what we call a core specialty two years, where these generic foundation skills and surgery will be learnt. I think it is very, very important that people do not go straight into their specialty, but that they do have exposure to other specialties in the first two years of starting, because they will be coming out of a foundation programme, many of them, with no exposure to surgery. It is quite possible to apply for a surgical post, believe it or not, with the way things are structured, without having done a surgical job other than your first foundation year. Q580 Dr Stoate: Before I bring Professor Gordon in, the cardiac surgeons that you quite rightly brought up, and I wanted to talk about, would not be required probably at all. That may be a broad statement, but as we know them today, in 20 years time, if it is foreseeable that cardiac surgery will be a thing of the past, what in your view will happen to those cardiac surgeons? Are they going to be trained today to have any role in the future? Mr Ribeiro: In fact, the Cardiac Thoracic Society has done a survey of its Fellows to find out what they would actually do, and I have got the results tucked away here somewhere, and what that actually showed was that 50% of those surgeons would be prepared to continue in cardiac surgery in non-consultant grades if necessary. That is the determination. They have trained to this high level of expertise and they do not want to through that away. All of them would naturally like to stay cardiac surgeons. Q581 Dr Stoate: But is there going to be any cardiac surgery for them to do is the point I am making? Mr Ribeiro: Well, yes and no. We talk about statins, we talk about stents, but stents can fail, and we do not know what the long-term is. In fact, in terms of research, we do not know what the long-term results are going to be for cardiac---- Q582 Dr Stoate: Can I stop you there. Are you hoping there will still be a role for cardiac surgeons and that stents will fail and we will still need cardiac surgeons, or are you--- Mr Ribeiro: No, no, no. Do not forget, the explosion in cardiac surgeons came about through the National Service Framework, I think it was under Milburn's time, which suggested that there should be an expansion, and, unfortunately, that expansion coincided with the drug treatment. Q583 Dr Stoate: That is my point? Mr Ribeiro: The point is that that workforce will now have to be redeployed. We should avoid making those sorts of mistakes in the future by, as I said, making sure people are light on their feet and can move into other services, and it is quite clear that 20% of the people surveyed were prepared to consider other social jobs and the rest would have had to redirect themselves to radiology or whatever. Q584 Dr Stoate: Professor Gordon, what do you think about this? Professor Gordon: I would very much like to echo Mr Ribeiro's point about lightness on the feet. I think medical medicine and the practice of medicine changes unimaginably in a lifetime career, and the kind of medicine that we saw in medical school is now history. The point I want to make is that one of the places where innovation in clinical care comes from is from the academic world. A good example is that when the HIV epidemic began there was no-one who knew how to treat this disease, and the first specialists in Aids all came from clinical academic infectious disease who had the flexibility and the background knowledge to be able to move into this new area. It is very important that we maintain that scale and flexibility of academic activity. We are very concerned, because the numbers of clinical academic staff are declining. We have published this morning our annual survey of clinical academic staff numbers, and we have enough copies of this for the Committee, which we will leave, and it shows that the total number of clinical academics has fallen below 3,000 for the first time. That is at a time when research is expanding and medical student numbers are expanding and the world is growing, and we are trying do what we do with fewer and fewer people, and so it is very important that, whatever the root causes of that decline, they are addressed because we will not be able to be flexible on our feet in the future if we do not have these people. Q585 Dr Stoate: A final point to Mr Streets. Do you envisage that the Royal College exams in future will be scrapped as a result of these competencies or will we continue to have some sort of parallel system of Royal College exams and competencies determining someone's fitness to practice? Mr Streets: There is likely to be both, in fact, because there is no doubt that within the CCT as it stands there will be college exams as part of the assessment process, but the arrival of PMETB has enabled people to be assessed purely on competence, complicated by the single Article 14 which has enabled us to look at somebody's training experience, qualifications and assess them as equivalent to a day-one consultant. In relation to the broader point you made, I would just like to make a comment on flexibility, because our belief would be that there is not enough flexibility in specialist training at the present stage, and we will work closely with the colleges on this. One option for us would be to look at a core and options approach within training so that people can flex what they do within a training programme. We think we need to see training and education more as a continuum and perhaps we need to look what is within the CCT and what is after the CCT. There are contractual issues there, because it is quite difficult at the moment for doctors to take time out to train, from a financial perspective we need to look at that, but most important of all, what we need at national level is a strategic approach towards this that looks five, or ten, or twelve years head. At the moment we do not have that, and that is the missing link. It is very difficult thing to do. We cannot predict the future, it is very evident to the technological change and many of the things you have considered, but we do need a strategic approach towards thinking about what the medical workforce should look like in ten years' time. Q586 Charlotte Atkins: Professor Paice, we saw the integration of the Workforce Development Confederations and Strategic Heath Authorities back in 2004. What impact has that had on the provision of postgraduate medical training? Professor Paice: I do not think that integration made a difference to postgraduate medical education and training. I do not think that integration made a difference. Q587 Charlotte Atkins: Obviously, one of the issues as well is the whole issue of the number of Strategic Heath Authorities being reduced down to ten. Do you feel that that will have an impact, adverse or otherwise? I will bring Professor Gordon after you have spoken. Professor Paice: I think one of the things which is a concern to anyone who is engaged in postgraduate medical or undergraduate medical education is whether this reduction in size, or at least a reduction in the number and increase in the size, of the SHA will make a difference to where education sits on the board or in the structure of the SHAs. It was a feature of the 28 SHAs that there was an educational presence on those boards, and clearly with the new structures that may well not happen. I think it is absolutely critical that postgraduate medical and dental education feature within that board structure. Q588 Charlotte Atkins: Do you think that the postgraduate deaneries will not have the same sort of relationship with the SHAs given that they are going to be reduced to ten? Is that your concern? Professor Paice: I do not think it is necessary for that to happen. I think it could be, and, indeed, certainly in London, where we had five SHAs and one London Deanery, I am extremely hopeful that the relationship may improve as a one-to-one relationship. So, I do not think that is necessary at all, it is just a question of making sure that education is up there. Professor Gordon: We are actually very concerned about these changes in the documentation about the strategic objectives of the new SHAs. There is not a single mention of education or of research, and I should mention parenthetically, and you may note, that the Health Care Commission also makes no mention of educational research in its core development and standards. To echo Professor Paice's point, there is now no obligation to have a representative from higher education on the board of an SHAs because there is actually a statutory instrument before Parliament at the moment removing that, and that means that there will be no movement of right on each SHA making sure that tri-partite mission of education and research alongside patient care is fully met, and I think this is very important indeed. We cannot really sensibly leave decision-making about how much resource and how much effort goes into education to local decision-making in SHAs where there is no-one with a flag, so it is a very serious problem. Q589 Charlotte Atkins: Professor Streets, do you want to come in on that? Mr Streets: Yes. We would welcome moves towards integration if it really means that chief executives of strategic heath authorities are going to prioritise training and education, and the proof of the eating will be in the pudding, and actually it is difficult to see how they will, given the other priorities they are going to be facing. We need strong deaneries if we are going to have good education, but the key goes back to the point I made earlier about national strategic leadership for medical education looking beyond the next year or two, and it will be fine for them to be integrated locally within SHAs, providing it was in the context of national leadership of medical education, really thinking beyond the next year or two, and it is difficult to see how strategic heath authorities will be able to do that. Indeed, one would not want ten different approaches towards that, you need one national approach to that. Q590 Charlotte Atkins: Interestingly enough, you made a comment about ISTCs and the fact they were going to be training in phase two. I think some evidence we received yesterday indicated that that was very much down to the deaneries and it would not necessarily be a contractual obligation? Mr Streets: There is no doubt that deaneries are absolutely critical to the delivery of medical education, and they must ensure that training provided in ISTCs is as equivalent to that that would be provided in an NHS hospital. Q591 Charlotte Atkins: Do you think that will happen? Mr Streets: It is a question you could ask Professor Paice about. Professor Paice: Only if there is the funding for it, because there is one thing that is absolutely clear about ISTCs and that is that they will do what it is that they are incentivised to do financially. Professor Gordon: I think it is important to point out that it is very difficult when the education and training levy within the SHA budget is not actually really ring-fenced, as I think probably it should be. Q592 Mr Campbell: As we know, education and training funding is basically supplied by the Strategic Health Authority, but last year it had a surplus of 500 million. You have got to wonder why. Did this really affect any training and education, and the second question which follows on from that, was it prevented from spending that money because of the defects in the health economy elsewhere? Professor Gordon: That is a question for the Department of Health, but I think it is quite likely that financial problems in the delivery of patient care may have to be bailed out, in the present circumstances, using money that should be for education and training, not just for postgraduate education and training but also the money that underpins the additional hospital and primary care costs of training medical students. The Department of Health has recently very clearly ring-fenced its R&D money and we believe strongly that the education and training money should be equally firmly ring-fenced, because if it is not it will be raided, and that is actually eating the seed-corn for the future. Q593 Mr Campbell: The big question is: is it being raided now or is it going to be raided? Professor Gordon: We believe has been raided now. Q594 Mr Campbell: It has been? Professor Gordon: My information is that it has been. Q595 Mr Campbell: So it is going to affect training and education? Professor Gordon: Yes. Certainly there is evidence in the reduced number of places commissioned in nursing. You have got Dame Gill Macleod Clark coming later, so you may be able to ask her about that. Q596 Dr Taylor: We have had evidence about nurse training, but, as far as you are concerned, the deficits have not yet affected medical training. Professor Gordon: No, but there is a process going on to look at the scale of the element of sift that actually supports undergraduate medical training to suggest that there might be a common rate and that rate might well be much less than the true cost, we believe. Certainly in many centres it will vary from one centre to another. So, we are very concerned about the process that is going on to review the levels of sift, and we believe that that could have a severely adverse effect on undergraduate medical training. Q597 Dr Taylor: Somehow the Government have found £765 million to lesson their deficits, and that would appear to have possibly come from the training budgets. Have you any evidence that that is the case? Professor Gordon: Not directly, no, I have not. Q598 Dr Naysmith: We are going on, finally, to the question of diversity. It seems to be fairly well recognised that a disproportionate number of doctors are female, white or Asian and middleclass. How can we encourage more working class men into the medical profession? Professor Gordon: The Committee members probably do not know the huge amount of work that medical schools do in trying to ensure the appropriate diversity of their intake. We have teams of staff and our students go out into primary and secondary schools. In my own centre we are involved in every school within the radius of Greater Manchester and we talk to children, we endeavour to find those who would have the aptitude and the ability and encourage them to come in. Sometimes they are dissuaded by other factors, particularly financial ones. It is very difficult if your parents are looking forward to you entering the paid workforce very early on and you are going to be a student for many years, and there, I think, obviously bursaries and other things can help in that way. The other development with which the Council of Heads and Medical Schools is involved is that of the UK clinical aptitude test. This is designed to test innate ability rather the kind of abilities that can be trained for and shown in public examinations, and it will also be looking for qualities such as integrity, empathy and resilience. So, we are looking for the basic qualities that the young man or woman has rather than what they have been coaxed to do in school, and about 75% of all medical and dental schools will require students to take UK CAT, and we believe that this will be a great help in picking out young people from all backgrounds who have the right ability and then we are very keen to get them through. Q599 Dr Naysmith: The Chief Medical Officer told us when we were discussing this subject that new medical schools had been more successful in this than other medical schools, the older, more established traditional ones. Should it not be those ones that they were really trying to get the sort of people you were talking about? Professor Gordon: I would be interested to know Sir Ian's data on that point. I come from quite an old medical school and we are working very hard. Q600 Dr Naysmith: Maybe it is misquoting him a little bit. What he said was that they recognised the importance of it and were trying much harder than the others. I think that is what he really meant. Mr Ribeiro: Can I follow up on that? We have worked very hard with the Department of Health over the last 20 odd years to increase the number of consultant surgeons, and, in fact, we have had in the last ten years a 60% increase in consultant surgeons. What we have noticed in that time is that the number of female consultants starting with them has increased from a point where we used to have something in the order of about 50 or 60 female consultants to 220, and that is still only 6% of the surgical workforce and there is a lot of work to be done to get that right. On the diversity side, I think I heard it quoted, and I cannot remember, in some of the evidence that was given, of I think Sheffield Medical School. One of the members of our council, Mr Andrew Rafferty, who is the Dean for Admissions, has indeed instituted a system whereby they go round all the local schools, and the local comprehensives and so forth, to make the point that medical training is a worthwhile thing to do, and what we as a college now feel is that, in order to recruit our workforce in the future, for which we will need to rely on the female workforce to maintain the surgical workforce, we will have to go into the medical schools, actively go into the medical schools, promoting surgery as a career for everybody to do. The question of diversity is quite a tricky one. You are right to say that there are increasing numbers of Asian women in surgery, in fact 25% of the intake at medical school is almost all female Asians in that context, but there is not the same amongst the Afro-Caribbeans, and the question is: why? We were recently in the West Indies, in Jamaica, doing a course there. A lot of their bright and very able young people go to the States for their training because their role models are in the West Indies. What we need are West Indian role models who are getting on into medicine. Without those role models, in the same way as women if we do not have women consultants as role models, you will not recruit. Q601 Mr Naysmith: While I have you in front of me why do you think it is that surgery has always had this reputation of not having many women in it? Why has it been unattractive for women? Mr Ribeiro: I think because it was the perception - and I will give you a very good example - of long hours, hard work and physical activity. That is no surprise that the percentage of women doing paediatric surgery is about 23% whereas the percentage doing orthopaedic surgery is less than 3%, and there is perception for orthopaedic surgery that you have to be a big, strong fifth row rugby player before you can do the surgery, and these stereotypical things do put people off, and I think that what we are realising is that women now drive heavy goods vehicles because technology makes it possible for them to steer a vehicle and turn it on a sixpence, and in the future these specialities which have been thought to be male preserves will, with the aid of technology, be open to all. Mr Streets: If I may make two very brief points on that. One is the flipside of the Working Time Directive, of course, as it will encourage more women into the medical workforce because it becomes more possible to run a medical career alongside a work-life balance, and what the evidence from the BMA is telling us is that doctors, both male and female, want a better work-life balance and that is one of the reasons why 60% of general practice registrars are women because they think in general practice they can achieve a better work-life balance. In terms of role models I think Professor Ribeiro's point is absolutely right and one of the things we hope Article 14 will do is to enable more people who previously have not been able to get through the assessment systems of colleges and others, to access the specialist register because of their experience, and what we are seeing through Article 14 is the doctors who previously would not have been able to become consultants are now eligible to apply. Many of those are from South Asia and therefore may become the role models of the future for some of the diversity issues we are talking about. Q602 Sandra Gidley: I was very, very struck, particularly with you talking about Asia, by the statistic we were given, which says that 19% of new medical students were Asian in 2001, while Asian people made up 7% of the UK population. Are the Asian students homegrown or are they overseas students who come and are very attractive to universities because they pay full fees? Professor Gordon: This is home grown. We are looking at a very strong demand for medical school places from school leavers of ethnic Asian origin, but UK home grown, and they are chosen purely on their aptitude and merit, and of course they are excellent students. The point is absolutely, though, why do we not have working class male students who have the ability, applying in the right numbers, and we do not know. We are trying. Chairman: Could I say that on the Sheffield Medical School I understand that it has one link with one secondary school in my constituency and not the other four? Could I thank you all for coming along this morning and giving us evidence on these points? Thank you very much. Witnesses: Professor Dame Jill Macleod Clark, Chair, Council of Deans of UK Faculties for Nursing and Health Professions, Professor Andrew Haines, Health Committee Member, Universities UK and Professor Tony Butterworth, Director, Centre for Clinical and Academic Workforce Innovation, University of Lincoln, gave evidence. Q603 Chairman: Good morning. Can I ask you if you can give us your names and organisation just for the record, please? Professor Sir Andrew Haines: I am Andy Haines; I am Director of the London School of Hygiene and Tropical Medicine and a member of the Universities UK Health Committee. Professor Butterworth: I am Tony Butterworth; I am a nurse by profession. I offered evidence in my capacity as a director for the centre at the University of Lincoln, but I have a previous career as a WDC Chief Executive. Professor Macleod Clark: I am Jill Macleod Clark and I am Professor of Nursing and Deputy Dean of the Faculty of Medicine and Health, University of Southampton, but I am here in my capacity as Chair of the Council of Deans for Nursing and Allied Health Professions. Q604 Chairman: Thank you very much for coming along. Could I ask Professor Butterworth a question, please? In your written evidence you stated that the previous "boom and bust" approach to workforce planning has largely been resolved over the past five years. How do you reconcile this with the current reductions in training places for nursing and other professions? And how can we avoid another "bust" phase? Professor Butterworth: When offering the evidence I think it was clear that the work of the then Strategic Health Authorities, the National Workforce Review Team and the WDCs had ironed out what had been quite a serendipitous approach to workforce planning, and I think that we had both geographic expertise across the country through the SHAs and the WDCs, and we are beginning to work intelligently with the hospitals and health communities in such a way that we were trying to join together workforce requirements with what they said they needed to deliver by way of service. We have not fulfilled that completely, by any means, but at least it was a step in the right direction. I think the immediate difficulties are occasioned by financial problems rather than a lessening of the requirement for the workforce number. Q605 Chairman: Can I ask the other two? Your submissions stated that training places have been cut by up to 30% for 2006/07. Is this the start of another "bust" phase in your view, or has the planning hiatus which has been described been resolved? Professor Macleod Clark: If I can answer that? I think it is definitely a very dangerous position in which to find ourselves. The overall reductions in commission numbers across the country are about 10%-plus and that is in nursing and the Allied Health Professions, but in certain areas they are much, much higher than that. For instance, the University of Western England has a 26% reduction in nursing numbers for this year, and a 31% in physiotherapy and the University of East Anglia has a 27% reduction in nursing and a 28% in physiotherapy. That is hugely greater than the "bust" cycle we saw in the 1990s where we had about a 20% reduction over a period of five years. You can see that if these figures were maintained for one more year even we would be much greater than those. Q606 Chairman: Do you have anything to add? Professor Sir Andrew Haines: Just to echo what my colleagues have said. I think it is very difficult for Higher Education Institutions to cope with this amount of variability and it really makes long-term strategic planning almost impossible. At the recent meeting of the UK Health Committee I was rather struck, looking at my colleagues around the table, by the dismay that they were expressing and the difficulties of forward planning of an HEI, which has quite a major commitment to the Health Service. I think it really makes the relationship very difficult and very fraught. As we have already heard, education and training is always susceptible to short-term pressures around finances and what we need really is a much more long-term and strategic view, and I think that will be greatly welcomed by the Higher Education Institutions. Q607 Chairman: Do you think that cuts in training places are a response to financial deficits in other parts of the National Health Service? Professor Macleod Clark: I think without doubt, and we do have some quite clear evidence that that is the case, that the Strategic Health Authorities in finding contributions to the financial deficits have raided the education budgets and they have particularly notably raided them in the Nursing and Allied Health Profession, NMET end of that budget. Q608 Chairman: If you have that evidence already could I invite you to send it in? Professor Macleod Clark: Indeed. Professor Butterworth: As a case example, when I was a Chief Executive of the Trent Workforce Development Confederation we would handle a budget of about £56m a year for education and training of the professions other than dentistry and medicine. The Strategic Health Authorities had a budget of £7m and therefore savings had been found from somewhere which was clearly not all from their own coffers, I think. Professor Macleod Clark: If I could add to that? For instance, in the Avon Gloucester and Wiltshire Strategic Health Authorities there is a record from the board meeting of a £10m saving on the NMET budget, which has gone into the deficits. Chairman: Thank you for that. Howard Stoate. Q609 Dr Stoate: Professor Clark, just a follow up to that. You said in your submission that the link between workforce planning and education commissioning is non-existent at least and tenuous at best. That is pretty alarming. How do you think we can put that right? Professor Macleod Clark: I think what is very clear is that current mechanisms are not working and they are not working for a number of reasons, notably because there is joined-up thinking and we do not have a national integrated workforce plan. The devolution of responsibility to Strategic Health Authorities has not been successful because it then puts those decisions at the vagaries of issues like financial deficits, and we need a joined up picture. I think although our medical colleagues, as evidenced in the previous session, do have some problems they are nothing compared with the problems that we have for the Nursing and Allied Health Professions, and that is partly because there is a bigger national picture for medical manpower planning. So I think that an integrated approach, and there are also real issues about the fact that we do not have similar funding streams and that is a nonsense. Q610 Dr Stoate: What would you do about it? How would you improve the situation? Q611 Dr Stoate: Is there a case, for example, to have a similar system for non-doctors as we have for the medical profession? Professor Macleod Clark: Yes, indeed there is. Q612 Dr Stoate: Would the other two agree with that? Professor Sir Andrew Haines: Yes, I would. I think that the arrangements for the medical profession work reasonably well, and I think also one could draw the distinction between the money being handled by HEFCE where it is relatively protected from these kind of short-term vagaries and the money being at the mercy of the SHAs, where inevitably it is going to be sacrificed for short-term emergency spending; it is always going to be raided for that purpose. So I think the point we would like to make is that there needs to be ring-fencing for the NMET budget, that this may be better done by removing it from the day to day vagaries of short-term financial considerations, and that one needs to look carefully at the medical model to see whether it actually is more generalisable to the non-medical professions. Q613 Dr Stoate: Do you have anything to add to that, Professor Butterworth? Professor Macleod Clark: I think that the original ambitions, which I described before, to try and link workforce planning to the delivery of service were good; I think it is the best idea to be able to do that, and although it was only partially successful I think that ambition needs to be pursued further such that it is not a separate exercise, workforce planning, from the delivery of service. You have an excellent expert national workforce review team who can give you technical advice and then take advantage of that at a local level. The discontinuity that we see at the moment, the difficulties of re-establishing new Strategic Health Authorities, has taken one eye off the ball for that, I think at the moment. Q614 Mr Campbell: Did the introduction of Workforce Development Confederations improve the workforce planning relations between the Health Service and higher education providers? Professor Butterworth: I left the higher education sector to become a Chief Executive of the Workforce Development Confederation and assumed that there would be rooms full of people with that expertise, but in fact there were not. We spent quite a lot of time encouraging and developing people with workforce planning expertise that we could draw from both the health and educational sector, and I think that they did seek to make a difference between the health and the knowledge economy, and I think it was a step again in the right direction. Q615 Mr Campbell: What has been the impact between the Workforce Development Confederation and the SHAs? Has there been an impact of that merger? Professor Butterworth: In Trent I held an executive appointment on the Strategic Health Authority so that allowed me to bring to their agenda at their board meetings educational matters across all the professions, which was very helpful, because they could then build in those things to their strategic requirements, so that entrée between institutions in higher education and the health strategic planners I think was significantly important. Professor Macleod Clark: I would say from the experience of our constituencies that the continual change that has gone on has been undermining. There has been a failure to have continuity in some of the people who we have been working with in partnership, a dilution of the expertise, which I think was pretty slim to start off with, and notably I think there has been a tendency to put a huge amount of resource into micromanaging the educational contracts, as opposed to developing a strategic long-term partnership to discuss the kind of workforce that is required locally. It would be an interesting test to see how much it actually costs to deliver this NMET education programme through the Department of Health mechanisms, if you were to compare it with the process that is used for medical students and for social work students. So our perception is that whatever changes have occurred the processes are not becoming better, they are becoming more disruptive and the partnerships between Higher Education Institutions and the SHAs have been undermined, and notably there is now no Higher Education Institute representative on the new Strategic Health Authority boards. Q616 Mr Campbell: Do you think that the reduction of SHAs from 28 to ten will make it better for education in the future? Professor Macleod Clark: I think that the problem goes back to how I answered a previous question, that I do not believe the mechanisms that are in place at the moment are the right mechanisms to predict and work with Higher Education Institutions to produce the workforce that we need for the future. So that simply reducing the number of SHAs will not help in its own right. Q617 Mr Campbell: Does anybody else want to say anything? Professor Sir Andrew Haines: Just to reinforce the point that I think that education and training is the victim of the constant reorganisation of the NHS without necessarily a very strong evidence-base behind it. One can see that in some areas, for example in London, having one SHA might be advantageous in terms of strategic planning across London, but a real issue is first of all the pace of the reorganisation, also whether or not Higher Education Institutions are going to be properly represented on the SHAs and the indication we have at the moment is that they will not be, and that seems to us a real lost opportunity in terms of engaging the higher education sector. Professor Butterworth: If the new SHAs have a mission which is quite tight and that is to look at the delivery of service and the commissioning of service then that is fine. If education and the provision of education is an afterthought, over which they have some control, that would be a great shame. I felt that perhaps within the 28 it was more focused, more purposeful, but they will become smaller and more beautiful and specifically focused in the business they will do. So there is a danger that education becomes an afterthought out of that strategic planning exercise. Q618 Chairman: Should it be taken out of their hands? Professor Butterworth: If it were properly thought through in such a way. I think it would be quite easy to do that, you could take it away from Strategic Health Authorities, but you would have to secure it in some other way and still have that interlocation with strategic planning somewhere. We could not ignore the Strategic Health Authorities and their mission to deliver services. Professor Macleod Clark: I think again that the medical model does work with a funding stream through HEFCE and indeed in Scotland the non-medical funding scheme is being channelled through the Scottish Health Higher Education Council. So I think there is a real potential to shift the way in which the funding is managed for the non-medical education budget. Professor Sir Andrew Haines: I would just that I think it is going to be very difficult for ten SHAs to really develop a national perspective on workforce development on education, so although there may be an argument for regional relationships between the NHS and HEIs, which we would welcome, as I say, that does not really deal with the whole issue of national planning and we need to look at the broader strategy, not just what is happening in the UK but also what is happening on the international stage. If you look, for example, in North America, it is quite clear that the USA is going to be importing more health professionals in years to come and that is going to have implications for the UK. We have been traditionally a major importer and certainly when I go around the world I get a lot of feedback about the UK's role importing many people from low income countries, and while we have tried to improve that situation in recent years I think we still have a responsibility to make sure that we do not adversely impact. That is not the sort of thing that we can do at the SHA level, that is the sort of thing that needs a national view. Q619 Charlotte Atkins: Professor Clark, the Strategic Health Authorities last year underspent by more than £500m. Clearly this must have had an impact on education and training and would you like to tell us what your experience is? Professor Macleod Clark: Yes, I think it refers back to the answer to the first question. There is no doubt that the underspends and more have been put into securing some amelioration of the basic NHS deficit. That has resulted in radical cuts in commissioned numbers for this coming year and we have ample evidence that it is precisely those pots that have been raided, as I said. Q620 Charlotte Atkins: So ring fencing does not work? Professor Macleod Clark: There is no ring fencing for that element of the budget. It has been token and indeed we have had a correspondence with Lord Warner, in which he again said that there would be no ring fencing for the year to come either. This is why I think we are in a very dangerous situation. Q621 Charlotte Atkins: So what do you expect to happen in the coming
year? Q622 Charlotte Atkins: Professor Haines, did you want to come in? Professor Sir Andrew Haines: Only to add that from the perspective of my own institution we obviously have concerns around public health and there is a similar picture there - 40% reduction in planned recruitment and public health training for 2006 compared with 2005, and academic public health also showing a decline. That is another point that is important to make, that if you allow the clinical academics, the nursing academics to decline, if you do not sustain them then of course you have lack of capacity to train people in the future. So, again, we need to iron out these fluctuations in demand and the fluctuations on financial pressures to Higher Education Institutions, otherwise we erode the base of the institutions. Professor Macleod Clark: Can I give you an example to bring it to light? From the Avon Gloucester and Wiltshire SHA again, the SHA set the WDC a savings total of £10m to contribute to achieving a balanced LDP and to avoid cost shifting to the service. This meant further reductions in education commissions had to be made, and we have many examples that we could give you. Q623 Charlotte Atkins: Overall do you think that too much is spent out of the NHS education and training funding used for medical training, as opposed to other forms of training? Professor Macleod Clark: I think there is a disproportionate spend. It would be quite inappropriate to say there is too much and the argument could well be there is far too little spent on the non-medical education training budgets. The disproportion is quite striking in terms of the numbers of qualified nurses and Allied Health Professions in the system and the amount of money that is spent, particularly in their continuing development and education, and that which is spent for the medical post-registration training, and this lies at the core of the problem about our inability to reform the healthcare workforce because there are no ring-fenced monies for continuing professional development in nursing and Allied Health Professions - or there are very few - and they are not linked to career pathways nor to trainee posts. I would give you the example of GP trainees where there is clearly a very obvious funding route; there is an obvious career route and ring-fenced monies to secure the future workforce in that domain. We know we need more nurse practitioners in general practice - first point of contact. There is no money, there is no ring-fenced money, there is no career framework, there are no training posts. Just to give you a tangible example, you ask about the disproportion. There are 127,000 nurses and Allied Health Professions currently studying part-time and the amount of money that is being invested in that is about £1,200 per student. In contrast, there are 35,000 posts for medical post-registration training and there is £40,000 per student allocated to that budget, and that is just one example, and we can give you others. Q624 Charlotte Atkins: So the government's plans to move the focus from the acute sector into primary care, therefore, is completely undermined by this lack of funding of posts and career pathways within the primary care sector? Professor Macleod Clark: Absolutely, that is spot on; that is the real problem, and it is why I come back to the fact that the current mechanisms for both commissioning and funding a non-medical education area is really not fit for purpose. Professor Butterworth: If I may pursue the example briefly? I quoted previously the funds available in Trent for the impact levy and of that we would have 5% or 10% for innovation, creation and retraining. If that has been withdrawn in order to balance other deficits then that opportunity to retrain and make people fit for purpose in other settings, in a primary care setting has gone and that immediate support is no longer there. Q625
Sandra Gidley: Professor Clark has moved on to the point I
wanted to raise, but you mentioned the percentage cuts in nursing intake but it
is not quite clear how the reductions in budgets have affected the ongoing
postgraduate nursing training. It is
not entirely clear to this Committee how the services and the courses are
commissioned anyway and it might be useful if you could outline how it
works. Who decides what courses are
needed? You have alluded to the fact
that some are just not being commissioned and it seems very airy-fairy; are you
able to put a bit of meat on the bones? Q626 Dr Taylor: This is really some of the most helpful evidence about the deficits that we have because we have been trying to get to the bottom of where the money has gone. Professor Butterworth, in your submission you said, when funding is tight, as now, the first casualty is CPD. Has basic nursing training been affected or is it all the CPD side? Professor Butterworth: There are two opportunities to support the educational enterprise. One is initial registration programmes, which is, as Jill described, managed in that particular way, supposed to satisfy the needs of the health economy. Continuous professional development is slightly different. There is some resource held centrally through the Strategic Health Authorities and some is held by the Trusts themselves in smaller proportion. So it is really hard to get a full picture of how badly that has been affected, but certainly some of the evidence offered here shows that difficulty that people are now experiencing, particularly if it is a government enterprise, to move so much more care into the primary care setting, and the opportunity to make people fit for purpose for that is quite badly affected through these changes. Q627 Dr Taylor: Can you just repeat the percentage of the Trent SHA money that comes from the training budget? Professor Butterworth: This is for two years ago, so I have not been in that position for two years now. Approximately £56m and of that about ten would be available for creating new courses, encouraging people to move into community focused posts, things of that sort. The rest was fixed on education commissions with the seven universities we did business with. Professor Macleod Clark: I think the answer to your question is that the reductions in the commissions are most definitely in pre-qualification and pre-registration as well as post-qualification. So that is where the numbers are that we derive for your two examples of 26% reduction in the West of England and a 27% reduction in East Anglia for nursing and 31% and 28% respectively in physiotherapy, pre-registration for this coming year. So there is no doubt that it is impacting across the piece. And there is absolutely no evidence that that is not related - coming back to Sandra's question - to the demands or the requirements of the Trusts, quite the reverse. We have examples in my own patch in Hampshire where, for instance, our local Trusts have been asking for graduate nurses because it is quite expensive to turn a diplomate nursing into a graduate after they have finished training, and yet the commissions have doggedly been for diploma level as opposed to graduate. So the answer to the question about is there a tie-in between what is needed in a local community and what is commissioned we have geographical examples of where that is not the case. Q628 Dr Naysmith: I had been intending to explore Avon Gloucester and Wiltshire and the effect on universities in the West of England, which is located in my constituency, but Professor Clark has brought out almost all of the points that need to be brought out there because I had been well briefed beforehand by Professor West. Professor Macleod Clark: Perhaps I could expand upon the question? Q629 Dr Naysmith: I was going to say that his letter to me, which brought all this out has been circulated with today's papers and I am sure it is going to provide a body of evidence for some recommendations when we come to make recommendations because it is clearly quite a devastating picture of what has happened. Professor Macleod Clark: And we do have other evidence we can let the Committee have. On that particular example, though, I think it is important, coming back to the post-qualification and career pathways within community nursing, that would be a programme that was supposed to produce your next generation of school nurses, community nurses, health visitors, and all the conversion programmes for nurses who want to be retrained to go into new posts. So it comes back to the workforce design and reform issue, and there were no intakes in your patch for those courses. Q630 Dr Naysmith: I agree with Richard that this is very really very important evidence and I am sure it will underpin some of the things we recommend. Just a couple of tidying up points, you recommended that HEFCE should take over the funding. Would that work? Have you looked very closely to see that HEFCE would be able to do it? Professor Macleod Clark: I think there is no reason in theory why it should not work. It would have to be handled and managed quite carefully because there are notable differences around bursaries, and at present the inability for universities to charge top-up fees, so there are differences in the way in which those programmes, currently commissioned from the Department of Health, work to the way that HEFCE normally does its business. But there are examples and social work would be another one, which works extremely well under HEFCE model. Q631 Dr Naysmith: So HEFCE would have the expertise? Professor Macleod Clark: They have the expertise and it is our belief that it would be much more cost effective. Q632 Dr Naysmith: The other thing you have already touched on as well is the question of education funding in primary care and public health. What changes do you think would need to be brought in to enable that to be done properly? Professor Macleod Clark: I think we must develop a mechanism for proper career pathway tracking, trainee posts and the ring fenced money to go behind that. In the absence of that we will not achieve a workforce reform shift, it just will not happen, because the current mechanisms unwittingly are creating a situation where we are simply maintaining the status quo. They do not allow a flexible, more imaginative and more forward-looking approach to workforce planning. Q633 Sandra Gidley: Professor Clark, the average dropout rate for the United Kingdom university courses is 14% but in nursing the average rate is 25%. Why do so many nursing students drop out and should we be doing more to try and retain them? Professor Macleod Clark: There are two things. The way in which dropout rates are calculated across the university sector generally, and the way in which they are calculated by the Department of Health are very different. So it is impossible to make a direct comparison. Our view is that the attrition rates in nursing and Allied Health Professions are very varied. For instance, you will have a higher attrition rate in learning disabilities nursing than you will in adult nursing. You will have a higher dropout rate in radiography than you will in physiotherapy. So it is quite difficult to lump it altogether because there are big discrepancies. If you use a similar methodology to the higher education model then it looks as if the nursing and Allied Health Profession attrition rate is very similar to other vocational or technical courses like engineering. So, again, the general figure that is produced at HEIs covers a multitude of courses, students on very different routes, and if you compare like with like, which is students who are undertaking courses leading to a vocation, profession involving some coursework which is in practice, then those would be the proper comparative figures. There is no doubt that nurses and Allied Health Professions have a tougher time at university than many other students; they have to work harder, they have to do practice, they are often older so they have other commitments. I think over 30% of recruits into nursing are now in their 30s and above, so you know that they will have other challenges and pressures that will make it more difficult. One of the things that is very worrying for us is that we know now, because of the problem about the lack of job opportunities that is looming, that many students are deciding that if they are struggling they do not want to stick with it because why would they if they are not going to get a job at the end of it? So we do not really believe that the figures for nursing, Allied Health Professions are that much higher than other students in similar circumstances, but now we may see a much greater hike in attrition because of these current factors. Professor Butterworth: It is known that one of the factor that mitigates against people dropping out is if they have good placement experiences, if they are content and cared for where they have those experiences by nurses and others who have been prepared for that role, and that lack of capacity to invest in that now compounds that difficulty, so the people you would want to make the students' experience a happy one need that adequate preparation. The reductions in funding may just work against that to worsen that particular thing, I think. Professor Macleod Clark: I think that is right. There was a very good move to create clinical placement facilitator posts for nursing and Allied Health Professions and those have all been eroded in this last round of cost cutting, and I think that that again is very short-sighted, but it comes back to the fact that the mechanisms for funding for non-medical education do not contain the processes for supporting a funding stream for the placement experience. So there is no money that follows the students into practice, unlike in medicine. Q634 Chairman: Professor Butterworth, your submission highlighted the shortage of healthcare educators in the UK. How serious is this problem and what is being done to address it? Professor Butterworth: There is some work underway to at least uncover some intelligence about that further. The United Kingdom Clinical Research Collaborative has commissioned some work which we are leading to look at what that looks like. That work for us has all the characteristics of the total nurse workforce. Also 25% of it is in the ages of 50 and 55, and the resolution to that in part is to make a career as an educator or as a researcher attractive. It is often serendipitous as to why people go into careers as educators or researchers, and to craft those pathways such that it is seen as a good thing to do and to be helped into those pathways, there are some quite easy ways to do that and we are about that business now. It is necessary to seek some investment to make that happen, to make sure that the next generation of educators are in place, first of all to deliver those new programmes, which we have talked about in the process of giving evidence so far. So it is a cause for great concern. Senior appointments at universities, for example, often have very poor shortlists because of lack of available candidates at the moment, and that is an increasing difficulty reported by a number of universities, but there is some work underway to try and address the difficulty. Q635 Dr Taylor: I think my questions are rather academic because of the lack of funds, but I will ask them just the same. We have been told that there are really no part time nursing courses in the UK. Is that correct? Professor Butterworth: That is not correct. Q636 Dr Taylor: Could you elaborate because it would seem to me that if 30% of the people coming into nursing are over 30, and certainly healthcare assistants who want to go on and become nurses are in the older age group, there have to be part-time courses, so what part-time courses are available? Professor Macleod Clark: We believe that there are currently about a dozen part-time courses offered in nursing across the UK and some in the Allied Health Professions. One of the difficulties again is the commissioning pattern because they have to be commissioned; you cannot run a course in a Higher Education Institution if you are not commissioned to run it. Professor Butterworth: Might I give an example? In Lincolnshire, which I used to have some responsibility for, where it is difficult to recruit people into posts because of the rural nature of the county, I commissioned a nurse registration programme with the Open University, that was largely work-based and quite flexible and had part-time opportunities. So there are mechanisms to do that if the commissioners are wiling to do it. Professor Macleod Clark: If I could give you an example? In one area in the UK part-time occupational therapy commissions have again been cut by a third for next year, so this will be a good example of where we make this rather bold statement about there being a disconnect between the commissions and the service requirements. Most universities have a part-time option on the stocks, but you cannot deliver it if you are not commissioned, so we cannot look at what we have in terms of a local potential workforce and offer that course unless we are asked to deliver it. And there are also issues because it is not necessarily cheaper to run a part-time course. There are sometimes additional expenses, students may need more support, but there would be a standard price for a course and some universities may feel it is simply not possible to deliver a quality course. Q637 Dr Taylor: Would that standard price be greater for a part-time course than a full-time course? Professor Macleod Clark: It would be extended over a longer period of time so the student would need a bursary over a longer period of time, and there are additional costs to a university to supporting a part-time student over a longer period of time. So it may be that that would be a disincentive if the price of that provision was not adequately costed. Q638 Dr Taylor: So the responsibility is entirely with the commissioners rather than the providers? Professor Macleod Clark: Yes, we are absolutely clear that the provision of part-time courses is there but it is not being commissioned. Q639 Dr Taylor: That is very helpful. Talking about flexibility, are there opportunities to change between different healthcare training courses, or if you are on a nursing course you have to stay with that and you cannot cross over? Professor Macleod Clark: No, within a university it is always possible to change course. The extent to which you might need to start again or get some advanced standing and accelerate your progress through another course would vary according to circumstance. But we come back to the commissioning because if I were to talk of my own patch we are given a target for student nurses, physiotherapists and Allied Health Professions, and there is a positive disincentive to get students to swap between courses if you have to pay a penalty, as indeed universities do, for having an attrition rate over a certain level, and at the moment it would be counted as an attrition from a nursing course, even if you were adding it to a physiotherapy course. So that comes back again to Sandra's question. Q640 Dr Taylor: Is it common for healthcare assistants to want to go on and train as nurses or is it unusual? Professor Macleod Clark: Common. But, again, it is one of the areas that has suffered because of this cost saving exercise because again they are more expensive - it comes back to the part-time route. They need support because they have been on salaries before and that money has been radically cut this year. Q641 Dr Taylor: So that would be an example of a part-time course, the healthcare assistant going up to registering. Professor Macleod Clark: Some of them will do a part-time course, some of them will do a full-time course, and the Open University runs a part-time version, which many healthcare assistants take. Chairman: Could I thank you all very much indeed. Could I say, Professor Clark, that the statistics that Sandra used earlier were given to us by the National Union of Students and not by the NHS! I do not know if that is relevant or not, you are a better judge of that than me! Thank you very much indeed for coming along. Witnesses: Dr David McKinlay, Director of Postgraduate GP Education, North Western Deanery, Dr Graham Archard, Vice Chairman, Royal College of GPs, Professor Selena Gray, Registrar, Faculty of Public Health and Mr Paul Holmes, Chief Executive, Kingston PCT, gave evidence. Q642 Chairman: Good morning, could I welcome you to this evidence session. Can I ask you if you would introduce yourselves and the organisation that you are from, for the record. Could I start with you, Professor Gray? Professor Gray: I am Selena Gray and I am the Registrar of the Faculty of Public Health, and I am also Professor of Public Health at the University of the West of England. Dr McKinlay: I am David McKinlay and I am the Director of Postgraduate General Practice Education in the North Western Deanery, a part-time GP in the Ribble Valley and I retire in eight days on the anniversary of 37 years' service in the NHS. Dr Archard: Good morning. I am Graham Archard and I am the Vice Chairman of the Royal College of General Practitioners and also Chairman of the Professional Executive Committee of the South and East Dorset PCT. I represent the RCGP today. Mr Holmes: Good morning. I am Paul Holmes; I am Chief Executive of Kingston Primary Care Trust and was formally Chief Executive of the South West London Workforce Development Confederation, which subsequently became part of the South West London Health Authority, where I was the Workforce Development Director. Q643 Chairman: Once again, thank you for coming along. Could I ask a question to all of you? The primary care workforce has expanded more slowly than the overall NHS workforce in the past five years. How much of a problem is this? Dr Archard: It has quite a radical effect. The complexities of secondary care are such that some of the work has had to be shifted towards primary care, and that is inevitable because of additional workloads in secondary care. To reflect the additional workload in secondary care there has been quite a dramatic increase in the number of consultant places to accommodate that increased workload. Add to that of course secondary care is also subject to the European Work Directive, such that particularly junior hospital staff are perfectly reasonably working far less hours than historically they would have done. The obvious knock-on effect of that has been that a significantly increased amount of work has been shifted towards the primary care sector. There has not been a comparable rate of increase in the workforce in the primary care sector and so inevitably there has been a problem in accommodating the additional workload, which is moving towards the primary care sector. This is not just in general practitioners but in all healthcare professions, such as nursing, physiotherapy, pharmacy and so on. So there is a very dramatic increase in workload in primary care, which is not being reflected in the increased workforce. Professor Gray: I think in terms of public health we are clearly very concerned that the public health workforce certainly has not grown at anything like the extent of the secondary care workforce, and yet we know the demands on public health are increasing, with chronic disease management, illness, the Wellness Report, there are increasing demands across health protection, health improvement and service quality improvement - the three domains of the public health practice - and yet we have a workforce that clearly is not growing and we are in danger of losing people through various reorganisations at the peak, sometimes, of their professional careers. Q644 Chairman: Your submission, Professor Gray, did point that out to us. Do you really think that this will be made worse by the reduction in the number of PCTs and SHAs? Professor Gray: I think we are very concerned that the current reorganisation does not lose yet more health professionals, and there clearly is the opportunity, with the merger of PCTs, in theory, to create larger, more robust public health teams. But we are anxious about the safeguards that are put in place to protect the public health workforce and to make sure that people are not lost along the wayside. I think we need proper guarantee that those posts are not going to be lost. Dr McKinlay: The difference in the ratio between GPs and specialists is quite dramatic. I used to give talks in the late 1980s and talk of an average health district and it was a quarter of a million people, 50 consultants, 100 GPs, 100 junior doctors and about a million consultations of which only 20,000 would have finished up in hospital. The ratio now is equal and so it was two GPs to one consultant, and it is now one-to-one. Then I think the other point that may be helpful to add is that the impact of the various reorganisations on young doctors on training is sometimes not appreciated. I set up the East Lancashire training scheme and in 1989 there were 130 applicants for four places on that scheme and in 1991 there were three applicants for four places on that scheme. As far as we were able to work out there was the 1990 contract which gave young doctors in training the idea that they were just going to push paper around for fund holding and not have time to see patients. At the same time there were the Calman reforms that gave young doctors the idea that they would all become consultants in six or seven years, and six or seven years later they found out that that was not the case. Then finally, in my own local area, there was a dramatic shift in the way that the University of Manchester trained its students and it kept them all close to the university, and to stereotype it we used to counteract two weeks in the concrete jungle with two weeks' hunting and fishing in the Ribble Valley, and the peripheral experience, the Ribble experience was taken away to keep the patients close. Those three factors dramatically affected recruitment in East Lancs., and it took us most of the 1990s to turn that around. Mr Holmes: If I could give you a very local perspective from South West London? It is not a general pattern if we look at it by individual profession, so, for example, across five PCTs in South West London during the period from 2000 to 2005 we saw a 23% increase in the number of general practitioners. Conversely, the number of practice nurses remained very stable during that period; there was a very small reduction of just under 2% in the number of practice nurses. And there was 100% increase in the number of healthcare assistants to a total number of just under 100, and that was quite significant because we did not have healthcare assistants in place in 2000. Q645 Chairman: Dr McKinlay, you said that there was a severe crisis of GP numbers in the North West. Dr McKinlay: Yes. Q646 Chairman: First of all, how has this been addressed? Also, could you tell us has the recent growth in GP numbers been inconsistent across the UK? Dr McKinlay: I think there has always been a north-south divide and within our actual area there is a microcosm of the London versus the rest scenario because Greater Manchester medical school is the focus of training, and I am afraid still, although less, we are all trained in tertiary care and we all work in secondary and primary care, and I do see that modernising medical careers as an opportunity to actually change that to some degree. East Lancashire is very severely affected, but even we have difficulty in persuading a large PCT like Morecambe Bay. Lancaster is an extremely popular market town - very difficult to get doctors to go to Barrow-in-Furness in the same area, so you get a microcosm within a small area. The Ribble Valley, where I work, is a bit of an oasis in the desert; it is relatively easy to get doctors to come to a nice market town like Clitheroe - it is not so easy to get them to go to Burnley. Q647 Chairman: Effectively the increase in GP numbers is inconsistent but historically they always have been inconsistent in terms of GP ratios with patients. Dr McKinlay: I think that is right but the problem is that it is going to be compounded by the retirement time bomb. Again, it is a slight stereotype but the survey we did in 1999 of all the doctors of over 50 in the North West, the doctors who have gone to the under deprived area were very often doctors from overseas, they came and they tried to get on in the hospital service, realised that at that time there was a glass ceiling and moved into general practice, and when we surveyed them the older GPs told us that they were going to go on working because they did not have the pension rights because they had been junior doctors in the hospital for a long time. For the younger GPs, the worrying thing from our survey was that the 50 to 55 year olds said, "We have our ISAs, we have our pensions, we are going to go when we are 55 to 60." And the other issue with retirement is that the doctors working in the Health Service now tend to be full-time with long hours. The workforce that is coming through to replace them is a strongly female workforce, but it is not just the female doctors who want to practise part-time it is male doctors as well. Q648 Chairman: If you have a need of more doctors in a place like Clitheroe, has anything that has happened in recent years, particularly the new contract, been able to give the PCT powers to induce people to go and work there more than being able to in the past? Dr McKinlay: I realise that the new contract has had a lot of bad press in terms of finance but we have just undergone a recruitment round for general practice and I think it has had an extremely positive effect. The combination of the publicity, which in my own experience is wrong, of high salaries for GPs, but probably more the out of hours issue because the most important aspect with GPs really was to spend your lifetime providing a service 24 hours a day had become unsustainable because of the expectations of patients. Twenty years ago, when I was out of my bed at night, it was either to deliver a baby or to see a seriously ill patient. I stopped doing out of hours nine years ago when I became director because I could not be in the Valley all the time. But even nine years ago you get called out every night for relatively trivial problems, and I think that is about the expectations. The patients that need our support and have the serious problems are the very elderly and they have always had a low expectation of care because they remember before the Health Service. I had a patient who died aged 101 two or three years ago, and her notes were like this (indicating a small amount). I have patients who are 16 and their notes are like this (indicating a large amount) and by the time they have something really wrong with them the Health Service is going to be groaning. Q649 Charlotte Atkins: Dr Holmes, and in fact Dr Archard as well might like to comment on this. We have seen the Our Health, Our Care, Our Say called for a 10% shift of activity from secondary primary care. Clearly, that is the way we are going, but what kind of changes in the workforce do we need now to achieve that shift? Mr Holmes: If I can give you some very practical examples of the sorts of changes that we have implemented in Kingston recently to respond to the shift of care into primary care settings, and I will give you two specific examples? We have a small number of community matrons within the Primary Care Trust and the work which the community matrons are doing is to develop an approach to individual patient care, which is called case management model. We have an assessment tool, and the acronym for it is PARR, which stands for Patients at Risk of Readmission, and basically through the process of assessment one can identify a cohort of patients whose history indicates that if they have a range of long-terms conditions there is a higher risk if they hit a crisis point at some point that they will tip into A&E and possibly subsequently into secondary care admission. The work which the community matrons do is that they each carry a caseload and they work with the GP, they work with the secondary care clinicians, and they develop a very comprehensive care plan to support individual patients, very much with an emphasis on supporting and helping an individual patient to recognise the symptoms, the signs of when they are likely to hit a crisis point. They provide support and advice to individual patients, and to give an example of the impact on that - and it is early days yet --- Q650 Charlotte Atkins: My own Primary Care Trust does a lot of work in this field and has been incredibly successful. Mr Holmes: It is very impressive and it is early days, but just to give an example one of our community matrons has 36 patients of the type I have described on her caseload, and over the previous year those 36 patients accounted for 85 admissions. The average length of stay for each of those patients is ten days and that equates to 852 bed days. Over the period since they have been caring for that cohort of patients we have had no emergency admissions. So it is an indication of the impact of that sort of change. Q651 Charlotte Atkins: Dr Archard, would you like to comment? Dr Archard: The 10% saving is very readily achievable when we look at what might be achieved as far as the shift in the work, as far as things like outpatient procedures and so on into primary care. Everything comes down, of course, to resourcing or human resources in the end. There are a number of ways in which this can be achieved and the most important of course is skill mix. While in an ideal world you would be able to recruit other members to the primary healthcare team to extend that work the reality is that we still do have a great shortage of other healthcare professionals, such as nurses, pharmacists and so on. I am very fortunate in my patch in as much as I live in a fairly well heeled area so it is not difficult to get hold of nurses to join the team, and as a consequence of that we have a very large number of nurses and a very small number of doctors by choice. In our particular practice we have over double the usual amount of patients per practitioner in our area because we are able to recruit nurses. The sort of areas in which we are trying to make some sort of headway into this sort of area is slightly different. Although there are community matrons in our area we are also trying a rather different tack, which is a liaison sister, which is some work that we are doing with the National Health Service Institute, which looks at nurses who are specifically dipping in and out of vulnerable people, usually the elderly, to try to reduce admissions to hospital and once in hospital to go into hospital to facilitate discharge, but unlike community matrons, who have a caseload, these nurses actually dip in and out and have a changing caseload. That is not a substitute, that is an addition to the community matron role, but it is something that as yet has not been explored very widely, but it is something which needs to be explored. The other obvious way of addressing the issue, of course, is with general practitioners with special interest, but because of the shifting balance of work towards primary care practices commonly are not very keen on general practitioners moving general practice with a special interest role because that will obviously remove them from the coalface of work at the practice, which leaves the remaining partners to do a great deal more work. So consequently there is a bit of a hiatus here in as much as a number of people would like to be general practitioners with special interest but they cannot move on in that direction. A third way of moving this forward as far as GPs are concerned is a fairly embryonic model which I am trying to introduce at the moment called a practitioner with extended knowledge, which would be that this would be somebody who had probably historically had a lot of clinical experience in a particular area when they were in hospital practice and as a consequence of that has maintained that interest but is not of the sort of level that one might expect from being a general practitioner with special interest. But this knowledge could be used within the practice; in other words, it would not take referrals from other practitioners outside the practice but would certainly look at areas within their own practice. These sorts of skills can be relatively quickly brushed up so that work could be shifted away from hospitals to the practice without having very much of a detrimental effect on the workload within the practice. Dr McKinlay: If I could add that areas of deprivation are not just with GPs, they are with the whole primary healthcare team. I think the mean that is quoted for practice nurses is 2.3 per GP; in Cumbria and Lancs it is one nurse to 2.3 GPs. So we have difficulty in recruiting all the way around. The other thing is, in practices that have developed the skill mix it is already factored in. I think most of the first rounds that took off have really been delivered by good practice organisation, including practice nurses through chronic disease management and things. So I am a little bit sceptical about skill mix being the panacea for everything; I think developing practices have already been working on skill mix for a very long time. Q652 Charlotte Atkins: We have had a lot of publicity about all the redundancies in the acute sector. Do you think that these redundancies are needed to achieve the changing structure of the NHS workforce overall, the balance between the acute sector and primary care? Dr McKinlay: I think it is vital that resource follows activity into the primary care sector and I think the nature of the Health Service of the future is that it should be well delivered at a primary or an intermediate care level. I do not think it is for me to decide how that resource shift comes about. It seems to be probably short-sighted to cut the coalface workers, but I am not qualified to answer that. I was very pleased to see in the new White Paper support for the community hospitals, but they need to be adequately resourced. We spent £100,000 of our fund holding savings on putting X-ray facilities into our community hospital and that enabled a large number of consultants to come and start delivering outpatients in the community hospital and saved a lot of patients a lot of journeys but also improved the service. Q653 Dr Stoate: I would like to pick up something that Dr Archard was talking about, GPs with extended knowledge. GPs have always done that. In my own practice, for example, I have a partner who is very good at dermatology, a partner who is very good at minor surgery and I do a lot of joint injections, and we have always referred people to each other. But does the Royal College seeing this a much more formal role with perhaps some way of actually providing resources to do it, or do you just see an extension of what is already going on? Dr Archard: I think it is a bit of both really. As you say, most practices do have these areas of extended knowledge within their practice team, and it is not just GPs of course, it is nursing colleagues as well. It is purely the fact that we all know, as practising doctors, the sort of skills that one has on leaving hospital practice are very soon lost, which is a disaster and a waste of enormous resource, and if we could look at the training structures, such that those people who have those interests are nurtured through their career in general practice to maintain that knowledge, that would be helpful. While there are those such as me who was a registrar in ophthalmology at one time - and I know very little ophthalmology now but perhaps more than the average GP - it would not take very much to bring me up to speed at a much higher level than I currently am because these things come back very quickly, as you know. If we were able to put that resource into those people who do have this bit of knowledge it would take very little to really bring those people up to speed really quite quickly, and this might be a facility to provide a facility to accept some of the work that is coming from the secondary. Q654 Dr Stoate: Is that not something the College could be involved in? Could you envisage, for example, a diploma type of qualification for GPs with extended knowledge in particular areas, and the College might be overseeing that as the educational overseer, if you like, of general practice. Dr Archard: Certainly the College should look very carefully at this sort of thing and there is no doubt that the College, as you are probably aware, is run on a faculty basis and in some faculties it is already being undertaken in as much as there are local certificates in knowledge of a particular area, which may take between three and five days training to bring people up to speed again. This is not national but certainly it is something that the College is looking at and it is something which I think the College could be encouraged to undertake even further to undertake these sorts of diplomas. Q655 Dr Stoate: To me that would be an extremely worthwhile thing to do. I want to move on to Dr McKinlay and talk about whether you think there is too much emphasis in medical training on the specialist workforce at the expense of a primary care workforce? Dr McKinlay: I think there is some recent evidence - it is not published yet, I have been supporting a young doctor who started looking at these issues when he was a student and he is now doing it in the FI - that there is still what has become known as the "hidden curriculum". Young doctors, undergraduates are prejudiced against general practice and the danger is that if they get a bad experience on their general practice attachment then that reinforces that prejudice. So we have evidence from an evaluation we did of giving PRHOs GP experience. In that, 55% of them that had not made their made up before for general practice once they had experienced it, and this is one of the great opportunities of modernising medical careers to make sure that every doctor has some experience of general practice in their foundation programme so that they are making a more informed choice. A charismatic lecturer was often the reason we made our career choices to graduate level and that is not good practice. The study seems to suggest that about a quarter of undergraduates think of general practice as a career, but the country needs half of them to be GPs. Q656 Dr Stoate: Do you think the MOC might put some of that right? Dr McKinlay: I do, once it is bedded in; if it is allowed to. I do not have figures for elsewhere but it seems from the publicity I am seeing that certain deaneries are going to make the expected cuts in their allocations by hitting general practice. I have worked with a Dean who is general practice centred and we will have over 90% of the Foundation II doctors going through general practice in the North West, but the funded aim for the first year is only 55%, although it is expected that it will be for everybody in due course. We have a particular problem with timing. Q657 Dr Stoate: Mr Holmes, with the reduction of PCT numbers from 303 to 152, do you think that will have an effect on workforce planning in primary care? Mr Holmes: Prospectively, yes. In London I think it is unlikely because in London the number of PCTs has remained stable. Outside of London, the experience which we typically have is of PCTs serving relatively small populations and therefore in terms of the management resources to support the work of the PCT in some cases is struggling, and to develop specialist management skills in areas such as workforce planning. So I would hope that there is potentially a positive outcome from the amalgamation of PCTs into monitoring areas in terms of being able to share those scarce resources. Q658 Dr Stoate: I appreciate that there is a management sharing and obviously you get greater expertise, but do you think that there may be some loss of local focus with PCTs, for example, becoming much larger geographically. Do you think that that might make it more difficult or less difficult for them to plan workforce needs in their area? Mr Holmes: Workforce planning takes place at a number of different levels. The level of the individual practice, for example, very, very practical workforce planning takes place, as you will be well aware, on a day-to-day basis as staff working in practices deploy their resources. If we think about longer term workforce planning - and your example of GPs with specialist interests is a very good example - to date in my personal experience that has often depended on the individual interests of individual practitioners and where those services are then delivered will often be dependent on where those GPs are practising. If we think about a more coordinated approach to development of such practitioners - and a good example in my own PCT is diabetic care - through the process of practice based commission 27 of the 29 practices are signed up to a model of diabetic care which they would like to develop, which is their initiative, and they want to develop a hub and spoke approach to diabetic care with one practice in each of four localities, providing up to level 2 diabetic care. To enable them to do that, we need to develop GPs with specialist interests in each of those four central surgeries. So it is a good example of where there is a potential by planning over a wider area where there could be a more coordinated approach to workforce planning. Professor Gray: I think there are some concerns that some of the issues that you heard about in the last session with SHAs taking money from the levies that that will affect both public health training and GP registrar numbers. There is some evidence that some of those things are seen as easy targets for savings and the numbers have been cut, so we have got four regions that have not got any public health training. I know there are regions where GPR numbers have been cut and again, not related to demand but related to balancing the books. Q659 Mr Campbell: What changes to the education funding systems are required to ensure that a greater proportion of resources go to primary care? Dr McKinlay: I could start with what was the basis of my evidence, that there was an extremely effective initiative three or four years ago but it was not from the levies, it was from the workforce group where £30 million was invested through the deaneries in capital premises to develop training capacity and that produced about 650 new training slots across England. That was so successful that we tried to keep it going in the North West with the co‑operation of two SHAs. We have spent about £2 million and we have created the numbers that were in my evidence: 29 new GPRs, 37 new foundation 2s but also 29 undergraduates and postgraduate nursing. In order to access this fund, our would-be training practices need to develop a multi‑disciplinary approach and the SHA has supported this on the basis that it is for allied health professionals. If we are putting funding in to provide a seminar room for teaching, that room is not just to be occupied for the two hours a week that the GP registrar is getting his tutorial, it has to be in use all the time. Our strategy to deal with these problems has been three‑fold. It has been to get out and talk to the PCTs, to produce the guide for the PCTs that I mentioned in the evidence, the gardener's guide on how to grow and keep your own GPs, and to invest in the capital. I think it has been a really good bang your buck for the NHS and the other thing is that patients benefit because there is some evidence that training practices are quality assured to a high standard and so the patients probably get a better service as well. Q660 Mr Campbell: What about your comments in your submission that there is a shortage of education facilities in primary care. You mentioned that in your submission. Can that be addressed? Dr McKinlay: We are addressing it and that is the way in which I was just mentioning it, capital outcome. There was a second tranche of money for primary care, £108 million a little while ago, that did not require a consultation with the deaneries. I surveyed my other fellow directors and with one exception, which was South Yorkshire that came to light only later when I shared this evidence with them, the deaneries were not consulted and that money had not been used to develop training capacity, which is a shame. There is a small sum of money called the Primary Care Development Fund that is out there now which again requires consultation with the deanery. They are very small sums and it is also deprivation weighted so some areas that could provide more training would not get that funding if they are considered to have enough doctors. In the North West six of the bottom 15 PCTs are in my patch so we would be very keen and we have pushed a lot. When you mention re-organisation, I have been around for a while and there has been roughly re-organisation every two years and there is a period of limbo while we are settling in. A key of our strategy has been getting out of the deanery and talking to the PCTs. Four or five of those meetings have been cancelled in the last few months by the PCTs because they did not know whether they would exist, so we have got a built‑in cycle of inertia while things bed in before the next. Q661 Dr Taylor: I want to go back to redundancies, first in primary care management and then possibly in public health too. Mr Holmes, obviously there is going to be a tremendous reduction in the number of PCT staff when we cut them. Do you think redundancies are mostly going to be in managers or will they be in people who are working on commissioning? Mr Holmes: The people who work on commissioning largely are managers working within primary care. Q662 Dr Taylor: I put that badly, direct service managers as opposed to those who are coping with commissioning. Mr Holmes: I think it more likely that the redundancies would come in the range of corporate functions within Primary Care Trusts. There are a wide range of corporate functions so, for example, in addition to commissioning there would be information technology support provided to practices and performance management of contracts, the actual administration of contracts, financial functions and human resources, et cetera. It is that range of functions where the bulk of redundancies would fall. The provision of community health services provided by Primary Care Trusts is a relatively small proportion of the business of the Primary Care Trusts and effectively it is an operational management service which needs to be supported. Q663 Dr Taylor: Do you think the economies that are forecast will be made? Cutting the PCTs by half, is that going to cut the staff by half or are lots going to have to go and continue to work for the bigger PCTs? Mr Holmes: I think we will see a significant reduction in the overall number of managerial and administrative staff within Primary Care Trusts. I could not venture a figure to you. Q664 Dr Taylor: Do you think there will be an overall saving? Mr Holmes: I think there will be, yes. Q665 Dr Taylor: In our inquiry into changes to Primary Care Trusts, we did get a statement from the Department of Health that public health departments would be excluded from the £250 million cost saving exercise. Is that being borne out? Do you hear of public health doctors who are likely to be made redundant where you lose a Primary Care Trust that has got its own Director of Public Health or an area like mine where you are going to lose three Primary Care Trusts and three Directors of Public Health, do you get any inkling that there are going to be redundancies there? Professor Gray: The statements made by the Department of Health are very helpful. I think what is not completely apparent is the mechanism by which they are going to make sure that happens. We have got a series of recruitment rounds taking place now with various guidance which does not give any guarantees that these posts will not be lost. What we want to see is a very strong line from the new SHAs and the regional directors of public health to make sure that the existing capacity is protected. We know from our survey that only 36% of the current ones feel that they have got enough people to do the job. We cannot afford to lose anyone in this round. Q666 Dr Taylor: Are most PCT directors of public health applying now for the one job that still exists? Professor Gray: Yes, in the next few months they will be going through that process. Q667 Dr Taylor: We have heard of one SHA Director at least who is resigning in complete frustration to all the changes. Are there any more that are going? Professor Gray: A number of the top tier, the regional directors of public health and the strategic directors of public health, who are currently going through the appointment round, have chosen to take early retirement or not to go through the process. Q668 Dr Naysmith: Mr Holmes, as you are well aware there have been new contracts in Primary Care for doctors, dentists and pharmacists and there were lots of ideas behind these contracts but they were supposed to improve productivity and quality at the same time. In your experience, have they done that? Mr Holmes: The dental and pharmacy contracts have only very recently been implemented, it is too early to say what the impacts will be. In relation to the GP contract, again I can provide you with some local evidence. The scores, as evidenced by the quality and outcomes framework, are uniformly higher across my own PCT, so 91% of the available points have been attained by the practices within Kingston and that compares very similarly with the national average. We have seen, in the first two years of the quality and outcomes framework within Kingston, a 5% increase in the number of points which would indicate that there are improvements in quality. For the forthcoming year, or the year we are in now, the bar has been set a little bit higher and it will be interesting to see whether we maintain the rate of improvement. Q669 Dr Naysmith: The QOF targets, being met and met much higher than expected, cost the NHS about £150 million nationally and some people are a little bit cynical about whether that quality of improvement has been reached and some suggest that there should be changes to the contracts to make the GPs work harder. Now, having been married to a GP for a long time, I know that many GPs work very hard but it does seem sensible that if these targets were met so quickly and so easily maybe you need higher and more demanding targets. Is that your view? Mr Holmes: Certainly as I said earlier, Dr Naysmith, for the current year we are seeing the targets being somewhat stiffened. The process of assessing the performance of individual practices is a very robust process in my own PCT. It entails a combination of PCT managers, non‑executive directors who are specially trained for the purpose and clinical advisors going into practices. One of the benefits we are learning from this process is that they are identifying where there are particularly good examples of good practice and are able to then share that learning across the Primary Care Trust. We should also remember that the quality and outcomes framework is not just about performance of individual GPs, it is about performance of the whole practice team and the more effectively the team work, the more likely their performance will be strong. Q670 Dr Naysmith: Do you think that the contract is delivering value for money? Mr Holmes: Again, I think it is too early to say. I think we need to allow a longer period of time to assess whether we secure continuous improvement over that period of time. Q671 Dr Naysmith: I agree with what you said about dentists, it is too soon to say about dentists, but with pharmacists it was last year that the contract was renewed and there has been a lot of talk about things. Do you think there is going to be delivery of some of these things that have talked about, pharmacies having places you can basically drop in and discuss aliments with pharmacists and so on. Is that beginning to happen? Mr Holmes: It is, we have seen some good evidence of an extended range of services being provided by practices. For example, in my own patch we have pharmacists who are now offering needle exchange services and safe needle disposal services, advice to individual patients, assessment of patients and something that we are particularly proud of in Kingston is last year we asked all pharmacists who contracted with us to support six public health campaigns during the year and they did that very effectively. Q672 Dr Naysmith: Do either of the other two general practitioners want to comment on what has happened since? It has been widely misunderstood in many places. It is a question of quality and value for money really. Dr Archard: The first point is that the very term Quality and Outcomes Framework would imply, and I think correctly, that all those practices which are achieving a high return on their points which is, as we have already heard the performance has been significantly greater than initially anticipated, is a demonstration first of all of quality because those markers were agreed markers between the profession and the department. These were markers of quality, not the only markers but nevertheless they were markers of quality. By achieving high standards in that, that would demonstrate that quality has improved. The second thing is that this is an outcome as well and by improving the quality of patient care, our outcomes should also be improving. It will not be in the first year but on the long‑term basis, outcomes will have improved. When it comes to productivity, this rather depends on what you mean by productivity. If you mean by that the number of patient contacts, then there is no doubt that patient contacts have increased dramatically within the primary health care in order to achieve the outcomes framework in as much as seeing patients more frequently, ensuring that people are chased up more for their regular reviews as well as for ongoing conditions. I do rather take exception to your words that targets were met so easily. Like most practices in my area, we scored extremely highly; the reason we scored extremely highly is because we worked extremely hard. We employed two full‑time nurses as well to try to move this agenda forward. We had practice meetings on a weekly basis to try to move the agenda forward. We had meetings with our patient group to try to find ways of encouraging patients as well to adopt the standards and so on and so forth. If my practice is anything to go by, and I have no reason to believe it is not, then it was far from achieved easily, it was achieved by extremely hard work. Q673 Dr Naysmith: Why then do you think there was this junction between what the Department expected to happen and what did happen? Dr Archard: There is an old adage which says if you want a GP to do something write the instructions on the back of a cheque, I do not think that is necessarily true but nevertheless there is some incentive there. Q674 Dr Naysmith: Some people would take exception to that statement! Dr Archard: If you do provide resources in the form of a financial reward that means, as in my case, we were able to employ two full‑time nurses and that resource enabled us to employ those people in order to achieve that quality objective. Without that resource, we would be unable to do so and that is why, the Government put their money where their mouth was and said in order to achieve this quality we need to put some money in. They put some money in perfectly appropriately and as a consequence that was reinvested in a big way by the primary care. Every single member of our practice team, from the most junior receptionist to the most senior nurse had a cut in the QOF and that is the case with a vast number of practices, everybody benefited from the QOF, everybody was a team member and it is because of that team approach, which has been encouraged by the QOF, that we were able to move forward. I have no doubt at all that, even with the higher setting of the level in the next year the performance will increase yet further. Dr McKinlay: I strongly support everything Dr Archard said, I have just one or two other small points. The risk here is to personal and continuing patient care which is much valued by patients and I think that has been put at risk by essential incentives to fragment the service. This is reflected in us having a cancer network, a vascular disease network and a diabetes network. My patients have diabetes and vascular disease and they are pretty depressed about it so which of the silos do they get fitted into? Primary care is one of the great benefits of the NHS and the patients need their advocate and their guide to the NHS more than they have ever needed them. If I get through next Tuesday's surgery, I will have got through my career without being sued, I do not think that is ever going to happen in the future because of the changing culture. When I mentioned my concerns about the retirement workforce, there was a follow‑up study to mine done in South Yorkshire by Dr Pat Lane - and the Chairman might be interested because Rotherham was included in that - it was clear that the same factors that were operational, revalidation, litigation and turning up the burner on the QOF in the wrong directions, i.e. more hoops, would have a detrimental effect on the people who are going to retire. It would seem that we are looking at about 15% of GPs in the next two to five years, there were one or two studies. There was a straw poll done the other week by one of the GP newspapers which said 17% in two years; the South Yorkshire survey suggests 22% in Barnsley and Doncaster and 14% in Rotherham and 10% in Sheffield we are in that sort of area but if we make life harder for a lot of GPs who feel they are working harder, it will affect retirement. The other bit of anecdotal evidence is that my team tell me that the gap between training and non‑training practices has narrowed substantially. I have got people going out to advise non‑training practices how to become training. We have had quality assurance of training practices for a long time. I have always defended the strengths of the independent contractor status because it gave us the flexibility to deliver a local service but the downside was that you have got to have an unacceptable practice, you have got an unacceptable face. That independence has gone so I think this framework has great potential to redeliver the quality and it was not always back of a cheque. For years GPs were paid to do cervical smears and the cervical smear rates did not respond as we wanted so it is not just about money, I think the culture has changed towards equality. Q675 Chairman: Can I have a supplementary on that. South Yorkshire has always had very high levels of GP patient ratios, I know 15 years ago it was the highest in England and Wales, that has changed a little bit now. I asked the question earlier about whether or not the new contract is likely to change in terms of getting GPs to come and work in places because we have on my border the constituency which has got the United Health Care preferred bidder in there to GP practices. One of them, as I understand from the MP there, has been empty for years and we could never deliver a GP to come and work in these mining communities or ex‑mining communities that we represent. Is it to be helped that we are going to be able to get the National Health Service to provide us with more GPs than what it has done for the last 60 years, particularly with our health inequalities? Dr McKinlay: If the PCTs have the resource and the flexibility to make it attractive. This is why our strategy is grow your own. There is evidence from a London study that people do settle near where they train. I am afraid disparity was mentioned about where GPs are trained, there was this idea a few years ago, which I was trying to rebut, that people would train in Brighton and work in Blackpool, it does not work like that. I think the MPC did quite a good job over the country, it had problems with London, but the Medical Practice Committee had its incentives like initial practice allowances to get people to set up in new towns and in deprived areas and over a number of years, they did quite a bit to improve it. It would be better local solutions but they need to be able to put together a package that is attractive. One of our other strategies is to get bright school kids and give them good quality work experience in general practice before the consultants in the teaching hospitals poison their minds and that has worked quite well in some of our deprived areas. Mr Holmes: I would totally endorse Dr McKinlay's comments. When I was working in the South West in the workforce development, we put a huge amount of effort into both retaining and attracting GPs, and I fully concur with Dr McKinlay's comments about the importance of hanging on to the trainees who you have. We spent a lot of time working with groups of GP registrars to find out exactly what they were looking for in a first job and did our utmost to work with PCTs to ensure that some of those aspirations were met. At the other end of the scale we did a lot of work with GPs nearing retirement who did not necessarily want to keep on day in day out - Dr McKinlay may be an exception - running their surgeries but were very interested in, for example, areas of work such as mentoring, supporting and developing GPs. We did our best to encourage that and to enable those people to stay in the workforce longer. I think you have to work really, really hard at it. Chairman: Could I thank you all very much indeed for coming along to this morning's session, and we have not run too far over this week I am pleased to say. Can I thank my colleagues for that as well, I hasten to add. Thank you very much indeed. I suspect it is going to be 2007 before this report comes out in any shape or form but it is a bit of a moving picture. Your assistance has helped us greatly this morning, thank you. |