Examination of Witnesses (Questions 200-219)
MS SIAN
THOMAS, MR
DAVID AMOS,
MR WARREN
TOWN, PROFESSOR
SIR ALAN
CRAFT AND
MS JOSIE
IRWIN
18 MAY 2006
Q200 Dr Naysmith: You will welcome
very much the change in waiting times that has taken place over
the last few years and the reduction in waiting times must have
made a huge difference to patients.
Mr Town: The evidence we have
at the moment is that the outpatient waiting times have doubled.
Q201 Dr Naysmith: We need proper
figures on that. You have talked quite a lot about physiotherapists
already and that is a good example of allied health care professionals.
That is quite a big and interesting bunch of people. There is
something quite interesting about physiotherapy. The Chartered
Society of Physiotherapy put in figures to suggest that currently
there are 1500 vacant physiotherapy posts in the NHS. Despite
that, one-third of those who graduated last year did not get jobs
in the National Health Service. There could be a couple of explanations
for that. One is that we are training too many physiotherapists
and these vacant posts are not really needed or, two, that cuts
are taking place because of the financial deficits.
Ms Thomas: My sense from working
with the Chartered Society recently with the people we met as
I described, and we are implementing our action plan on this,
is that there are probably three or four key things going on for
the profession. One is that clearly there is a demand, as one
of my colleagues said, for physiotherapists who are more senior
and more skilled to start taking on roles that previously were
done by, for example, doctors. There is now a framework in place
to enable some of that to happen; for example, triaging patients
before they have to get into an acute setting. There is a time
lag in the training that is needed for these graduates to get
up to that skill level. That is one issue. The second issue is
that the number of vacancies that we have seen in physiotherapy
certainly has not decreased at all. One reason for that is because
there is a demand for more of the senior people, and we are tracking
that. One of the things we have agreed with the CSP is that we
will do some work with employers to help fast-track some of these
graduates who cannot get jobs into some of those more senior roles.
Q202 Dr Naysmith: There is another
group of these professionals that I know something about, clinical
psychologists. People suffering from mental illness often say
that they really would like talking therapies rather than drug
therapy. That is a very commonly expressed view and yet they sometimes
have to wait months to see a psychologist. Why is it that we cannot
switch resources from one part of the service that people say
they do not like so much into another one for which people are
making a demand?
Ms Thomas: Perhaps Josie Irwin
could help me out here, but I think the talking therapies plans
are all about what kind of health care professionals can take
on that work. It may not just be about psychologists but also
about what mental health nurses can do to help deliver those sorts
of care for patients. Certainly, we as employers are working with
the Chief Nursing Officer on various plans. It is not normally
the kind of area that mental health nurses perhaps in the past
have worked in but we would like to see that extended.
Q203 Dr Naysmith: This is something
that has been around in mental health for quite a long time. For
the last five years, these people have been saying that and yet
we do not seem to be moving towards that kind of service.
Ms Irwin: I do not need to help
my colleague out because she has articulated very clearly the
innovative thinking that is going on right now to try to develop
the roles in order that things can be done much more quickly.
Q204 Dr Naysmith: So you think that
is one of the answers then?
Ms Irwin: Yes.
Mr Town: There is the issue on
financial deficits. Historically there have been a number of short-term
posts for physiotherapists when they graduate but, with the deficits,
those posts are not going to be created and therefore there is
that particular loss. It is also important to recognise that a
number of overseas-qualified physios are coming into the workforce
as well. In the last three years, 6,000 new overseas-qualified
physiotherapists have entered. For example, in London alone, the
physio departments rely on an Australasian workforce. I have just
come back from Australia where they are cutting back on their
workforce, and so there will be a problem with that as well.
Q205 Dr Taylor: Before going on to
medical employment, I want to go back to quality of care and insert
just a bit of realism. Today, before this meeting, I have just
had two complaints. One was from a friend across the river that
an elderly person has been in hospital for quite some days and
the nurses have been camped round the nurses' station rather than
actually nursing. I get these sorts of complaints at home about
lack of continuity of care, lack of communication between patients,
doctors and nurses. One has got to put an air of realism into
this. It is absolutely marvellous that nurses are taking on lots
of extended duties and doing other things but is not the quality
of actual bed-side nursing care suffering tremendously?
Ms Irwin: I said earlier that
one of the employment surveys that we carry out on an annual basis
has indicated that 25% of nurses felt that they were not able
to deliver the quality of care that they would like to be able
to deliver. Of course we would have to be concerned about that.
It is difficult, though, to respond to the kind of anecdotal information
that you have just provided. It is very important to say, in response
to any concern that has been registered such as you describe,
that that is challenged by the patient in that particular setting.
Q206 Dr Taylor: I have got to get
back at Sir Alan on the dig that all MPs, particularly me, are
protecting their interests. I have been trying to tell the Government
for a long time how to get away with mergers and my message is
falling on deaf ears. There are ways it can be done. However,
going on to medical employment, in your submission, Sian, I think
you say the expansion in medical school places since 1997 has
led to the over-supply of doctors rising from 7% to 12% by 2009.[1]
The Chief Medical Officer last week told us that medical unemployment
is highly unlikely. Would you agree with that? What is your projection
based on?
Ms Thomas: Our assessment of the
situation is that, given where we were a number of years ago,
we certainly now have a situation where we have many more home-grown
doctors. UK graduates have improved significantly. There now is
a supply to the entry level posts for doctors. We want to see
all doctors get their first job in the NHS. Certainly, if we embark
on training doctors through medical school, that should be what
employers seek to do. There is an issue about how many doctors
in the future we will need. There are all sorts of complicated
dynamics around that. One is that the medical workforce now has
far more women in it, and so what will the contribution of those
people be in the next 20 years? The second is as we have described:
the setting in which people are working is changing, so we may
need to mix the specialisms and the settings between hospital
and community. The third issue is the impact of the Working Time
Directive. All of those three things together are now being analysed.
Our view is that it would be a good thing to have a modest over-supply
of doctors. It is something we have never had. We think that that
happens in every other profession and there is not any reason
why it should not happen in medicine. There were days when people
did not put an advert out for a consultant because they knew they
would not get an applicant. That obviously cannot be right when
we are trying to deliver patient care. We want applicants; we
do not just want one but a number so that we have a choice. That
drives up competition, which drives up quality, in our view. We
are certainly not saying that we want to see unemployed doctors.
I think that ought to be made very clear. As a group of employers,
we are not saying that. We are saying that we are in a global
market here; doctors will have choices about which country they
want to work in now more than ever before. Our view is that there
will potentially be a modest over-supply, but more work needs
to be done to understand exactly, in 2020 and 2030, what the true
scenario will be with all of these new graduates that we now have
in the marketplace.
Professor Sir Alan Craft: Could
I add that it is extraordinarily difficult to predict what we
actually do need because of all the reasons that have been said?
We now have 70% of medical students are women and even the men
want to work less than full time. We have desperately been trying
to get our number of doctors up to the European norm but even
that is a false comparison because the way that they practice
medicine in European countries is completely different. They have
under-employed—they do not have unemployed doctors, at least
not many, in France, Germany, but they have doctors that certainly
do a lot less than doctors in this country do just because of
the way that they practise in primary care, primary care specialists
are often under-employed compared to what they are in this country.
So I do not think we should be driving ourselves to get up to
the European norm, we should be trying to provide the number of
doctors we need for the service that we think we will need in
15 years' time. If anybody can predict that with accuracy then
they are better than we have been doing for the last 50 years.
Q207 Dr Taylor: Do we have any idea
how many unemployed doctors there are in this country at the moment,
taking those from abroad as well?
Ms Thomas: We might be able to
give you some data.
Professor Sir Alan Craft: There
was a big fuss last year about the number of newly qualified doctors
who did not get first jobs. In fact it was slightly more than
we usually have but every year there are about 80 to 100 of our
graduates who do not get a job, either because there is not one
geographically that they can get, or because they do not want
one—there are quite a number of people who deliberately
do not want one and opt out for a while.
Q208 Mike Penning: So you go to medical
school, spend all that time and all the state funding is there
and they do not want to be a doctor?
Professor Sir Alan Craft: Which
takes you right back to how do we get the right people into medical
school, and that is another challenge.
Q209 Dr Taylor: How do we square
this apparent excess of doctors with the College of Physicians'
census in 2004 that shows many specialities have tremendous numbers
of unfilled posts in them, particularly geriatric medicine and
palliative medicine?
Professor Sir Alan Craft: Because
in order to fill them you need to train people and that training
takes seven years. So once you spot where the difficulties are
you then redirect your needs into those specialities, providing
you have some sort of national planning.
Q210 Dr Taylor: And how do we get
flexibility? At the moment we are told that cardiac surgeons are
going to have to be retrained to do other jobs. How do we get
flexibility into workforce planning?
Professor Sir Alan Craft: I think
what you have to do is to get flexibility into doctors' training.
I do not know about the other healthcare professions. What we
have to do is to make sure that all doctors have a generic training
and then they have a bit of specialist training on top of that
to do whatever it is, but also to recognise that they will probably
not be doing that for all their life, that they may well have
to be retrained. The cardiac surgery one is a very good example
of the fact that we thought we knew what cardiac surgery was being
done and what would be done for the next 20 years, when all of
a sudden a new medical innovation came along which said it could
all be done by radiologists, but we do not have enough of them.
So we have too many cardiac surgeons and not enough radiologists.
Chairman: Could we move on to pay schemes?
Ronnie Campbell.
Q211 Mr Campbell: Now we have seen
an increase in staff and reasonable pay—I will not say it
is brilliant but it is reasonable to what it has been—do
you think the Agenda for Change and the new medical contracts
is providing a better deal for clinicians? Do you think it has
provided a better deal for clinicians?
Professor Sir Alan Craft: From
the medical point I cannot speak for Agenda for Change, but from
the medical point of view there are two new contracts. The GP
contract has provided a much better life for GPs—they have
got rid of all of their night work and, if you read the Press,
they have all increased their salaries by a significant amount.
One of the problems with that is that a lot of the nighttime work
has actually been moved to hospital and the funding has not gone
with that. So for the GPs themselves it has been good but for
the service it probably has not been as good as all that. From
the consultants' point of view they had a new contract as well,
which is a work sensitive contract, and that has had a mixed reception.
It has been very divisive in places.
Q212 Mr Campbell: Do you think it
is a better deal for the patients as well as the taxpayer?
Professor Sir Alan Craft: I think
the out of hours care for general practice; the primary care is
not such a good deal as they used to have.
Ms Irwin: I think from the Royal
College of Nursing perspective that the new Agenda for Change
and the pay system is a very good deal indeed. It has to be good,
does it not, I think, to have introduced into the NHS a proper
job evaluation system which does mean for the first time in the
NHS there is equal pay for work of equal value? The job evaluation
system, by the way, also for the first time probably recognises
the work of nurses in that it is capable of measuring caring skills.
What Agenda for Change also does, through the knowledge and skills
framework, by providing a way of measuring competence and a way
of ensuring that nurses can develop in their roles, is to provide
enormous potential both for the nurse to progress in her career
and also to improve the quality of care that she is providing
to patients. I think evidence that Agenda for Change is already
working Agenda for Change has just been implemented. However,
in evidence that we submitted to the pay review body last year,
we were already showing signs of improved recruitment and retention
as individual members of staff waited for their Agenda for Change
outcome, and that has to be a very important marker in terms of
improving quality of care to patients. So it is a good thing for
the individual member of staff but it is also good for the patient.
Mr Town: Endorsing most of what
Josie says but with some degree of caution—which I seem
to be doing a lot today—is that we are beginning to see
problems in relation to Agenda for Change working in partnership
with some employers refusing to engage in partnership, the most
prominent ones being the Foundation Trusts, and one particular
Foundation Trust has already stated that its board is legally
liable therefore whatever decisions need to be taken will not
be taken in partnership, and therefore we begin to wonder how
Agenda for Change will operate within Foundation Trusts. The other
difficulty we would see is that if the deficits continue to increase
then the potential for using the knowledge and skills framework
and for the job evaluation system to operate may also come under
pressure as individuals do progress and therefore are entitled
to move into the job evaluation scheme and therefore may increase
their potential earning, but will an employer be able to pay for
that and will they therefore start looking at rationing?
Q213 Mr Campbell: As you say, Mr
Chairman, Foundation Hospitals that are employers have a better
system in Agenda for Change.
Mr Town: No, I said that they
do not have to operate within Agenda for Change.
Q214 Mr Campbell: Then which system
are they operating?
Mr Town: At the moment they are
operating with Agenda for Change but they have the option not
to.
Q215 Mr Campbell: Have they taken
up that option?
Mr Town: Not so far.
Chairman: We have some specific questions
on Agenda for Change a bit later on.
Q216 Sandra Gidley: Is that not a
real concern though if the aim is to move to all Foundation Trusts
eventually?
Mr Town: Absolutely, and the concern
was always expressed when Foundation Trusts were established,
and a number of organisations, including the radiographers and
some other allied health professions, were trying desperately
to put the Agenda for Change terms and conditions as a minimum
standard within the Bill that introduced Foundation Trusts, but
the government refused.
Q217 Mr Campbell: The Chairman has
said Agenda for Change is coming up later on, so I will go on
to my next question. What is happening with the improvement of
productivity through the pay reforms?
Ms Thomas: Can I respond to the
pay agenda? It is a broad comment about pay reforms that overwhelmingly
they are good deals for patients, employers and the staff themselves.
Next week at your Committee we have brought some experts to deal
specifically with some of your questions about the pay reform.
I would like to respond to the issue about the collegiate of health
employers, including Foundation Trusts, and our view is that this
is a fantastic framework. It is a world class knowledge and skills
framework in healthcare, and we even have private sector employers
looking at the knowledge and skills framework and saying, "This
is a great framework, we are adopting it," so I would say
that there is no doubt that if anybody chose not to they would
have to have a pretty good pay framework as an alternative.
Q218 Mr Campbell: Can you give us
some examples?
Ms Thomas: We have no examples
where people are not adopting Agenda for Change. The final point
is about partnership working, which is to say that one of the
biggest things to come out of Agenda for Change is the fantastic
partnership working with staff organisations, and we would see
that as one of the major improvements.
Q219 Mr Campbell: But there are no
examples for seeing the productivity coming from pay reforms?
Ms Thomas: On the issue of productivity,
what you mean by productivity we would describe, as employers,
productivity as helping people in the individual teams and the
individuals themselves to take on more work or do things differently
to enable improved patient care to happen, and our view is that
the knowledge and skills framework is the perfect framework to
enable that to happen safely because those competences can be
managed.
Ms Irwin: I would just add to
what my colleague has said, in terms of actual practical on the
ground examples of where Agenda for Change is beginning to make
a real difference in delivering services differently, improving
patient care and improving outcomes in a value for money way—because
I think that is what you are driving at—my colleague's NHS
Employers' website in fact has a number of examples as Trusts
work them through appearing, and one I would like to refer to,
which I highlighted earlier, one NHS Trust in the southwest of
England where they have introduced associate practitioners to
work alongside community mental health nurses—a different
way of working—which has enabled them to reduce enormously
the agency bill that they were having to pay for qualified nursing
staff and at the same time improve the access of patients to the
mental health service. We will see more of those examples as it
was only March this year that Agenda for Change was fully implemented
across England.
Chairman: Can we move on now to consultant
contracts, Sandra Gidley.
1 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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