Examination of Witnesses (Questions 340-359)
PROFESSOR DAME
CAROL BLACK,
MR GEORGE
BLAIR AND
DR KAREN
BLOOR
8 JUNE 2006
Q340 Anne Milton: I find it enormously
frustrating listening to what you have to say. It is a continuing
theme of a lot of these evidence sessions that I listen to something
that has been going on for 20 years. It seems so utterly simple,
does it not, to work out how to move patients around a hospital,
be it an acute admission or an elected admission, or out-patients
or in-patients. Why do you think it has not happened? With all
your experience, why has nobody ever got to grips with it?
Professor Dame Carol Black: I
am probably giving you a fairly local feel and I could be quite
wrong but it is rather about living in silos. The consultants
have lived in their silos, put their heads down and do their clinical
work but we have not communicated well. A huge amount of this
has been about communication with doctors, managers, other health
care professionals, the clinic clerk. We have just not had the
right environment, and perhaps the right drivers, to get us together
to say this is what would be so much better for patient care.
We have managed to do it, for example, much better now in acute
care, the A&E end of the hospital. There is a much better
throughput. It requires local doing, because I do not think this
is something the centre can actually do. It will vary with geography
and with the people who work in an environment. As president of
the College I have travelled a huge amount to many hospitals in
the country and I see some hospitals that do it extremely well.
There are very good examples out there of where this has been
looked at and tackled but spreading good practice in the NHS seems
to be remarkably difficult.
Q341 Anne Milton: Something we all
want to happen, for 10, 20, 30 years, is just not happening even
though we all want it to happen.
Professor Dame Carol Black: There
are examples of where it has happened but it is how do we get
that. It is about getting people to actually be singing to the
same hymn sheet.
Q342 Dr Naysmith: Before we go into
my questions I will pick up on what has been said. There are some
really good examples of the flow improving. There are a couple
of good examples in my own constituency relating to breast cancer
in women where they come in the morning, have a biopsy, and by
the evening they have had the results of the biopsy and, if necessary,
counselling. That all used to take days before. It can be done
and it ought to be done, but, as you say, it is more often in
the acute sector that it gets done like that. I wanted to talk
about what you were talking about before but in the context of
the large increase in staffing that has taken place in the National
Health Service since 1999. I want to start with the quotation
from Dr Bloor's written evidence to us that "before planning
to increase the stock of human resources it is essential to establish
that the existing workforce is working effectively". From
some of the things that have been said already, and maybe you
could expand a little bit, did the NHS do this prior to this rapid
growth? You have indicated that maybe you think it did not, but
why did it not do it?
Dr Bloor: No, I do not think it
did do that, and it is contemplating further increases without
doing that now as well. We have some evidence of that. There are
huge variations in activity rates between hospitals, general practices
and individual doctors. There are huge variations in activity.
Admittedly some of these measures are quite crude and do not pick
up overall productivity, including the quality measures that Carol
has mentioned and that are obviously desirable, but there are
some substantial variations, and largely unexplained variations,
in what people are doing and what different organisations are
doing. I do not think we really did address the effectiveness
of the workforce enough before we expanded it.
Q343 Dr Naysmith: Why not?
Dr Bloor: I guess it comes back
to the discussions we were having on the last point about lack
of communication between different organisations and between different
teams within an organisation. There were some interesting points
made in the Reform Report about the difference between primary
care and secondary care on this kind of responsiveness issue.
They were saying there was a different mix of staff in primary
care compared to secondary care, but it was also a difference
in the responsiveness of those staff to different situations as
well. It is a small example, but as a non-executive I visit local
general practices to look at their patient satisfaction questionnaires.
By the time I go, they have the results of the questionnaire.
In one of my local general practices there was a point about a
children's play area and where the letter box was. The GP I was
discussing this with said they had had that comment on one questionnaire
and they had re-organised the children's play area and moved the
letter box. I thought in a hospital or a PCT, or even the University
of York, that small change would take months of deliberation and
sub-committees. It is sometimes easier for small organisations
to move and respond faster than bigger organisations where there
are the silos that Carol mentioned. In terms of why we have not
made sure that the workforce was working more effectively before
expanding it, I do not know. Perhaps we should ask the Department
of Health about that.
Q344 Dr Naysmith: I am using Carol's
example of a rheumatology clinic and going off for tests and coming
back. With the expanding workforce, you could either, find a cleverer
way of doing that and get more patients through faster in a better
way or you could just run another clinic if you have more staff
in the same old-fashioned way. Why do we not do the first thing
I mentioned and try to look at more intelligent, cleverer ways
of doing the same sort of thing without getting more staff to
do more of what has gone on before?
Dr Bloor: I do not have good evidence
for this but I wonder whether it might be about empowering teams
within organisations to make those kind of changes. I cannot believe
that the rheumatology service that Carol describes could not sort
that kind of thing out if they were given the freedom to do that.
I wonder whether there is a role for saying what a team is and
empowering them to make small changes, sometimes small changes
at the margins, to improve effectiveness. Some hospitals do that
and some do not.
Q345 Dr Naysmith: The problem with
this is the increases in pay, and all that sort of thing, have
followed behind the increase in the workforce. It would have been
better the other way around, as already mentioned. Do you think
that is the case? We should have looked at all of this before
introducing Agenda for Change, or is it part of Agenda
for Change?
Dr Bloor: Some of the variations
that we have seen are emerging as a result of the contract changes
and we will get better information in the future because of some
of the changes that have been introduced. Perhaps we did not know,
and could not have known, some of those issues earlier.
Mr Blair: I think there are other
issues to do with bottlenecks. The NHS has so many different staff
groups, some of who are key for diagnostics. Professor Black has
already made a crucial point about the use of scanners which are
crucial for this. Whilst overall you can see big increases in
staff, we have had additional scanners, but we do not have enough
staff to use them. That has a negative effect on productivity,
spending more on capital but not getting commensurate output from
it. There are quite fundamental strategic issues if you want to
look at productivity and improve it and say where are the bottlenecks
in the NHS now, in five years time, and how can we plan for them.
Diagnostics is a crucial area. How do we incentivise people to
introduce skill mix faster? There are assistant practitioners
being introduced, an excellent role, very useful, and yet I would
argue that the pace of innovation is too slow for our needs. It
is predictably slow because that is what happens when something
new is introduced. I would argue that we need to think what is
important, what do we need to happen, and what can we do to incentivise
those service managers who do new and difficult things.
Q346 Dr Naysmith: Do you think what
is missing are incentives to do it?
Mr Blair: In that particular example,
yes, because it was very well project-managed that assistant radiographer
programme nationally and there was money invested in education
and training. I would argue that for a busy service manager it
might be interesting to wait and see what their colleagues down
the road do and how successful it is. Why should somebody dive
in straight away if they are very busy. We should reward them
by some means of additional monies for training, development,
or to spend on the staff appropriately to attend conferences so
that people see some rewards if we want to get people to do more.
I do not necessary mean money in their pockets, I mean money for
their clinical areas.
Professor Dame Carol Black: It
is always easier to do what you normally do. It is easier to put
another doctor or another nurse into a clinic than to take the
much more difficult, both mental and cultural, things that are
needed to really sit down all together and say how on earth do
we change this for patient benefit. That requires much more planning.
It requires that you put much more intellectual effort into this.
People are so busy trying to meet the workload they have that
it seems the easiest thing, I suspect, to say if we employ another
person that we will send another X patients through the system.
Of course that is not the best way to think about it. When the
European Working Time Directive came upon us, what people did
was employ more doctors because that is what we had to do, but
that did not give much time for constructive thinking about anything
else.
Q347 Dr Naysmith: That leads on to
what was going to be my next question. Have there been other changes
since 1999 which have had an effect on productivity? The European
Working Time Directive could have had the effect of making the
existing workforce work shorter hours but more effectively but
you say we just employed more doctors.
Professor Dame Carol Black: We
simply had to. Our doctors in training really deliver a huge amount
of service. When you did the calculations if we literally did
not employ more pairs of hands you would not have been able to
fill the rotas. You would not have had human beings to do 24 hours
a day. It was not a question of those people working smarter.
Q348 Dr Naysmith: With the existing
workforce and the additional ones that you needed, the numbers
overall could have been reduced if we had the existing ones to
work smarter.
Professor Dame Carol Black: You
still have to cover. Maybe what they do within the hours they
are there we could say could they work smarter, but it is a fact
of life that to keep patients safe you are going to have to have
an adequate level of cover. We are just about down to the bare
bones now. We could not really reduce night cover medically any
further.
Q349 Dr Naysmith: There has to be
a minimum.
Professor Dame Carol Black: Most
hospitals have worked very hard to try and meet the European Working
Time Directive and have pared down their night cover to a considerable
degree.
Q350 Dr Naysmith: My final question
was going to be something slightly different but it comes in now
quite well. When we were in California we had a session with Bob
Brook, one of the directors of RAND Health, a thinking out of
the box organisation, coming up with lots of interesting suggestions
which I could put to you now. He suggested where some things could
be done more cost effectively. For example, not everybody who
was performing cataract surgery had to be a fully qualified surgeon,
and you could do this kind of thing using highly trained technicians
but not necessarily people who had gone through full medical and
surgical training, and probably ophthalmological training as well.
That is very much out of the mainstream thinking but it is a possibility.
It is a very routine thing and you can learn to do it. Things
like reading mammograms which do not require full medical training,
could some of the things that radiologists currently do be outsourced
to areas in different parts of the world where they do a mechanical
read and send back the reports? Obviously this is looking very
much into the future, but are things like that not considered
rather than just employing more doctors?
Professor Dame Carol Black: I
hesitate to comment about surgery so I am not going to offer you
a comment on cataract surgery, but if I look into a world I know
much better, physicianly medicine, there are many things that
people other than doctors could do. We know that and we are fully
supportive of extended roles of medical care practitioners. In
fact, our College, along with the general practitioners and the
University of Birmingham, has written the curriculum for the medical
care practitioners for the Department of Health so we do not have
a problem with that. People can work to protocols, so if this
is a protocol driven exercise, which you are implying surgery
is, that is fine, but when you train a doctor you do have excess
knowledge. You have that knowledge which you only use may be 10%
to 15% of your time but my goodness is that valuable when the
difficult cataract comes up or the difficult mammogram. I would
suspect your family, as much as for mine, would like to know that
the person looking at that mammogram would be able to cope with
the 15% when you need the extra knowledge. It is a way to go to
a certain extent but you have to be very sure that you do not
disadvantage a patient by reducing that extra knowledge which,
in any profession, you get but you do not use all the time. You
should not underestimate the value of that.
Q351 Dr Naysmith: Dr Brook was advocating
it, not necessarily me. How about the other two in the context
of what has happened since 1999?
Dr Bloor: Professor Brook has
some fascinating ideas. There is evidence that some of these tasks
can be done by other individuals. There has been a recent large
trial of nurse endoscopy which demonstrates that nurses can do
most of the endoscopies that are within their protocol. There
are complicated ones and that is where you need a doctor, and
there are also training issues which Dame Carol can comment on
in a more informed way. There are some tasks that can be done
by people other than doctors. The American evidence is quite contradictory
on this. A lot of the time what they call non-physician clinicians,
people who are not doctors, are brought in and can do tasks, can
see patients and do it well but they tend to operate as complements
to doctors rather than as substitutes. We are not always saving
money or reducing the workforce but what we are doing is adding
in another level of care. If that is improving patient care, that
is fine, but it is important to note that certainly from research
evidence they are often operating as complements and not necessarily
as substitutes.
Q352 Dr Naysmith: They could theoretically
increase the throughput if what they are doing is hanging around
waiting for the occasional emergency.
Dr Bloor: I am sure they could.
Mr Blair: I very much like your
international approach rather than saying certain things are happening
very dramatically how can we respond. There are sometimes changes
in response to crisis measures. It is fascinating looking at the
States where nurse anaesthetists have had a much more advanced
role than they have had in England for something like 25 or 30
years, and the question is would that be useful to introduce here.
I am surprised that that sort of thinking does not take place
a lot more often. I know when German operating teams came to Britain
there was real consternation that they have fewer roles. Quite
often it was the consultant, another skill mix, that had a wider
role which meant that you had fewer workers. They had expensive
people, fewer of them, but doing more things. I would see more
the point about there is lots we can learn from other countries,
they have done certain things that we have not for 20 or 30 years,
let us evaluate to see to what extent we can bring that to Britain.
Professor Dame Carol Black: Could
I make one correction? We have nurse anaesthetists.
Mr Blair: But to the sort of standards
that the Americans work, which is virtually on a par with consultant
anaesthetists. It is very much more advanced practice. I did not
make that point well enough. We do have them but in Britain it
is a much more junior role compared to America. Thank you for
that correction.
Dr Bloor: It is important to target
your most expensive resources, and in the NHS that is our doctors,
our consultants and our GPs. It is important to target those resources
where they are needed most, and if there are some of these tasks
that can be done by other people then that might be more efficient
but it is not necessarily going to save money.
Q353 Dr Naysmith: Do you think the
Royal Colleges are obstructing developments in this kind of area?
Professor Dame Carol Black: Emphatically
no, certainly not in the last four years. If you think about our
workforce unit and the work that we have done, we have provided
figures, and very useful figures, to the Department for many years.
We have worked in very close collaboration with them on the workforce
requirements within our 28 specialities. We have always tried
to be reasonable there and to work it out and we now have a very
good relationship. The fact that they use our figures would indicate
that they do have faith in them and believe in them. We have,
over the years, had an increasingly more efficient workforce unit.
As far as medical care practitioners or extended roles, the interest
really started in the Royal College of Physicians under my predecessor,
Sir George Alberti, because it was during his time that we had
our first Working Party on skill mix. We have been very supportive
of skill mix. What we are not supportive of, and I would indeed
hope you would not be supportive of, is having a lot of additional
practitioners who do not work to national standards. You require
that your doctors are all trained to national standards, that
we have competencies which are assessed and then we have continuing
professional development. The only caveat we would put to extended
roles is that it ought to be on a national basis so you can move
anywhere in the country with those qualifications. You would like
a medically qualified person to have competencies against which
you would be assessed, and presumably in some ways you would be
revalidated. That is just one more example that there has been
a change. I would not like to tell you that 25 years ago perhaps
there would have been such an open door to these changes, but
I think we have been very welcoming. All our specialities, for
example endoscopy and gastroenterologists, have worked very constructively
with nurse-led endoscopy. Certainly in my own speciality we have
physiotherapy-led spinal clinics and nurse-led clinics. If you
look at any of the medical Royal Colleges they have all been endeavouring
to embrace this.
Q354 Dr Naysmith: Some people would
suggest some of your fellow college presidents have been less
progressive in this area than you have. I am sure you will not
want to comment on that.
Professor Dame Carol Black: Of
course it is variable, and some people find it more difficult
to change than others and have memberships and fellowships whose
views they have to consider. We have all been moving down a road,
some of us faster than others.
Dr Naysmith: We now have thoracic surgeons
results on the internet.
Q355 Chairman: There has been a debate
around areas like the limitation of types of surgery in treatment
centres in terms if you only have one or two joints, as opposed
to three, four, five, six or seven joints. The profession has
had comments about that. Not that every surgeon has to be all
singing all dancing, but I know in terms of the potential changes
for training there has been a heavy debate that should not happen
and we should not restrict. Would you agree with that in general
terms, I do not mean in any specific area?
Professor Dame Carol Black: You
mean the work that could be done within an ISTC?
Q356 Chairman: Yes, in the sense
that some colleges have commented that it is restrictive in terms
of what they can and cannot do because you are looking at probably
one or perhaps two knee joints and that is it, whereas in quite
a lot of orthopaedic surgery you have a wider choice than what
is in treatment centres. Do you think that has been an issue?
Professor Dame Carol Black: I
do not honestly think I have enough information to give you a
considered answer. It has not been something that has been in
the forefront of my own college. What we would feel about Independent
Treatment Centres is we would like the people who work in them
to be appropriately qualified and perhaps rotate through the units
in the NHS. As physicians if we develop ISTCs for gastroenterology
or diabetology, it would be to everybody's advantage, especially
if they are going to be teaching ISTCs, that those people working
in the ISTCs could rotate through the NHS hospital. It would better
collaboration and very reassuring to the doctors who work within
the NHS. It would be a possible way to go that might improve some
of the fears and worries that are around.
Chairman: That is probably for another
inquiry. I will move on to the David.
Q357 Mr Amess: I am not going to
ask Mr Blair if you are comfortable with your name, or if you
are the result of a glorious union between George Bush and Tony
Blair, and ask you about the collection and use of information
about productivity. You said it needs to be improved, could you
expand on that and tell us what it is you want to collect?
Mr Blair: My perspective on a
national level is that we must improve quality indicators to fully
engage consultants. For it to work, it has to be real for clinicians
at different levels. For instance, a radiologist would have some
different indicators or measures for him or her than there would
be for a surgeon. All that sort of thing needs to be thought through.
The other thing that needs to support that information, information
is only useful if people use it. What I was wondering is at what
point does a nurse, a doctor or a physiotherapist enter a discussion
like this about working practices and working smarter. There are
all sorts of tools and techniques that can be used. Where do they
learn that? When do they learn that? I am not at all clear how
that happens, I would argue that for information to be really
effective that needs to be underpinned.
Q358 Mr Amess: Do NHS organisations
tend to measure activity rather than productivity? Is there any
evidence of this trend?
Mr Blair: The honest answer is
it varies enormously. The NHS has suffered very badly from old
information systems that do not talk to each, produced by different
functions at different timescales. The information side is not
well resourced, so if there is any time for economies because
those are the sort of areas that are very vulnerable. Perhaps
that is an issue to put to you. Some analytical staff could easily
be called men in suits, or women, but they could be easily those
people first for the chop because they are not hands-on. Giving
you a metaphor, in the Battle of Britain radar was crucial so
that the scarce resources were most effectively deployed. There
was no clamouring for scrapping the radar and having more pilots.
We need to have a debate where there is more local investment
in making information work for the clinicians and give them information,
less data, less frequently, but something which they have been
involved in, their colleges have been involved in the various
measures, because they will differ.
Q359 Mr Amess: We will certainly
reflect on the advice you are giving us. Finally, Hospital Episode
Statistics (HES), how useful are they in measuring productivity
or is it all a waste of time?
Dr Bloor: Hospital Episode Statistics
are an administrative data set. They are a routinely collected
data set about patient episodes. They were not designed to measure
doctor productivity or productivity of the health workforce at
all. They are far from ideal as a measure of productivity but
I think that they do have a role. You asked earlier about whether
the NHS is an organisation prone to measuring activity rather
than productivity. I would argue that until quite recently they
tended to ignore both. We can get very tied up in quality measures
and in trying to find an ideal measure of productivity that adequately
takes into account patient case notes and quality of care. We
can get paralysed by that. I would argue that there is a role,
and we have done some of this recently at York for the Department
of Health, to share information about crude activity levels adjusted
where we can for differences in patient case mix. Despite its
inadequacies, and there are many, it can act as a catalyst for
developing those better indicators. Until we share information,
until we use information, there is not the incentive to make it
better. I would argue that Hospital Episodes Statistics does have
a role in producing something that is better than nothing. I will
expand on that if there is more time.
Professor Dame Carol Black: I
would say that as far as HES data is concerned one of the things
we have tried to do for clinicians through our Informatics unit,
which is in Swansea, is to encourage them to use that data. They
can come and we will help them burrow down into their own data.
We do bear in mind that it does not do out-patient work, it does
not tell you anything about the telephone calls a doctor makes,
anything about management, anything about all our other activities,
but I think clinicians do need to learn how to use what we have
got. We have had increasingly better uptake. People have learnt
quite a lot about themselves when they have burrowed down into
this data. It is what we have at the moment but we would like
to see it made much more sophisticated and that is what is needed.
Dr Bloor: The out-patient data
is developing and it is in process. I think Dame Carol's college
has been leading this question of clinicians looking at their
own data, validating their own data and beginning to use it. That
can only be a benefit.
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