Examination of Witnesses (Questions 603-619)
PROFESSOR DAME
JILL MACLEOD
CLARK, PROFESSOR
SIR ANDREW
HAINES AND
PROFESSOR TONY
BUTTERWORTH
29 JUNE 2006
Q603 Chairman: Good morning. Can I ask
you if you can give us your names and organisation just for the
record, please?
Professor Sir Andrew Haines: I
am Andy Haines; I am Director of the London School of Hygiene
and Tropical Medicine and a member of the Universities UK Health
Committee.
Professor Butterworth: I am Tony
Butterworth; I am a nurse by profession. I offered evidence in
my capacity as a director for the centre at the University of
Lincoln, but I have a previous career as a WDC Chief Executive.
Professor Macleod Clark: I am
Jill Macleod Clark and I am Professor of Nursing and Deputy Dean
of the Faculty of Medicine and Health, University of Southampton,
but I am here in my capacity as Chair of the Council of Deans
for Nursing and Allied Health Professions.
Q604 Chairman: Thank you very much
for coming along. Could I ask Professor Butterworth a question,
please? In your written evidence you stated that the previous
"boom and bust" approach to workforce planning has largely
been resolved over the past five years. How do you reconcile this
with the current reductions in training places for nursing and
other professions? And how can we avoid another "bust"
phase?
Professor Butterworth: When offering
the evidence I think it was clear that the work of the then Strategic
Health Authorities, the National Workforce Review Team and the
WDCs had ironed out what had been quite a serendipitous approach
to workforce planning, and I think that we had both geographic
expertise across the country through the SHAs and the WDCs, and
we are beginning to work intelligently with the hospitals and
health communities in such a way that we were trying to join together
workforce requirements with what they said they needed to deliver
by way of service. We have not fulfilled that completely, by any
means, but at least it was a step in the right direction. I think
the immediate difficulties are occasioned by financial problems
rather than a lessening of the requirement for the workforce number.
Q605 Chairman: Can I ask the other
two? Your submissions stated that training places have been cut
by up to 30% for 2006-07. Is this the start of another "bust"
phase in your view, or has the planning hiatus which has been
described been resolved?
Professor Macleod Clark: If I
can answer that? I think it is definitely a very dangerous position
in which to find ourselves. The overall reductions in commission
numbers across the country are about 10%-plus and that is in Nursing
and Allied Health Professions, but in certain areas they are much,
much higher than that. For instance, the University of West England
has a 26% reduction in nursing numbers for this year, and a 31%
in physiotherapy and the University of East Anglia has a 27% reduction
in nursing and a 28% in physiotherapy. That is hugely greater
than the "bust" cycle we saw in the 1990s where we had
about a 20% reduction over a period of five years. You can see
that if these figures were maintained for just one more year they
would be much greater than those.
Q606 Chairman: Do you have anything
to add?
Professor Sir Andrew Haines: Just
to echo what my colleagues have said. I think it is very difficult
for Higher Education Institutions to cope with this amount of
variability and it really makes long-term strategic planning almost
impossible. At the recent meeting of the UK Health Committee I
was rather struck, looking at my colleagues around the table,
by the dismay that they were expressing and the difficulties of
forward planning of an HEI, which has quite a major commitment
to the Health Service. I think it really makes the relationship
very difficult and very fraught. As we have already heard, education
and training is always susceptible to short-term pressures around
finances and what we need really is a much more long-term and
strategic view, and I think that will be greatly welcomed by the
Higher Education Institutions.
Q607 Chairman: Do you think that
cuts in training places are a response to financial deficits in
other parts of the National Health Service?
Professor Macleod Clark: I think
without doubt, and we do have some quite clear evidence that that
is the case, that the Strategic Health Authorities in finding
contributions to the financial deficits have raided the education
budgets and they have particularly notably raided them in the
Nursing and Allied Health Profession, NMET end of that budget.
Q608 Chairman: If you have that evidence
already could I invite you to send it in?
Professor Macleod Clark: Indeed.
Professor Butterworth: As a case
example, when I was a Chief Executive of the Trent Workforce Development
Confederation we would handle a budget of about £56 million
a year for education and training of the professions other than
dentistry and medicine. The Strategic Health Authorities had a
budget of £7 million and therefore savings had been found
from somewhere which was clearly not all from their own coffers,
I think.
Professor Macleod Clark: If I
could add to that? For instance, in the Avon Gloucester and Wiltshire
Strategic Health Authorities there is a record from the board
meeting of a £10 million saving on the NMET budget, which
has gone into the deficits.
Chairman: Thank you for that. Howard
Stoate.
Q609 Dr Stoate: Professor Clark,
just a follow up to that. You said in your submission that the
link between workforce planning and education commissioning is
non-existent at least and tenuous at best. That is pretty alarming.
How do you think we can put that right?
Professor Macleod Clark: I think
what is very clear is that current mechanisms are not working
and they are not working for a number of reasons, notably because
there is no joined-up thinking and we do not have a national integrated
workforce plan. The devolution of responsibility to Strategic
Health Authorities has not been successful because it then puts
those decisions at the vagaries of issues like financial deficits,
and we need a joined-up picture. I think although our medical
colleagues, as evidenced in the previous session, do have some
problems they are nothing compared with the problems that we have
for the Nursing and Allied Health Professions, and that is partly
because there is a bigger national picture for medical manpower
planning. So I think that an integrated approach is needed and
there are also real issues about the fact that we do not have
similar funding streams and that is a nonsense.
Q610 Dr Stoate: What would you do
about it? How would you improve the situation?
Professor Macleod Clark: We would
have an integrated workforce plan at national level with long-term
strategic planning, not too much anxiety about do we exactly get
the numbers right because I do not think anyone can ever do that.
But we do know that we will need more health and social care professionals
over the next 10 to 15 years and not less, and we do know that
we need to be flexible in the types of professionals that we produce.
So that means that you have to have the big, broad joined-up picture,
and I also think that we need to have joined-up funding streams
because if you have separate funding streams each of those is
vulnerable and if they are not ring-fenced for education they
become increasingly vulnerable.
Q611 Dr Stoate: Is there a case,
for example, to have a similar system for non-doctors as we have
for the medical profession?
Professor Macleod Clark: Yes,
indeed there is.
Q612 Dr Stoate: Would the other two
agree with that?
Professor Sir Andrew Haines: Yes,
I would. I think that the arrangements for the medical profession
work reasonably well, and I think also one could draw the distinction
between the money being handled by HEFCE where it is relatively
protected from these kind of short-term vagaries and the money
being at the mercy of the SHAs, where inevitably it is going to
be sacrificed for short-term emergency spending; it is always
going to be raided for that purpose. So I think the point we would
like to make is that there needs to be ring-fencing for the NMET
budget, that this may be better done by removing it from the day
to day vagaries of short-term financial considerations, and that
one needs to look carefully at the medical model to see whether
it actually is more generalisable to the non-medical professions.
Q613 Dr Stoate: Do you have anything
to add to that, Professor Butterworth?
Professor Butterworth: I think
that the original ambitions, which I described before, to try
and link workforce planning to the delivery of service were good;
I think it is the best idea to be able to do that, and although
it was only partially successful I think that ambition needs to
be pursued further such that it is not a separate exercise, workforce
planning, from the delivery of service. You have an excellent
expert national workforce review team who can give you technical
advice and then take advantage of that at a local level. The discontinuity
that we see at the moment, the difficulties of re-establishing
new Strategic Health Authorities, has taken one eye off the ball
for that, I think at the moment.
Q614 Mr Campbell: Did the introduction
of Workforce Development Confederations improve the workforce
planning relations between the Health Service and higher education
providers?
Professor Butterworth: I left
the higher education sector to become a Chief Executive of the
Workforce Development Confederation and assumed that there would
be rooms full of people with that expertise, but in fact there
were not. We spent quite a lot of time encouraging and developing
people with workforce planning expertise that we could draw from
both the health and educational sector, and I think that they
did seek to make a difference between the health and the knowledge
economy, and I think it was a step again in the right direction.
Q615 Mr Campbell: What has been the
impact between the Workforce Development Confederation and the
SHAs? Has there been an impact of that merger?
Professor Butterworth: In Trent
I held an executive appointment on the Strategic Health Authority
so that allowed me to bring to their agenda at their board meetings
educational matters across all the professions, which was very
helpful, because they could then build in those things to their
strategic requirements, so that entrée between institutions
in higher education and the health strategic planners I think
was significantly important.
Professor Macleod Clark: I would
say from the experience of our constituencies that the continual
change that has gone on has been undermining. There has been a
failure to have continuity in some of the people who we have been
working with in partnership, a dilution of the expertise, which
I think was pretty slim to start off with, and notably I think
there has been a tendency to put a huge amount of resource into
micromanaging the educational contracts, as opposed to developing
a strategic long-term partnership to discuss the kind of workforce
that is required locally. It would be an interesting test to see
how much it actually costs to deliver this NMET education programme
through the Department of Health mechanisms, if you were to compare
it with the process that is used for medical students and for
social work students. So our perception is that whatever changes
have occurred the processes are not becoming better, they are
becoming more disruptive and the partnerships between Higher Education
Institutions and the SHAs have been undermined, and notably there
is now no Higher Education Institute representative on the new
Strategic Health Authority boards.
Q616 Mr Campbell: Do you think that
the reduction of SHAs from 28 to 10 will make it better for education
in the future?
Professor Macleod Clark: I think
that the problem goes back to how I answered a previous question,
that I do not believe the mechanisms that are in place at the
moment are the right mechanisms to predict and work with Higher
Education Institutions to produce the workforce that we need for
the future. So that simply reducing the number of SHAs will not
help in its own right.
Q617 Mr Campbell: Does anybody else
want to say anything?
Professor Sir Andrew Haines: Just
to reinforce the point that I think that education and training
is the victim of the constant reorganisation of the NHS without
necessarily a very strong evidence-base behind it. One can see
that in some areas, for example in London, having one SHA might
be advantageous in terms of strategic planning across London,
but a real issue is first of all the pace of the reorganisation,
also whether or not Higher Education Institutions are going to
be properly represented on the SHAs and the indication we have
at the moment is that they will not be, and that seems to us a
real lost opportunity in terms of engaging the higher education
sector.
Professor Butterworth: If the
new SHAs have a mission which is quite tight and that is to look
at the delivery of service and the commissioning of service then
that is fine. If education and the provision of education is an
afterthought, over which they have some control, that would be
a great shame. I felt that perhaps within the 28 it was more focused,
more purposeful, but they will become smaller and more beautiful
and specifically focused in the business they will do. So there
is a danger that education becomes an afterthought out of that
strategic planning exercise.
Q618 Chairman: Should it be taken
out of their hands?
Professor Butterworth: If it were
properly thought through in such a way. I think it would be quite
easy to do that, you could take it away from Strategic Health
Authorities, but you would have to secure it in some other way
and still have that interlocation with strategic planning somewhere.
We could not ignore the Strategic Health Authorities and their
mission to deliver services.
Professor Macleod Clark: I think
again that the medical model does work with a funding stream through
HEFCE and indeed in Scotland the non-medical funding scheme is
being channelled through the Scottish Health Higher Education
Council. So I think there is a real potential to shift the way
in which the funding is managed for the non-medical education
budget.
Professor Sir Andrew Haines: I
would just say that I think it is going to be very difficult for
10 SHAs to really develop a national perspective on workforce
development on education, so although there may be an argument
for regional relationships between the NHS and HEIs, which we
would welcome, as I say, that does not really deal with the whole
issue of national planning and we need to look at the broader
strategy, not just what is happening in the UK but also what is
happening on the international stage. If you look, for example,
in North America, it is quite clear that the USA is going to be
importing more health professionals in years to come and that
is going to have implications for the UK. We have been traditionally
a major importer and certainly when I go around the world I get
a lot of feedback about the UK's role importing many people from
low income countries, and while we have tried to improve that
situation in recent years I think we still have a responsibility
to make sure that we do not adversely impact. That is not the
sort of thing that we can do at the SHA level, that is the sort
of thing that needs a national view.
Q619 Charlotte Atkins: Professor
Clark, the Strategic Health Authorities last year underspent by
more than £500 million. Clearly this must have had an impact
on education and training and would you like to tell us what your
experience is?
Professor Macleod Clark: Yes,
I think it refers back to the answer to the first question. There
is no doubt that the underspends and more have been put into securing
some amelioration of the basic NHS deficit. That has resulted
in radical cuts in commissioned numbers for this coming year and
we have ample evidence that it is precisely those pots that have
been raided, as I said.
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