Examination of Witnesses (Questions 620-639)
PROFESSOR DAME
JILL MACLEOD
CLARK, PROFESSOR
SIR ANDREW
HAINES AND
PROFESSOR TONY
BUTTERWORTH
29 JUNE 2006
Q620 Charlotte Atkins: So ring fencing
does not work?
Professor Macleod Clark: There
is no ring fencing for that element of the budget. It has been
token and indeed we have had a correspondence with Lord Warner,
in which he again said that there would be no ring fencing for
the year to come either. This is why I think we are in a very
dangerous situation.
Q621 Charlotte Atkins: So what do
you expect to happen in the coming year? Professor Macleod
Clark: My nightmare prediction is that there will be a
continual raiding of this budget unless it is ring-fenced, unless
it is protected, and I think the implications on that for even
the short-term workforce requirements could be devastating because
what we do absolutely know is that for instance that reduction
in commissions is not related to the reduction in demand; it is
a response to being able to raid a pot of money.
Q622 Charlotte Atkins: Professor
Haines, did you want to come in?
Professor Sir Andrew Haines: Only
to add that from the perspective of my own institution we obviously
have concerns around public health and there is a similar picture
there—40% reduction in planned recruitment and public health
training for 2006 compared with 2005, and academic public health
also showing a decline. That is another point that is important
to make, that if you allow the clinical academics, the nursing
academics to decline, if you do not sustain them then of course
you have lack of capacity to train people in the future. So, again,
we need to iron out these fluctuations in demand and the fluctuations
on financial pressures to Higher Education Institutions, otherwise
we erode the base of the institutions.
Professor Macleod Clark: Can I
give you an example to bring it to light? From the Avon Gloucester
and Wiltshire SHA again, the SHA set the WDC a savings total of
£10 million to contribute to achieving a balanced LDP and
to avoid cost shifting to the service. This meant further reductions
in education commissions had to be made, and we have many examples
that we could give you.
Q623 Charlotte Atkins: Overall do
you think that too much is spent out of the NHS education and
training funding used for medical training, as opposed to other
forms of training?
Professor Macleod Clark: I think
there is a disproportionate spend. It would be quite inappropriate
to say there is too much and the argument could well be there
is far too little spent on the non-medical education training
budgets. The disproportion is quite striking in terms of the numbers
of qualified nurses and Allied Health Professions in the system
and the amount of money that is spent, particularly in their continuing
development and education, and that which is spent for the medical
post-registration training, and this lies at the core of the problem
about our inability to reform the healthcare workforce because
there are no ring-fenced monies for continuing professional development
in Nursing and Allied Health Professions—or there are very
few—and they are not linked to career pathways nor to trainee
posts. I would give you the example of GP trainees where there
is clearly a very obvious funding route; there is an obvious career
route and ring-fenced monies to secure the future workforce in
that domain. We know we need more nurse practitioners in general
practice—first point of contact. There is no money, there
is no ring-fenced money, there is no career framework, there are
no training posts. Just to give you a tangible example, you ask
about the disproportion. There are 127,000 nurses and Allied Health
Professions currently studying part-time and the amount of money
that is being invested in that is about £1,200 per student.
In contrast, there are 35,000 posts for medical post-registration
training and there is £40,000 per student allocated to that
budget, and that is just one example, and we can give you others.
Q624 Charlotte Atkins: So the Government's
plans to move the focus from the acute sector into primary care,
therefore, is completely undermined by this lack of funding of
posts and career pathways within the primary care sector?
Professor Macleod Clark: Absolutely,
that is spot on; that is the real problem, and it is why I come
back to the fact that the current mechanisms for both commissioning
and funding a non-medical education area is really not fit for
purpose.
Professor Butterworth: If I may
pursue the example briefly? I quoted previously the funds available
in Trent for the impact levy and of that we would have 5% or 10%
for innovation, creation and retraining. If that has been withdrawn
in order to balance other deficits then that opportunity to retrain
and make people fit for purpose in other settings, in a primary
care setting has gone and that immediate support is no longer
there.
Q625 Sandra Gidley: Professor Clark
has moved on to the point I wanted to raise, but you mentioned
the percentage cuts in nursing intake but it is not quite clear
how the reductions in budgets have affected the ongoing postgraduate
nursing training. It is not entirely clear to this Committee how
the services and the courses are commissioned anyway and it might
be useful if you could outline how it works. Who decides what
courses are needed? You have alluded to the fact that some are
just not being commissioned and it seems very airy-fairy; are
you able to put a bit of meat on the bones?
Professor Macleod Clark: Yes.
I think it is an extremely good question. In theory the WDD reflects
the needs of its Health Service provider constituents and should
take a view from those Trusts and other providers what is required
in the future. In reality there are pressures from the centre
to meet targets in terms of numbers and that is quite a compelling
motivator, I think, for those working at SHA level, and in reality
the decisions that are made do not seem to necessarily concur
with the requirements of individual Trusts. So just to put some
flesh on that for you, you ask about post-qualification training,
we know that there is a real need for more nurses in the community.
We had examples of SHAs in the West of England, with one of them
where there has been 100% reduction in the community nursing commissions
this year at post-qualification level, and we could find you many
more if you would like those. The same is true for post-qualification
in the Allied Health Professions, particularly in physiotherapy.
Q626 Dr Taylor: This is really some
of the most helpful evidence about the deficits that we have because
we have been trying to get to the bottom of where the money has
gone. Professor Butterworth, in your submission you said, when
funding is tight, as now, the first casualty is CPD. Has basic
nursing training been affected or is it all the CPD side?
Professor Butterworth: There are
two opportunities to support the educational enterprise. One is
initial registration programmes, which is, as Jill described,
managed in that particular way, supposed to satisfy the needs
of the health economy. Continuous professional development is
slightly different. There is some resource held centrally through
the Strategic Health Authorities and some is held by the Trusts
themselves in smaller proportion. So it is really hard to get
a full picture of how badly that has been affected, but certainly
some of the evidence offered here shows that difficulty that people
are now experiencing, particularly if it is a government enterprise,
to move so much more care into the primary care setting, and the
opportunity to make people fit for purpose for that is quite badly
affected through these changes.
Q627 Dr Taylor: Can you just repeat
the percentage of the Trent SHA money that comes from the training
budget?
Professor Butterworth: This is
for two years ago, so I have not been in that position for two
years now. Approximately £56 million and of that about 10
would be available for creating new courses, encouraging people
to move into community focused posts, things of that sort. The
rest was fixed on education commissions with the seven universities
we did business with.
Professor Macleod Clark: I think
the answer to your question is that the reductions in the commissions
are most definitely in pre-qualification and pre-registration
as well as post-qualification. So that is where the numbers are
that we derive for your two examples of 26% reduction in the West
of England and a 27% reduction in East Anglia for nursing and
31% and 28% respectively in physiotherapy, pre-registration for
this coming year. So there is no doubt that it is impacting across
the piece. And there is absolutely no evidence that that is not
related—coming back to Sandra's question—to the demands
or the requirements of the Trusts, quite the reverse. We have
examples in my own patch in Hampshire where, for instance, our
local Trusts have been asking for graduate nurses because it is
quite expensive to turn a diplomate nursing into a graduate after
they have finished training, and yet the commissions have doggedly
been for diploma level as opposed to graduate. So the answer to
the question about is there a tie-in between what is needed in
a local community and what is commissioned we have geographical
examples of where that is not the case.
Q628 Dr Naysmith: I had been intending
to explore Avon Gloucester and Wiltshire and the effect on universities
in the West of England, which is located in my constituency, but
Professor Clark has brought out almost all of the points that
need to be brought out there because I had been well briefed beforehand
by Professor West.
Professor Macleod Clark: Perhaps
I could expand upon the question?
Q629 Dr Naysmith: I was going to
say that his letter to me, which brought all this out has been
circulated with today's papers and I am sure it is going to provide
a body of evidence for some recommendations when we come to make
recommendations because it is clearly quite a devastating picture
of what has happened.
Professor Macleod Clark: And we
do have other evidence we can let the Committee have. On that
particular example, though, I think it is important, coming back
to the post-qualification and career pathways within community
nursing, that would be a programme that was supposed to produce
your next generation of school nurses, community nurses, health
visitors, and all the conversion programmes for nurses who want
to be retrained to go into new posts. So it comes back to the
workforce design and reform issue, and there were no intakes in
your patch for those courses.
Q630 Dr Naysmith: I agree with Richard
that this is really very important evidence and I am sure it will
underpin some of the things we recommend. Just a couple of tidying
up points, you recommended that HEFCE should take over the funding.
Would that work? Have you looked very closely to see that HEFCE
would be able to do it?
Professor Macleod Clark: I think
there is no reason in theory why it should not work. It would
have to be handled and managed quite carefully because there are
notable differences around bursaries, and at present the inability
for universities to charge top-up fees, so there are differences
in the way in which those programmes, currently commissioned from
the Department of Health, work to the way that HEFCE normally
does its business. But there are examples and social work would
be another one, which works extremely well under HEFCE model.
Q631 Dr Naysmith: So HEFCE would
have the expertise?
Professor Macleod Clark: They
have the expertise and it is our belief that it would be much
more cost effective.
Q632 Dr Naysmith: The other thing
you have already touched on as well is the question of education
funding in primary care and public health. What changes do you
think would need to be brought in to enable that to be done properly?
Professor Macleod Clark: I think
we must develop a mechanism for proper career pathway tracking,
trainee posts and the ring fenced money to go behind that. In
the absence of that we will not achieve a workforce reform shift,
it just will not happen, because the current mechanisms unwittingly
are creating a situation where we are simply maintaining the status
quo. They do not allow a flexible, more imaginative and more
forward-looking approach to workforce planning.
Q633 Sandra Gidley: Professor Clark,
the average dropout rate for the United Kingdom university courses
is 14% but in nursing the average rate is 25%. Why do so many
nursing students drop out and should we be doing more to try and
retain them?
Professor Macleod Clark: There
are two things. The way in which dropout rates are calculated
across the university sector generally, and the way in which they
are calculated by the Department of Health are very different.
So it is impossible to make a direct comparison. Our view is that
the attrition rates in Nursing and Allied Health Professions are
very varied. For instance, you will have a higher attrition rate
in learning disabilities nursing than you will in adult nursing.
You will have a higher dropout rate in radiography than you will
in physiotherapy. So it is quite difficult to lump it altogether
because there are big discrepancies. If you use a similar methodology
to the higher education model then it looks as if the Nursing
and Allied Health Profession attrition rate is very similar to
other vocational or technical courses like engineering. So, again,
the general figure that is produced at HEIs covers a multitude
of courses, students on very different routes, and if you compare
like with like, which is students who are undertaking courses
leading to a vocation, profession involving some coursework which
is in practice, then those would be the proper comparative figures.
There is no doubt that Nurses and Allied Health Professions have
a tougher time at university than many other students; they have
to work harder, they have to do practice, they are often older
so they have other commitments. I think over 30% of recruits into
nursing are now in their 30s and above, so you know that they
will have other challenges and pressures that will make it more
difficult. One of the things that is very worrying for us is that
we know now, because of the problem about the lack of job opportunities
that is looming, that many students are deciding that if they
are struggling they do not want to stick with it because why would
they if they are not going to get a job at the end of it? So we
do not really believe that the figures for nursing, Allied Health
Professions are that much higher than other students in similar
circumstances, but now we may see a much greater hike in attrition
because of these current factors.
Professor Butterworth: It is known
that one of the factor that mitigates against people dropping
out is if they have good placement experiences, if they are content
and cared for where they have those experiences by nurses and
others who have been prepared for that role, and that lack of
capacity to invest in that now compounds that difficulty, so the
people you would want to make the students' experience a happy
one need that adequate preparation. The reductions in funding
may just work against that to worsen that particular thing, I
think.
Professor Macleod Clark: I think
that is right. There was a very good move to create clinical placement
facilitator posts for Nursing and Allied Health Professions and
those have all been eroded in this last round of cost cutting,
and I think that that again is very short-sighted, but it comes
back to the fact that the mechanisms for funding for non-medical
education do not contain the processes for supporting a funding
stream for the placement experience. So there is no money that
follows the students into practice, unlike in medicine.
Q634 Chairman: Professor Butterworth,
your submission highlighted the shortage of healthcare educators
in the UK. How serious is this problem and what is being done
to address it?
Professor Butterworth: There is
some work underway to at least uncover some intelligence about
that further. The United Kingdom Clinical Research Collaborative
has commissioned some work which we are leading to look at what
that looks like. That work for us has all the characteristics
of the total nurse workforce. Also 25% of it is in the ages of
50 and 55, and the resolution to that in part is to make a career
as an educator or as a researcher attractive. It is often serendipitous
as to why people go into careers as educators or researchers,
and to craft those pathways such that it is seen as a good thing
to do and to be helped into those pathways, there are some quite
easy ways to do that and we are about that business now. It is
necessary to seek some investment to make that happen, to make
sure that the next generation of educators are in place, first
of all to deliver those new programmes, which we have talked about
in the process of giving evidence so far. So it is a cause for
great concern. Senior appointments at universities, for example,
often have very poor shortlists because of lack of available candidates
at the moment, and that is an increasing difficulty reported by
a number of universities, but there is some work underway to try
and address the difficulty.
Q635 Dr Taylor: I think my questions
are rather academic because of the lack of funds, but I will ask
them just the same. We have been told that there are really no
part time nursing courses in the UK. Is that correct?
Professor Butterworth: That is
not correct.
Q636 Dr Taylor: Could you elaborate
because it would seem to me that if 30% of the people coming into
nursing are over 30, and certainly healthcare assistants who want
to go on and become nurses are in the older age group, there have
to be part-time courses, so what part-time courses are available?
Professor Macleod Clark: We believe
that there are currently about a dozen part-time courses offered
in nursing across the UK and some in the Allied Health Professions.
One of the difficulties again is the commissioning pattern because
they have to be commissioned; you cannot run a course in a Higher
Education Institution if you are not commissioned to run it.
Professor Butterworth: Might I
give an example? In Lincolnshire, which I used to have some responsibility
for, where it is difficult to recruit people into posts because
of the rural nature of the county, I commissioned a nurse registration
programme with the Open University, that was largely work-based
and quite flexible and had part-time opportunities. So there are
mechanisms to do that if the commissioners are willing to do it.
Professor Macleod Clark: If I
could give you an example? In one area in the UK part-time occupational
therapy commissions have again been cut by a third for next year,
so this will be a good example of where we make this rather bold
statement about there being a disconnect between the commissions
and the service requirements. Most universities have a part-time
option on the stocks, but you cannot deliver it if you are not
commissioned, so we cannot look at what we have in terms of a
local potential workforce and offer that course unless we are
asked to deliver it. And there are also issues because it is not
necessarily cheaper to run a part-time course. There are sometimes
additional expenses, students may need more support, but there
would be a standard price for a course and some universities may
feel it is simply not possible to deliver a quality course.
Q637 Dr Taylor: Would that standard
price be greater for a part-time course than a full-time course?
Professor Macleod Clark: It would
be extended over a longer period of time so the student would
need a bursary over a longer period of time, and there are additional
costs to a university when supporting a part-time student over
a longer period of time. So it may be that that would be a disincentive
if the price of that provision was not adequately costed.
Q638 Dr Taylor: So the responsibility
is entirely with the commissioners rather than the providers?
Professor Macleod Clark: Yes,
we are absolutely clear that the provision of part-time courses
is there but it is not being commissioned.
Q639 Dr Taylor: That is very helpful.
Talking about flexibility, are there opportunities to change between
different healthcare training courses, or if you are on a nursing
course you have to stay with that and you cannot cross over?
Professor Macleod Clark: No, within
a university it is always possible to change course. The extent
to which you might need to start again or get some advanced standing
and accelerate your progress through another course would vary
according to circumstance. But we come back to the commissioning
because if I were to talk of my own patch we are given a target
for student nurses, physiotherapists and Allied Health Professions,
and there is a positive disincentive to get students to swap between
courses if you have to pay a penalty, as indeed universities do,
for having an attrition rate over a certain level, and at the
moment it would be counted as an attrition from a nursing course,
even if you were adding it to a physiotherapy course. So that
comes back again to Sandra's question.
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