Examination of Witnesses (Questions 80-99)
MR ANDREW
FOSTER, MS
DEBBIE MELLOR,
MR KEITH
DERBYSHIRE AND
DR JUDY
CURSON
11 MAY 2006
Q80 Dr Taylor: Could you give us
some examples? What would these personal objectives be? To do
more operations, see more patients in outpatients? What are they?
Mr Foster: They could be quantitative
objectives, they could be related to the data that Mr Derbyshire
has described will be available on productivity information, they
could be related to service improvement and quality improvement,
they could be related to redesigning, multi-disciplinary working.
The real objective, what we really want to do here, is to ask
each NHS organisation what they are trying to achieve, probably
the best resource available to them to achieve that is their consultant,
so let us put into their job plans what their contribution is
to what the organisation is trying to achieve.
Q81 Dr Taylor: Would it not have
been easier just to go for a fee-for-service contract and why
was that not done?
Mr Foster: As I am sure you know,
that is a very big question and fee-for-service is generally out
of favour throughout the world where it is being used because
fee-for-service tends to incentivise inappropriate behaviours
and tends to lead to loss of control of the finances of the system.
Q82 Dr Taylor: Was it seriously considered
or was it discarded right at the beginning?
Mr Foster: In the initial stages,
over all of the contracts, we looked at the possible reward systems
which were available throughout the world and in the case of the
GMS contract what we have come up with is something which is a
world leader in linking pay to system quality and what we come
up with in Agenda for Change is another world leader which rewards
people for developing their personal skills in line with what
the organisation is trying to achieve.
Q83 Dr Taylor: Will the new contract
encourage people who do a lot of day surgery?
Mr Foster: That is an example
that you could put in. If we know that the national average day
case rate for some particular procedure is 85% and we know that
a particular consultant is doing 70%, you can put into a personal
objective an agreement that that should rise to 85%.
Q84 Dr Taylor: Could that extend
to lengths of stay?
Mr Foster: Another really, really
good example of precisely what you should do, yes.
Q85 Dr Taylor: Finally on changing
roles, has there been any evaluation of any possible disadvantage
of changing roles? I am thinking really of junior doctors no longer
having to take blood, which was one of the best ways of making
sure that you could always get a needle into a vein. Now they
are losing out on that practice. Has there been any evaluation
of any disadvantages of these sorts of changes?
Mr Foster: I am not aware of any
evaluation of disadvantage, although the Hospital at Night project,
which has looked at the reorganisation of services and roles at
night and weekends, seems to have demonstrated very, very large
benefits indeed in terms of quality of patient experience, allowing
junior doctors' training to be better delivered because they spend
less of their time working at night and a reduction in the procession
of faces that you have if you are sadly admitted to a hospital
at night. Anecdotally one hears of the type of problem that you
hear, but I am not aware of a whole-scale evaluation.
Q86 Chairman: You talked about the
pay bands in Agenda for Change. Is it your knowledge that any
pay bands for nurses have been moved to a lower rate of pay through
Agenda for Change?
Mr Foster: I do not know personally
of that, but given that there are 400,000 nurses, it is possible.
Q87 Chairman: It is quite possible
that that would have happened and the scene you described earlier
may not be the case in some instances.
Mr Foster: I certainly know that
where protection has had to occur, the more common areas where
this has happened have been in administrative and clerical and
managerial jobs.
Q88 Chairman: Not in nursing staff?
Mr Foster: I am not saying that
there are not any, because I do not want to give you the wrong
impression, but I certainly have not heard of many instances of
nurses being banded lower than their current pay.
Q89 Jim Dowd: Briefly, after that
tale of woe of Dr Taylor's thwarted clinical career, may I just
ask you one question on productivity? There is a problem with
productivity right across the British economy, public sector,
private sector et cetera. The ONS recently brought out a report
showing six different indicators of productivity in the NHS. You
chose to adopt one of those six which coincidentally or incidentally
was the one which showed the highest figure. (a) Why did you choose
that? (b) Is it not important to have a durable and broadly accepted
measure of productivity within NHS staff at all levels?
Mr Foster: I am in the fortunate
position of having the best expert in the Department next to me,
so I shall pass it over.
Mr Derbyshire: The answer to (b)
is easier than the answer to (a). The obvious answer to (b) is
that we do need a better measure of what the NHS produces, not
just in terms of the number of treatments but the health benefit
which accrues from those treatments and also the patient experience
of going through the system. Waiting times of six months have
gone down significantly and that is of value to people. The physical
facilities in which they are treated has value for people, as
does the amount of time they get to speak to the consultant. We
need to bring all those things into the measure of output before
we can actually have a proper debate about whether productivity
is rising in the NHS or not and the ONS, under Sir Ron Atkinson,
did work with the Department of Health to improve the measure
of output that we had previously which was about the cost of the
number of treatments. Over the long run, that has been increasing
by about 0.5% to 1% per annum in terms of productivity. When we
put more money into the NHS with the NHS Plan investment, we expected
productivity would not actually rise. We did not anticipate that
we could put all those new resources into the system and get productivity
as well. What we do have is a significant increase in output and
outcomes and the ONS measure does give a range of the level of
output growth over the NHS over the last five years. Yes, the
Department published the high one as being the best available,
but they also included the others and explained the different
methodology to make it transparent.
Q90 Dr Naysmith: Mr Foster again.
We have had a number of submissions from education providers indicating
that they do not think they are sufficiently involved in workforce
planning; sometimes they say they are involved too late or not
at all. What do you think we can do about that? Do you agree with
that and do you think there is a plan to address it?
Mr Foster: This was one of the
identified weaknesses in 1999 and again, when workforce development
confederations were established and required to set up their stakeholder
boards, they were required to have representatives of education
on those boards to address that issue. I am interested that that
is what the educational institutions have submitted to you in
evidence. In my five years in the Department I have had no complaints
from educational institutions to me that they do not feel they
have been adequately involved. It may be that there are some local
instances where relationships have not been as good as they might
be, but, again, it seems to me that that is another opportunity
for this Committee to recommend to us that we identify any shortcomings
and look to strengthen them.
Q91 Dr Naysmith: Perhaps we will
pursue that a bit more with the people who have said that to us.
Do you think there is any role for the independent sector as far
as education and training are concerned?
Mr Foster: Definitely; yes. Mr
Campbell asked some questions. When you say the independent sector
. . . ?
Q92 Dr Naysmith: I do not necessarily
mean providing—
Mr Foster: There are the existing
private hospitals. There are nursing and residential homes, which
is a very large sector. There is the first wave of independent
sector treatment centres that the Government commissioned where
we are not explicit about training and then there is the second
wave where we are explicit about training. Yes, it will be absolutely
clear that they must provide that.
Q93 Dr Naysmith: You see it only
in terms of the second wave.
Mr Foster: We are requiring it
in the second wave.
Q94 Dr Naysmith: Is there a chance
you will be extending it more widely?
Mr Foster: Yes. For each of those
sections of the independent sector we have different levers available
to us and the strongest lever available to us is where it is our
money which is commissioning the services, thus we can require
it in the wave two contracts. We should also like initially to
encourage it to be introduced into the wave one contract and then
when they are up for renewal at the end of their five years, we
shall obviously have the opportunity to extend to them as well.
Q95 Mr Amess: Witnesses, we are anxious
to wrap up this session because we have had enough. So very, very
quickly, recruitment from overseas. We all know what went on,
we have lots of doctors and nurses and others, marvellously handled,
very, very successful and now we have people here, educated here,
who cannot get jobs or are losing their job et cetera. First of
all, from one of you a comment on that approach and has the Department
done any work to see whether taking staff from the developing
world has in any sense damaged those countries? If you do have
some work on it, is the Department trying to cover up releasing
that information? Try to say something to make it more interesting
at the end.
Mr Foster: I shall hand over to
Debbie in a moment because she has led in this area, but if I
go back to 2001-02 when we were tasked with these massive increases
in the NHS workforce, we knew how many people we had already commissioned
to come out of training, we knew approximately what the average
retirement rate was and we knew approximately what the average
return rate was, in other words people who have had a career break.
When we put all those things together, we knew that we did not
have enough input of nurses and doctors to deliver the capacity
that was required to achieve the main objectives of improving
access. Thus we set up the international recruitment programme
with the international code of practice which still remains, as
I understand it, the best in the world, which means that we only
recruit actively from countries where their governments agree
for us to do so and that has been the biggest single contribution
to achieving the workforce capacity that we have needed over the
last few years. Now we face a situation where funding growth begins
to reduce, where a balance between supply and demand is much closer.
The numbers coming out of domestic training, because we have been
investing in that year on year, are increasing. We are becoming
less and less reliant year on year on staff from overseas and
many of them came over here with fixed-term contracts of two to
three years which are now not being renewed for that very reason.
We have to balance the obligation we have to our home grown-students,
the workforce planning needs of having the capacity to meet the
demand in the system, and the international duty you have in the
countries from which these staff have come. As we said earlier
in response to questions, workforce planning is a very difficult
art to get right, but as of where we are now, we have the nearest
to a balance than we have ever had.
Ms Mellor: You asked two questions,
one was about unemployment. There certainly have been problems
with doctors, a lot of them from the Indian sub-continent, who
have come here, who have taken the exams, got their GMC registration
and have not then been able to get into the NHS. What happened
was that, on the back of the NHS Plan and the work that we were
doing around international recruitment in the medical side, which
was focused very much at consultant level and for GPs, a sort
of message got out that England was expanding and needed doctors.
Although we have worked very hard with the British Council, with
our High Commissions in the Indian sub-continent and with the
GMC to get out some very clear messages that there were limited
recruitment opportunities in the NHS, there has been a large number
of doctors who have come over here over recent years speculatively
hoping that they would get in and I am afraid a lot of them have
been disappointed. One of the things that we have done, apart
from trying to get these messages out, is that we have actually
looked at the system that we have got in place with the Home Office
around work permits. We recently changed the permit-free training
arrangements so that we have brought into line with the way that
all other professions and staff groups are treated the way in
which we operate work permit arrangements for the medical profession.
That has been very helpful in sending out a very final and clear
signal that actually it is sensible to check on what the job opportunities
are before you go through the difficult and expensive process
of getting onto the register and coming over here to find jobs.
We are introducing, to support the Modernising Medical Careers,
the MMC process, and the new arrangement for training doctors,
a new centralised web-based recruitment system which will give
us a much simpler and more cost-effective way and more sensible
way of getting doctors into the various training programmes. It
will also help us manage the flow and the routes into the NHS
for international medical graduates and it will make sure that
there is a sensible, clear, open route which does not have them
coming over here speculatively. I am hoping that we have made
improvements there. The second question you asked was about the
ethics of what we are doing and what the impact had been in developing
countries. We are the only developed country which has actually
developed policies and practices and an ethical recruitment code
of practice to try to manage international recruitment. We have
certainly made clear that, within the NHS to start with, we did
not want to see active recruitment from developing countries with
vulnerable healthcare systems and we worked hard with the independent
sector and with the recruitment industry to revise, improve and
extend that code so that it covered our partners in the independent
sector and was also supported by the Recruitment and Employment
Confederation. You asked what we are doing in terms of having
an understanding of the way in which this is having an impact
in developing countries. I have to say we have built up a very
close working partnership now with DFID and we are also working
with the World Health Organisation—you will have seen their
recent report which flags what we are doing around ethical recruitment—and
with organisations like the International Labour Organisation
and the IOM. There are several programmes which are being taken
forward to look at the impact in various, particularly sub-Saharan,
African countries to see what the impact is and what can be done
to help those local healthcare systems address some of the push
factors which are fuelling the emigration from their countries.
I am not quite sure that we have any secret information that we
have not published anywhere. We do have a Memorandum of Understanding
with South Africa and we have a lot of discussions and debates
with them.
Mr Amess: So no cover-up. Thank you very
much indeed for your comprehensive reply.
Q96 Chairman: My colleague wants
to ask you a specific question in relation to EEA doctors. May
I first ask you about this issue of working within the code of
practice with the independent sector? My understanding is, and
correct me if I am wrong on this, that if somebody came in from
a country that we would not directly recruit from because of the
weakness of their healthcare system, it does not mean to say that
they could not work within the independent sector for a length
of time and then be recruited by the National Health Service.
That length of time is six months. Is that correct?
Ms Mellor: It has certainly happened
and we do know that within the independent sector there has been
quite a level of recruitment and some of that is from the developing
countries that we would not like to see and some of that indeed
has been the basis of our discussions with countries like South
Africa.
Q97 Chairman: But there is no statutory
regulation which could stop them doing this, so if they do not
volunteer to cooperate, then it does not get done. Is that correct?
Ms Mellor: Yes, but, as I say,
we have worked with the Independent Healthcare Federation and
with the Recruitment and Employment Confederation to try to extend
our code of practice. What will actually really help us to address
this issue is that the Nursing and Midwifery Council have brought
in new arrangements for the training of nursing recruits from
overseas and what that requires is that they have to go through
a period of training within a higher education institute. That
is quite a costly process and it is going to be a very difficult
process to do if you do not have an employer fully backing you
and being prepared to fund it. That will make the kind of opportunistic
individual immigration a little bit more difficult for the individuals
because it will be more difficult to organise and it will be more
costly to do. The real answer to this is that we have supply and
demand matched far more, particularly in nursing, so I would hope
that even those bits of the independent sector that are not aware
of and are not complying with the code of practice would find
that they can actually recruit far more easily from within the
UK or indeed from within Europe without the additional expense
and difficulty of going to the Philippines or South Africa or
Ghana or Kenya.
Q98 Chairman: Do you have regular
meetings with DFID about these issues?
Ms Mellor: Yes.
Q99 Dr Stoate: It is obviously very
good news that we are now producing more medical students of our
own and more medical graduates; that is obviously very welcome.
Nevertheless, we have relied on the NHS for generations, on the
good will and the hard work of huge numbers of doctors and others
from the Indian sub-continent who come here and work tirelessly
for the NHS for a long time. I have been contacted by a significant
number of doctors who now have recently found out, for whatever
reason, and these are non EEA graduates, that they either will
not be able to get a job, they are not eligible for a job and
that the current job when it finishes will not be renewed, that
they will not be allowed to complete their training and, obviously
for good reasons, they are pretty upset. How has this been allowed
to happen? Why was there not a much more planned and orderly transfer
once we knew that we were beginning to produce our own graduates
in sufficient numbers?
Ms Mellor: We started looking
at the work permit arrangements and the need to have another look
at that last July, when we started to talk to the Home Office
and also to the deans about how the whole regime—
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