Examination of Witnesses (Questions 392-399)
PROFESSOR BONNIE
SIBBALD, MS
DEBORAH O'DEA,
DR HUGO
MASCIE-TAYLOR
AND MS
ALISON NORMAN
15 JUNE 2006
Q392 Chairman: Good afternoon. Would
you like to introduce yourselves?
Ms Norman: I am Alison Norman.
I am here as a member of the Board of NHS Employers, but I am
also Director of Nursing at Christie Hospital in Manchester.
Dr Mascie-Taylor: I am Hugo Mascie-Taylor;
I am also on the Policy Board of NHS Employers. My day job is
Medical Director at Leeds Teaching Hospital Trust.
Professor Sibbald: I am Professor
Bonnie Sibbald, a professor of health services research with the
National Primary Care Research and Development Centre in the University
of Manchester.
Ms O'Dea: I am Deborah O'Dea.
I am Director of Human Resources and Organisational Development
at St Mary's Hospital in Paddington, and I am also President Elect
of the HPMA (Healthcare People Management Association).
Q393 Chairman: Once again, welcome.
Can I ask a general question to all of you, but I hasten to add
that if what you want to say has been said, you do not have to
repeat it. Changes to skill mix and the development of new and
extended clinical roles such as specialist nurses is currently
very fashionable in the National Health Service. Can you tell
us why this has happened, and what is the evidence base for these
types of changes?
Professor Sibbald: I am happy
to comment on this, at least from the perspective of primary care.
There are three main drivers of this change. The first is the
presumption that one can save costs by using nurses as opposed
to physicians. The second is that one can enhance the quality
of healthcare by adding specialist nurses and others to physician
teams. The third driver is medical workforce shortages, either
nationally, regionally or locally.
Ms Norman: I agree with Bonnie,
but would add to that. The liberation from the nursing point of
view in terms of what nurses traditionally did and what they are
now doing came in 1992 when the regulatory body introduced scope
of practice which basically enabled nurses to build on the basis
of their professional training and education and to go into other
roles. Over that period of time there has been a tremendous development,
both in terms of specific specialist roles; but also generically,
for example the nurse practitioner—those in primary care
and those in acute hospitals—who can enable first contact
with patients and speed up the process of care and support. Some
medical shortfall has driven some change, but, equally, it has
been the need to enable patients to get early and efficient access
to care, and to ensure that patients get continuity. One of our
problems is that in relying on doctors in training to provide
much service contribution, you do get discontinuity. A specialist
or advanced practitioner nurse within the team can provide sometimes
the one bit of consistency that a patient with an illness over
a long period of time will get.
Q394 Chairman: Andrew Foster gave
evidence to us on 11 May, and he said that redesigning the skill
mix will enable us to get higher output or productivity. Do you
agree with this, and is there evidence that these changes are
cost-effective? I know that Professor Sibbald has a view about
that. Do you agree that it is going to get higher output or productivity?
Dr Mascie-Taylor: I would absolutely
agree with the drivers that have been set out to you. Given the
drivers, which essentially are the existence of various facts,
then they predict the answer to your question, because if it is
the only or the best way of doing it, it would have the effect
that you are talking about. The danger would be if one undertook
skill redesign for less good reason, and then it might not have
the desired output. I suppose my point would be that if the employer
takes the view that that is the optimum way of achieving a desirable,
then it will work. If it is done for other reasons—and there
are various other reasons why it might be done—then the
outcome is less certain.
Q395 Chairman: Can you give us an
example of the reasons—just one?
Dr Mascie-Taylor: Certainly. There
is a mix here of employer ambition and professional ambition,
and it is necessary, if you want to achieve changes in the skill
mix, to have both of those; but sometimes the balance is in favour
of professional ambition as opposed to the needs of employers;
and the appropriate and correct balance needs to be put into that
if the desired effects on productivity and quality are to be had.
Professor Sibbald: The research
that we have reviewed in primary care suggests that on most occasions
you will not get gains in productivity or reductions in cost.
The reason for this is that at least in the research setting,
when you substitute a nurse for a doctor, nurses tend to consume
more resources than physicians but generate the same high quality
of care output; but as they consume more resources, that eats
into the savings you get in their salaries, so the overall effect
tends to be cost-neutral. We also know that without very tough
management strategies, when you add a specialised nurse to a physician
team in the expectation that the doctor will delegate away elements
of that care to the nurse, physicians tend to continue with their
previous activities, so the nurse is then as it were doubling
the volume of service but not enhancing the efficiency of the
service.
Ms Norman: There are other elements
obviously around patient quality and patient safety, for example
protecting junior doctors particularly from being thrown into
the front line in the way that traditionally they were, often
in areas where they may not have had the opportunity to gain expertise—and
I would cite particularly out-of-hours use of experienced nurses
who are often the first port of call for dealing with patient
care. In my own hospital, which is a specialist cancer hospital,
our out-of-hours nurse practitioners probably are in a significantly
better place for the specific cancer problems for patients than
the doctors in training who may also be part of that night-time
team. Although efficiency and cost-effectiveness has to be important
to us, the issues of patient safety and ensuring that people who
are not fit for purpose in dealing with those patients' needs
are not put in a position where they have to, must equally be
important to a concerned employer.
Q396 Sandra Gidley: Is there a flip
side to that? As a patient, I would probably want the most experienced
person, but it has also been put to us that the situation you
are describing actually reduced training opportunities for junior
doctors. How do we make sure that doctors have access to training
and make sure that there is expertise and safety for the patient?
Ms Norman: You make an important
point. In my own place of work we have to undertake a lot of invasive
procedures with patients and give them drugs. One of my concerns
is that, to be honest, nurses have almost entirely colonised that
area of work and do it very well; and it is important that we
have to remember that doctors have to be able to understand that
too. This is essentially around the practical skills that doctors
have. There may be a need to balance the learning needs and protective
learning time for doctors in training and their exposure to practice,
but in a way that does not expose patients to being practised
on, and supported. There may be particular times when that balance
is not quite right. I think that within individual hospitals and
in discussions with medical trainers you need to ensure that doctors
get that exposure as well.
Dr Mascie-Taylor: I agree with
that and support it. It goes back to the point I was making, that
one needs to decide at the outside what the objective is. Is it
quality; is it quantity; is it cost reduction; is it improved
training; what exactly is the purpose? The employer needs to drive
that and drive it effectively, and then good things can be achieved
in a number of those areas although not necessarily all of them.
It is perfectly possible, and should be the case, that competent
nurses, trained doctors—there is absolutely no reason why
doctors cannot learn from people other than doctors. If it is
set up in that way it works well. If the training of doctors and
indeed any other professional is ignored, it will not work well.
It comes from the same point: what is the purpose of this, and
how do we set it up in such a way to make it work?
Ms O'Dea: The experience in our
trust is that where you involve the clinical professionals, doctors
and nurses, senior doctors and nurses, at the coalface, in the
redesign of these roles, it works extremely well. If you hand
them down and tell them how things are going to change, it tends
not to. They take into account that the juniors will need training.
I can give you a couple of very good examples. Currently, we have
nurse practitioners that take the place of SHOs on the rota. Professor
Lesley Regan, who was involved in the design of this, tells me
that not only does this vastly improve patient care because of
the continuity, but also it assists in teaching the juniors that
are still coming through. She is very keen to continue with that
practice. Equally, we have nurse practitioners working alongside
doctors in the care of TB patients, and the studies have shown
that those patients comply with the drug regimes far more when
they are seeing the nurse practitioners. It is very difficult
to put a cost on that or a saving, in terms of productivity; but
there is a very clear benefit in terms of patient care.
Q397 Chairman: The think tank Reform
gave evidence to this Committee and they said that the NHS should
have more investment in fewer people—and they were talking
about a percentage reduction in the workforce; that with the right
investment there could be a better National Health Service. Do
you think there is a risk that skill mix changes means that we
are dumbing down the NHS workforce?
Ms Norman: This is the point that
Hugo has made. Dependent on the motivation and the big picture
that you are looking at of skill-mix change, it can be enormously
enabling as well. It can enable somebody with more advanced or
developed skills to be able to devote time to that. Often, those
criticisms of the NHS in terms of the people who are non-clinical,
who are clerical administrative staff—I see little purpose
in one of my highly qualified nursing colleagues doing work that
one of our clerical colleagues could do better, in order to enable
that nursing colleague to spend time with patients, and managing
his or her team of colleagues. Equally, at the other end of the
scale, properly trained and qualified assistant practitioners,
who can undertake very important aspects of the fundamental care
of patients, for example ensuring patients who need assistance
with eating are provided with that assistance, are fundamentally
important. It is all about the quality of management and the way
that you deploy the art and science of skill mixing.
Q398 Mike Penning: Can we develop
a little more the effectiveness of changes. How well do the current
workforce planning structures in the NHS encourage work on skill
mix and role redesign? The leading part of this is, how could
it be improved? Nothing is perfect, so how do we move on from
here?
Ms Norman: The way that it can
be improved is building on what has worked very well in the past,
for example the work of the Modernisation Agency previously, and
increasing the new Institute for Innovation and Skills, in supporting
good initiatives and enabling other organisations to follow on.
That is a key role for NHS employers as well. One of the major
criticisms of the NHS is that you have a very good idea in Shrewsbury
but do you do it in Stafford?
Q399 Mike Penning: Everybody is re-inventing
the wheel, all around the NHS?
Ms Norman: Yes, or, rather more
worryingly re-inventing the flat tyre, which can also happen.
Often we learn more from people's mistakes than we do from their
successes. It is about giving people the tools to undertake the
work within their own context and environment, and sometimes the
use of drivers. There is no doubt that bringing down access times
for patients has been a real driver for change. Sometimes it has
felt like quite hard work, but it has been a very good thing in
liberating our thinking and our ideas about what essentially is
a team endeavour in healthcare. You do need to work with a team
to get these ideas into place and working properly.
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