Examination of Witnesses (Questions 380-391)
PROFESSOR DAME
CAROL BLACK,
MR GEORGE
BLAIR AND
DR KAREN
BLOOR
8 JUNE 2006
Q380 Dr Taylor: Coming back to quality,
which is what we all desperately need, how should data relating
to quality and to outcomes be collected? Have any of you any ideas?
Professor Dame Carol Black: Could
I just give you two examples of perhaps the way it has been collected
through the Royal College in the national stroke audit and the
myocardial infarction audit, both of which were national audits
set up by the Royal College's Evaluation Unit. The important thing
about those audits was that they involved clinicians right from
the beginning. They helped design the programme, they fed their
own data in, they knew the data were safe and they were going
to be compared with each other, but you had managerial buy-in
because 100% of the acute hospitals in this country participate,
so you had hospital buy-in, you had doctor buy-in, they could
see where they were and nobody wants to be bottom of the list.
Therefore, I think you can do it effectively as long as you plan
it properly and it is on a topic that people think to be important.
Improving door-to-needle time improves mortality, so no doctor
is not going to want to do an audit that actually does that, but
it is getting it aligned to appropriate patient outcomes.
Dr Bloor: I think there are some
really interesting developments in this kind of outcome measurement
within individual specialties, so, as Dame Carol mentioned the
myocardial infarction audit, there are also joint registers and
that kind of thing and cancer registers that are developing lots
of quite detailed information about patient outcome, but within
clinical specialties. What I would like to see in addition to
that is something generic that we can use across specialties,
something like EQ5D or SF36, one of these measures—
Q381 Dr Taylor: Help! You are going
to have to expand on that.
Dr Bloor: I am sorry, it is a
generic measure of quality of life. EQ5D is a simple five-question
scale basically asking how you are with five very simple questions
and it has a kind of thermometer where you can locate your own
state of health on one day. It has been used across clinical trials
in all kinds of different areas, but it has not been used to routinely
measure how patients are doing in the NHS. A different quality-of-life
measure, SF36, is one developed by the RAND Corporation, and I
believe you visited them recently, and that has been used in BUPA
as part of their everyday routine data collection in patients,
so they give patients these questionnaires before they are admitted
and then again six months later and they see whether there is
a difference; they see essentially whether patients are feeling
better six months after their operations. It is not rocket science.
I think we could add that level. I think the bottom-up development
of real detailed clinical measures is essential, but I would quite
like to see that generic measure of simple health, how is a patient
feeling, on top of that.
Q382 Dr Taylor: So the best measure
of outcome is to ask somebody how they are?
Dr Bloor: Yes.
Mr Blair: I do not have anything
to add to that. There were some good answers there.
Q383 Charlotte Atkins: We have heard
that workforce planning in the NHS has traditionally focused just
on measuring and controlling staff numbers, and that is what everyone
tends to focus on whether they are going up or going down, so
how do we get the NHS instead to focus on the whole issue of productivity
and closer links between the workforce and financial planning
because it seems to be woefully lacking at the moment?
Mr Blair: I think there is quite
a trick with regard to finance people. I think there would be
real value in getting finance people to have a great understanding
of the workforce issues. I have been involved a huge amount in
workforce planning training and training HR people and some of
them are not sufficiently networked in with finance people and
what I thought was that we have not been thinking, I would say,
widely enough, so broadening finance thinking with regards to
the workforce, because that is where most of the money is, would
be incredibly useful, so that would be one thing I would suggest,
a key target audience.
Q384 Charlotte Atkins: It seems amazing
to me that it has not happened already. Given that the NHS spending
is largely about employing staff, I would have thought that the
two were so intimately involved and connected that you could not
do financial planning without knowing exactly what the workforce
implications were.
Mr Blair: Well, if that were so,
how come there is the issue I have presented with the scanners,
that you have scanners which are switched off at five o'clock
and the finance director is quite happy to sign off, "Yes,
we need more"? I am not saying that they are not needed further
down the track, I am not saying that we are doing well nationally
compared with other countries, but clearly there is a lack of
think-through and particularly an understanding of where the bottlenecks
are in the hospital. I think it goes back to this silo thinking
and I think that probably is one of the issues which is again
coming up and hitting us in the face.
Q385 Charlotte Atkins: Does it not
say something about the quality of our financial planning within
the NHS when they are just turning off a scanner at five o'clock
and then thinking about needing more scanners because they have
got several which they have turned off at five o'clock?
Mr Blair: I am wondering whether
that is further down the system and that the people in finance
are quite removed and will not really know much about clinical
things, so I think the NHS is really like a sort of vast old clock
with lots of different cogs which do not always mesh in with each
other and what are sensible decisions at one point. For instance,
if you are the manager of a radiography department and all of
a sudden you are offered a new piece of equipment and you know
that next year it will not be on offer, you are going to say yes,
so that is a sensible decision for that manager, but it is not
necessarily sensible for the whole NHS or perhaps for the finance
of that hospital to do so, so what we are left with are people
in a fragmented system making what, in their individual cases,
are sensible decisions, but collectively they do not add up. It
is that collectivity, how to make the NHS, even within trusts,
a more holistic sort of organisation which is key.
Q386 Charlotte Atkins: So is this
happening anywhere? Are there changes anywhere which are approximating
to what you are saying needs to be done?
Mr Blair: Please, with something
as large as the NHS there are all sorts of areas of excellence.
I have come across a few, but I cannot sit here and tell you the
scale of what the good practice is and where it is.
Q387 Charlotte Atkins: Maybe you
could let us know because I think we obviously ought to be looking
at good practice and, from what you are saying, it does not seem
to be hugely prevalent.
Mr Blair: Let us say, there are
too many examples where it is clearly not there. I think that
might be a better way of putting it.
Dr Bloor: Just to go back to your
question about the disjointedness of financial and workforce planning,
I think it is partly just timescale. We make a decision to increase
medical school intake in October and we are making a decision
to increase the medical workforce in 10 or 12 years' time and
the financial plans are not that long, so there is a problem there.
I think that Dame Carol's earlier example about looking at pathways
of care and integrating workforce planning, not looking at the
medical workforce on its own, not looking at the nursing workforce
on its own, that really needs to happen and there are examples
of this. The Australian Medical Workforce Advisory Committee and
I believe the Canadian systems as well have made much more of
an effort to integrate their overall workforce planning techniques,
although sometimes they still take out medics as a separate case
which I think we probably need to stop doing.
Q388 Charlotte Atkins: Well, that
is one of the issues, is it not, Dame Carol, that the medics often
are taken out as a special case and do not see themselves as part
of the overall workforce in the NHS? Would they be willing to
embrace this more inclusive change?
Professor Dame Carol Black: I
think that you now do see examples and I think you can see it
in some of the Royal Colleges in the sense that they are embracing
medical care practitioners and they are bringing into their colleges
either through associateships or affiliateships non-medically
qualified colleagues. I think just one other thing perhaps to
put into the equation somewhere is that we are feminising certainly
the medical workforce and that does have an effect on numbers
and how it is going to pan out in the future. Remember, even though
you may have numbers, they are not all whole-time equivalents,
so you see a large increase in the number of GPs, but how many
are whole-time equivalents? There are lots of different factors
and perhaps the one thing we have really been thinking about recently
is how flexible we could make the physician workforce. I cannot
talk for other specialties, but we really have to try and make
it as flexible as possible because we do not know really what
the needs necessarily are going to be. We can say we are all going
to live longer, we are going to have more chronic disease, we
think it is going to look like this and we need to work with colleagues
in the community, but we somehow have got to build much more flexibility
into the workforce to be able to move laterally, and that is quite
a challenge, but one I think we have got to face.
Q389 Charlotte Atkins: Do you think
that the medical profession is likely to embrace this flexibility?
It has not always been known for its flexibility.
Professor Dame Carol Black: I
think you have got to start very early on with the young and try
and get them to see the world in perhaps a different way. If you
just take planning in the 65 specialties which we have in this
country, it is, I think, fairly obvious now that, even if you
qualify in medicine and you are guaranteed perhaps your foundation
course, you may have to be flexible about doing a specialty that
was not your first choice. Years ago you were going to be a neurologist
and that is what you went for absolutely 100% and you wanted to
work in London. Well, it is quite possible that now you might
have to think about perhaps being a geriatrician or a clinical
geneticist and you might go and work in Manchester. I think it
is that sort of flexibility—
Q390 Charlotte Atkins: Or indeed
having more than one specialism. I was talking to a consultant
in my own local hospital, North Staffordshire University Hospital,
who was pointing out that when you have consultants who are just
pure specialists in one field, therefore, you overnight have to
employ several consultants to ensure that everything is covered.
It seems to me that you are talking about flexibility, but how
about the medical profession looking at a range of specialisms
rather than just one pure specialism?
Professor Dame Carol Black: Well,
we are doing that, for example, with the College of Anaesthetists,
the College of Emergency Medicine and the intensivists in how
we could devise a much more "composite training" and
then the opportunity to work either in the emergency room or you
may want to spend some time in the acute admissions ward, you
might even wish, as a physician, to be able to spend time on the
intensive care ward. Now, this is in these four specialties and
it is quite reasonable and easy to start with these. We obviously
need to extend that idea and perhaps you might see yourself acquiring
an additional competency, so, if you were a respiratory physician,
but your trust required a special skill akin to your specialty
we may in the future devise competencies that you can acquire
post-CCT competencies and that would be another way of extending
your skill base and being more flexible.
Q391 Dr Naysmith: A general physician
maybe!
Dr Bloor: Well, there are two
conflicting trends here, are there not, because you have got this
need for flexibility, but you also at the same time have the drive
towards sub-specialisation and more and more sub-specialisation
where we have two or more orthopaedic surgeons who do not focus
on the ankle, and that kind of thing is happening more. I think
the sub-specialisation is perhaps limiting the flexibility, and
perhaps there is a difference between surgery and medicine, but
there seem to be kind of conflicting trends here.
Mr Blair: Picking up the point
about the 65 specialties and given the need to plan for that many,
without doubt some of those plans will be proved wrong by events.
I think the issue is not so much to be surprised by it, but to
try to identify that early on. I heard in 2003 about cardiothoracic
surgeons and that was just a workforce planner, not somebody involved
in medicine, so the word was on the street that that was a problem
area and I think we all ought to have a recipe of what we do if
there is a specialty with substantial over-supply, what the process
is for rapidly retraining people, some sort of accelerated scheme
so that it is not as if, "Oh dear! We got it wrong".
Well, life is like that for something with so many changes and
with the planning over such a long timescale, so I think there
is much greater need for contingency planning and also looking
at scenarios, looking at the impact of technological change much
more widely and advertising that on the Net, "These are the
views of changing technology". That would be very useful
to share to involve people like surgical manufacturers of equipment
because what they are designing, in three or four years' time
people will be using, so there is a great deal of value to be
picked up from intelligence from that source as well, so we need
a great deal of flexibility and not to regard it as, "Oh,
we've got too many of these people. Oh, we've got it wrong".
We need to have the flexibility to sort them.
Chairman: Well, could I thank all three
of you very much indeed for this session. I suspect it will be
next year before you see the outcome of this inquiry, but thank
you very much.
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