Examination of Witnesses (Questions 680-699)
MS ANNE
RAINSBERRY, MR
JOHN SARGENT
AND MS
TRISH KNIGHT
14 DECEMBER 2006
Q680 Chairman: You would not have
thought that the skills were lost, they were just elsewhere, as
it were?
Ms Rainsberry: Yes.
Mr Sargent: With one possible
rider, and a very personal one in a sense, that what was lost
were nearly all the WDC chief executives, many of whom were very
experienced people who had been chief executives and directors
through their careers who then finished up, as with myself, retiring
early. So that was a loss, I would suggest, and there were some
very talented people around the country who are no longer available
to support this and give the leadership perhaps at regional, SHA
or WDC level that many of us feel would have still been useful.
Ms Knight: One thing that the
WDCs should be remembered for is that, for the first time, you
really got an alignment between workforce planning and the commissioning
of non-medical education. They were really making a difference
in that area.
Q681 Chairman: Of course, we have
now had the change from 28 SHAs down to ten. Do you think that
the new SHAs will have the right people and skills for effective
workforce planning and will workforce planning be a priority for
the new SHAs? I have no doubt you will have seen some stuff that
has been in the media that we brought out in our deficits inquiry
and earlier in this inquiry as well.
Ms Rainsberry: In my view, the
answer would be, "Yes", to all of those questions. In
London we have a Board director who is responsible for workforce,
which is myself. We have a team which has strengthened the whole
level of strategic workforce planning which in the previous workforce
directorates, which were the successors to the WDCs and the SHAs
in London, relied predominantly on relatively junior staff to
undertake workforce planning. We have certainly taken the opportunity
in London to address that and have made very senior appointments
in order to take that forward and, in terms of our planning frameworks
that recently have been published, we have taken the opportunity
to integrate workforce with an action service planning—so
commissioning and provider development.
Q682 Chairman: So you think that
PCTs should have a role to play in this work?
Ms Rainsberry: Definitely. If
we are to make a reality of Commissioning a Patient-led NHS,
then commissioners, PCTs, if they are thinking about strategically
shifting the direction of care, need to understand what that means
for workforce and appraise themselves of the plans of the providers
so that workforce follows service, and at the moment PCTs, certainly
in London, do not get involved in that dialogue, which I think
is a gap that we must fill.
Q683 Chairman: Would you suggest
that PCTs should be given responsibility as opposed to being asked?
Ms Rainsberry: I would not say
responsibility, if you are meaning devolving MPET and so on, but
I think the way in which we work with them as stakeholders to
commission services and to commission education should be the
same. The same forum should be used in the way that we do that.
Q684 Mr Campbell: Moving along a
little bit, Chairman. What role should the Department of Health
play in workforce planning? For example, should medical training
workforce growth targets continue to be determined centrally?
Ms Rainsberry: My view is that
the Department of Health has a key role in setting the medium
to long-term planning assumptions with which Strategic Health
Authorities should plan, ie financial. Generally, if you take
Your health, your care, your say, looking at what planning
assumptions at a high level we should be taking into account,
Strategic Health Authorities should plan within that. What I would
say is that the way in which planning for the medical workforce
and rest of the workforce is done in two different silos, one
set being done by the department with HEFCE and the others with
the SHAs, is very divisive and mitigates against us being able
to think more flexibly about redesigning the workforce; so that
is something I would want to see.
Q685 Mr Campbell: We were told some
time ago by the WDCs that they were pressurised by the Department
of Health to meet the National Health Plan workforce growth targets
regardless of local needs.
Ms Rainsberry: Yes, I was in a
regional office at the time. I do remember that. I think that
is true.
Q686 Mr Campbell: That is a fair
assessment of what occurred?
Ms Rainsberry: Well, not pressurised,
I think there was obviously some work done nationally which identified
that this was the level of growth that was required and, therefore,
a tension was created where, in the longer term, we required that
growth (indeed, actually we have got over-supply now, but we needed
that growth), but in some parts of the country that created a
pressure where that growth was not necessarily affordable.
Q687 Mr Campbell: Is there any way
of avoiding that sort of interference?
Ms Rainsberry: Of the department?
Q688 Mr Campbell: Of the department.
Mr Sargent: I do think that there
is more that can be done around this. I certainly believe, and
I agree, the department has a very important role. I think it
has a key leadership role in shaping what should happen. The best
example I can give you is that all of us knew back in 2004 that
another Spending Review was coming, and most people can guess
roughly what it might turn out like, and it certainly will not
be growth in money terms of 7.3% that we have seen during the
Spending Review. When you bear in mind there is a four-year lead
time to get one more or one less registered nurse, or anybody
else (it is more for doctors, of course), there is a very strong
argument that back in 2004 the Department of Health should have
been anticipating the most likely scenarios within the next Spending
Review, the commissioning changes should have been flagged up
by 2004 and reductions should have been occurring from 2005 onwards
in anticipation of the next Spending Review. Furthermore, if we
are serious about looking at changing roles and getting more flexibility
in the workforce, there is an argument that that should go further
and some of the resources released should go to developing existing
members of the workforce, many of whom receive little investment
in their development at all.
Q689 Dr Naysmith: Could I just explore
some of that before we leave it. What you said, Ms Rainsberry,
is really quite incredible. You were saying the centre was pressurising
organisations (and you said that is what happened) to take on
staff when they knew they could not afford to pay these staff,
which would inevitably mean either cuts in some other parts of
the service or it would mean they would eventually be in deficit.
Is that what was really happening?
Ms Rainsberry: No. I think the
question was put to me, "Were they being pressurised?",
and I said there was a tension that was created.
Q690 Dr Naysmith: You said, "Yes,
that's right."
Ms Rainsberry: Yes, there was
a tension that was created.
Q691 Dr Naysmith: No, you said, "Yes,
they were being pressurised"?
Ms Rainsberry: Yes, but the tension
that was created was that the department has a legitimate role
in saying over the long-term we need this level of supply. In-year
a health economy may well have financial pressures where they
feel they are not able to commit to that, and they would interpret
that as being pressurised into making commitments that they feel
they cannot make in-year, whereas the longer-term strategic perspective
would suggest that they do need to make this commitment. So I
can understand that the parties involved, certainly on the ground,
would have felt that there was some pressure to do things which
they felt they could not in the short-term commit to.
Q692 Dr Naysmith: Were they not justified
in feeling like that? Were they not justified in saying: "Look,
we have not got the finances this year to take on these extra
staff or take on these responsibilities, so we are not going to
do it"?
Ms Rainsberry: I think at SHA
level, and at the time you are talking about it would have been
regional offices, there was always some brokerage in understanding
that issue and understanding whether there were other areas of
the health economy, other organisations, who could take additional
commissions.
Q693 Dr Naysmith: Do you mean they
expected they might be bailed out at the end of the year, because
they had made it clear—
Ms Rainsberry: No, I think at
a regional level you had a responsibility to see, where there
were particular financial pressures for organisations or health
economies, whether across a region you could meet the necessary
growth in workforce supply but without putting pressure on particular
organisations. That would be a sort of response you would take
at a regional level.
Dr Naysmith: We will probably return
to this.
Q694 Chairman: We were trying to
tease this out with previous witnesses in both this inquiry and
also in the deficits one. We were told by the Secretary of State
that trusts who had overspent should not have employed people
if they could not afford it, but what you describe to me here
is a direction, effectively, saying that you must.
Mr Sargent: I think we must draw
the distinction also between members of staff and students. What
we are essentially talking about is the commissioning of student
numbers.
Q695 Chairman: As opposed to post
numbers or jobs?
Mr Sargent: Absolutely.
Chairman: Thank you for that.
Q696 Dr Taylor: I think you have
all implied that the Department of Health's job is to take a view
of long-term priorities. It seems to me they have made a bit of
a mess of it. Are they capable of taking that on? How should they
be changed so they do it a bit better, or am I being excessively
rude about them?
Ms Knight: I think what we have
seen is that in some of their policies they actually have not
really considered the financial implications of the workforce.
If we take Our care, our health, our say, it is an excellent
policy document, but actually what does that mean, not just in
workforce terms but in the finances of workforce, and that is
where I think they should be leading us.
Q697 Dr Taylor: Do you think it is
possible for anybody to predict what doctors you will need in
12, 15 years' time? Is it an impossible task?
Ms Knight: I think in terms of
doctors it probably is impossible, but what we should be able
to predict is the types of skills and competences that you are
going need in that time span. You will never get it exact—we
can never get it exact; it is not an exact science—but we
should be able to make some fairly broad statements about the
type of skills and competences we need.
Q698 Dr Taylor: Would you limit the
Department of Health's role to this long-term priority setting,
and, if you do that, how would you split up the other jobs between
the Strategic Health Authorities and PCTs? At the moment it seems
to me very muddling and to find out what bit is responsible for
what is extraordinarily difficult?
Ms Rainsberry: My view would be
that the department could strengthen its expertise in the area
of strategic workforce planning. I think that would be most welcome.
A number of the things that are impacting on the workforce at
the moment, the European Time Directive is one example, have been
known about for many, many years, and the impact of that could
be modelled as some of the demographic changes. So I think we
could make a real contribution at that level to doing that. I
think the role of Strategic Health Authorities is to do what it
says in the name, which is to lead the strategy for a health economy,
and that must include workforce strategy. In order to be able
to do that, we have to have the ability to plan the total workforce,
not parts of the workforce. The way in which MPET is currently
managed needs to be re-looked at—there is an MPET review,
which you will be aware of—which means that at the moment,
at its crudest, we could integrate service financial workforce
planning at a Strategic Health Authority level, and we are planning
on doing that; but the way in which MPET comes to us in the Strategic
Health Authority is in predetermined packets and, therefore, we
cannot actually implement the strategic plan because we are already
committed to spending X on this and Y on that. I think with Strategic
Health Authorities (we have got 10 now) there is a real opportunity
to provide proper leadership at that level within the over-arching
strategic framework which the Department of Health should be providing.
That would be my vision.
Q699 Dr Taylor: We are told at the
moment it is the department that determines the size and the distribution
of the MPET levy. Should they continue to determine the size,
or does that not rather tie you, as a Strategic Health Authority,
into what you do if the size is decided for you?
Ms Rainsberry: Yes, I think that
would need to be a dialogue. I think you need a bottom-up from
Strategic Health Authorities, a strategic overlook from the Department
of Health and a dialogue where we agree between us what it should
look like.
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