Examination of Witnesses (Questions 105-119)
PROFESSOR SUE
HILL, SIR
LIAM DONALDSON,
DR DAVID
COLIN-THOME,
PROFESSOR BOB
FRYER AND
MR ANDREW
FOSTER
11 MAY 2006
Q105 Chairman: Good morning. May I welcome
you all to the first session of our inquiry into workforce planning?
May I ask you for the record just to introduce yourselves?
Professor Fryer: My name is Professor
Bob Fryer. I am the National Director for Widening Participation
in Learning, that is I look after the learning of the non-professionally
qualified staff in the NHS.
Dr Colin-Thome: Dr David Colin-Thome,
National Clinical Director of primary care and a GP for some 35
years.
Professor Hill: Professor Sue
Hill, Chief Scientific Officer of the Department of Health with
lead responsibility for healthcare scientists.
Mr Foster: Andrew Foster, until
recently Director of Workforce.
Sir Liam Donaldson: Liam Donaldson,
Chief Medical Officer for England and the UK Government's Chief
Medical Adviser.
Q106 Chairman: I hope Andrew that
you now have a copy of your interview. I asked that you be given
a copy of it. There will not be any questions in this half which
directly relate to it. I am sorry about that; we assumed you would
have seen it. May I start by asking the first question to Sir
Liam Donaldson? May I also say I am very pleased to have you back
here in your role as Chief Medical Officer? The last time you
gave evidence to this Committee you made some impact in relation
to the subject matter that you were championing. I just hope that
this Committee's report and any subsequent actions were helpful
in championing your cause and I am very pleased indeed at the
way things are progressing.
Sir Liam Donaldson: Thank you
Chairman. I do not intend to make any impact today.
Q107 Chairman: In 1999 this Committee
was advised that an oversupply of doctors was highly unlikely
before the year 2020. We have received evidence from the NHS Employers
that there is currently a 7% oversupply of doctors and that this
will rise to 12% by 2009.[2]
How did this occur and is this a desirable scenario?
Sir Liam Donaldson: My own view
is that I do not really accept the assessment that there is an
oversupply of doctors. Even if you look forward to those distant
time spans that you have mentioned, we shall still be lower than
the OECD average. When I came into post in 1998, we were above
Turkey, but otherwise we were the lowest OECD country for doctors
per head of population. We are still behind and I do not see ourselves
as producing an excess of doctors at all, indeed with demographic
trends, with the fact that we shall have a 70% female medical
workforce in the next few years, with changes in technology, with
greater specialisation, we are still going to need a lot of doctors.
Q108 Chairman: You heard the last
couple of questions we had in the previous session. It is very
difficult to relate to OECD levels and ratios about doctors to
population as opposed to the actual needs of doctors within the
system. Clearly this inquiry is going to be looking at the needs
of different levels of clinical and others caring in the healthcare
system. Is there no sort of optimum level within our system as
opposed to saying that, if it is different to the OECD level or
it is still lower than the OECD level, then there is still a need
for doctors? Is that not quite the way we should be looking at
it?
Sir Liam Donaldson: There are
several benchmarks that you can choose. The most difficult benchmark
is to predict future need which has always been unpredictable
in the past. I have a fair amount, through representing the UK
on the World Health Organisation, of insight into other healthcare
systems and even at an impressionistic level, it is clear that
many other healthcare systems are able to provide faster care
than we do at the moment with a skilled competent doctor. We do
pretty well and we are improving but the basic infrastructure
of care in this country, which includes the number of doctors
and nurses, is still expanding and it needs to expand further.
Q109 Chairman: You do not think with
the expansion of medical schools that medical unemployment is
inevitable?
Sir Liam Donaldson: No, I do not
think so at all.
Q110 Chairman: Presumably at other
grades as well, in terms of nursing and things like that.
Sir Liam Donaldson: I do not know
so much about nursing, but as far as medicine is concerned, I
do not think we shall see that. We have never seen it so far.
Q111 Chairman: Do you think that
anybody who goes to medical school in this country and after very
many years becomes a doctor, at whatever level, has a right to
have a job within the system?
Sir Liam Donaldson: Yes, they
do in the first instance and then, after that, it depends on how
well they do their job and how well they perform and so on. But
yes, the aim is to give every graduate a post to go into at the
time of their qualification.
Q112 Chairman: Should that be under
all circumstances?
Sir Liam Donaldson: Well, unless
there are concerns about somebody's competence, health, conduct
and provided that they want to have a job. As you know there is
a small number of medical students who, having graduated, go into
other professions. Obviously there is a small proportion like
that, but as far, for example, as this forthcoming summer is concerned,
we expect to be able to put all our medical graduates into the
first year of what is now called a foundation programme, which
will take them through two years uninterrupted of basic medical
education, which will be of a more educationally based nature
than has been the case in previous years.
Q113 Chairman: If it was the case
in this more transparent health service that the Government and
the general population desire to know the costs of the National
Health Service, as opposed to what it spent, if we are moving
to payment by results, if I were running a trust and I had an
option of either setting on two doctors directly from medical
school, in their next phase of training as it were, and spending
money from my budget to do that, as opposed to saying that I have
a target to meet from my budget, maybe for elective surgery or
something, and under those circumstances I have to spend the money
on the patient and not on the doctor, would that be unacceptable?
Sir Liam Donaldson: There is a
lot wrapped up in that question. Obviously, we want patients to
be seen by skilled, competent doctors, but at the same time most
chief executive officers of hospitals would know that if they
do not invest in the future, then they will not have high quality
doctors in the future. You do need both. These fears of expediency
on the part of hospital chief executives are often talked about,
but I have yet to meet one who would dilute the quality of training
in their hospital, the quality of research and all the other things
which eventually contribute to high quality patient care.
Mr Foster: I just wanted to talk
about medical unemployment and to link it to the previous session
where Debbie Mellor was talking about overseas graduates. In so
far as there is medical unemployment in this country, that is
where it is; it is for the several thousand who came here on spec
without specific jobs hoping that they could find ones easily.
That is where the medical unemployment lies. Because there were
several stories last year about unemployment of UK graduates,
the GMC conducted a study of the last three cohorts which found
that the problem is absolutely tiny. Of the 2005 graduate cohort,
there were six unemployed and four of those were not actually
looking for jobs. Of the 2004 and 2003 graduate cohorts, there
are about 20 and 30 in each case who are currently unemployed
but generally that is because they are looking for a job that
geographically suits them and have not been able to find it. Those
numbers are absolutely tiny. So UK graduate medical unemployment
is not really an issue.
Q114 Dr Stoate: The Royal College
of Physicians have told us that the number of doctors receiving
specialist training under Modernising Medical Careers is likely
to exceed the number of posts ultimately available. Is that true
or not?
Sir Liam Donaldson: We do not
know what the number of specialist posts will be in 10 or 12 years'
time. The Royal College of Physicians have been very supportive
of the Modernising Medical Careers programme, they are helping
us in the planning, but, as you well know, there are great changes
in medicine occurring all the time. For example, it takes 12 years
to train a cardiac surgeon. Within the last five years, the developments
in treatment of heart conditions, with the possibility of minimally
invasive treatment, has meant that we are probably now going to
have heart surgeons in excess of the numbers that we shall need.
So a 12-year training programme and a five-year change in technology
which has transformed the position for that particular specialty
and I could give other examples. You have to keep these things
constantly under review. If you settle on a figure now that you
are definitely going to need in 12 years' time, then we shall
see problems in the planning of the specialist workforce.
Q115 Dr Stoate: Do you see a contradiction
though between that and the answer you last gave. You could not
see any realistic chance of unemployment in medical graduates
and now you are saying that as we cannot possibly predict what
we are going to need, then we may not need these graduates which
we are currently training.
Sir Liam Donaldson: No, I am talking
about the balance between specialties. There are 59 specialties.
If we have 59 rigid boxes all with a number in them for 10 years'
time and then we sit back and do something else until the clock
ticks round, then we shall have problems. We have to evaluate
the need specialty by specialty, but on the whole, given the position
internationally, the trends in the burden of disease, the growth
of technology, the feminisation of the workforce, I think we shall
need more doctors.
Q116 Dr Stoate: That is true, but
if someone has done a specialist training programme, then that
trains them to be a specialist in a particular area or field.
If that is no longer required, then we may have an overall matching
number of doctors, but if people with very specific higher training
cannot then get a job in that specialty because it does not exist
anymore, for example, then that is unemployment surely.
Sir Liam Donaldson: I do not think
so. We need to take a more flexible approach. I cannot believe
that the excess of cardiac surgeons that we would have, if we
just simply sat back and waited, would mean all of those doctors
were made redundant. They will be able to adapt the skills that
they have gained in surgery and in the diagnosis of heart disease
and treatment of heart disease into other specialties. For example,
vascular surgery, operations on blood vessels, is a specialty
which is going towards, not exactly disappearance but almost so.
Now radiologists can push wires and tubes into those same blood
vessels and do the treatment that would in the past have required
a full-blown operation. We have to keep all of these things under
review.
Q117 Dr Stoate: Just to go back to
my first question, so the Royal College of Physicians is wrong,
there will not be these specialist trained doctors who are going
to have no jobs to go to. That is what they are saying to us and
you are saying they are wrong.
Sir Liam Donaldson: If they are
saying it in such black and white terms, then that is not right.
If they are expressing a general concern that we need to get the
specialty training right for the future, and they themselves have
had ideas about redefining some of the specialties within the
medicine, it is something that we need to work with them on and
we do work with them. I do not mind them making provocative statements
from time to time because that keeps us all on our toes.
Q118 Dr Stoate: They keep us amused
as well. Just a final point. What will the impact of Modernising
Medical Careers be on the non-training service posts, which the
Royal College of Anaesthetists have called the so-called "failed
doctor" grade? That was not my expression that was theirs.
What do you see happening in that situation?
Sir Liam Donaldson: We shall probably
see fewer of these posts which are really designed within local
organisations to meet a service need because we are going to see
an expansion of training posts following on from the medical school
expansion. I do not like that description, and neither do you
by the way you asked the question, but we do have to remember
that there are many doctors today, for family reasons or work/life
balance attitudes, who do not necessarily want to go on to become
principals in general practice or consultants. For example, some
of the most talented doctors in the country are in such posts
in very specialised areas of practice. For example, I know of
a radiologist who is very expert in the ultrasound diagnosis of
certain conditions, who, although a staff grade, has cases referred
to her from consultants because they regard her as the best opinion
in a particular field. We must not regard these posts as posts
which are not valuable and do not have a future; they do and they
are very important.
Q119 Dr Taylor: Can we come on to
the European Working Time Directive? Can you bring us up to date:
In 2004 the aim was 58 hours. I cannot remember what happened
about those European cases and time on-call counting within those
hours. What is the state with that?
Mr Foster: In 2004 there was a
reduction to 58 hours but the main impact of 2004 was that the
rest aspects of the directive came into play, as interpreted by
the SiMAP/Jaeger judgments, which are the two that you are referring
to, which effectively meant that we could no longer staff hospitals
with doctors who were resident on-call. Instead we had to move
to a pattern of shift working. What has happened since is that
there have been many, many attempts within the European Union
to revise the Working Time Directive laws as they apply to rest
and at this stage no agreement has yet been reached. There is
a lot of consensus that SiMAP/Jaeger are having an unhelpful effect
in some medical specialties and there is a common desire to overturn
it, but it is intertwined with several other issues of the opt-out
and so on. The next stage is a meeting in June under the current
Austrian presidency which is going to hammer out yet another attempt
to produce a compromise solution to it. At the moment we are still
stuck with it. The next phase of the Working Time Directive is
in 2009, when we have to reduce doctors' and trainees' working
to 48 hours a week. That in itself will be a very, very big challenge,
even more so if we still have not resolved the SiMAP/Jaeger issue.
It underpins some of the comments that Sir Liam was making about
workforce planning. Clearly, if you currently get 56 hours from
a junior doctor and in future you get 48 hours, that drives a
need for greater numbers.
2 NHS Employers have subsequently submitted a correction
to its written evidence on this point. The evidence should have
stated that there are currently 12% more Foundation level medical
training posts available than there are medical students graduating
in the UK each year. If current trends continue, this figure will
fall to 7% by 2008-09, increasing the risk of an overall oversupply
of medical graduates. Back
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