Examination of Witnesses (Questions 260-270)
MS SIAN
THOMAS, MR
DAVID AMOS,
MR WARREN
TOWN, PROFESSOR
SIR ALAN
CRAFT AND
MS JOSIE
IRWIN
18 MAY 2006
Q260 Jim Dowd: A quick look at training—and
I know this was referred to earlier in passing. Agenda for Change
and also Modernising Medical Careers encourages the cultivation
of "competencies" as the essential building blocks for
both training and career development. For anybody in any particular
order, (a) has that been useful, is it a welcome development;
and (b) has it provided additional flexibility amongst the workforce?
Ms Irwin: Very useful and is beginning
to provide that flexibility. The concern, though, that I go back
to, the NHS' own annual staff survey showed for 2005 that there
was a reduction both in the number of appraisals that had been
carried out, which obviously is an annual interview that identifies
development needs, and also there had been a reduction from 2004
in the number of what are considered to be quality appraisals,
ie that go through all the processes and are supported by development
funds and so on. So the potential has begun to be realised and
I repeat what I said earlier, that there is a concern that the
financial difficulties that the NHS has encountered present the
challenge to continued progress of the initiative.
Professor Sir Alan Craft: From
the medical point of view it is very important. All the colleges
are developing competency-based curricular with competency-based
assessments built into them, and I think it will be important
for the future and it will give more flexibility so that you know
what competencies people do have from what they do not have, and
you can actually give them targeted training to get them. The
one issue which is coming up is the time to do the competency-based
assessments, to do the appraisals, and I think that is probably
greater than was initially thought would be necessary, and building
in the time into people's job plans to do the training and assessment
is something which the NHS has to take seriously and has not taken
seriously in the past.
Mr Town: The allied health professions
have used continued professional development for many years and
the problem, as has been as identified in CPD, is having the time
and the money in order to achieve the objectives and the targets
that are set. At the moment there are very few care set outlines
for allied health professions and it is very difficult to establish
to what extent that will have impact for the immediate future.
Q261 Jim Dowd: Would it be a vehicle
by which we could transform surplus cardio thoracic surgeons into
paediatricians—into geriatricians?
Professor Sir Alan Craft: You
could not transform them into paediatricians, that is very difficult.
You need to look at what skills they have and if they are surgeons
they need to be redirected building on the competences that they
already have.
Q262 Jim Dowd: This is probably specifically
for you, Professor Craft. Has it led to a shortage in training
posts?
Professor Sir Alan Craft: A shortage
in training posts? No. The training posts have increased.
Q263 Jim Dowd: Sorry, medical training
posts.
Professor Sir Alan Craft: The
medical training posts have increased over the last few years.
Q264 Jim Dowd: What about the growth
in the numbers of staff grade doctors in recent years? How can
we improve the status of staff grade doctors?
Professor Sir Alan Craft: That
is a huge issue, particularly for things like the European Working
Time Directive. Trusts employ huge numbers of SASG doctors—Staff
and Associate Specialist Grade doctors or Trust doctors, call
them whatever they want to—there are a lot of them in the
system. What we are doing with Modernising Medical Careers is
trying to assess their competencies and see where they fit in
comparison to people who are being trained so that we actually
know what their competencies are and can employ them accordingly
to their competencies, but also if they want to move up in their
career you actually know where they are and what competencies
they need to progress.
Q265 Jim Dowd: The increase in the
numbers of them, though, has that been a positive development
or a negative one? What does it reflect?
Professor Sir Alan Craft: It was
an essential move to actually cope with the Working Time Directive.
It would have probably been better to go for fully trained doctors
but you cannot pluck fully trained doctors off trees, it takes
time to train them. So as a short-term measure it was probably
good; as a long-term measure I think that the NHS needs to know
the competencies of the doctors that it is employing so that they
can give appropriate care to their patients, and we do not know
that at the moment. But we are working towards it.
Ms Thomas: Could I just make two
points from an employer's perspective? I agree entirely with everything
that has just been said by Sir Alan, and that is about the challenge
of the infrastructure issues, which I think is what you were alluding
to. We have these frameworks but there are clear challenges on
infrastructure. One is our concern—and I know it is a concern
in the education world—around the clinical educator challenge,
so are there enough clinical educators to train all of these people?
Two is enabling people to build time into their busy jobs for
this role. And the third is around the protection of funding.
So where we have funding for learning and development all of us
commissioners and employers need to find ways in which we protect
that as far as possible.
Professor Sir Alan Craft: Could
I just add to that the importance of the NHS taking education
and training seriously and not raiding the education budget when
times get tough.
Jim Dowd: I was going to ask a previous
question about the substantial and significant growth in health
commissions at university places for health-related posts in the
last six years, which have gone up overall by something over 40%
and in some cases 70% but I will not go into that now.
Q266 Dr Taylor: We have covered the
extended roles but I wanted to ask Sir Alan, in your submission
you say, "We recognise that there will be an increase in
multi-professional working, however we are clear that healthcare
teams should be led by medical doctors." Obviously I feel
strongly about that as well but I would like you to justify it
to some of our colleagues.
Professor Sir Alan Craft: I think
it is important that doctors are trained differently, doctors
are trained to deal with uncertainty, and I think particularly
for the healthcare practitioners and other professions they can
work very well once you know what the diagnosis is, and they can
work down algorithms and patient pathways and all sorts of things.
But it is when uncertainty comes into being that people need to
know when they are uncertain and know where and how to ask for
help, and that is usually from the medical side of things. So
we are very keen that there should be a team looking after patients
and that there is always a medical person within that to ask for
help if needed.
Q267 Dr Taylor: Do the doctors require
extra training to take on that leadership role, or is it something
that they have always done?
Professor Sir Alan Craft: It is
something that they have always done but they do need extra training
to do that and we are working with the Institute of Improvement
and Innovation to improve the leadership and management skills
of all doctors, starting at undergraduate level.
Q268 Dr Taylor: What are the feelings
of the other professionals?
Ms Irwin: I think from our perspective
Sir Alan just said that when things go wrong the advice and assistance
would usually be provided by the doctor within the team, and I
think the key word there was "usually". We would argue
that there is potential for the leadership to be provided elsewhere
within the team and for that leadership to be provided by a nurse.
Not always, but there are circumstances in which that would be
highly appropriate.
Mr Town: I would agree that there
are other avenues and other alternatives and it is a matter that
we see it as equal partnership within that team. It may be that
within AHPs the consultant roles may take that lead as opposed
to a medical consultant. There are a number of changes taking
place in the NHS and in the way that the healthcare team operate
and the care pathway is structured, and I think we need to reflect
on what is the best for the patient, not necessarily best for
the professional group that is involved.
Q269 Chairman: Can I ask you what
I think is probably the final question? A lot of this workforce,
new staff employed since 1999 in the National Health Service,
has been recruited from abroad—this is employed as opposed
to coming here for training purposes. Do you think that this is
a sustainable strategy for the Health Service workforce?
Ms Irwin: Just to respond on that,
initially the look to overseas countries to provide nursing staff
was a short-term stopgap measure which quickly became embedded
because of shortages and supply not coming through from university
places because the previous administration, prior to 1997, had
drastically reduced it. I think one of the sad facets of the current
situation is that there are currently 37,000 internationally recruited
nurses waiting for adaptation placements in order to qualify to
work as registered nurses in the UK, and they cannot get an adaptation,
either because the Trusts cannot free up the capacity to provide
them with a mentor, which is a consequence of the current situation,
or they do not have the money to provide the development opportunity.
In the future there is going to be increasingly a pull from the
US and Australia, for example, that have their own particular
difficulties, that may mean some of the internationally recruited
nurses hop from the UK to Australia or the US. So I have a very
large question mark over the sustainability of that as a means
of procuring qualified nursing staff.
Q270 Chairman: Sir Alan?
Professor Sir Alan Craft: I do
not think that we should be relying on international medical graduates
for the future. I think it has been wrong that we have denuded
quite a lot of countries, particularly African countries, of people
that they desperately need, and I think that the new immigration
rules that have just come in will stop all of that. I do not think
that we will ever be self-sufficient within the UK for our workforce
but I think that we would hope to be self-sufficient within Europe,
and given the freedom of movement and the fact that English is
spoken by virtually every doctor in Europe that many doctors will
come here. The challenge therefore is to make sure that there
is some equity in the standards across Europe and that is a whole
other ballgame. The one thing I think we should do and which has
been lost with the new immigration laws is the opportunity for
countries like Sri Lanka and many other countries in developing
their workforce, where they have always sent people here for two
years of targeted training before they can become a consultant.
The new immigration rules have stopped that happening so they
are now going to Australia or the United States, and I think in
the long-term in terms of the UK influence worldwide we have missed
a big trick there.
Mr Town: Very quickly, most of
the points have been made about the need to be ethical about overseas
appointments. A key element of an AHP qualification is that it
is transferable and you do work within a global market, but you
cannot expect that your own healthcare system will be propped
up simply by importing from abroad. Individuals come from abroad
for a number of reasons, not necessarily to enhance the NHS but
maybe to enhance their own benefits or to ensure that they are
able to sustain their own families overseas. What is needed is
a sustainable workforce planning for the NHS which can also incorporate
any overseas employment and assist with overseas employment.
Ms Thomas: What I would say is
given the change in the diversity of the workforce we agree with
the comments that Sir Alan made, that going forward we would hope
to see that Europe sustains a healthcare workforce for itself
in the future, but we would always have a mix, is our view. I
think on the point about workforce planning, there is no perfect
committee structure or planning structure which will ever be able
to overcome these challenges of the time lag and the complexity
of the healthcare world that we are in, but it needs to happen
at all levels and effectively at the employer level and effectively
at the national level and probably something in between, and if
we can get the mix between social care workforce planning and
healthcare workforce planning between the independent and public
sector I think we are better placed now to do that given that
we are at this point of the investment in the workforce being
much better. We would certainly want to urge the Committee to
let us see that continue and not have this feast and famine which
we have had in previous years.
Mr Amos: Just in a nutshell, I
should declare an interest as the person who led on international
recruitment nationally from the period that you have described.
Clearly less reliant, but I think we should welcome a labour market
scenario where we continue to welcome in colleagues from abroad
to bring in their skills and experience perspective, either on
a short or longer-term basis, but also to encourage and not panic
if NHS workers go abroad as well. International recruitment in
and out flow did not start in 1999, and that is good for us as
an employer and in the service for staff to go abroad for a time
to develop their own skills and experience and then to bring those
back to the NHS.
Chairman: Thank you all very much indeed
for coming along and giving us evidence. Sorry about the overrun,
but thank you very much indeed.
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