Examination of Witnesses (Questions 333-339)
PROFESSOR DAME
CAROL BLACK,
MR GEORGE
BLAIR AND
DR KAREN
BLOOR
8 JUNE 2006
Q333 Chairman: First of all, could I
thank you for coming along and helping us with this inquiry. This
is our third session today and I know some of you have caught
the flavour of the last session we have just finished. Could I
ask, for the sake of the record, that you introduce yourselves
and your organisations.
Professor Dame Carol Black: I
am Carol Black, currently President of the Royal College of Physicians.
I am also a rheumatologist and work at the Royal Free Hospital.
Dr Bloor: I am Karen Bloor, a
Senior Research Fellow at the University of York in the Department
of Health Sciences. I am also a non-executive director on Selby
and York Primary Care Trust.
Mr Blair: I am George Blair, Managing
Consultant at Shared Solutions Consulting. I am also a director
of the HR Society, which is an interest group with special interest
in workforce planning where I have spent much of my working career.
Q334 Chairman: Once again, thank
you for coming along and helping us. Could I begin by asking a
question to all of you. The think tank Reform has argued that
if the NHS focuses on improving productivity then it will be able
to the reduce the size of its workforce by 10%, describing this
as a realistic medium-term outcome. Is this a credible or desirable
scenario?
Professor Dame Carol Black: Thank
you for that interesting question. Could we reduce the workforce?
If we did increase productivity, and it depends how you define
productivity and I would put into that not just efficiency but
quality which is very important, then you may certainly be able
to reduce it a little. If you bear in mind the other counter-factors,
for example the European Working Time Directive, you are going
to have people working a shorter time, consultants as well as
doctors in training, so you are going to need a workforce to cope
with that. Patients' needs are increasing so you have to balance
that. We have an ageing population. We seem to be also increasing
the diseases which come from our own behaviour, such as obesity,
poor sexual health, and excessive alcohol consumption. If you
balance these things, if you factor in that you would like to
improve quality and you wish to meet the needs of patients, I
am not at all convinced that you are going to reduce the workforce
requirement spread across the different health care professionals
by a great amount.
Dr Bloor: I looked at the Reform
Report and it was an interesting report and had some useful points
to make, but at times it lacked a really clear evidence base.
Q335 Chairman: It was more theoretical.
Dr Bloor: Yes, I think so. That
10% seems to be a rather ambitious target. The NHS, and healthcare
in general, is a labour-intensive industry; it is about caring,
and it is always going to be difficult to make the level of productivity
improvements that would generate that kind of staff saving, particularly
in the context of some of the demand factors that Carol mentioned.
Mr Blair: Across the board 10%
to me sounds very much like the approach that everybody has to
make 10% across the board savings this year, when there are certain
areas that can make substantially more than 10% savings with the
right sort of investment and other areas where there is much,
much less scope for doing so. I think a more interesting question
would be what is the scope to increase productivity and what timescale
and what sort of investment is needed. In some areas there is
considerable scope, particularly where technology changes. If
technological changes are properly anticipated and planned for,
and organisational structures are changed, then you can make much
more in those areas. There are some good points made about other
areas which are inherently labour intensive. For instance, a district
nurse visiting an old person in their home perhaps a 10% saving
in their time may not be a good idea.
Q336 Anne Milton: To come on to what
you said that this is just about saving money, it is a rather
theoretical look at different ways of treating the workforce.
The idea that you put more investment in fewer people, I would
be interested to hear your views. What we are talking about is
working smarter. You are right, Dr Bloor, that the NHS is about
caring but that is not just about numbers. There is a sense that
we all run around doing lots of activity but not necessarily achieving
very much, therefore if you invest in your workforce and get them
to work smarter maybe you could reduce the workforce.
Mr Blair: Let us be specific.
If we look at pathology, there are huge changes there with capital
investment. The non-urgent work could go to big centralised automated
laboratories and save a huge amount, so that is an area where
much more could be achieved and that is an example of working
smarter. I am very keen on that notion of working smarter in those
sort of specific areas. The other thing about working smarter,
the NHS drowns in data but it has very little information. By
information I mean information, and particularly for clinicians,
which is there in one document which pulls things together. I
would argue the most useful thing, if we are talking about productivity,
is to involve clinicians in it. The earlier discussions were about
you have had the money, have you delivered. I think there is another
question, how do we encourage you. Clinicians are very keen to
improve the quality of care. Let us have quality of care indices
included, and that would involve clinicians a lot more. Quality
can also impact on costs through hospital acquired infections.
In order to support your view about working smarter, I would say
it is crucial that information needs to be presented very much
better, and its for clinicians because they are the ones who effectively
will deliver productivity. If it is other organisations pointing
out the naughty boys and girls, perhaps that is needed to some
extent but that is not going to motivate anybody. I am very much
in favour of what is called elsewhere a dashboard of key indicators,
so that in one document a whole range things to do with throughput,
quality of care and quality of patient experience are there on
the wall for clinicians and they monitor it themselves. That would
be the sign of success. That is what, for instance, in terms of
working smarter, Toyota have been brilliant at. They are the world
leader in terms of improving productivity because they get their
staff to monitor what they do over a wide range of activities
and drive down waste. We need to present this in a way which is
meaningful for clinicians not just meaningful for management consultants.
Dr Bloor: I think your question
was more investment in fewer people.
Q337 Anne Milton: That is right,
but feel free to expand.
Dr Bloor: That statement lacks
a real evidence base. As George says, there are some areas of
the Health Service where that might be the case. There is some
quite interesting research evidence from the States that looks
at the appropriate level of training of nurses and whether a more
highly trained nurse gets clear patient outcomes, reduced mortality,
reduced readmissions, reduced unnecessary complications, that
kind of thing, so there is some evidence that better trained people,
even fewer better trained people, can be more effective than increasing
the number of people. There is some evidence that contributes
to that, but in general to say more investment in fewer people
across the Health Service is a bit of a sweeping generalisation.
Q338 Anne Milton: It is a very big
statement, but what you would suggest, if I summarise, is more
work needs to be done and there is early evidence to say that
might be worth it.
Dr Bloor: I am a researcher or
I would say that.
Professor Dame Carol Black: I
will restrict myself to talking about doctors working smarter
if that is what you ask. It would be difficult to think how you
would change, at the moment, the hours they are working. If you
are saying we will have fewer doctors but make them work longer
hours, certainly for physicians they are already working about
59 hours a week so you could not really have fewer of them working
longer. The things that would be extremely helpful, for example,
would be if we could separate more appropriately acute admissions
and our more elective work because most of us are schizophrenically
trying to do two things. We try to look after the ever increasing
acute medical take, and we are trying to do out-patient work,
endoscopies, et cetera. That means you are trying to do two jobs
so you are probably not terribly smart at either. If we do develop
this speciality of acute medicine appropriately, then that would
help us be smarter. We would be smarter in our work if we had
our diagnostics better arranged, if we did not have to stop at
5 o'clock being able to get a CT scan, for example. It would also
be an enormous help if there had been some systems reform before
we did all the other things like introduce a consultant contract.
In fact, the system had not been reformed so consultants were
paid more money but in a system which would not support more efficient
working. The final point I would like to make is about data, which
has been brought out before. Doctors are really interested in
data that relates to outcome and are not interested in data for
data's sake. If you want us to work smarter and you want to engage
us, then it has to be for patients' benefit. It has to have relevance.
Q339 Anne Milton: Loaded at the front
end, as you say. Could you be more specific on systems reform?
Professor Dame Carol Black: Perhaps
I could use my own speciality as an example. I am a rheumatologist
and the flow of patients through the rheumatology department in
which I have worked for many years could be greatly enhanced.
We bring people back to do all sorts of investigations, we send
them upstairs to get their blood tests and they wait an hour and
a half up there, they come down and might need a knee X-ray so
they come back with that. They come to me in a clinic that is
already ongoing and already working behind time. If you go to
some hospitals in other countries, they have worked out how patients
flow around systems. They have made it possible for us to work
more efficiently. I am sure you could take any speciality, often
the X-rays are missing, the notes are often missing and then you
scrabble around for that, so it is all about how you provide the
actual environment in which you could make us work smarter.
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