Examination of Witnesses (Questions 166-179)
MS SIAN
THOMAS, MR
DAVID AMOS,
MR WARREN
TOWN, PROFESSOR
SIR ALAN
CRAFT AND
MS JOSIE
IRWIN
18 MAY 2006
Q166 Chairman: Good morning. Thank you
for coming to the second evidence session on our inquiry into
workforce planning. Could you introduce yourselves for the record?
Ms Irwin: Josie Irwin, Head of
Employment Relations for the Royal College of Nursing.
Professor Sir Alan Craft: Alan
Craft, a paediatrician in Newcastle but my present position here
is as Chairman of the Academy of Medical Royal Colleges.
Mr Town: Warren Town, and my day
job is Director of the Society of Radiographers, but I am here
in the capacity of the Secretary of the Alliance for Health Professionals.
Ms Thomas: Sian Thomas, Deputy
Director for NHS Employers, which is the employers' organisation
in the NHS.
Mr Amos: David Amos, Director
of Workforce at University College London Hospitals NHS Foundation
Trust.
Q167 Chairman: May I say before we
start the session that, sadly, we have lost one of our parliamentary
colleagues who died last night. He was on the Opposition benches
and at least three members of this committee will be leaving for
a short period of time during this session in recognition of that
event. I start with the first question in relation to the trends
in workforce supply. This is purely an extension from the session
we had last week. This question is probably for all of you in
turn. There has been a number of development in the NHS workforce
since 1999, including rapid increases in staff numbers and some
workforce reform. Could I ask you individually what you believe
have been the major successes and failures of the past few years.
Ms Irwin: One of the major successes
in the last 10 years has been, from the Royal College of Nursing's
perspective, to increase the numbers of nurses in the UK NHS workforce
by some 85,000 since 1997. However, one of the issues which you
will have read in our evidence is that the quality of workforce
planning in the UK means that we do not know where all those nurses
have gone; we do not know how many of them have stayed in the
UK; we do not know how many of them have stayed in the NHS. That
is an issue in terms of workforce planning because, right now,
and I think our evidence has highlighted this, we are in a situation
of global shortage in respect of nursing staff and other countries,
such as the United States and Australia, are proving to be attractive
draws to those people. In terms of other challenges, because you
have asked the extent to which things have been done well or not,
we also have an issue in respect of the whole workforce, but more
particularly in respect of nursing and ageing. For example, at
the moment there are about 100,000 nurses aged over 55, so set
to retire within the next 10 years. Another issue about workforce
planning in the UK is that we do not know very much about the
retirement behaviour of these nurses: when they are likely to
retire, what sort of things might influence them in terms of retiring
now, except that we do know, for example, that the uncertainty
generated by some of the NHS reforms is causing people to wonder
if they would like to retire now. The overall point I am making
is that there is a degree of uncertainty in workforce planning
that means that the success of importing new numbers of nurses
into the UK is challenged by not knowing enough about what has
happened to them once they have entered the workforce.
Professor Sir Alan Craft: From
the medical point of view, there has been a large increase in
the number of doctors working in the NHS, and this is partly in
home-grown doctors; we are increasing the number of medical students
and the output from medical schools is increasing. We have also
had a large increase in the number of international medical graduates
coming over the last few years and they have been encouraged to
come. We have also had a significant increase in the number of
European doctors coming, particularly in 2004 from the new accession
states; we had quite a big influx of doctors from the former eastern
Europe. We have had quite a large increase in the medical workforce.
There has been a big recognition over the last few years that
we cannot go on as we always have done with the pattern of medical
health care. There is a variety of matters driving us to look
at what we do, particularly in specialist practice but also to
some extent in general practice. All the Royal Colleges are looking
at how they can provide a workforce fit for the future. The problem
is that we have a lag time between looking at what the future
is and training anybody for that, which can take anywhere between
eight and 10 years. By the time you get to eight to 10 years,
that has probably changed anyhow. One of the things that we are
building into all our training systems is flexibility so that
people are capable of adapting to whatever it is they are going
to have to do in 10 years' time. We recognise that there are an
awful lot of things that doctors do that other people could do
quite nicely and probably better to some extent. We have welcomed
the advanced roles that nurses have taken up. We are generally
supportive of health care practitioners, medical care practitioners,
social care practitioners. We are a bit concerned about what you
call them. In general, we are very keen on them but also very
keen that they should be part of a medical team. We are a little
concerned that they may be working in isolation. Things have changed
greatly and they will change more over the next few years but
planning is difficult.
Mr Town: With regard to successes
for AHPs, there have been a number of innovations on extending
roles, taking on extra responsibilities and working with non-qualified
staff to extend their roles. These measures would allow the AHPs
to develop their specialist skills and take over roles at a higher
level. There have been failures in that there has been no indication
that there has been an associated increase in the levels of recruitment
or levels of staff to the service. The fact is that at the present
level we anticipate that at best we can stand still, but we cannot
innovate without that extra number of staff. The current round
of uncertainty about finance will do no good either because, in
truth, the jobs being cut are going to be junior jobs. That does
not allow the seniors to take on extra roles that they tend to
do as extra responsibilities. Like others, one of our major problems
is that within all the AHPs there is an indication that many will
retire within the next 10 to 15 years. Without an increase in
numbers at the lower levels, there will be a shortage of skills
in the more qualified and more experienced grades. This may be
exacerbated, we do no know, if the pension debate is not settled.
Ms Thomas: I agree with many of
the comments made by my colleagues, and that is the difficulty
of coming near the end. I would like to make a few points on behalf
of NHS Employers. I have no doubt that, from an employers' perspective,
if you look back over the last five or 10 years, we have made
huge improvements in the number of people working in the NHS and
certainly that has had a demonstrable impact on patient care.
We are very clear that the numbers of people working in the service
now compared to 10 years ago has dramatically changed and the
gap between the number of people we need and the number we have
is now much narrower than it was. Certainly, there is a new set
of challenges and I think that has been described by my colleagues.
Q168 Chairman: The increase is the
success in all this as far as the NHS is concerned. The failure
side, in a sense, is that it has probably not been terribly coordinated
in terms of finance.
Ms Thomas: That is certainly true
but the integration between finance, workforce and what the service
wants can always be improved. In some parts of the country that
challenge is graver than in other parts. We are seeing that the
vast majority of employers are now able to plan better and coordinate
their working teams because of that huge increase in the number
of people. The challenge for the future is that most of our people
have been trained in a hospital setting; we need to improve the
vast majority of their training when the shift in care is towards
more primary care working. Also, new roles bring on new sets of
challenges, as my colleagues here have said, around integrating
the team, making sure there is a competence framework. That has
been put in place in the Knowledge and Skills Framework that we
have, to deliver all of that. There is a platform to secure for
the future and to overcome some of these challenges.
Mr Amos: Perhaps I could add something
from the personal perspective of someone who was an HR director
in London in the mid to late Nineties. We have seen a transformation
in the health care labour market, particularly in London. I know
the situation then was a factor that prompted your committee to
do the work it did. In headline terms, back in London at UCLH
we have seen a growth in the workforce, which you and colleagues
have acknowledged. There has been a very substantial reduction
in the number of vacancies. Many trusts now have talent pools,
as they call them, of people who want to come to work and who
are waiting for the advert to be placed. We have seen a reduction
in turnover and reductions in areas such as temporary bank and
agency working. Overall, we have a far more diverse workforce
than we have ever had. I say that as a massive, positive tribute
to NHS and other health care providers which have recruited and
developed staff. There is much more we can do in that area. That
is a very significant feature of the couple of hundred thousand
people working in the NHS in London. It indicates the great potential
that the NHS has if it continues to take advantage of the talents
and potential of the individuals working in the NHS. In terms
of prospects, as your committee has already acknowledged, we need
to work out how we can get more from the NHS and from other staff
working in health care (I know that is a central part of your
inquiry) and to make sure that we get staff in the right place
within NHS organisations. Within my trust, for example, we are
working increasingly with day cases rather than inpatients. We
need to move staff between sectors. That is one of the key characteristics
of what is changing at the moment.
Q169 Dr Stoate: You have always said
quite clearly that there has been a huge increase in the workforce
of the NHS. None of you seem to have disagreed with that statement.
What we find so frustrating and mystifying on this committee is
why that huge increase in staff does not seem to have been accompanied
by the necessary measures of reform. Why has reform been so slow,
given the huge increase in staff?
Ms Thomas: It is true to say that
reform is now more of an issue than perhaps it was five or 10
years ago. It is definitely true to say that we have new polices
which employers are implementing. The career framework was not
in place five years ago to enable people to shift between the
sorts of jobs we did. I think we could give you many examples
where within the NHS people are doing things differently with
community matron roles, lots more specialist nurse roles and emergency
care practitioners. Those measures are beginning to change the
way that patients receive care along the route of referral, but
we need to do more.
Q170 Dr Stoate: We have plenty of
examples of best practice. We have been sent lots of memos and
we have spoken to many people about best practice. Why is best
practice still only best practice and not normal practice? Why
is it that the NHS is so slow to reform as an organisation?
Mr Town: Going back to the point
about the increase in staff, yes, there has been an increase but,
as I said before, certainly for the AHPs, that is a standing still;
it is not moving matters very far forward. Equally, as long as
the Government introduces new plans, new ideas and new strategies,
we have to meet those demands as well. That may be ISTCs or it
may be admission to a patient-led NHS. We then have to develop
new plans and put those plans into practice, but if we are only
standing still with the staff we have, we are not going to make
the innovations that you think are going to happen in the NHS.
I have one word of caution and it is a health warning for one
particular area of staff where there has not been an increase
but a dramatic shortage of staff, and that is in cancer care with
radiotherapy. That is definitely a problem. Also, the increases
in themselves must be planned in association with the outturns
of how many are leaving and how many are not taking up posts.
In physiotherapy, for example, there have been increases but there
are also physiotherapists not taking up posts because there are
not any posts, and that means losing people.
Q171 Dr Stoate: I accept that but
there are examples where there have been massive increases in
certain sectors of the NHS and yet that still has not been accompanied
with enough reform. Perhaps Professor Craft might be able to help
us.
Professor Sir Alan Craft: One
of the problems is that the NHS is not a national organisation.
Deliberately, it has been devolved to lots and lots of smaller
things. You are right that there are some good examples of good
practice and new innovations in some places but not far away they
are doing things in the old-fashioned way. When the Modernisation
Agency was in existence, they had regular documents coming out
about sharing good practice. My own college, the Royal College
of Paediatrics, produced a very influential documented called
Old Problems Need Solutions. We had case studies about
how it had been done in different places and that has helped to
reorganise and improve services all over the country. You are
right that there is a lot of sharing to be done. If the best practice
was universal practice, things would be much better.
Q172 Dr Stoate: They would. We find
it difficult to understand why that should be. Turning to something
else, the number of non-clinical staff has risen just as fast
as clinical staff. Is that justified?
Ms Irwin: May I pick up your previous
point and contest what you have said about there having been no
reform?
Q173 Dr Stoate: I did not say there
was no reform but that it was too slow and it is not widespread
enough.
Ms Irwin: The point, as articulated
by Professor Sir Alan Craft, is that there are all sorts of examples
of good practice occurring at local level, all of which have contributed
to the targets set by Government being achieved. The problem is
that the Modernisation Agency has been abolished. One of the things
that this inquiry is highlighting is the lack of robust workforce
planning. What we do not have is an agency that collates that
evidence of good practice. Returning to the question that you
have asked about the numbers of support staff in the service,
that in itself is evidence of people working in new and different
ways, of working as teams to change the way the patient moves
through the service. In itself, that may be a good thing, so I
would contest that as well.
Q174 Dr Stoate: I have not really
heard answers that I am satisfied with. You all come up with good
reasons why things have not changed but those have not satisfied
me as to the need for radical reform in the NHS. Last week, Andrew
Foster told us that he thought the workforce planning system was
overheated. Surely that is more of an understatement than anything
else? Surely we should expect the NHS to reform, given the huge
amounts of resources going in and huge increases in staff numbers?
Surely the Government has a right to expect this reform? Why is
it taking so long? I do not think any of you have really addressed
that issue.
Ms Thomas: Perhaps it would help
to describe one of the roles of NHS Employers in trying to share
best practice with employers. We are a year old. We are new in
our role but increasingly over the last years that is exactly
what we have been doing. The examples I have given you are in
things like the emergency care practitioner, midwifery, chronic
disease management, respiratory care and health care sciences.
We are doing huge amounts of work in those areas. There is not
enough time to sit here and describe them all to you. Some of
those are replicated nationally. Nurse prescribing, for example,
is a national reform in the way that that profession implements
its practice. I think it is true to say that we are on a huge
journey. It is quite right to say that we need to get on with
delivering all the changes needed, and that is certainly what
we are doing. Our role is to try to help employers share where
they can what they do best and to learn from that.
Professor Sir Alan Craft: I want
to return to this and to say that it is not all our fault. People
on your side of the table have a role to play as well. The biggest
problem in reorganisation and redesign of services is the local
MP who wants to continue to have his hospital doing the same thing
it has always done, to have its maternity unit, its A&E unit
and everything else, which we know in the modern system they cannot
have. I think there is a great deal of education to do on your
side of the fence as well.
Dr Stoate: That is a good answer.
Q175 Charlotte Atkins: Recent reports
about NHS redundancies have suggested that the vast majority of
job cuts are reductions in posts rather than in personal redundancies.
I know that obviously the RCN has been running their Keep nurses
working: keep patients safe campaign. What is your view? Is
it mostly about posts and not actual real redundancies?
Ms Irwin: Shall I respond to that
first as I think Charlotte mentioned the Royal College of Nursing
campaign. We have actually been very clear from the outset of
the campaign, which we embarked upon in the autumn of last year,
that we are concerned about posts being lost from the service.
We started mapping the numbers of nursing posts that trusts were
shedding as a consequence of reorganisation in the autumn of last
year. More recently, we have seen, with the advent of turnaround
teams going into trusts just after Christmas, for example, those
post losses also being redundancies. For example, on Monday of
this week a set of redundancies was announced through a Section
188 notice in Nottingham. I think we ought all to be as concerned
about the loss of posts as of individuals. In respect to nursing,
I draw to the committee's attention some evidence which we have
included in our written evidence. We know, for example, that the
nursing workforce is very stretched, that on average a nurse works
six extra hours in excess of the normal working hours each week,
and that is a day a week. That is indicative of nurses working
at full stretch. The loss of posts and the loss of agency temporary
staffing resources all add to that workforce stress, and therefore
the impact on the patient. Yes, the focus is on posts, but I would
say that that is as concerning as the loss of individual jobs
from the service.
Q176 Charlotte Atkins: Are you saying
therefore that it would not be possible or advisable for management
to look at the mix of nursing skills and just change the mix?
Are you saying it has to stay as it is?
Ms Irwin: No, I am not saying
that. One of the problems about what is happening now, though,
is that the workforce changes and the loss of nursing posts is
not as a consequence of an all-out change of service design or
a service improvement but much more a knee-jerk reaction to the
deficit situation. I know that the committee will be having a
separate inquiry into deficit. No, I think it would be a misinterpretation
of the RCN's campaign if it were to be seen that we are arguing
against any effective mix of skill, but it is highlighting the
fact that the posts that are being lost from the service at the
moment are not part of that. It is a knee-jerk, short-term reaction
to the deficit situation.
Q177 Charlotte Atkins: Since 1999,
we have had something like 75,000 extra nurses. Are you suggesting
that pre-1999 patients were not safe? The title of your campaign
is Keep nurses working: keep patient safe. Does that indicate
that before 1999 patients were not safe?
Ms Irwin: No, not at all, and
our focus right now is on the consequences of ill-thought out
reductions in posts as a consequence, say, of a knee-jerk reaction
to financial deficits rather than thinking through service improvements.
Those 85,000 nurses that have entered the UK from 1997, in our
view are all being effectively used and deployed in improving
patient safety and patient care.
Q178 Charlotte Atkins: What your
campaign seems to imply is that these reductions in posts will
actually put patients at risk, whereas in fact overall there has
been a substantial increase in the number of nurses in the NHS?
Ms Irwin: There has been, but
the point that I am making is that because of the crudity of workforce
planning, as I have said before but to repeat the point, the reductions
in posts that we are seeing right now are not as a consequence
of thought-out service change, service improvement, but rather
they are a knee-jerk reaction. There is no thought-out rationale
to bring health care assistants into the mix, for example. The
challenge is to patient care because, as I have already highlighted,
the nursing workforce is so fully stretched at the moment. If
there are ill-thought out reductions in posts rather than effectively
thinking through a proper skill mix, that will inevitably impact
on the quality of nursing care that a nurse can give. I would
like to use the words "quality of nursing care" very
carefully rather than "patient safety".
Q179 Jim Dowd: On that point, and
you have said it a number of times, you used this horrendous cliché
about a "knee-jerk reaction" to deficits. I would like
to know what you think should be done about the deficits, other
than the Government ladling out more money. My local trust went
through a realignment of services to live within its budget, which
then implied a certain surplus of individuals. Why is it that
this obsession with posts, and in local government terms it is
the establishment, only exists in the public sector? In the private
sector, you just live within the budget and employ the people
you need to do the job; there is no such thing as posts and establishment.
Ms Irwin: I apologise if I used
a cliché but perhaps I can use different language. The
example that you have just set out would appear, without knowing
all the detail, to be a good example of looking at ways in which
a budget deficit can be addressed and thinking about sensible
ways of realigning the service in order to do that. The RCN's
concern is about losses of posts where the service reduction is
ill-thought out and the posts—
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