Examination of Witnesses (Questions 120-139)
PROFESSOR SUE
HILL, SIR
LIAM DONALDSON,
DR DAVID
COLIN-THOME,
PROFESSOR BOB
FRYER AND
MR ANDREW
FOSTER
11 MAY 2006
Q120 Dr Taylor: Is there still the
concern among some junior doctors about the lack of training even
at the 48-hour level?
Mr Foster: Yes, we have received
concerns from various specialties that because of the change to
shift working, they have to spend an increasing proportion of
their work at nights and weekends when they are not typically
being trained by consultants. Some of the logbooks from surgeons
and anaesthetists in particular show that they are getting less
direct training than under the previous system. We have a project
called Hospital at Night which is designed to correct this and
the best examples show that by cross-cover between medical specialties
and by enhancing the roles of non-medical staff, we can go back
to having most of the trainees available during the daytime and
we can improve their training.
Sir Liam Donaldson: There are
also some very innovative new teaching methods in some specialties.
For example, in radiology we now have three academies around the
country, one in Norwich, which I visited last Friday, which train
the young doctors on digital x-ray images in a databank. Rather
than sitting as an apprentice in hospital looking at one x-ray
at a time, they are able to have a databank which includes abnormalities
and findings from images all over the world and they are taught
specifically and they are given feedback on their competency.
In some of the skill-based specialities, it is possible to use
techniques of simulation to fill in that gap which, as you rightly
point out, because of the lower hours of exposure in a conventional
training, mean that people do not see as many patients as they
would have in the old days.
Q121 Dr Taylor: Is there any answer
for junior surgeons and the worries that by the time they become
consultants they will probably have done relatively few of the
sorts of operations they will then have to go on to do?
Sir Liam Donaldson: Probably the
main solution would be to look at those technologies of simulation
which, as you know, in minimally invasive surgery are now quite
advanced.
Mr Foster: In addition to that,
what the Hospital at Night project tells us is that there is very
little, almost no, actual surgery which needs to be done or should
be done at night in hospitals and yet we have a lot of surgical
trainees on-call at night. By providing suitable cross-cover arrangements,
you can return to the situation where the high proportion of their
time is available during the day where they can get those experiences
of operations.
Q122 Dr Taylor: Can you forecast
whether the aim is going to be, to cover the 2009 problem, to
employ more doctors or to shift the work that doctors do more
onto other staff like the nurses?
Mr Foster: This will vary according
to the geography of an organisation. There are certain critical
masses for some specialties that you have to maintain, so in some
cases, in rural and remote hospitals, you can only resolve this
by increasing the number of doctors. The best practice in large
hospitals is to do exactly what you say, to have better cross-cover
arrangements between the medical specialties and to enhance the
roles of non-medical staff.
Q123 Dr Taylor: Does the affordability
of this by 2009 worry you?
Mr Foster: Yes, it will be part
of our spending review bid for next year to recognise the costs
that are applied by it.
Q124 Jim Dowd: I just want to come
back to Sir Liam on this question of training. I saw a release
from the BMA a year or so ago saying that medicine is the most
socially exclusive of all higher education or degree courses.
The only one that was more socially exclusive was veterinary medicine.
If you are from a manual household background, you are 200 times
less likely to get a course in medicine than you are if you come
from a professional or A-B group background. Given the fact that
it is so divisive and exclusive, given the fact that the technology
is changing the nature of the training, one of the reasons that
it is as divided as it is, is because very few people, other than
from a relatively prosperous background, could contemplate training
for seven years, 10 years, 12 years. Are you taking the opportunity
to change the courses, obviously in concert with the great gatekeepers
of the royal colleges, to ensure that you can reduce courses as
technology changes, which, at the same time, will encourage people
from non-traditional backgrounds to come into medicine? One of
the big problems we have with the health service is that it is
actually almost entirely middle class practitioners and almost
entirely working class patients.
Sir Liam Donaldson: It is a very,
very important area and it is one which has always concerned me.
There has been a change towards a more balanced entry of medical
students to medical school. We are certainly well represented
now in some ethnic minority groups, although not the Afro-Caribbean
community where the entry levels are very, very low. The social
class differences are still quite marked as you have pointed out.
We have done a lot of work with medical school deans, particularly
in the new medical schools which have been established over the
last few years, and I chaired the committee which established
them, to lay down criteria so that for them to be successful in
being awarded more places they had to improve access to disadvantaged
groups. It is very important, it is important for doctors to have
insight into the communities that they are serving. We are trying
to do as much as we can, but to some extent it means going back
into the education system earlier on to make sure that those students
have the opportunity to get the right qualifications at GCSE and
A-levels to get in. It is possible to get into medical school
with other sorts of qualification now as well and certainly the
new medical schools, Peninsula would be an example, University
of East Anglia another example, they do have a much more diverse
range of students than they have had in the past.
Mr Foster: There has been some
research carried out which demonstrates that one of the biggest
problems is that students from poorer backgrounds or from certain
ethnic minorities, not all ethnic minorities, do not perceive
that they have the chance to become a doctor; they really think
they are excluded. Some of these more modern medical schools that
Sir Liam has described are doing out-reach activities where existing
working class medical students go out to schools and say "You
can do it. I have done it" and that has been demonstrated
to be one of the most articulate ways of breaking down that particular
problem.
Professor Fryer: There is evidence
that the real issue is not simply the level of the A-levels that
students from non-traditional backgrounds get, but the wrong ones
too. For example, chemistry is often a lack. Some medical schools
around the country are now working with local further education
colleges and with local schools to put in, at no cost to the student
let me say, that additional training so that they can get the
qualifications in the relevant areas. It has been very responsibly
done because they are very keen not to take students from disadvantaged
backgrounds and then get them into a system where they fail. There
has been a scheme, for example, with London FE colleges working
with the University of Southampton specifically to target Afro-Caribbean
students where the FE college plays a key role in preparing them
for entry into medical school. We could give you some data on
that.
Q125 Chairman: Are you aware, not
the new schools, that the Sheffield Medical School has links with
comprehensive schools in South Yorkshire, one in my constituency
in Dinnington, where they actually visit and chat to the head
about the brighter pupils in there who may have no links at all
with the medical profession on a family basis at it were, but
are taken out and encouraged to go into medical school through
our current education system. That seems a very sensible approach
in terms of this issue of the social class and medical education.
Professor Fryer: There are many
examples of that around the country and I want to say that the
medical profession themselves have been very good in doing mentoring
and coaching and indeed it would be good to see this as part and
parcel of NHS organisations, seeing themselves as exemplary employers,
reaching back into the education system to raise aspirations,
to provide information and to work alongside the young students.
That has been happening and where it happens it is extremely effective.
Q126 Jim Dowd: The note I saw from
the BMA did admit that this was an area where they were just not
doing well enough. That was the tone of it rather than anything
else.
Professor Fryer: There is still
a long way to go.
Q127 Dr Naysmith: We have spent a
lot of time this morning, as we usually do, talking about doctors
and nurses and allied professionals, but actually the section
of the workforce which is growing fastest of all is the scientific
workforce. I have one or two questions for Professor Hill to answer
in that area. What are these staff doing and do you think the
numbers are going to continue to grow?
Professor Hill: We now know more
about the composition and the roles which are undertaken by the
scientific workforce than we did. For example, we now classify
the healthcare science workforce into 51 disciplines and they
are grouped into three broad-brush divisions: life sciences, which
include genetics; physiological sciences are those that work predominantly
in clinically facing specialties like cardiology, respiratory
medicine; and those in physical sciences and engineering, from
the medical physicists supporting imaging and cancer treatments
for example, through to clinical engineers, who are engineers
who design equipment or work and develop rehabilitation-type solutions,
to maxillo-facial prosthetists. In terms of the numbers employed
within the workforce, there has been an increase of 5,814 over
the 2001 baseline. We have done a lot of work to collect more
detailed information on the scientific workforce through the introduction,
for example, of the T-matrix which is the scientists' specific
part of the Department of Health census which is collecting information
on 18 disciplines in six employment grades as well as the rest
of the disciplines in the more aggregated data. To provide us
with more information in terms of the age, profile of the workforce,
the future planning arrangements for the scientific workforce,
we are working with three strategic health authorities on a more
detailed workforce project, that is Trent Strategic Health Authority,
North Central London and Greater Manchester. That is giving us
a greater insight across the totality of the workforce.
Q128 Dr Naysmith: So they are clearly
a key section of the workforce and you think they are going to
increase in numbers in the future.
Professor Hill: They are a key
section. The recognition of their contribution to healthcare is
growing and the importance, for example, of many of the scientific
disciplines in delivering the 18-week access target by better
diagnostic service provision, is obviously driving some of the
changes. In terms of the workforce profile for the future, we
shall need to increase the workforce but not necessarily more
of the same. There needs to be a greater focus on the scientific
workforce skills which are required to deliver service functions
as opposed to the old traditional routes and associated with that
will be more assistants and associates, which will reflect the
increasing automation in some parts of the workforce, the demand
for higher types of low clinical risk activities. Equally, there
will be the requirement for more advanced and consultant practitioners
to support the advances in science and technology and the need
for more specialist advice and interpretation.
Q129 Dr Naysmith: Just before we
go into that in a little bit more detail, I used to teach scientists
in that category before I became an MP. One of the things that
they always used to tell me was that they were not paid nearly
enough money. Mr Foster, you were talking in the previous session
about Agenda for Change. Have they significantly improved under
Agenda for Change?
Mr Foster: As Professor Hill has
said, there is no simple answer to that because there are 51 different
specialties. However, the job evaluation scheme is designed to
recognise the complex range of skills, knowledge and environmental
difficulties that people have to face. Yes, their skills are properly
recognised in the new job evaluation scheme and many of them have
benefited considerably, particularly in terms of the starting
salaries for laboratory staff.
Q130 Dr Naysmith: I am glad to hear
that. When talking about this group of staff, is the increase
a result of the development of new roles or is this just employing
more people in existing roles?
Professor Hill: There is a combination.
There is no doubt some of the work that we have done to introduce
a new career framework for healthcare scientists has focused the
scientific workforce on the development of new roles, that is
both from a national perspective in some of the work that we have
been doing, but also locally to meet local service requirements.
The bulk of the increase we have seen to date has probably been
in more traditional roles, but we are seeing a change in the profile
towards more new roles being commissioned and funded.
Q131 Dr Naysmith: One of the things
that we have frequently heard in this Committee in the past is
that the NHS is pretty slow at taking advantage of new technology
and, even when it comes in one bit of the National Health Service,
it often does not spread very quickly to other parts of the NHS.
Could that be partly due to not taking advantage of new technologies
because of workforce shortages? Is that a possibility? You may
not agree with what I said in the first place, but it has certainly
been said in this Committee often enough.
Professor Hill: The evidence we
got from the functions which are undertaken by the Healthcare
Science Workforce is that they are adopting new technology. For
example, they have been our key drivers in the adoption of new
in vitro diagnostics for example and some new diagnostics
which support, for example, cardiac physiology interventions or
indeed more handheld portable-type investigations in respiratory
physiology. So this workforce has been a leader in terms of adoption
of new technology. Our challenge is actually how we can use the
skills and talents of the Healthcare Science Workforce to help
the rest of the workforce adopt new technology. Indeed, we are
working on a competence framework, based on the healthcare science
competences which might be applicable across the wider healthcare
team, around adoption of new technologies.
Q132 Dr Naysmith: One of the things
which has been said to us by some of the companies who manufacture
some of this new equipment is that they would like perhaps to
get involved in training National Health Service staff. One can
understand from their point of view why it would be a good idea,
but it is also possible that they could bring about change more
quickly, if this happened. What do you think of that idea?
Professor Hill: Yesterday I was
just out at the Medtronic Training Centre in Switzerland looking
at the type of simulated training that they are providing for
interventional cardiac devices as well as training some of the
cardiac physiologists, for example in interpreting echo-cardiography.
There has been quite a substantial uptake in England by both the
medically qualified staff and the scientific workforce in accessing
training solutions provided by the independent sector and that
is quite common across a number of the different healthcare science
disciplines.
Q133 Dr Naysmith: So that sort of
thing is something that you would be happy to encourage.
Professor Hill: Yes. In terms
of the future and the way in which technology is advancing, there
will be a need both for us to reflect the ability to respond to
that technology in both pre- and post-registration education and
training programmes, but also in solutions with the independent
sector and other providers of such training on highly specialised
pieces of equipment.
Q134 Dr Naysmith: I have one final
question to do with the fact that biomedical sciences are a key
diagnostic group within the National Health Service but the training
of them is not within the control of the Department of Health.
Is that something which is a problem, or is it something which
worries you?
Professor Hill: We are modernising
pre-registration education and training for both of the two currently
regulated healthcare scientist groups, the clinical scientists
and the biomedical scientists, to make them more fit for NHS purpose.
That is being done in conjunction with educational providers and
in a separate stream of work we have discussions ongoing with
the Department for Education and Skills on how we might drive
changes in the funding and the arrangements for the delivery of
these new NHS fit-for-purpose programmes in the future.
Mr Foster: This is an inevitable
difficulty when you have graduate professions which contribute
employees to many different industries. It would be difficult
for the NHS to say they insist on monopolising it. It is the collaborative
arrangements which Professor Hill described which really are our
best bet.
Q135 Mr Amess: Professor Fryer, it
is your job apparently to devise and implement a strategy to improve
access to learning across the NHS. How are you doing? Please do
not be immodest.
Professor Fryer: The first thing
we are going to do is build on the success which is there already.
By comparison with the rest of the British workforce, this is
the most highly qualified and highly skilled workforce in the
country. Just to give you an example, there is a big concern in
the country about the numbers of people qualified at what is called
level two or above, about the equivalent of five GCSEs. 80% of
the NHS workforce is already qualified at that level or above.
So the first thing is to build on success. The successes also
include a very innovative scheme which was introduced as part
of the NHS Plan to provide dedicated money year on year for unqualified
staff either to acquire NVQs or to use what was called an individual
learning account to get other money. This is not year zero. This
is not the Pol-Pot regime, we are starting and the NHS has much
higher aspirations for the qualifications of its staff than does
the rest of British industry because it wants to get a very, very
professional staff. Specifically what this means is also attending
to things which do need improving. One of the areas needing improvement
is around literacy and numeracy levels. We know that this is a
problem across the British economy and indeed in health and social
care generally we more or less match the challenges which are
faced in the rest of the British economy, that is that about one
fifth of all adults have some problems with literacy and almost
50% have some problems with numeracy. How we have been tackling
that is to work very closely with the Department for Education
and Skills and with local education providers to put in place
specific programmes which are aimed at healthcare staff. All the
evidence around the world shows that if you actually build literacy
and numeracy into the local work and personal circumstances of
people, it is much more effective, so we have started in that
direction. Secondly, there are possibilities for progression.
For example, we are currently already recruiting about one fifth
of our nurses from healthcare assistants. Healthcare assistants
form one of the largest sections and one of the fastest growing
sections of the workforce and we have provision in place whereby
healthcare assistants can get financial support to undertake their
training so that they can progress into nursing. In fact we have
set an ambitious target of systematically moving that up to 25%.
That would be a second area in which we are doing some work. A
third area in which we are doing some work is that we are trying
to reach back into the labour market, both amongst young people
and in socially-deprived communities, to get training levels up
so that when people enter the workforce they have higher levels
of training, in very close collaboration with the Department for
Work and Pensions and with Jobcentre Plus so people do not lose
their benefit while we bring them up to a threshold of qualification.
Those are just three examples of how we are doing this.
Mr Amess: You have already answered the
second half of my question, so I am going to give you A++.
Q136 Dr Taylor: That is encouraging.
I am delighted to hear that you are encouraging healthcare assistants
to go on to become fully qualified nurses. We have been given
some figures. We have been told that £4 billion is going
into the Multi-Professional Education and Training Levy and that
more than half of that is spent on medical training when doctors
only account for 9% of the workforce. Is that right?
Professor Fryer: It is not quite
accurate.
Q137 Dr Taylor: Please correct the
figures we have been given.
Mr Foster: The figures you have
been given are correct, but this is really about how we fund doctors
in training. A large part of that actually pays their salaries.
Rather than paying their salaries through their employers, because
they are doctors in training their salaries come through these
training budgets.
Professor Fryer: If you take the
length of time a doctor needs to be trained, part of that training
has to be covered by them still earning some money.
Q138 Dr Taylor: That is why it is
such a very large proportion, because it is training. I am with
you. On the surface it looks very unfair, but in fact . . .
Professor Fryer: No-one would
argue that it is yet as fair as it might be, but there have been
considerable improvements and the gains have been year on year
and we want to see that continue to make sure that the appropriate
levels of funding are made available at each level of the career
framework of Agenda for Change. Sir Liam was talking earlier,
for example, about Modernising Medical Careers. That means smarter
and newer ways of spending the money we have so that there is
more money to be spent across the board. We do not see any decline
in standards in training doctors and other clinical staff, but
things like the digital learning and the e-learning have allowed
us to release resource so that other people can then have additional
training. Most of the training at the lower end of these scales
does not take so long, but there is still the issue, if you want
to remove people from the workforce so they can do this training,
of backup costs. What we are trying to do there is develop a systematic
approach to work-based learning and to e-learning so that you
do not have the double cost of both the education and the backup.
Q139 Dr Taylor: May I ask about these
conferences which are advertised so widely? The Health Service
Journal every week has three or four glossies and for a day
conference the typical cost is £440.63. Who pays for that?
Are you paying for that? Are you getting value for money out of
it or are these conferences an entire waste of time and making
money for somebody else?
Professor Fryer: I am not going
to generalise about conferences. First of all, the conference
world is a market world and education is a very big and growing
market; in fact probably now the fastest growing market for conferences.
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