Examination of Witnesses (Questions 1-19)
MR ANDREW
FOSTER, MS
DEBBIE MELLOR,
MR KEITH
DERBYSHIRE AND
DR JUDY
CURSON
11 MAY 2006
Q1 Chairman: May I say good morning and
welcome you to the Committee? May I ask you to introduce yourselves
and your positions for the record please? May I start with Dr
Curson?
Dr Curson: I am Dr Judy Curson.
I lead the Workforce Review Team which is an expert group of NHS
staff providing national analysis and modelling of workforce in
the health professions. We work on behalf of and make recommendations
to strategic health authorities.
Ms Mellor: I am Debbie Mellor.
I am head of Workforce Capacity in the Department of Health where
my remit is ensuring that the workforce planning and the supply
and demand are effective.
Mr Foster: My name is Andrew Foster.
For the last five years I have been the Director of Workforce
at the Department of Health. As of last week, I have moved onto
a new role, but I did not want to miss the pleasure of meeting
you all just one more time before I went. If I could have the
opportunity in a moment just to say a few opening remarks, I should
be grateful.
Mr Derbyshire: I am Keith Derbyshire.
I am a Senior Economist Adviser in the Department of Health. I
have worked on workforce issues in the past and am currently working
on productivity.
Q2 Chairman: May I welcome you all?
This is the first session of our inquiry into workforce planning.
Mr Foster, you said that you would like to say a few words first,
by all means do.
Mr Foster: I am actually particularly
grateful to this Committee which in 1999 undertook a review of
workforce planning which identified a series of weaknesses and
failings and led to a major overhaul from a document produced
internally by the Department called A Health Service of All
the Talents and then to a restructuring of workforce planning
which has become more robust year on year. I should not like to
pretend by any means that we have a perfect workforce planning
system now, but we have the closest thing to a balance between
demand and supply for healthcare staff that we have ever had,
as measured by the lowest vacancy rates for most of the main professions
that we have ever had. I am very pleased that the Health Select
Committee is going to focus on us yet again, because I am sure
that we have further improvements to make, which we plan anyway,
but it was the impetus from you in 1999 that pushed this much
more to the forefront of the NHS planning systems and has been
a real benefit.
Q3 Chairman: Thank you very much.
I wonder whether any of my colleagues here were actually on the
Committee at that time; I was not.
Mr Foster: Debbie Mellor was part
of the team that provided help last time as well.
Q4 Chairman: Let us pursue how that
report and the subsequent actions got round. You have probably
seen on the news this morning that we are being lobbied by NHS
workers again today here in Parliament. I suppose many people
out there, members of the public, would ask the obvious question.
A few years ago we were told the NHS was short of staff, yet now
we seem to be making people redundant. Why is this?
Mr Foster: The headlines are a
gross misrepresentation of what is really happening. For the last
five years we certainly have had a remarkable increase in the
number of staff. It is about 200,000 increase in staff in just
the last four years and the last figure, the last year for which
we have accurate records, is the year which finished September
2005, which showed that there was a further 34,000 increase in
staff last year. This year, many organisations are having to make
sure that their workforce plans are aligned with their financial
plans and many are announcing intentions to reduce the number
of posts in their organisations. However, when you plough beneath
almost every single one of those headlines, they are reductions
in numbers of posts, not making actual staff redundant. Typically,
we did a poll of this when we had a HR conference in Birmingham
the week before last, where about 1,000 HR managers were present
and typically, the ratio of actual compulsory redundancies to
the headlines is about 1:100; so in organisations making 300 post
reductions, three compulsory redundancies. There are one or two
exceptions to that, but for the very large part this is to be
achieved through natural turnover rates, typically 10% in any
organisation in a year, through reduction in reliance on agency
and temporary staff and not through making actual staff redundant
and particularly not clinical staff.
Q5 Chairman: May I ask you about
nurses in particular? The NHS Plan set the target of expanding
the nursing workforce by 20,000 nurses between 1999 and 2004.
Recent evidence shows that the nursing workforce in fact grew
by 68,000 during that period. Why did this actual expansion so
greatly exceed the target expansion?
Mr Foster: Well, the NHS Plan
target said at least 20,000 nurses and then it went on to roll
that target forward in a series of two further documents which
had a target going up to 2008. Yes, we have very significantly
exceeded the targets that were set and that is really based on
the needs of local organisations to meet the demands of the access
targets, increasing the capacity necessary to reduce waiting times
and to improve quality through delivering the national service
frameworks. So the main reason is that the figures that were in
the NHS Plan and the subsequent documents were minimum targets
and they do explicitly say that.
Q6 Chairman: I accept that they were
minimum targets, but the plan in 2000 has been overshot, for want
of a better expression, by 340% as far as nurses are concerned.
It seems to me that when you talked earlier about this issue of
workforce plans having to come into line with financial plans,
most people would ask why workforce plans were not in line with
financial plans, or the other way round, in the year 2000 when
the NHS Plan was first published. Why do we wait while there is
this perceived crisis? I accept, looking at these figures, I do
not disagree for one minute, that the actual job losses are far
below what has been grabbing the headlines in the media. What
grabs the headlines in the media grabs the public as well. Why
were we not having financial and workforce plans working alongside
one another logically for the last six years?
Mr Foster: For the last five years
we have had workforce and financial plans which have worked alongside
each other quite comfortably, as witnessed by the fact that the
NHS has achieved its targets and stayed within financial balance
until the last year, 2005-06, when there were well-publicised
significant difficulties. I accept that there was a degree of
over-heating in the system just in this last year, where people
clearly have taken on more than they could afford and there is
some evidence of that, for example in North Staffordshire, which
is one of the organisations with the biggest problems and has
announced 1,000 job reductions, where it actually took on 300
extra staff in the first quarter of last year. The integration
of financial and activity planning has not been as good as it
might have been everywhere. For example, if you take last year's
planning process, there is a challenge in the system that was
created following the last HSC report so that organisations submit
workforce plans at the beginning of the year and in April 2005
organisations submitted workforce plans which totalled an increase
of approximately 6%. These were then challenged by the central
workforce planning process and they were told that those did not
really match up with the financial environment that they were
entering. As a result of that, the plans were redrawn and predicted
a 2% increase in the workforce in 2005-06, which is in fact very
similar to what was achieved when you look at the September 2005
census figures. It is a system which has worked relatively well
for four or five years, but has just slightly over-heated in the
last year.
Q7 Chairman: Does this scenario of
over-heating, as you call it, help to explain the current trend
towards deficits and redundancies in parts of the NHS? Is that
basically what you are saying?
Mr Foster: Yes. The NHS does have
deficits in 2005-2006. Two thirds of the money that we spend is
on staff and therefore, in order to bring it back into balance,
clearly staff numbers have a very significant part to play. Thanks
to the very high turnover rate that happens naturally every year,
we have the opportunity to do that with minimum redundancies.
Q8 Anne Milton: Notwithstanding that
the nursing workforce has expanded more quickly possibly than
intended, the number of central administrative and management
staff has grown more quickly still. In fact these figures in front
of me show that nurses as a whole have gone from 30% of the workforce
in 1999 to 29% of the workforce, whereas the support staff and
senior management have grown quite substantially as a percentage
of the total workforce. Can you justify that?
Mr Foster: I can explain it and
I can also point to what is likely to happen by the time that
you get the next set of figures. Broadly speaking, what has happened
over the last five years is that we have brought a level of management
into primary care that was never there before. So the creation
initially of primary care groups and then primary care trusts,
each with their own management teams, is an attempt to introduce
management into primary and community care that was never there
before. If you look at the level of management in NHS acute trusts,
you will see that there has been no growth at all, or only growth
which is proportionate to the total increase in the size of organisation;
so the significant growth has come in primary care. As part of
the manifesto commitment last year, the Government announced their
intention to reduce £250 million out of management costs,
a process which is now working its way through with the reduction
in numbers of strategic health authorities and primary care trusts
so that by the time you get the next set of results, you should
see a reduction in that figure which will bring it much more into
line with the rest of the workforce.
Q9 Anne Milton: I have to ask you,
because I think the public would want to know, what the management
in primary care has been managing?
Mr Foster: It has been managing
the change in the system which seeks to prepare for less care
to be delivered in hospitals, more care to be delivered in primary
care settings and in the patient's home. It is managing that pathway
of the patients.
Q10 Anne Milton: You are going to
have to have another go Mr Foster, because I do not think that
anybody reading this would be entirely clear what you mean by
that.
Mr Foster: What I would really
like to do is ask you to ask that question again in the second
half of our session when we have Dr David Colin-Thome present,
who is the Tsar of national primary care and who will be able
to give a better answer than I can.
Q11 Anne Milton: It has been management
for primary care, for practices and district nurses and . . .
?
Mr Foster: It is also commissioning.
It is also allowing GPs, on behalf of patients, to plan services
and giving them the management support that they need to do so.
Q12 Anne Milton: Right; so the managers
have been helping the GPs.
Mr Foster: Yes.
Q13 Mr Amess: What you have just
said is just barking mad. I am trying to reflect on it. We have
more staff in the primary care trusts to sort things out because
of the way the practices with the hospitals are changing and at
the same time we are reorganising primary care trusts, we are
going to cut down the numbers, we are going to streamline the
numbers. This is an absolute shambles. This is not planning: this
is just all over the place. I am sorry, but what you have just
said to the Committee just does not make any sense whatsoever.
You want us to leave it alone until 11.15am when the Tsar comes
in and I realise you have moved on to another job, but you were
the guy. You started off praising us for what we did in 1999,
but honestly you could do a little bit better in trying to expand
on what you said earlier, just to make sense. The general public
are not idiots.
Mr Foster: Okay. One thing I said
was that we want a trend whereby people are treated less in hospitals
and more in their homes and in the community; I do not think anybody
would disagree with that. We said we have a trend where we want
to have the patient experience in primary care better managed;
I do not think anybody would disagree with that. We would say
that we have reached a point where we recognise that this had
resulted in a disproportionately high management cost going into
primary care, so there is now a correction of the order of £250
million to concentrate that into a smaller number of larger organisations
carrying out the same task; I do not think anybody would disagree
with that. You have all of those three trends working at the same
time which is a complex set of changes to manage but each of the
three are things which I think people would agree with.
Q14 Anne Milton: I just want to come
back on one thing. The managers are for primary care and yet the
number of GPs as a percentage of the workforce has gone down from
2.7% to 2.6%. The number of practice nurses, which I should say,
if there is an increasing emphasis on primary care, you would
expect to have gone up, but that has gone down. It is hard to
understand this.
Mr Foster: If you look at the
community nursing figures, what you are seeing is a much greater
flexibility here.
Ms Mellor: The community nursing
figures have been going up steadily year on year and we now have
over 100,000 community nurses working in primary care.
Q15 Anne Milton: It is not whether
they go up or not, it is what they represent as a percentage of
the total workforce. That is the crucial thing. The fact that
they have gone up or down is not quite the point. It is the fact
that as a percentage of the total workforce those numbers are
going down.
Ms Mellor: In community nursing,
the numbers are going up.
Anne Milton: No, you are not listening
to what I am saying: as a percentage of the total workforce, not
the actual numbers.
Q16 Dr Naysmith: Are you saying there
has been an expansion in primary care trust management staff or
in primary care delivery in the primary care setting?
Mr Foster: I am saying that there
has been definitely an increase in the number of primary care
trust management staff and the plan is to shift care from secondary
care to primary care.
Q17 Dr Naysmith: Not many people
would disagree with that. What are the primary care trust managers
doing for primary care that was not being done before?
Mr Foster: Commissioning is the
main answer to that.
Q18 Dr Naysmith: Do you mean commission
things at a primary care trust level?
Mr Foster: Commissioning integrated
care between secondary and primary care. The secondary care are
provider organisations: they do not plan the whole patient pathways;
they do commission the services; they do not decide what is delivered
where, that is the role given to PCTs as advised by the experts,
the GPs.
Q19 Sandra Gidley: Let me get this
straight. We have had an increase in primary care management over
five years, the agenda you have just mentioned about moving care
close to home and all of the other rhetoric, I would perhaps agree
with, but I have seen little movement in that over the last five
years. What I am struggling to understand is how services have
been improved for patients; not the man on the Clapham omnibus,
but the man in Clapham hospital's bed. There seems to have been
no corresponding increase in workforce in primary care, which
I could understand if this increased number of managers was delivering.
So how has this actually improved for the patient? Can you give
me a practical example, because I am struggling to get my head
round this?
Mr Foster: In answer to the two
questions here, what you have seen in the last five years is slightly
more growth occurring in the hospital sector than in the primary
care sector and the benefits to patients you can demonstrate in
terms of the dramatic reduction in waiting at every level of the
system from A&E to outpatients to inpatients to cancer care,
the improved clinical outcomes in terms of reduced death rates
from coronary heart disease and cancer and the emphasis of shifting
into primary care has been a plan for a while which is now really
being given much more impetus by the White Paper, Our Health,
Our Care, Our Say and through the creation of the new GMS
contract which has a much better quality control of primary care.
You can demonstrate the quality outcomes in primary care as measured
through the quality and outcomes framework which is used to remunerate
GP practices. So you can see demonstrable benefits there. The
real stage of transfer from secondary to primary care is about
to begin.
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