Examination of Witnesses (Questions 20-39)
MR ANDREW
FOSTER, MS
DEBBIE MELLOR,
MR KEITH
DERBYSHIRE AND
DR JUDY
CURSON
11 MAY 2006
Q20 Sandra Gidley: But the demonstrable
benefits you talk about are because you are actually paying GPs
to deliver certain services and they deliver if they are paid.
I cannot see how that is linked to the increase in management.
Mr Foster: No, but you asked me
what the demonstrable benefits were of the increase.
Q21 Sandra Gidley: The demonstrable
benefits of the increase in management and actually most of what
you said was related to secondary care, the reduced times for
operations. Basically we welcome all that, but I cannot see the
benefits in primary care.
Mr Foster: You cannot just stop
doing some practices in a hospital and start doing it in primary
care. You need to manage the transition, you need to manage the
patient flows and you need to manage the training of the staff
who will apply the extra skills. So there is a management task
in changing from something which is predominantly hospital oriented
to something which is delivered much more in the home.
Q22 Sandra Gidley: But you also said
that there is a lot more impetus to this care close to home and
we are now reducing the managers. What have they been doing for
five years?
Mr Foster: The managers have been
changing to an environment where there is a greater level of management
in primary care, but in response to the workforce statistics that
we have seen about the disproportionate growth, what we have found
is that the size of unit which is typically commissioning care
in primary care, the PCT, has been too small. The big hospital
trusts have been powerful organisations and have not been able
to be sufficiently bossed around by the PCTs. The plan now is
to have a smaller number of much more powerful PCTs, with greater
powers of commissioning, building on the work which has been laid
to shift from secondary to primary and strengthened by the direction
set out in the White Paper.
Q23 Sandra Gidley: So will the current
changes mean a reduction or an increase in the number of managers
working at primary care level?
Mr Foster: It will mean a reduction.
The next workforce figures you will see will show a reduction
of managers working in primary care trusts.
Q24 Sandra Gidley: I have never seen
a single organisation that has resulted in large-scale management
redundancies.
Mr Foster: It is required. The
£250 million manifesto commitment saving is disaggregated
to each strategic health authority so that it has to be achieved
at PCT level. The process of reducing from 300 PCTs to a number
which has yet to be announced, but something of the order of half
of that, will result in £250 million of management savings
and that will show through in next year's figures.
Mr Amess: Would you agree that it does
not look very good? Nurses in 1999 30% fallen to 29.6%, bureaucrats
6.7% up to 7.7%, senior management 2.2% up to 2.9%.
Chairman: I was going to put that question
back to Debbie Mellor because what Anne Milton was pursuing and
what you have just said there is that there is no contradiction.
If some parts of the workforce are expanding by a few percent
that does not really say there are not more people working in
that particular area. That is basically what our witnesses are
telling us about these differentials that there are in the tables
we have seen.
Q25 Dr Stoate: At the risk of being
politically incorrect, I would have to say that the health service
has been woefully under-managed for generations and in fact I
have to say that some of the management increases in primary care
have been very welcome. I am not talking about the number of administrators
but the number of managers, and I really mean managers, is actually
extremely welcome and has actually knocked some sense into what
has been an extremely disparate sector of the health service for
far too long. What I want to move on to is your memorandum which
indicates that the focus over the last five years has largely
been on expanding the workforce and the memorandum goes on to
say that over the next five years, it is going to focus on the
transformation of the workforce. Perhaps you would like to explain
what that means?
Mr Foster: The NHS Plan of 2001
produced by Alan Milburn started off with an analysis based on
a variety of consultations but one of them was asking the public
what they wanted to see. The number one thing that the public
said that they wanted to see in 2001 was more staff better paid.
What has really happened over the last five years is precisely
that. More money has gone into pay, the numbers have increased
by about 200,000 and we have introduced new systems of remuneration
which are designed to increase the flexibility and productivity
of the system. We have achieved the input targets. We are now
shifting to looking at the output targets.
Q26 Dr Stoate: That is my point.
We are seeing the extension of numbers; now we want to see the
transformation of the service. I want you to explain how that
is going to happen.
Mr Foster: Exactly. Mr Derbyshire
on my left is our expert in productivity and I shall pass it on
to him in a moment. Broadly speaking, there is a series of measures
which have been well described by the former Modernisation Agency
of high impact changes which require you to redesign the way services
are delivered so that you reduce the length of stay in the hospital
sector, you do as much work as day case procedures as you can,
you adjust the skill mix of your team so that the work is done
by the person who is safe to do the work but is most economically
efficient. For example, some years ago you might have seen a doctor
taking a blood sample from a patient, then we have had phlebotomists
who have been trained to do it, then we have had nurses who have
been trained to do it and now we have healthcare assistants who
are trained to do it. So the same procedure can be carried out
much more economically, effectively by somebody who is a member
of the team and who can then be remunerated for taking on extra
responsibilities. So that redesign of services and redesign of
skill mix will enable us to get a higher output or productivity.
Q27 Dr Stoate: Are you confident
that will happen? All of that sounds lovely in theory and I am
quite sure that is the intention, but are you convinced that is
actually what is going to happen?
Mr Foster: That is what is already
happening and what we want to do is to accelerate it.
Mr Derbyshire: If we go back to
the NHS Plan in 2000-01, then the decision was made to increase
the inputs into the National Health Service by a significant and
sustained amount and a lot of the increase in inputs was the increase
in labour force which we have seen achieved. Over the past five
years the output of the NHS has increased more or less in line
with those inputs. What we should like to do is further increase
the rate of improvement of the output of the NHS as fast as the
increase in the input.
Q28 Dr Stoate: Could it not be said
though that it was somewhat reckless to expand the workforce massively
without sorting out the outputs as a priority right from the beginning?
All we are left with then are the charges, which we have heard
from many members of the Committee today, of a massive explosion
in management, but seemingly not enough to show for it yet. Is
that not the charge that it is too easy to levy at you?
Mr Derbyshire: There was a risk
with the rapid expansion of the NHS that not all of the increased
resources would be deployed on improving patient health. The question
about managers is not what the increase in managers has been,
but precisely what they have done to facilitate improved health
outcomes.
Q29 Dr Stoate: That is exactly the
question. What have they done? It leaves open the question. We
have seen the massive expansion, we can look at the huge input
into the health service, but can you honestly say that enough
has changed to justify that?
Mr Derbyshire: In aggregate terms,
we can, and working with the ONS and the Atkinson review of How
to Measure Government Outputs, if you move away from crude
measures of what the NHS produces in terms of patient treatments
and begin to look at the quality and the health benefits those
treatments deliver, then output has risen in line with inputs.
Then there is a micro question about whether the mix of inputs
is correct. Andrew made the point about PCT managers that maybe
the organisations themselves were badly configured; they were
perhaps too small for the role that they have gradually been evolved
to do and we are putting that right for the future. One of the
underlying reasons for their smallness to begin with was to work
together in a community of GPs to organise services at primary
care level as well as commission from secondary care.
Mr Foster: On the point you made
right at the start of your question about management, if you do
patient surveys or if you even think anecdotally of the instances
you know of where friends or relatives of yours have been using
healthcare systems, by and large the time that they spend with
the clinician is excellent; they have a fantastic service. It
is their travel through the system that is often unsatisfactory
and it is more management of the pathway that is needed and better
management and that is really what we are trying to achieve in
line with international best practice. We spend less than 3% of
the NHS pay bill on managers and that compares well with anywhere
else in the world.
Q30 Chairman: May I just ask you
about this issue of transformation? We are all very well aware
of what the public's attitude was to the NHS Plan: more staff
and better paid. In a recent interview that you gave to the British
Journal of Healthcare Management, when you were talking about
the workforce side of this, you said that we have to lose 1940s
ways of working and need a more flexible workforce with more patient-centred
care. Did you genuinely feel that there were still 1940s ways
of working in the National Health Service? Not in whole, but in
part or in whole?
Mr Foster: Yes. I have given one
example already, which was taking blood samples. Take another
example, prescribing. We now have nearly 10% of the nursing workforce
doing some form of prescribing. Several years ago only doctors
prescribed. Now that is about really dramatically changing the
division of labour within the workforce and allowing people with
appropriate training to carry out tasks which they are perfectly
skilled to do. Nearly 10% of the nursing workforce is a very large
amount of transformation indeed, but that hides a plethora of
exciting new roles. In any healthcare organisation you visit you
will not only find these extended roles, people doing tasks that
they did not do before, but you will find some completely new
roles. We now, for example, have approximately 800 emergency care
practitioners who are people who will deal with sick and elderly
patients in their own home, avoiding them being admitted to hospital,
which is not just an economic benefit to the system, it is infinitely
preferable for the patients themselves. We could go on to give
you countless examples of new roles in the therapies, in science,
GPs with special interests, which are really about the transformation
of the workforce away from the rather rigid silos of apples and
pears, nurses, doctors and so on that there used to be.
Q31 Anne Milton: Would you expect
the pay to go with it? Doctors at one time prescribed and they
were the only people who prescribed, then nurses extend their
role and start prescribing. Would you expect, say, if you took
nurses, that they would get increases in remuneration to reflect
that?
Mr Foster: Yes.
Q32 Sandra Gidley: The accusation
is that they become a cheap labour force. It is cheaper for nurses
to prescribe than it is doctors.
Mr Foster: No. It is cheaper for
nurses to prescribe than doctors, and if you train a nurse to
take on a significant amount of extra responsibility and pay them
for taking on that extra responsibility, you have a win-win. You
have a better opportunity for the nurses.
Q33 Anne Milton: You would expect
pay to increase with the extension of role.
Mr Foster: That is exactly what
Agenda for Change is designed to do. It is actually to incentivise
people to take on added responsibilities and pay them more for
it. If you look at the pay bands of Agenda for Change, band five
is a newly qualified nurse, band six is probably a ward manager
but then you see nurse endoscopists, cardiac theatre nurses and
a whole range of extended roles at band seven and above reflecting
the fact that they have taken on extra responsibilities.
Q34 Anne Milton: There is some concern
about that within some of the professions within the NHS. It is
not so much an increase but equivalent pay scales that they are
looking for.
Mr Foster: The whole system is
based on a very complex job evaluation scheme which took seven
years to develop but working in partnership with the trade unions.
It is probably the most thoroughly tested job evaluation scheme
anywhere in the world and is widely regarded by the trade unions
as a very successful joint development.
Q35 Chairman: Are there any practical
measures beyond Agenda for Change that workforce planners are
using to get this transformation in terms of maybe skilling?
Mr Foster: Yes. May I broadly
say that we recognised that in workforce planning there is a degree
of bottom-up: how many people are going to be retiring over the
next few years? There is a degree of top-down: what are the major
changes in demography, technology, international immigration?
Then what we do is some skill specific analysis: what are the
skills we need for cancer services of the future? Rather than
saying we need to commission so many more nurses or so many more
physiotherapists or whatever, we are looking at the competences
that we require as an added input to workforce planning. Judy
sits at the heart of this complex web, so may I perhaps ask her
to answer that?
Dr Curson: You are asking about
what workforce planners can do to support transformation.
Q36 Chairman: Yes, practical things
beyond Agenda for Change.
Dr Curson: One of the issues is
that as workforce planners we can come up with plans. It is down
to trusts and to service managers in the trusts to implement those
and that can be an issue with new roles. For example, graduate
mental health practitioners, where a new role was developed which
crossed the boundary between social work, OT, nursing. Sometimes
it can be difficult to convince service managers in trusts who
are under a lot of pressure to take on new roles and to work in
different ways, so one of the things is for workforce planners
not to work in isolation and come up with great dreams of wonderful
new roles that will make a difference, but to ensure that that
is embedded in the way people work locally and that they actually
want the roles and are going to know how to use them. A number
of projects are going on nationally and at local level to try
to support people to make those changes so that workforce planning
does not take place... We have talked about it not taking place
separately from financial planning, but it is actually very important
that it is not separate from service planning because otherwise
there is a risk that workforce planners come up with new roles
and then no-one wants to employ them.
Q37 Jim Dowd: There has been a significant
number of changes in workforce planning in the last five or six
years. I just mention the National Workforce Development Board
replaced by the Workforce Programme, the Workforce Numbers Advisory
Board replaced by the Review Team. Why have there been so many
changes and surely they are more disruptive than beneficial?
Mr Foster: What you are describing
are not fundamental changes, these are evolutions. So for example,
you talked about the Workforce Programme Board and its predecessor
the National Workforce Development Board, there was really a sort
of modest adjustment of the membership of effectively the same
body to make sure that we had better representation from strategic
health authority management. There is no fundamental change going
on there.
Q38 Jim Dowd: Are you saying then
that was because the SHAs developed over time and the relationship
needed to change?
Mr Foster: Yes; exactly. The original
National Workforce Development Board was a stakeholder board which
sat at the pinnacle of the workforce planning process and we recognised
that we needed to get a better buy-in from the strategic health
authority management. That is why that changed.
Q39 Jim Dowd: Then of course the
SHAs were reorganised.
Mr Foster: And then the SHAs have
been reorganised, but all that will mean is that there will be
different individuals, but we will still have the SHAs represented
within the process.
Dr Curson: I would echo some of
that; a lot of it has been evolution. My team used to make recommendations
on medical workforce to a body called SWAG. It then made recommendations
to the Workforce Advisory Board and now we go to the Workforce
Programme Board. Basically the team has been doing very similar
work with the same group of stakeholders over that five-year period,
so it does feel more evolutionary than revolutionary in that sense,
although I accept that there have been a number of changes.
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