Examination of Witnesses (Questions 320-332)
DR JONATHAN
FIELDEN, MS
KAREN JENNINGS
AND MR
ALASTAIR HENDERSON
8 JUNE 2006
Q320 Charlotte Atkins: The idea that
somehow this is constrained by the budget seems to me a false
economy.
Mr Henderson: As you will know,
there are a number of organisations who have severe financial
difficulties. I am not sure that in those positions there is necessarily
any one particular bit of the budget that has to be per se
immune if there are savings to be made. But I would quite agree
with you, and I think most trusts would agree, that it is clearly
short-sighted in the long term to take money out of the training,
but that is not going to happen with the KSF.
Q321 Charlotte Atkins: Have we not
heard earlier that huge amounts of money have gone into staffing,
and, whatever level of staff, we are fearful that we are just
not getting the productivity gains that we should be getting out
of the vast sums of money that have been rightly invested in staff.
Surely it is a very, short-term expedient then to start cutting
the training, which is absolutely vital if we are going to get
the true productivity gains out of our investment.
Mr Henderson: One trust, I think
Central Cheshire Primary Care Trust, has told us that one of the
things, interestingly, the KSF has allowed them to do is to make
better use of their training resource budget. Perhaps in the past
it was slightly random and training went to some of those who
maybe put their hand up and seemed very keen on it rather than
necessarily those at whom it was most directed. The KSF, this
PCT tells us, has allowed them to work out where the best need
is and they have said it has made better use of their training
budgets there.
Q322 Charlotte Atkins: But are they
also cutting the overall budget?
Mr Henderson: I have no idea about
that particular organisation.
Q323 Charlotte Atkins: The important
thing is—and I would hope the employers are going to make
very strong representations to acute trusts and to PCTs—that
training should be absolutely key here. We are going to get the
productivity gains that the Government and we as consumers of
the Health Service have a right to expect.
Mr Henderson: I think that is
right. Remember, the NHS's training budget is absolutely vast
and still huge sums are being put into that. We are just saying
that I am not sure individual organisations would support ring-fencing
budget A or budget B, because there are equal calls for a particular
cancer budget or whatever. There has to be then some flexibility,
and clearly no trust is going to want to cut off its nose to spite
its face by cutting back training, but, if you are making financial
savings, you have to have flexibilities of where to use them.
Q324 Charlotte Atkins: Training is
just seen as an easy pot, is it not, to cut?
Mr Henderson: Not just in the
Health Service but across organisations, that has been the case.
I am not sure that is the case in every organisation. I think
there is increasing recognition of the importance of that, but
I am saying that there are organisations that would not want,
if they are having to balance their books, their hands tied precisely
about where they do that.
Ms Jennings: I wonder if I may
introduce that there are major, major reforms. It is a continuous
process in the NHS, as we know, but with Our Health, Our Care,
Our Say and the migration of the workforce from secondary care
into primary care, we are going to need to see a step up in the
investment in education and training. Also, with the demographics
that face us, we are going to have to make sure that we have enough
staff in the NHS to keep going. We have a third of the nursing
workforce due to retire in the next five to 10 years and where
are we going to get them from if we do not start to grow our own.
As I said earlier, we need to make sure that we do not disillusion
those healthcare assistants, those who cannot get any access to
education and training. They have that glass ceiling at NVQ Level
2, and yet there are all these amazing developments that they
are getting involved in now. And it is not just healthcare assistants
who support nurses: you have physiotherapy support workers, occupational
therapy support workers and speech therapy support workers—all
of them working in the community to get older people out of hospital—who
require education and training. They can go on to assist those
professionals, such as the occupational therapists that we spoke
about earlier, going on to grow that workforce. It is absolutely
crucial, if we are going to have that world-class healthcare service
that we keep talking about.
Q325 Chairman: Would you leave us
that letter that you have there.
Ms Jennings: Yes. Absolutely.
Q326 Dr Taylor: I would like to congratulate
Karen on her tremendous defence of the healthcare assistants and
the training, and to wonder if this sudden cut in the training
budget is anything due to the Government's deficits and its attempt
to minimise the deficits.
Ms Jennings: Dr Taylor, I think
it is to do with that.
Q327 Dr Taylor: That is where they
found the money.
Ms Jennings: We have one third
of trusts which are in debt. One third of NHS Trusts that we know
are in debt. As I believe I said earlier, when you make cuts and
announce redundancies, that is the last measure. There will have
been a whole raft of other measures put in place to save money.
Under education budgets—we know from hearing that from our
members—KSF is becoming an almost impossibility.
Q328 Mr Amess: Let us not quote my
namesake any more. UNISON said that Agenda for Change "...has
fostered a partnership between Health Service managers and employees"
and everyone thinks this new partnership is wonderful. I would
be delighted if someone would quickly tell me when I have finished
what we mean by "this partnership". Obviously when people
are given more money they are absolutely delighted. Look at Members
of Parliament: we are all delighted when we get our extra little
bit of money, so we are all bound to say this is fantastic. But,
in reality, it would appear that the Government now feels that
this has been rather an expensive arrangement in hindsight. What
do the Panel think about that?
Ms Jennings: I think there are
some extraordinary examples of partnership—from even before
Agenda for Change came into being. If I may give you an
example of the London Ambulance Service. That was a service that
was on its knees and it was about to be disaggregated, disbanded
and reorganised elsewhere. A visionary chief executive and a visionary
branch secretary came together and provided the solutions for
the London Ambulance Service. They were then at the cutting edge
of how an ambulance service should model itself. They introduced
appropriate responses; in other words, technicians, paramedics,
going out on bicycles, motorbikes, cars and, indeed, helicopters—you
did not need to go out in an ambulance truck every time—and
also a range of different skill mixes, so you do have the ambulance
technicians, you do have the paramedics, you do have the researchers.
The benefit realisation is that there are good industrial relations—because
it was appalling before that—and response times were improved
upon and came in under what the response time targets were. You
now have the reconfiguration of the ambulance service based on
that incredible model of partnership. Again, this is an ambulance
service that has worked through Agenda for Change fairly
peacefully as well. There are many, many other examples of partnership
that I can give you. Clearly, when you come up against a situation
where there are deficits and difficulties, I think it is incumbent
upon the chief executives and the board to work with the trade
unions to ensure that they find joint solutions to it. What is
unacceptable is when there are announcements about redundancies
and job freezes and they have not spoken to the branch about it.
I think the Department of Health did not demonstrate itself very
well as a role model for partnership last year when it parachuted
in the reconfiguration of Primary Care Trusts and Strategic Health
Authorities. I think they have recognised and apologised for that
and have attempted to move on to make sure that there is closer
collaboration and information. We want to see a lot more consultation
out of the Department of Health before decisions are taken and
we hope that we will move on from that position.
Mr Henderson: If you think that
introducing a pay reform unit brings benefits, brings everybody
rushing out in gratitude, please let me put you right on that.
What I think we mean by the partnership that really has worked
well for Agenda for Change, and I think, in large places,
with the consultant contract implementation as well, is with management
and staff representatives genuinely tackling problems and the
issue together, and finding that it is in their benefit to seek
a solution together rather than have what may have been rather
more adversarial approaches before. In another example from the
example Karen used of the Ambulance Service, the National Blood
Service, the Blood Authority, which had a history of pretty poor
relations, has introduced Agenda for Change on a joint
basis that has improved things for the staff and has improved
the service enormously. When we talk about that, I think it is
about cooperation, behaving as grown-ups, to address problems
together. I think you are right, that it is easier to do that
when you are doing something nice. It is more of a challenge when
you are doing something less nice, like potential workforce reductions.
I think that will be a test, but I am confident that in a number
of places relations that have developed will mean that those are
addressed on a "nobody wants to do that" basis but will
be dealt with jointly and on a grown-up basis. Behaving as a grown-up,
I think, is what partnership is about.
Q329 Mr Amess: Some vicious attacks
have been made upon the consultants. They are not all playing
golf on the golf course, are they, Richard? That is an unfair
caricature, so can we have your version.
Dr Fielden: I think it has always
been an unfair caricature. Without a doubt, there is clear evidence
of the huge amount of work consultants deliver for patients within
the NHS. Partnership, I think, has been aided by the consultant
contract substantially. The tools are there for that adult and
often difficult discussion. I think we are seeing the number of
programmed activities for consultants now being focused down,
the overall numbers coming down, so that they really are focused
on the hours that are needed for patient care. In trusts where
the trust management are working in partnership with their consultants,
you see dramatic improvement. My own trust has gone from deficit
last year to predicted surplus this year. That is because we worked
very closely with our senior managers and the consultant body,
through improving our A&E to deliver all the A&E targets
98% of the time; bringing in a clinical decision unit that has
dramatically changed emergency medicine; improving intensive care;
separating the elective and emergency workloads—so that
we can really focus the skills that we have to where the patients
need it. That works where you have partnership. Unfortunately,
that partnership is often put under stress by often centrally
driven, short-term financial measures. Where that partnership
is then fractured, you have organisations that continue to fail
and they cannot address those difficult decisions. The consultant
contract, in particular, does give you the tools to do that, but
very often centrally driven short-term measures mean that that
partnership is fractured.
Ms Jennings: As we increasingly
move into situations where there are retrenchment measures taking
place within trusts, some of our branches are telling us that
they are starting to lose their facility time and time off to
be able to do the necessary trade union activities to participate
fully in partnership. I think it would be helpful for the Committee
to think about that and to make comment on that, because if we
want to continue with an NHS that celebrates the partnership that
it has and the relative industrial peace that it has, we need
to make sure that there is proper trade union time and facility
time for them to participate in the activity.
Q330 Mr Amess: Although it is tempting,
I must not prolong this session. I think the answer was that you
think the money that you have is reasonable. As you know, we are
having an inquiry into deficits and these things can be teased
out there. Specifically to UNISON, given that you welcome this
spirit of partnership: Do you think what is happening at the moment
with jobs being lost is going to sell this?
Ms Jennings: Thank you for the
opportunity to come back in again. Since the NHS ten-year plan,
the NHS has made great strides on investing in the workforce,
on the human resources agenda, on very valuable equal pay system.
I think it has set the standard for all others to follow. I think
the more recent reforms are very worrying in terms of the unravelling
of that cohesion of the NHS. I do believe that the trust debt
situation is going to impact badly, but I think the trust reforms
more than the existing debts at the moment are going to have a
great impact. On the outsourcing of services, the supply of services,
the outsourcing of community services, although we have had a
retraction of the statement from the Department of Health that
all PCTs will divest themselves, it is quite clear that the direction
of travel remains the same and there appears to be a favouring
of the private sector, influencing the development of the private
sector. It is that which concerns us in relation to the harmony
of the NHS, the solidarity across the NHS, and also we do not
think it is cost-effective or cost-efficient. I think a lot will
be undone in terms of the national bargaining and the human resources
agenda in relation to that.
Q331 Mr Amess: Finally you got the
money, you got it quickly, but there is the impression that the
changes which the Government wanted to working practices has not
been entirely secured. Is that unfair?
Mr Henderson: No, I do not think
it is unfair. As you described, it is changes to working practices
and culture, and changes to working practices and culture do not
happen overnight, nor can we expect them to. There are more and
more examples of these benefits coming through. That tap is going
to come more and more on stream, to mix a few metaphors.
Ms Jennings: There are more changes
than are being reported and I do not think enough is being done
to measure the benefits of those changes. Alastair mentioned earlier,
for example, the NHS Blood Service which has made huge changes
in terms of benefits realisation. It is now a 24 hour, seven day
a week service. It has improved its recruitment of transport services
to such an extent that the service no longer has to rely on couriers
and that has saved them £2 million. Who is talking about
that? Who is talking about those savings that are going on? If
you look at what Primary Care Trusts are doing in relation to
developing skill mixes, bringing in support staff to work with
district nurses, occupational therapists, and so on, they are
keeping people out of hospital longer and those benefits are not
being measured in terms of costs. That really does need to offset
some of the other concerns we have around productivity and the
overspends in some Trusts.
Q332 Mr Amess: Are the consultants
going to do what the Government want them to do?
Dr Fielden: The consultants are
focused on what they need to do for patients. If what the Government
wishes to do is in line with what patients need, and that increasingly
is focused on a local level, then those two visions are aligned.
Coming back to the contract, I think that does give the tools
to ensure that at local level the Trusts and consultants can ensure
they deliver for patients in the most appropriate and value for
money way. Unfortunately sometimes Government whim and short-term
policy changes mean we cannot do that and it gets in the way.
Mr Amess: We have three splendid advocates
for their cases.
Chairman: Could I thank all of you for
coming along this morning and helping us with this particular
session. We are now going to move on.
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