Examination of Witnesses (Questions 140-159)
PROFESSOR SUE
HILL, SIR
LIAM DONALDSON,
DR DAVID
COLIN-THOME,
PROFESSOR BOB
FRYER AND
MR ANDREW
FOSTER
11 MAY 2006
Q140 Dr Taylor: Who pays that £440.63?
Professor Fryer: It is a combination.
Very often it is local organisations which pay and local NHS organisations
will have policies on what sorts of conferences and what sorts
of benefits they expect to derive for their organisations and
their patients. So they might pay. Sometimes individuals pay.
Very rarely does any payment come from the centre or from the
money we reserve for training for the staff that we have been
talking about.
Q141 Dr Taylor: It is all a local
decision.
Professor Fryer: It is largely
a local decision.
Q142 Dr Taylor: Would anybody keep
an eye on value for money for that? Who should it be?
Professor Fryer: It should be
the local managers who sanction the attendance. There should be
reports back from conferences and the benefits should be spread.
There is a bit of a culture in the country—and this is nothing
to do with the NHS—of people seeing conferences as an individual
benefit and not as a corporate benefit. We need to ensure that
we are much choosier about who goes to what conference and be
clear what the benefit is. You cannot generalise: some are extraordinarily
valuable; some, quite frankly, I would not spend the time of day
on.
Q143 Dr Taylor: Any comments? Am
I alone in being worried about these?
Mr Foster: We have worried about
them in the Department of Health from time to time. You occasionally
see an overseas conference which has a very large number of UK
delegates going to it and you wonder why it should be beneficial
that so many go. There are waves from time to time of carrying
out exactly what Professor Fryer described: much tighter local
arrangements to make sure the value for money is being achieved.
There is no doubt that the conferences have the potential to supply
good training on the issues of the day from the experts who know
what they are talking about and are much appreciated. There was
a conference yesterday addressed by Sir Liam on MRSA, which I
think in fact was free of charge to delegates but which was extremely
well received.
Q144 Dr Taylor: Free of charge? That
is excellent. How did they manage that?
Sir Liam Donaldson: I did not
actually speak at it. I do speak at most conferences, indeed it
is probably years since I sat in the audience at a conference
and it would be the greatest pleasure if I could have the opportunity
not to be the speaker for once.
Q145 Chairman: In view of what you
said earlier about the issue of numeracy and literacy of the workforce,
do you feel that the proposals for extended vocational training
from 14 to 19 in secondary education and in further education,
potentially higher education, have any implications for the NHS?
Professor Fryer: Very, very important
implications. In fact I have been talking to Lord Leitch precisely
about this. As the largest employer nationally and locally we
have a great interest in what goes on in schools. Indeed it is
very difficult for any employer to correct what does not happen
in schools. That is a national issue. It is extraordinarily difficult
and it is much harder for us to correct it. We are very keen to
see the development of the combined routes both academic and vocational;
indeed some would argue that healthcare is par excellence
an area where you need both academic and vocational aspects of
work. The healthcare scientists would be a very good example and
I would argue indeed that surgery does; it needs certain of the
skills which are much more associated with vocationalism. We are
very keen to work very closely, very keen to see the new vocational
certificates being very much geared towards the NHS. We have our
Sector Skills Council, Skills for Health, which takes an active
interest in that and no doubt they will talk to you about that
when they come. I work very closely with the Sector Skills Council.
Q146 Chairman: Could you tell us
what will be the role of the knowledge and skills framework in
improving education and learning in the NHS?
Professor Fryer: The particular
advantage of this is that it affords an opportunity. Every year
there is an entitlement in the NHS and, again, that makes it almost
unique amongst British employers. There is an entitlement to an
annual appraisal and interview and discussion on your personal
development with your manager. Out of that can come a personal
and learning development plan. The huge advantage of the knowledge
and skills framework is that you can look at what you need to
do, where you need to develop and be trained and if necessary
get additional credit qualifications in order to progress through
that career ladder. The knowledge and skills framework, with this
built-in entitlement is a tremendous opportunity for building
and growing our own workforce and that has huge advantages. Some
of the issues we discussed in the first half in terms of recruitment
can be counteracted. There is evidence that it actually reduces
labour turnover and absenteeism and raises the morale of staff,
in particular what this does is actually hold out the prospect
to somebody who comes in at a relatively modest level to improve
their professional skills and competences and indeed their life
expectancy, because higher qualifications in education are closely
associated not only with material life chances in the way of money,
but mental health, wellbeing, participation in the community and
so on. The knowledge and skills framework is a tremendous tool.
What we want to do is to support local managers in getting the
most out of it. Year on year we can see improvement, but there
is some way to go.
Q147 Chairman: Is it likely to be
hampered by other areas of the Agenda for Change like the job-matching
process and things like that?
Professor Fryer: It is not necessarily
likely to be hindered by other processes. What it does require
is that in that dialogue between local managers and their staff,
which goes on annually, those managers themselves have a very
clear understanding of the service delivery and the service improvement
that the body as a whole is trying to achieve and therefore what
their future needs may be. It cannot be done in isolation. It
needs those people to have a clear understanding about the priorities
and the challenges which their healthcare organisation is facing.
Q148 Chairman: Do you believe that
the constituent parts of the National Health Service, including
representative bodies of the workforce, have endorsed the knowledge
and skills framework?
Professor Fryer: They were involved
in designing and testing it and developing it. I should say that
the representative bodies, the trade unions and the professional
bodies, including the royal colleges—do not exclude them—have
been very, very positive about the whole notion of widening participation
and progression. What we need to do now is year on year show the
improvements. They have been very supportive of it and Andrew
can no doubt talk about how they helped to design and build it
and test it.
Mr Foster: The knowledge and skills
framework really is the centrepiece of the pay system. As I said
earlier on, it really is quite a unique pay system which rewards
personal development with pay development which aligns the two.
The knowledge and skills framework was designed over a period
of a five-year negotiation, working with the trade unions and
professional bodies in the NHS and you would not find a single
one of those bodies which would come here and say anything negative
about it except that it must be implemented properly. If you analyse
somebody's learning needs and fit them into their knowledge and
skills framework then you have to be sure you can follow through
delivering the learning and training which is required by it.
For the last 12 months we have been getting people onto the Agenda
for Change and as of March we had 99% of the non-medical English
workforce being paid under Agenda for Change, but that is only
the start of it. Now we have to get all the benefits out of the
knowledge and skills framework and align the learning needs of
individuals with the service needs of the organisations.
Q149 Charlotte Atkins: Earlier on
Mr Foster you passed the baton to your colleague Dr Colin-Thome
on primary care. Maybe we ought to ask the question first of all
which Mr Foster was having some difficulty answering. What exactly
do managers in the primary care sector do? That was one of the
questions with which Mr Foster was having some difficulty.
Dr Colin-Thome: It depends at
what level. There are two levels. There is one at the primary
care trust level, which is not really primary care; it is the
organisation which funds the whole health service. They have a
key role there in making certain that resources are allocated
and so on. There has also been a growth in management at general
practice level. One of the tests for us in general practice is
to have our practice better organised. Sometimes, although the
doctors and nurses can be good at their clinical work, they are
not effective at running an organisation and making it more effective.
For instance, if you look at one of the drivers in the new GP
contract the quality and outcomes framework, it is about getting
systems in place for people with long-term conditions, chronic
care. That takes a different mindset than is often around amongst
clinicians. At PCT level they have a significant function and,
as you know, we are halving the number, which I know in your area
has caused some issues. We are halving the number so there will
be a smaller number of PCTs because you can have a critical mass
of people working together for one organisation. At practice level
there is a significant need not to grow a lot more, but to have
better quality managers and in some practices they did not have
much management at all. Perversely, the quality and outcomes framework,
which will give better clinical quality to patients, needed better
management.
Q150 Charlotte Atkins: I think you
are right in saying that PCTs are going to be halved as opposed
to reduced by two thirds, if the feedback I am getting is correct.
There is a move by the Government, rightly in my view, because
I think my primary care trust does an excellent job, to shift
from secondary to primary care. However, what we are seeing in
terms of workforce is that it does not seem to be paralleled by
an increase... Obviously there is an increase in staffing at primary
care level, but there seemed to me to be more of an increase in
hospitals. For instance, if you look at nurses, there is an increase
in nurses in hospitals but not as large an increase in practice
nurses. Similarly, if you look at the increase in consultants,
there seems to be a disproportionate increase in consultants as
compared with GPs. Why is that?
Dr Colin-Thome: That is historic.
I do not want to criticise previous ideas, but there basically
has not been enough investment in primary care. It has taken a
long time to recognise that primary care is the biggest provider
of clinical care; we do about 85% of all the consultations. International
evidence has also been gathered by people such as Barbara Starfield
and locally by Brian Jarman that increasing the number of primary
care professionals, including doctors, makes a difference not
only to the satisfaction of people with the health service but
makes it more cost effective and now there is some actual connection
with better outcomes. In one sense it is probably our fault by
being, so-called, independent contractors. The health service
has focused on the salaried end of organisations such as community
nurses and staff in the hospitals and left primary care independent
contractors a bit adrift. What I welcome about the policies which
really have happened in the last 15 years is the greater focus
on primary care, but the investment has not followed. That is
maybe the reason for the lurid headlines about how much we are
paid in primary care now. It does seem to have worked, because
there has been a huge growth in doctors in general practice; an
increase of about 1,000 a year in the last three years. That is
head count rather than whole-time equivalents. In the last four
or five years there has also been a growth of something like 18,000
nurses, of which only 3,000 or so are practice nurses.
Q151 Charlotte Atkins: That is the
point, the proportion, in terms of the percentage increase in
practice nurses, is far less than nurses overall and that is a
concern. You focused on GPs, but clearly the work of primary care
is heavily carried out not just by GPs but by practice nurses,
by health visitors, by community matrons, people like that who
are making a vast difference in the quality of primary care and
the experience of the patient.
Dr Colin-Thome: That is where
the biggest growth has been, in community nurses who are not employed
by GPs; they are community-based staff. The issue for us then,
and sometimes we have not been good at working with organisations
outwith the people we employ, is how does the registered population,
which is quite unique in British general practice, be the population
base to look after communities, rather than just about general
practice and its own organisation. If you look at the general
growth of community nurses, it has been about 12,000 in the last
five years. These are community-based staff that will do some
of the work. It is not all going to be done by general practice.
The other issue about more care out of hospital is that will not
all be done by primary care workers. What we are arguing about
is that we need our hospital-trained staff, but working in different
ways nearer the community. For instance, some of the community
matrons will traverse primary and secondary care and work with
social care to get a better package of care. It is not just "Let's
shut the hospital and give it to primary care", it is increasingly
about where the care takes place and some of that will be our
secondary care colleagues, including especially nurses rather
than consultants, doing some of that work.
Q152 Charlotte Atkins: Obviously
in terms of the increased role that nurses are taking on that
makes a lot of sense. Can you just answer one question about the
redundancies in the secondary care sector, in the hospitals? Would
you put that down at all to the increase in resources going to
the primary care sector or would you see it more as a function
of the primary care trust holding their acute hospitals to account
and in fact defining where their residents, their patients, will
be treated?
Dr Colin-Thome: It is a consequence
of the realisation that in Britain, compared with a lot of equivalent
healthcare systems, we put people in hospital, which modern medical
care and healthcare do not lend themselves well to. For instance,
because of the work of community matrons, these are case managers
who are nurse trained—
Q153 Charlotte Atkins: Managing emergency
admissions much better?
Dr Colin-Thome: No, they are actually
managing people with complex long-term conditions, with co-morbidity,
the group of people, not that many, who often have more than one
chronic illness. The crude figures are that about 5% of our population
account for 42% of all the bed days. The international evidence
on case management is that you can often reduce emergency admissions,
though the evidence is sometimes not clear. The biggest difference
they make is shortening lengths of stay, because people can go
home early and that will have a big impact. If a lot of patients
with chronic long-term conditions are the biggest inhabiters of
hospital beds and we can shorten their lengths of stay without
affecting, in fact improving, their wellbeing and their life quality,
then we do not need as many beds as we have traditionally had.
It is often where care is taking place. The issue which is going
to be interesting is that out of the redundancies not many were
fully directly employed nurses. What will happen is that there
will be more growth in primary care, because more care will be
done and things like practice-based commissioning will be driving
some of that. It is where care takes place. Some of the more lurid
headlines about sacking are really just saying that we are using
resources not very appropriately by keeping people in hospital
unnecessarily when their care could be done better in community
settings. Just as a very practical example, I am doing some work
with the teaching hospital in Manchester where they have asked
me to be their lead primary care adviser for the hospital. I can
do it part time along with my other commitments. What we have
come up with is that the hospital and the PCT, without getting
in the way of contestability and choice and all that and being
transparent, are saying they want a joint venture around urgent
care and long-term conditions so we can rationalise where the
care takes place and have fewer headlines. You will find more
and more growth of that much more imaginative working. If you
look at the acute hospitals project, of which I was a member,
about reshaping the future hospital, there is a move to say that
care could be done in different ways. That is a generally accepted
view now.
Q154 Charlotte Atkins: How do we
make sure that the education facilities of the NHS follow the
staff? The impression we get is that a lot of the education and
training takes place in the secondary area. How do we make sure
that the innovative things which are happening in primary care
are backed up by education resources? I should be interested to
know how much clinical training is available in the primary care
sector and what the proportions are, how much per head someone
in the primary care sector gets in terms of training as compared
with the acute sector.
Dr Colin-Thome: I cannot help
you there.
Mr Foster: I do not have that
information available.
Q155 Charlotte Atkins: Could you
let us have it?
Mr Foster: What I can say is that
the post-registration training monies are held by the strategic
health authorities. They are not held by the trusts or the PCTs.
The strategic health authorities can direct those monies to support
what is generally trying to be achieved. In this case what is
generally trying to be achieved is a transfer of work from hospital
settings to primary and community care settings and there are
plentiful examples of where staff are being trained to do that.
I went to Epping Forest a few weeks ago and saw a team of staff
who had previously been nurses working in the hospital who are
now providing step-down arrangements in the community for the
people Dr Colin-Thome identified, the over-75s who have the most
frequent admissions to hospital. They were now being looked after
by a case manager, either in their own homes or in a community
hospital. This was a much better service from the patient's point
of view and was much more efficient from the whole health economy
point of view and was an example of where posts will be transferred
from secondary settings to primary and community care settings.
Dr Colin-Thome: Also our community
nurses are trained in community settings; we have a post-graduate
degree. Practice nurse training is within the gift of general
practice and I have to admit that sometimes that varies. The drivers
of the contract which looks not just at clinical care, and therefore
they have to have an expertise to do this well, but also at the
organisational standards we are setting about having work plans
and so on for our staff on which we have to be measured, will
drive better training in general practice as well. Many practices
do excellent training, but there are accusations of variation,
though of course all our community nursing services are trained.
Some of the community matrons are nurses coming from hospitals
who might have emergency knowledge and can work well across, but
they still need some training and we do have some training programmes
for our community matrons and we have produced a competency framework
and so on to get that training.
Q156 Charlotte Atkins: Who is making
sure that the health authorities are performing equally well across
the country? There has been a huge variation in the ability of
strategic health authorities to perform.
Sir Liam Donaldson: On medicine
it is pretty standardised. There has been a major shift at both
the undergraduate and postgraduate level to introduce more time
in general practice and that is determined by national curricula.
I do think there has been a massive change over the last 10 years
in medicine. As far as nursing is concerned I guess it would be
more determined by local practice.
Dr Colin-Thome: Yes.
Q157 Charlotte Atkins: To be honest,
I am not quite so interested in doctors and nurses; I am actually
more interested in the overall workforce in the NHS because very
often it is these people, certainly community nurses, but other
staff as well within the NHS, the carers, people like that, who
are the ones who have the most contact with the patient.
Dr Colin-Thome: The training which
some of the work people like allied health professionals, physiotherapists,
have in hospitals is relevant to what we want in community settings.
In the White Paper we have made quite a significant commitment
to training programmes for carers, which we focused on earlier.
I actually lead on the long-term conditions programme for the
Department of Health and that is a significant part of our strategy
because we recognise that most care is informal or self-care and
both the patient who has the condition needs to be given more
training programmes, which we are doing with things like the expert
patient programmes and the diabetes programme, but also we need
to be committed to carers.
Professor Fryer: You are quite
right that there is a whole range of people within the team and
healthcare assistants form a very large group, a fast-growing
group in the workforce—
Dr Colin-Thome: Including in primary
care.
Professor Fryer: As longevity
increases and we know that not only is there a small proportion
of the population which makes huge demands on the service, but
actually it is age-related too in those last 10 years of life,
healthcare assistants become very important and if you want evidence
of what happens when you do not get it right, have a look at the
research which was done on the Paris heat wave and the Chicago
heat wave. Very often it was this level of skill and expertise
and training that was lacking. I spoke early on very positively
and I am feeling very positive about what the NHS is doing, but
there is a lot more to do. The White Paper was extraordinarily
honest. There is a sentence which the Secretary of State put in
her recent White Paper, Our Health, Our Care, Our Say which
said that sometimes we find that the least well-served communities
in terms of healthcare are served by the least well-trained staff.
We do need to do more. The obverse of me saying that 80% of the
staff in the service are at level two or above—if I put
it the other way round—is that we find that 28% are on level
two or below. When the NHS staff survey, which is a very important
source of information, suggests that up to one fifth of staff
claim they receive no training at all, we all in this room know
who they are without having to ask. We are doing well, there is
this shift, healthcare assistants are an important component of
that change and we need to do much more. Anything your Committee
suggests that we need to do more for those staff will have me
throwing my hat in the air.
Dr Colin-Thome: If you are looking
at chronic diseases, it is unfortunate more of us are getting
these, but it is a vehicle for working better together, one of
the things we are going to work on with not just with our secondary
care colleagues but social care colleagues who have many of those
skills we lack. This is not about a healthcare system on its own
and long-term conditions management is the practical way that
that can be demonstrated. Some of the most effective ways of not
needing to admit people to hospital include having social care
input.
Q158 Sandra Gidley: You mentioned
lurid headlines about wages and I want to bring you back to those.
Whilst the press will always pick on the sensational, you cannot
get away from the fact that there is a £250 million overspend
on the GP contracts and they are figures supplied by the Department.
Why did it go so wrong?
Dr Colin-Thome: I do not know
that it went wrong.
Q159 Sandra Gidley: From the GPs'
point of view it probably went exactly right.
Dr Colin-Thome: The trouble is
that the contract is quite unique, because it is the world's largest
quality-based contract that anybody has attempted. What our trade
union, the BMA, the Department and also our expert panel estimated—because
we had no baseline data—was that we would hit about 75%
of the quality points. Some people might say that we did better
because it was too easy, but actually there has been quite a significant
investment in people such as healthcare assistants and nurses.
It is actually quite hard to get to 91%. There was enough money,
given that PCTs have had a huge increase in their allocation.
So they did have money to compensate for that, but we did overachieve
and that is to our credit. If you look at things like chronic
disease, which amounts to 50% of the points, we know that better
care systems for people with chronic conditions will increase
longevity as well as quality of life. There is a drive to do that.
The other issue which is interesting is that it was not uniformly
spread. Some PCTs actually balanced. Maybe they had made a better
assessment, maybe they had baseline knowledge of what their GPs
were doing but some managed to balance their books and not overspend.
It is a global sum. The other interesting thing is that the overspend
or underspend or whatever bore no correlation to the QOF scores.
It was not as though the biggest overspenders were where the practices
had the highest QOF scores. It is interesting that one of the
issues we are trying to look at is how local health organisations,
who are much more knowledgeable about local conditions, can make
an assessment of both the needs of their communities, but also
the capability and capacity in their local organisations. That
is what the new PCTs will have to do in spades to have that knowledge.
Wrong maybe, because it is hard often to allocate and to know
exactly the monies you require, and you could equally argue that
about out of hours care, but again there was huge variation in
PCTs about how they spent their money, so in a global sense you
might say we got it wrong, but it is local organisations which
obviously have to have a better assessment. What is fantastic
now is that the GP contract has given us that baseline and now
that we are doing it with all that effort, we are going to try
to make it a bit tougher so that it is about continuous improvement.
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