Examination of Witnesses (Questions 60-79)
MR ANDREW
FOSTER, MS
DEBBIE MELLOR,
MR KEITH
DERBYSHIRE AND
DR JUDY
CURSON
11 MAY 2006
Q60 Mr Campbell: What is the current
formal role of NHS foundation trusts in the local workforce planning?
It is in the nature of these trusts basically to integrate the
workforce development through the local development plan. Has
that been happening in the foundation trusts?
Mr Foster: By and large, yes.
They have a duty of cooperation, so there is a duty to contribute
to workforce planning. Although they have many freedoms, they
do not have the freedom to opt out of workforce planning. So by
and large yes, they have been contributing well to the whole system.
Q61 Mr Campbell: Are they actually
working well within the health service economy? Are they contributing?
Mr Foster: Yes.
Q62 Mr Campbell: Does the workforce
work in the same way as it works elsewhere in the hospital trusts?
Mr Foster: Debbie may want to
give you more detail, but the fundamental workforce information
is a common set of workforce information which foundation trusts
have to give us in exactly the same way as all other organisations,
so that we can have integrated workforce planning for a whole
strategic health authority.
Q63 Mr Campbell: Are you telling
the Committee that there is not much difference between the foundation
trusts and a normal hospital which is not a trust?
Mr Foster: In this specific respect,
yes.
Q64 Mr Campbell: In workforce planning,
Mr Foster: Yes.
Q65 Mr Campbell: May I ask you the
same question in relation to the independent sector? We see the
growth of the independent sector rising very fast in places. Is
the same thing happening there? Are these people on board as well
with the planning of the workforce?
Mr Foster: Again, that was a change
that was made following A Health Service of All the Talents
where workforce development confederations were established with
the explicit duty of setting up stakeholder boards which involved
independent sector providers as well as NHS providers. I do now
know whether Judy or Debbie want to comment on further strengthening
which has taken place?
Dr Curson: It does rely on cooperation.
The independent sector is not required, for example, to participate
in electronic staff records, which is only one of the ways that
we collect data, but my contacts with them, both at national and
at local level, have shown that they do want to cooperate because
they are dependent on the same staff that we need and generally
there is enthusiasm for cooperation, although recognising that
they are in competition and that some issues are commercial in
confidence. At this stage I am cautiously optimistic that we shall
be able to continue to workforce plan. Clearly one sector where
we have not had very good data has been the nursing home sector
which is very disparate, which has been in the independent sector
for many years and which does employ a large number of nurses;
it has more beds than NHS hospitals. We are very hopeful that
we shall continue to get reasonable data but it is not consistent
and they are not bound by the same systems that the NHS is.
Ms Mellor: In the recent White
Paper it was recognised that we do need to have more integrated
workforce planning across health and social care. One of the things
that we committed to do was actually to work with local government
to try to bring the workforce planning arrangements, particularly
in social care and the independent sector, and particularly the
independent sector nursing homes which have been more difficult,
within the system.
Q66 Mr Campbell: The danger with
the independent sector, as we found out before, is that the training
is not as good in the workforce as it is in the health service
itself and it is a little sore which needs to be put right; their
training methods or their training in general is not as good for
the workforce. I do not think they plan it very well either.
Ms Mellor: It is varied. It was
particularly an issue in the first wave: how they were set up
and how training was written into the contract. The people who
were organising that have learned from that first experience and
now training is included in the contracts. Again, it does need
people to work together locally because often, if you take, for
example, orthopaedic surgery, what is offered in the independent
sector is a very important part of the routine joint replacement
surgery, but it is not the full range of orthopaedic surgery and
therefore a training programme both needs that independent sector
provision in order to train staff, but equally the independent
sector needs the NHS, so it is about cooperation, having rotational
programmes across the two in order to do good training.
Mr Campbell: As long as we have our finger
on the button.
Q67 Sandra Gidley: A lot of NHS workers
have had new contracts and you have submitted information showing
how much that has cost, but it is quite alarming to see an annual
overspend of £250 million on the new GP contracts, £220
million on Agenda for Change and £90 million on the new consultant
contract. Why does there seem to be a consistent pattern of significant
overspend and what will be done to redress this?
Mr Foster: The answer to that
question differs for each of those three contracts so I shall
try not to give an over-long answer. In relation to the GMS contract,
that was created with a built-in ability to overspend if quality
targets were exceeded and of the £250 million overspend £150
million is accounted for through over-achievement on quality.
I do not want to make over-achievement on quality sound like a
bad thing because obviously it is not. What this means is that
by the objective criteria which are independently established
as the best measures of what primary care could contribute to
improved health outcomes, we have done better. For that overspend,
we do have something in return. The rest of the GMS contract overspend
principally relates to setting up the new out-of-hours scheme.
It was very difficult to predict what number of GPs would retain
an out-of-hours responsibility, how many would transfer them to
cooperatives and what alternative arrangements could be put in
hand in collaboration with secondary care providers, drop-in centres
and so on. Obviously it is very important to have a fully comprehensive
out-of-hours service and that is why that has over-spent. Do you
want me to stop or go on to the other two?
Q68 Sandra Gidley: It might be useful
to just question something at that point. It seems to me that
when GPs have been offered money for doing something, they usually
try to maximise their salary; not just GPs let us be fair, anybody
would do that. Certainly in conversations with my local primary
care trust leads they said they knew that their local doctors
would get their acts together and they all achieved just over
99% in my home town, which was much greater than anticipated.
There is a little bit of a head-in-the-sand over that. How was
the prediction made? What basis was used? Was it plucked out of
the air? Was it based on previous changes? Why was it so out of
kilter as a result?
Mr Foster: Again, I was not directly
party to that but I understand that it was a negotiated figure.
There was evidence from the academic centres that were drawing
up the criteria about what the current level of performance was
and therefore what might be achieved. There was a desire by the
GP negotiators to set the bar as low as possible. There was a
desire by the Department negotiators to set the bar as high as
possible and in the end there was a negotiated figure.
Q69 Sandra Gidley: But how did they
know what was going on? I find it difficult to find any baseline
figure for what was actually being achieved.
Mr Foster: I would prefer to transfer
that more detailed question to Dr David Colin-Thome when he comes
later on, but I understand that a university was allocated to
collect the data and to ascertain the baselines.
Mr Derbyshire: Could I just make
a point on the GP contracts? There was a great deal of uncertainty
about what GPs could achieve in these areas. The GPs may have
known, and your GPs may have known, but the centre did not know.
Having the contract out there which rewards the activities of
GPs, we now know how effective that can be and we now know how
relatively easy it is to achieve certain levels. We can recalibrate
the GP contract using the incentive structure to achieve more
outcomes in future.
Q70 Sandra Gidley: I am not knocking
the increased output; I welcome it. It is just a shame that we
could not have set the bar a bit higher, as you said. If we get
started on out-of-hours, we will be here all day, because I can
go on about that forever, so perhaps we should move on to Agenda
for Change.
Mr Foster: The situation at present
is that we do not know yet exactly what, if anything, Agenda for
Change has cost over the estimate. We have a series of very important
sources of information though and the most important one is that
we did test Agenda for Change for a year in 12 early implementer
organisations and, at the end of that, we were able to analyse
36,000 pay records which demonstrated that on average the cost
of Agenda for Change had been accurately estimated. The second
piece of information we have is a sample which took place partway
through last year when roughly 40% of staff had been assimilated
onto the new system, which was estimating an overspend of approximately
£100 million and possibly some extra costs relating to replacing
staff who had added holiday entitlements. This was an estimated
study and our experience is that organisations which are asked
to estimate costs tend to err on the cautious side so that when
their financial year-end comes along, they cannot get criticised
for having got it wrong. The third is that we are now getting
a series of anecdotal reports from organisations which have analysed
the introduction of Agenda for Change this year and they range,
as reported in The Guardian last week, from Bedford Hospital
Trust, which believes that it has over-spent by £1 million,
to Leeds Hospital Trust, which is the biggest trust in the country,
which has implemented within budget. If you put all of the available
information together, it suggests that there may have been an
overspend of the order of £100 million, which I deeply regret,
but getting an overspend of £100 million on a pay bill of
£30,000 million is about as close as you can get to landing
on an aircraft carrier on a sixpence and is infinitely better
than the last time we tried to do this on the nurse grading scheme
where there was just a complete loss of control. Although there
has been an overspend, it has been fantastically close to what
was intended.
Q71 Sandra Gidley: But with Agenda
for Change a proportion of staff had a decrease in salary. Has
that not been demotivating? Do you think that is acceptable?
Mr Foster: In the early implementer
sites 8.5% of staff required pay protection. Nobody has actually
had a decrease in pay: some people's pay marks time until inflation
catches up. On the early implementer sites it was 8.5%, but then,
working with the Modernisation Agency and others, we found opportunities
for those members of staff to take on extra responsibilities to
move to a higher pay band. To give you an example of this, you
could find a medical secretary whose job evaluation would allocate
them to pay band three, which would mean that they would be moving
to a lower pay rate than they had previously been on. So then
there was a national project to design an advanced role for medical
secretaries who would take on administrative work currently done
by consultants, for example maintaining their clinical governance
records or their records for revalidation. This enabled the post
to take on extra roles and responsibilities to move it to band
four, so that those staff did not have to face a pay reduction
and again is beneficial to the whole system. It is still more
economically efficient for the medical secretaries to do that
work than for the much higher paid consultants to do the work.
The figure that we now have for the 900,000 or so staff that have
now gone fully onto Agenda for Change is that only 4.5% of staff
have required pay protection and it has been a hugely complex
system with 650 different jobs or grades. It would never have
been possible to give everybody a pay increase, or if we had done,
it would simply have cost a huge amount more. Getting it down
to 4.5% requiring protection has been another very good achievement.
Q72 Sandra Gidley: Could we then
finally finish with the consultant contract overspend of £90
million?
Mr Foster: The consultant contract
overspend, on the basis of returns from individual organisations
in the year 2004-05, was £90 million and the principal reason
for that was that a higher number of programmed activities was
given to consultants than had been expected. The whole agreed
negotiation with the BMA presumed that we would be able to reduce
the average working week of a consultant to about 47 hours and
thus they would get 10.7 programmed activities of four hours each.
The actual outturn was just over 11.1 and that difference of half
a programmed activity per consultant explains the vast proportion
of the £90 million over-spent. Because of that overspend
there was an adjustment to the tariff price which providers received
in 2005-06 which was actually higher than £90 million and
therefore the consultant contract overspend, which we know has
reduced in 2005-06, because most organisations have negotiated
a small reduction in programmed activity, is not part of the financial
pressures that have been experienced in 2005-06, because it was
more than picked up in the tariff price.
Q73 Sandra Gidley: The King's Fund
Report yesterday was very critical of the implementation and you
have talked about programmed activity, but there seems to be an
opportunity missed to link pay to increased performance. Do you
agree with that criticism?
Mr Foster: It is fair to say that
a lot of organisations put more effort into simply getting people
onto the new system than generating the benefits from it and it
was a difficult and complex task to negotiate. This is not something
you do at a national level; you effectively have 30,000 individual
local negotiations with individual consultants. It is fair to
say that many organisations, at least in the first year, did not
reap the benefits that we hoped for. They have then been supported
in a process of job plan reviews which have been taking place
this year, and are going to be given much better data, which Mr
Derbyshire may want to talk about in a moment, which will enable
us to use the mechanisms of the contract which is about transparent
job planning, but also about setting objectives for individual
consultants which would give us much greater optimism that these
tools will be used more effectively in future years.
Mr Derbyshire: Just to back that
up, with the new tools and levers of the new consultant contract
we want to give the NHS more benchmark information which can actually
show at consultant level what the relative performance of their
consultants is compared to their peer group in the same specialty.
That actually will not only incentivise the managers to begin
to ask questions but the consultants themselves will be interested
to know where they are in the national distribution of productivity.
Q74 Sandra Gidley: Is that not available
now?
Mr Derbyshire: No. It is going
out this month.[1]
Q75 Dr Naysmith: Mr Foster, you said
that you ran pilots for the Agenda for Change people in a dozen
or so different places.
Mr Foster: Yes.
Q76 Dr Naysmith: Did you think of
running pilots for the GP contract and the contract for the consultants
and if not, why not?
Mr Foster: We would have liked
to have run pilots for both the consultant and GP contract, but
we were not able to agree that with the British Medical Association
in each case. We did the closest thing we could do to that which
was desktop exercises and dummy running in real organisations,
to see in theory what this would mean. Inevitably that does not
provide you with the same quality of data as when you actually
practically test it.
Q77 Dr Naysmith: So are you saying
the GPs held out against doing a pilot?
Mr Foster: I was not involved
personally in the GPs' negotiations but in the consultants' negotiations
I certainly wanted to have actual piloting and they would not
accept that.
Q78 Dr Taylor: It has been a great
disappointment to me; I have missed out throughout my career.
When units of medical time came in I was stopping being a junior
doctor and stopped being a consultant long before these came in.
Just going back to the GP contract very quickly, one of you said
the GP contract rewards activity. Points have been made to me
by GPs that the QOFs really were too easy and they were doing
them in any case and all this has meant is that they have ticked
boxes to show they are doing it. Have you any proof that they
are doing things now that they were not doing before?
Mr Foster: I should really prefer
to have Dr Colin-Thome answer that because he will be better able
to do it. In relation to the first portion of you question, Debbie
Mellor is also responsible for the return-to-practice scheme where
retired practitioners can receive suitable training and rejoin.
Q79 Dr Taylor: No, I am not tempted
at all. Just going back to the consultant contract and job plans,
in a previous inquiry not all that long ago we were horrified
to discover that a relatively small proportion of consultants
actually had job plans even though they had been in existence
for years, long before this new contract. Are all consultants
now fitted up with job plans and does their pay depend on that?
Mr Foster: Yes, all consultants
now have job plans and it is a condition of agreeing a job plan
to be able to go onto the new consultant contract in the first
place, so in that sense, yes, it is linked to their pay. The other
piece of leverage inside the consultant contract which has generally
not been used as well as it might is the ability to agree annual
personal objectives with each consultant, for those objectives
to be reviewed at the end of the year because pay progression
through the scale, which sadly you were not able to enjoy when
you were a consultant, is dependent on meeting the job plan and
delivering the agreed personal objectives.
1 Note by witness: The consultant productivity
data may be released later than May in order to be issued with
other benchmark information currently in preparation Back
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