Examination of Witnesses (Questions 700-719)
MS ANNE
RAINSBERRY, MR
JOHN SARGENT
AND MS
TRISH KNIGHT
14 DECEMBER 2006
Q700 Dr Taylor: At the moment it
is very much top-down?
Ms Rainsberry: Yes, we are given
an allocation.
Mr Sargent: It should be a function
of integrated service workforce and financial plans, which would
be put together by the 10 SHAs and then 10 discussions with the
Department of Health. At the end of the day, if the MPET was not
enough or, indeed, too much (whichever way it was) to match up
to those 10 plans, then you do need another discussion and the
SHAs then ought to be able to say, if MPET is not enough to do
what you want for the whole of your plans, if that is the way
it turns out, then the plans should be amended until they are
properly integrated and affordable.
Q701 Dr Taylor: We heard in the deficits
inquiry that a great deal of pressure was put on Strategic Health
Authorities not to use all their MPET money?
Ms Knight: It might be worth just
saying what the effect on the budget cuts with us has been; and
that has been our inability to actually second people into training,
which is a way that we have found very effective. If you take
a healthcare assistant and you second them through training, they
stay with you and they are a very effective professional. What
has happened with the MPET cuts is that we have had to totally
stop being able to do that.
Ms Rainsberry: I think this particular
year it has been quite unusual, the size of the reduction and
the timing of it, and because of the way the MPET budget is constructed,
you have very little room for manoeuvre at Strategic Health Authority
level once you are in that situation. Having said that, the role
of the Strategic Health Authority is to balance the competing
objectives that we are given. So, the big number one, of which
you are aware, is to balance the books, and we have to make decisions
about how we do that along with all of our other obligations and
priorities. I hope (and I can say I think in London this is the
case) that we tackled that in a way which did not store up longer-term
problems for MPET. We looked to see how we could make reductions
without having to reduce the stock programmes that people were
already on and things like that.
Mr Sargent: That does highlight
a strategic dilemma, if we are honest about it, because if the
money available to deliver the future workforce is squeezed through
short-term pressures, then where is the changed workforce of the
future going to come from? In particular, if we are currently
training more people than we need for jobs that are paying more
than they need to be if you look at the jobs differently and we
do not invest in developing the ones who could deliver the work
at an affordable price, then the focus on the short-term "balance
the books" actually misses a very important trick here, that
that money would be better invested in a longer-term view, taken
within a proper strategic approach, which would develop the people
we need at a price we can afford to pay as a country from the
overall sums voted by Parliament to support the National Health
Service.
Q702 Dr Taylor: Who should be deciding,
and at what level should it be decided, that public health is
just as well advised upon by non-medically qualified advisers,
who would be a lot cheaper than public health doctors?
Mr Sargent: It is not particular
public health doctors I was thinking about.
Q703 Dr Taylor: No, that is what
I was thinking about!
Mr Sargent: But they are a good
example too. It is looking at what competences do you need and
what is affordable to deliver the quality of service that is deemed
appropriate. The big numbers (and in truth they are not in the
public health doctors) are in delivering care in wards, in health
centres, and so on. If all the money goes into, for instance,
registered nurses, doctors or even public health doctors, then
it is not there, where the system is now, to support, say, the
development of more skilled health care assistants, assistant
practitioners. That is where the really big numbers are and that
is where the big savings are, the current savings on the financial
side, in terms of balancing the books in the longer-term.
Q704 Dr Taylor: As the NHS are relying
more and more on the third sector, do you as a group have any
input into planning workforce requirements in the third sector
or do you take that into account?
Ms Knight: I think that is a very
important point. You mentioned about workforce planning being
done by PCTs, but I think actually workforce planning across health
communities is really important and is the one area where we have
actually had to concentrate in order to incorporate all the providers
of healthcare, whether they be independent sector, private sector,
social care; and that is going to be a difficult task because
the data systems are very different, and the like, but it is something
that, as workforce planning needs, we have got to tackle.
Ms Rainsberry: I think it is already
happening. In London this year, because we have been very alive
to the issue of the financial position in London, therefore trusts
are holding vacancies—the real risk of potential newly qualified
nurses, for example, not being able to gain employment—we
have had very productive discussions with other sectors about
providing employment, either on a short-term or medium-term basis,
because all the evidence is that if a nurse, for example, once
qualified, does not get into nursing within a certain period of
time, we lose them completely. So we have been very keen to work
with other partners to try and secure them into the healthcare
workforce and, hopefully, back into the NHS.
Q705 Chairman: Trish, you mentioned
one of the White Papers that has been published by the department,
Our health, our care, our say, which suggests that the
mode of travel is from the acute to primary and then, within that,
pro health issues as opposed to ill-health issues which dominate
the scene of healthcare in this country. Why have we not seen
shifts in issues about public health personnel in the way that
we have done with the acute sector in the last few years? What
are the implications for these White Papers? Should we be seeing
movement in public health professionals?
Ms Knight: Yes, I certainly think
we should.
Q706 Chairman: Why are we not?
Ms Knight: I think because it
is a complex workforce, because it covers all organisations. It
is not just a health issue, this is an issue for local authorities,
environmental health and the government offices and, therefore,
to plan that workforce is very tricky because no-one really takes
responsibility for that planning. There was an attempt, I think
nearly six years ago, to do a national public health workforce
plan, but I think it fell on affordability because when you look
at numbers it is fairly difficult. I think what we have to do
is to use some of our existing workforce and to change the way
they work. Let us take health visitors, who at the moment tend
to focus on individual clients. We need to change the way they
operate to actually look after the population and to be a public
health specialist in the true sense of the word.
Q707 Dr Naysmith: We have talked
quite a lot about the lack of integration of workforce and financial
planning in response to the series of questions that Richard asked,
but I think Anne said this has been a very special year, a very
unusual year in some ways, and we have seen a lot of over-shooting
of past workforce growth targets, particularly this year, which
has resulted in serious financial problems in various parts of
the service. Are you aware of there being better planning by some
SHAs and WDCs than others, and, if so, how did some of them manage
to do their planning and their integration better than others?
Ms Rainsberry: Being fairly new
in post, I am not aware of the performance of other Strategic
Health Authorities.
Q708 Dr Naysmith: Why were SHAs and
WDCs as a whole unable to prevent this overshooting of targets
in some cases producing financial problems?
Mr Sargent: I am not entirely
sure which targets you are referring to. Are you talking about
the workforce expansion targets?
Q709 Dr Naysmith: Yes.
Mr Sargent: There are a couple
of things. First of all, the workforce expansion targets were
just for workforce, and it brings us back to this baseline issue
that actually, if you look at all the workforce targets that ever
were over the years from 1999 to 2008, I think you will find it
comes to something like 116-120,000, but if you look back a good
few years at the amount of money that was available and negotiated
between the Department of Health and the Treasury, you would find
that it would pay the wages of many more people than the workforce
expansion target. So I do not think there has been a case of overshooting
the workforce expansion target. What there has been of late, specifically
with regard to the students, is that the students that are being
trained in significant numbers did not anticipate the financial
problems that surfaced last year and still do not fully anticipate
the changes that most people would expect in the wake of the next
Spending Review.
Q710 Dr Naysmith: Before you go any
further, can I read you some figures. Between 1999 and 2004 the
variants from the targets that were set, and they were all achieved
but for consultants, actually except for consultants it was 3%
under target, but for GPs it was 105% over the target, for nurses
it was 340% over target and for allied health professionals it
was 69% over target. That was not just students.
Mr Sargent: What I am saying is
that the student numbers, first of all, took a while to build
up in anticipation of the very large growth of monies that were
put into the delivery of service in the NHS. There is a four-year
lead time. So what was happening, colleagues round the table and
round the country were building up the commissions, and the Department
of Health was on the case, but that took time to work through.
In the years you refer to, that was when the demand for more staff
was at its height and then there were concerted efforts (and the
Department of Health worked incredibly hard at this) to bring
in things like "return to work", international recruitment,
and so on, because the money they had available for service delivery
did then outstrip the supply. The supply has since caught up.
Q711 Dr Naysmith: One of the things
you said earlier is that Strategic Health Authorities had this
sort of balancing act to perform. It was you, Mr Sargent, that
said that?
Ms Rainsberry: I think it was
me.
Q712 Dr Naysmith: I am sorry, it
was you. We have not done a very good job of balancing these things
out, have we?
Mr Sargent: I think there are
significant constraints, as we have said, and that is why you
are looking at this, but by the same token let us not forget that
over the years, despite all the figures we can band about, the
number of people who have qualified and been through training
and not found jobs is relatively small and the problems are relatively
short lived, and vice versa. So, whilst we can be very critical
and think there are a lot of improvements and that is what we
should be doing, by the same token I think it is wrong to be over-critical,
because in a lot of ways the system has worked relatively well
for many years. My belief is that the strategic change is a remedy,
but we do need to move on and we do need some fundamental changes
now to respond to the challenges of the future.
Q713 Dr Naysmith: What are the changes
that we need to see?
Mr Sargent: Two in particular,
and they are linked. The first one is a real move towards strategic
workforce planning which takes place within a properly integrated
approach to workforce financial and service planning; and the
other thing that comes with it is that the world we are moving
into, the strategic drivers we already know about, let alone the
ones we do not, means to me that the healthcare employer of the
future will have to be at least significantly dependent on a more
flexible workforce than currently, and that means that we would
need to start planning the services in part around the competences
that are needed to deliver the sorts of services that we are looking
for. That does mean new roles in a whole lot of ways—it
is starting to happen already, but probably considerably more
so—and it does mean that not all the work will be neatly
parcelled up within the professional boundaries that we have seen
historically, because the explosion of knowledge and technology
just by itself means that it is going to be increasingly difficult
to sustain.
Q714 Dr Naysmith: That is all very
important, but given that that is 70% of the costs of the National
Health Service and running the National Health Service workforce,
is it not a bit daft that financial planning and workforce planning
are not much more closely linked together?
Mr Sargent: I would agree that
historically it could have been a whole lot better. I also feel
significant strides have been made, but to answer your point directly—"Is
there still some way to go?"—yes, I believe there is.
Q715 Dr Naysmith: What is the barrier
to it happening? It happens in big private firms, private companies?
Ms Knight: Maybe we could see
the deficit as actually an opportunity to drive this, because
you will only manage the deficit by managing your pay bill, and
if we have proper, good workforce development and HR practices
coming out of that, because they have got to manage their pay
bill, and a real look, as John says, at what their workforce need
is, then maybe we will see an opportunity coming out of the deficits
which we had not really realised to actually link financial and
workforce planning.
Mr Sargent: Specifically, I have
a personal view on at least part of the answer to the very valid
question you raise. I think what lies behind a lot of this is
essentially a cultural issue whereby HR and workforce issues are
seen in many trusts, PCTs and other organisations as a second
order of priority, because the short-term imperatives—balance
the books, waiting lists targets and so on—compared, as
I was saying, with a four-year lead time to get one more or one
less nurse, make it hard to reconcile and get your head round
as something that is really important when there are all these
short-term issues on your desk. I think one of the key things
we need to address is to try and get a cultural change that sees
this as key and part of that integrated approach.
Q716 Dr Naysmith: In our recent deficits
inquiry we came across two or three trusts where the finance director
was referring to the board that they were in financial difficulties
and at the other end of the organisation they were still recruiting
and putting out adverts to recruit staff. That seems barmy, does
it not, Ms Rainsberry?
Ms Rainsberry: Yes, it does seem
barmy. I read your report. One of the issues that was referred
to in your report about deficits, one of the pressures, is the
new pay arrangements (ie the unit cost for the people that are
being trained and are coming into the workforce has gone up).
Equally, the amount of work we are doing is increasing, and therefore,
if you do not redesign your services and you do it in the old
way, then the yearly cost is going to become higher and higher.
I think there is a danger in just seeing workforce planning as
the Holy Grail to everything. I think workforce planning at a
national level leads to informal workforce strategy, which will
be about balancing supply and demand, but what we tend to do then
is just assume that education commissioning is the way in which
we balance supply and demand, and that inherently will cause financial
problems. I think what we need to do at a national level is understand
what other elements we are anticipating. This is where I come
back to the planning assumptions that the department have set
within a strategic framework. How much are we planning to close
that gap through productivity of the existing workforce, for example,
or creating new roles within the existing workforce, and so on?
If we are able to join up nationally all the different elements
for workforce strategy rather than just looking at education commissioning
in a silo, I think that would be extremely helpful.
Q717 Dr Naysmith: Finally, one of
the things that is immediately cut when any National Health Service
organisation gets into financial difficulties is the developmental
activities of the workforce, which are referred to by some as
expensive luxuries. That must be wrong too. What would be your
view on that?
Mr Sargent: I absolutely agree.
You would hope that the programme of investment in the development
of the staff is within the strategic framework and, if it is and
that is what goes, it is crazy, because you may hit a short-term
target, like balance one bit of this year's books somewhere, but
we do have a responsibility collectively to deliver the healthcare
of the people of this country for future years, and that means
developing the staff who are able to do that. So, unless it is
put back very quickly— I do not think it matters if it was
three months taking it and it was definitely put back next year,
if you are looking over a ten-year period, but if it is just take,
take, take, then that is very short-sighted.
Ms Knight: I would like to add
that I think Strategic Health Authorities and the Deaneries have
a responsibility to have some kind of performance management of
the trusts and organisations about what they are doing around
education and development, a proper agreement that they will go
on educating staff.
Q718 Sandra Gidley: A question for
John Sargent initially. In your written submission you talk about
the mismatch between the workforce figures predicted in the NHS
plan and the level of funding growth. Why did that mismatch occur,
do you think?
Mr Sargent: I suspect, in truth,
that different, as it were, sections in the Department of Health
were concentrating on different aspects of the Health Service.
I think (and it is true of most organisations in my experience)
if you have got a lot of people effectively working on different
projects, the analogy is, if you throw a rock in a pool, there
are ripples and you have got to think where the ripples land.
I think, in part, what happened there was the Department of Health
did very well, relative to other departments, on the financial
settlement side and I think that the workforce targets were up.
When people were looking at that in the Department of Health,
it was also functioning physically, "How many extra people
can we develop through the systems as they are?" So there
was always going to be tension if you expressed it in, "How
many extra numbers of wages can we afford to put on the payroll",
and compared that with how many extra people physically did you
think you could put in, because most people, do not forget, in
the NHS complain those workforce expansion targets were too high
and could not be met. In fact, as somebody else has said this
morning, they were significantly over-met in total at the end
of the day, though not necessarily in the individual silos. So,
I think there was a lesson learned there, if you like, that the
government policy moving towards average OECD country levels of
expenditure on health overtook some of the workforce planning
targets at that time and so there was mismatch. I think a lot
of that has been learnt and it is being brought together now.
Q719 Sandra Gidley: Why was all the
money spent on workforce rather than drugs? We all hear tales
of drug rationing, et cetera. Why was it all poured into that
stream?
Mr Sargent: It was not all poured
into that stream.
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