Examination of Witnesses (Questions 400-419)
PROFESSOR BONNIE
SIBBALD, MS
DEBORAH O'DEA,
DR HUGO
MASCIE-TAYLOR
AND MS
ALISON NORMAN
15 JUNE 2006
Q400 Mike Penning: Individual teams
in different parts of the NHS, even though they may be doing exactly
the same job, are not developing at the same speed; they may be
doing very well but there is no continuity throughout the NHS.
Ms Norman: I think there is more
than there was because of the work that has gone on, for example,
through collaborative projects, in cancer care for example. The
cancer collaborative has provided us with a really clear framework,
and indeed in terms of measuring our performance in cancer you
jolly well need to respond to that toolkit if you are not actually
delivering. There is no doubt that there is still work to do.
Within organisations you will find some things that are day-to-day
working practice, and other teams might be less open to it, so
you need to do your own internal work on that.
Dr Mascie-Taylor: Locally, to
encourage employers very strongly to look at the most effective
way of performing their functions, so support from the centre
for local employers, taking on these issues and working with the
professions locally. As has already been said, that produces far
more ownership and far more likelihood of success than some imposed
directive. The difficulty with that is that it produces lack of
symmetry, and one has to accept a degree of lack of symmetry if
you want to empower local people. The balance is, I think, with
empowerment rather than looking for symmetry, which hopefully
addresses—
Q401 Mike Penning: Is not the problem
with that though that if you do not have symmetry, you increase
the postcode lottery in healthcare?
Dr Mascie-Taylor: Yes, there is
an absolute balance to be struck—I agree with you. You cannot
necessarily always have both. You have to have some of both. I
would go for empowering local employers to work with local people,
but set a balance, because there is a national role which seems
to me about offering examples of good practice to employers and
helping them learn from them and providing evidence that they
work, that is they achieve that which they set out to achieve,
and they do not achieve other things—so to be clear about
that. I think that nationally it would be useful for more departmental
support explicitly for employers; and, again in that balance,
slightly less engagement with individual colleges, which have
a vital role in training, education and good-quality service delivery;
but they also have another role, which is about the interests
of their members.
Q402 Mike Penning: The drivers that
Alison was referring to, so a sympathetic driver rather than a
target-driven driver.
Dr Mascie-Taylor: Yes, but these
are all balances, are they not? I agree with you that we should
avoid postcode lotteries when we can, but you have to do this
at a local level if it is to work. The trick is to have a fairly
light touch from the centre about specifics, and a strong drive
from the centre about supporting and enabling employers as opposed
to dealing with endless professional bodies and, if you like,
picking up too strongly on their vested interests.
Q403 Mike Penning: Is there a light
touch coming from the centre?
Dr Mascie-Taylor: It varies.
Q404 Mike Penning: That is a politician's
answer!
Dr Mascie-Taylor: This would be
the last place for me to blame politicians!
Professor Sibbald: The situation
in general practice and primary care outside the acute sector
is much more challenging. There is a need to have a clarity of
objective as to why you are changing skill mix. This has been
said before. It is a solution to a problem, so you need to analyse
your problem carefully to know whether a particular skill mix
change is right for your organisation—and it may not be.
That goes to your point that there needs to be local variation.
The second point has to do with good human resources, skills and
management, which are not think on the ground in primary care.
They are small self-employed businesses generally speaking, and
they do not have the kind of input that enables them to make complex
skill mix changes to support the process of change very easily.
It is difficult for me to see how that can be altered. It needs
to be addressed. The third thing that is different about primary
care is that often changes in skill mix happen much more rapidly
than in the acute sector, partly because they are small organisations
and are less tightly managed and regulated; and that often means
that you have employers, employees—nurses in particular—taking
on new and expanded roles, without yet having an educational infrastructure
to support that change. That is where there needs to be a much
more responsive educational system to keep pace, as it were, with
the changes going on in that.
Ms O'Dea: I would agree with Dr
Matthew Taylor that the important balance here is between the
local ownership—without that these things just do not work—and
central regulation, I suppose, of how we consider whether these
things have worked or not. I have seen some very good practice.
South Tees in particular has a very good practice around deciding
that things have not worked and stopping them; and I would like
to see some more of that. There is good practice from the employers'
organisations, their large-scale workforce team, sharing best
practice. Within that also we need to ensure that people implement
that best practice in the way it was intended, and do not over-egg
the jobs that people are not qualified to do. I think that I would
recommend that the Institute of Innovation and Improvement and
the Employers' Organisation need to set a framework for us around
the testing of these jobs, and ensuring the safety of these jobs
and that they work. That is where the centre comes in; it is in
setting frameworks and doing some education.
Q405 Mike Penning: That is very interesting
because it sounds very ad hoc as to what best practice
is being shared at the moment; so would you say that the NHS is
good at piloting these sorts of projects, and are they pulling
together the information well enough and distributing it throughout
the NHS so that everybody does not re-invent the wheel every five
minutes, and so that you can share the best practice in a more
sympathetic way rather than moving on, as we discussed, with a
postcode lottery system?
Ms O'Dea: It is the "not
invented here" syndrome that tends to be the problem, rather
than the centre saying, "let us pull this together".
It is a need for local ownership, and that is the balance that
we have to get right.
Q406 Mike Penning: Where you have
got local ownership and somebody is doing it quite well, with
best practice and so on—is that being drawn into the centre
and then distributed back out correctly, with the correct amount
of information; or is it done ad hoc throughout the organisation?
Ms O'Dea: I think it is a mixture.
In the large-scale workforce team, for example, the alternative
support worker has proved very popular and has been a very successful
initiative. It has been taken up by NHS employers, and they are
supporting local employers in implementing this new role. Those
initiatives are excellent. We have to make sure that the others
are tried and tested and really do achieve what they set out to
achieve in the organisations that are testing them, before we
get over-enthusiastic about sharing that practice. We often share
it before we have really tested it.
Q407 Mike Penning: Is the funding
there to do this, or are you robbing Peter to pay Paul to get
this funding? Is the funding coming down from central government
to allow you to do that?
Ms O'Dea: There are some national
workforce projects that are fully funded to go out and pilot,
for example, what we ought to be doing around team-working; what
we ought to be doing around the European Working Time Directive.
However, local employers will see their own needs and will invest
in improvements that they believe benefit their patients and their
staff.
Q408 Mike Penning: Many local employers
in the NHS are in deficit, so there is quite a difficult decision
to be made here, surely, as to whether there is a funding need
or not; and if it is left completely up to the individual trust
or individual strategic health authority and they are in deficit,
it is not going to happen, is it?
Ms O'Dea: As I said, there is
a mixture. There are some central initiatives, but there are also
local people who want to make changes for the better within their
own organisations, and they will continue to find the money to
do that if they believe that will improve—
Q409 Mike Penning: I wish they could
find it in my part of the world!
Professor Sibbald: You asked about
the evidence base for change. As a researcher, my evaluation is
that there is a wholly inadequate evidence base to support most
skill-mix change—that people for example believe that nurses
would save money when substituting general practice; and the evidence
base is that that does not happen. My view is- as I would say,
as a researcher—that we need more research!
Q410 Mike Penning: More research,
more money, of course!
Professor Sibbald: Also more money
for the research.
Dr Mascie-Taylor: In terms of
mechanisms by which people learn, some of it can usefully be through
a national centre, but a great deal of it is horizontal, and some
of it is international. There are a number of mechanisms, all
of which work in different ways. In terms of evidence base, it
is crucially important if we are to convince various groups of
professionals of the need to change. Finally on resources, there
is resource, but if one were to compare the amount of resource
to the resource that drives clinical change, it would be far less.
Less resource goes into service change than into clinical change.
Ms Norman: What we need is the
opportunity for there to be a framework whereby good practice
could be disseminated, and an ability within the organisation
to have organisational development resource to bed it in. That
is something that traditionally NHS organisations have not been
terribly good at. It is something that often gets squeezed first
in times of difficulty. Where it does work, if I could give an
illustration—the emphasis that was driven to some degree
politically some years ago, around enabling non-medical people
to prescribe, which is now coming into play—if you like
it was a political idea that was enabled through the NHS system
and the strategic health authority. However, it is down to individual
organisations to make sure that they have planned how that will
be implemented and that they are careful about who goes to do
the course, and that they are then able to work in practice. An
illustration of how well that can work: we have a consultant in
palliative care, a nurse in my organisation, who works closely
with the Macmillan community specialist nurses in Manchester.
We believe we are getting evidence (a) that because of the prescription
of opiates, pain-controlling drugs, by that nurse prescriber fewer
patients are having emergency admissions, and less use is being
made of our out-of-hours GP locum or on-call systems. That has
got to be better for patients. What I would love to be able to
do is to have Bonnie come and research this because I do think
there is a dearth of research into some of the changes that we
are making, and it would be good to be able to demonstrate that.
Q411 Mike Penning: It is quite interesting
that you use the analogy of palliative care, which is outside
the NHS in most cases. We draw down on them enormously—the
Macmillan nurses and the hospice movement in general. It would
probably be great to see Bonnie come in and do some analysis on
that, to show what is going on.
Ms Norman: The NHS of course does
fund it. In terms of Macmillan, they give their name and their
money for three years. The name stays but the NHS often, or the
individual hospice, picks that up.
Q412 Mr Campbell: When we talk about
spreading innovation within the National Health Service, because
we have heard in evidence that it is always a bit slow on the
take-up when it comes to that sort of line, can we learn anything
from the independent sector on innovation? Can they teach you
anything? Is there anything there? We are told in evidence that
the private sector is better than the NHS at innovation. Do you
have any evidence of that?
Dr Mascie-Taylor: I am absolutely
not familiar with the evidence that it is better than, but absolutely
open to the idea that the private sector innovates well. I would
argue that in certain areas the NHS innovates well. I do not see
a lot of point in which is better at it. I think they do it differently.
What might be really helpful would be for me to look at the freedoms
the private sector has to innovate. If one accepts, for the sake
of argument, that the private sector innovates well and maybe
better, what is it that allows it to do that? I think it is about
the fact that it is often in limited areas of business as opposed
to global business. It therefore can direct its workforce more
appropriately. It is often less constrained. It has a limited
area of activity, and far greater managerial freedom. It is less
heavily directed, less heavily regulated, and less heavily target-driven.
If you accept your thesis that it is good at it or better at it,
you have to look at what are the factors that allow it to be good
at it or better at it. My view would be that it is about limited
rates of activity, greater managerial freedom, and probably less
power amongst individual professions and unions.
Ms Norman: We can also learn lessons
from the "not-for-profit" sector. If you look at organisations
like the Marie Curie Cancer Care and Macmillan, those organisations
are very close to what people want and how people are feeling;
hence they come forward with services that meet those needs. The
fourth point to add to Hugo's very excellent list would be being
close to the patient and to the community; and perhaps the NHS
has not always been as good at that as it needed to be.
Dr Mascie-Taylor: That is because
they often in a necessary but limited area.
Professor Sibbald: I would say
that NHS general practices—and the important thing here
is that they are independent contractors into the NHS—are
some of the best innovators in the world, and they adapt to change
extremely quickly. I am thinking here of general practice-based
counsellors as an example—mental health counsellors. There
were about 12 in the country in 1980; by 1992 a third of general
practices had one on site; and by the late 1990s more than 50%
of general practices had them on site. The other point I would
make is that the extended multi-disciplinary teams in general
practice in this country are thought to be the best model by other
Western developed countries around the world—so the United
States, Australia, Canada, France and New Zealand. They are all
looking to our model of care as to the way they want to move in
their country.
Q413 Mr Campbell: Will payments by
results make it better to get innovation from the Health Service—or
is that a tricky question?
Dr Mascie-Taylor: A really tricky
question!
Ms Norman: It will if it works.
Dr Mascie-Taylor: You could construct
it in such a way that it might. If you are going to use a quasi
market system to drive change, the changes which it produces will
depend absolutely on the ability of the market-makers to drive
change. I do not think any of us know, on this side of the table,
quite how that market will be constructed, and therefore in what
way it will drive us. We await with interest.
Professor Sibbald: I would say
again the difference between the acute and the primary care sector
is that payment by results will reward the acute sector for activity
and volume, so it is a volume-driven thing. People have an interest
in doing more, which is a desirable thing in some respects. In
general practice however the payment system there is paid for
performance and is about quality of care produced; and that is
only a segment of income that is balanced by capitation and other
basic fees. That blended payments system, as it is often known,
is thought by most academics at least to be the best possible
balance in terms of achieving high-volume and high-quality care.
Q414 Dr Naysmith: The Modernisation
Agency was scrapped a couple of years ago. We had some evidence
here that that might have been a loss. Andrew Foster, for instance,
said that the skill mix projects had become more fragmented as
a result of the loss of the Modernisation Agency. Do you agree
with that?
Ms O'Dea: I think there is a gap
that needs to be taken up by organisations like NHS Employers.
We have to use the infrastructure that we have now to co-ordinate
it in the absence of the Modernisation Agency.
Q415 Dr Naysmith: Do you think it
was doing a good job in this area?
Ms O'Dea: I think it raised the
profile of these sorts of things across the sector in a way that
that profile had not been raised before.
Q416 Dr Naysmith: Do you think you
will have to find some other organisation to fill its place, or
to do the role that—
Ms O'Dea: I think the needs may
be slightly different now, but I think there is still a need for
some central framework around some of this, as we have been talking
about this morning.
Q417 Dr Naysmith: What has been the
impact on the National Practitioner Programme? Do you think it
gave the wrong message, that it was not really a priority?
Ms O'Dea: I think that where these
innovations were started they have continued. What is really important
was that people locally started to think about what was the best
way to deliver care. We have a plethora of examples to show that
where that continued, it continued very well. It served its purpose
extremely well in getting local people to change the way they
were practising.
Q418 Dr Naysmith: Dr Mascie-Taylor,
do you think it has meant fragmentation and giving the wrong messages—scrapping
it?
Dr Mascie-Taylor: I think the
Modernisation Agency played a useful role. As I indicated earlier,
there are many ways in which people learn, and one of those ways
is through a central body, and the Modernisation Agency in part
was that. I do not think that is the only way of doing it. I cannot
see a great deal of point in getting into a debate about whether
it was the right or wrong decision; more important is the need
to look to the future and recognise that the centre, the national
body, has a role, not the only role, in producing useful change
and innovation, and also in producing the research that would
support it. How you want to badge that is a secondary question
that I would be happy to talk about, although I do not consider
myself particularly expert. If, as often appears to be the case,
there is a perceived need to change a national organisation, it
is sometimes easier for the service if what it does changes, whilst
its name does not. What is particularly disruptive is when its
name changes and what it does does not!
Ms Norman: The Modernisation Agency
was a turn-around team for practice, to help practice be fit for
purpose and be able to meet different challenges. We continue
to need that kind of supporting service.
Q419 Dr Naysmith: Where is it coming
from now?
Ms Norman: As Deborah said, I
think NHS employers can help fill that gap. There has been space
left, and we need to find ways of filling it. If we need finance
turn-around teams, as is happening quite a lot in the service,
we also need that kind of support to help us turn around services
and to get that spread of good practice. I do believe—I
probably would say this, would I not—that NHS employers
can help with that, along with some other organisations.
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