Examination of Witnesses (Questions 800-819)
MR PETER
STANSBIE AND
MR DAVID
HIGHTON
14 DECEMBER 2006
Q800 Dr Naysmith: It is quite important.
Mr Stansbie: Absolutely. It is
emergency care practitioners, where we have worked with Sir George
Alberti on this. We have developed competences for what are called
emergency care practitioners. These are people who are skilled
in dealing with emergencies. They are rather different to paramedics
and doctors and nurses. They may come from any of those backgrounds.
An estimate in the south west is that for each emergency care
practitioner that they appoint it saves the health economy £56,000
a year. If you estimate—again, I am using Sir George Alberti's
figures, not ours—that we need perhaps 1,000 to 2,000 of
those in England, you are talking about savings of £50 million
to £100 million a year. What are those savings? You do not
actually save that money in health. It is simply about using that
money more efficiently. That is on the money side. The real gain
is that people are getting treated effectively, more appropriately
and where they need to be treated. Those are things that happen
across the board. I had to smile this morning because we have
also done a lot of work in public health and our competences were
used to make sure that specialists in public health could be people
other than doctors. In Swansea we have just used those competences
to map the whole public health workforce. It is a huge workforce.
That looks not just at health but social care, the voluntary sector,
the leisure sector and all of those things. I think they are very
powerful.
Q801 Dr Naysmith: Perhaps the most
interesting thing about all this is that these priorities and
what you are talking about now were set out in A Health Service
of All the Talents in 2000, a National Health Service document;
and yet if that is true—and I think probably you would agree
that a lot of the stuff was that was in there—why has not
the health service made more progress in implementing these changes?
Mr Stansbie: They have made a
lot of progress. The examples I have given are small examples.
This morning there were other examples given, I hope using our
competences. It does take a long time to change the health service,
partly because of the length of time it takes to train people,
a minimum of three years but for doctors and most nurses a lot
more. The other thing is there are very big cultural issues in
health. The public need to feel secure and safe and have to be
secure and safe. The natural pressure is to make sure that all
of the things you are doing are ultra safe because doctors, nurses,
physios and OTs, the longstanding professions, have a history
of that. For the newer work, it does take a long time. The other
thing is that—blowing the trumpet for Sector Skills Councils—we
were only licensed in 2004 as a Sector Skills Council. We are
licensed by the Department for Education and Skills and one of
25, so we only started this in 2003, in fact, and our predecessor
bodies were not in the mainstream. We have been very heavily supported
by all four health departments, by NHS employers and by the independent
sector. That is why I think the whole issue of employers driving
this gives us a real chance to make a difference.
Q802 Dr Naysmith: That is very helpful
and it is very encouraging to hear that is beginning to happen
but in a positive way, are there any features of current workforce
planning structures that make the approach you describe easier
or more difficult to achieve?
Mr Stansbie: I think we are moving.
Our Sector Skills Councils are working regionally in England now
and bringing employers together at that level. I really do think
this issue of getting things coming from the bottom as well as
from the top is crucial to it. Some of the existing mechanisms,
which quite naturally concentrate on existing professions, as
David has said, incremental changes to those existing professions
and on some of the education you need for that, could change and
could change effectively. Again, I think it is about building
on that and making sure that we can use all of the skills we have
got across the workforce. It is very worrying that we heard people
who are perhaps at the bottom end of the skills spectrum are going
to suffer as a result of the funding cuts when what we need to
do, particularly given demographics, is bring people in at that
level and give them the ability to get their skills up and, indeed,
move through the training. I think some of our existing systems
do not help us with that. We are all trying to make some changes
in this and that would be a big change if we could make it.
Q803 Sandra Gidley: David, you talked
about the huge potential for increasing flexibility by using staff
in extended roles. Who is best at this, the independent sector
or the NHS, and why?
Mr Highton: I do not know, and
bear in mind I am only talking about the part of the independent
sector that delivers NHS care; I do not know very much about private
hospitals. I think, because of the point Peter made about the
ability to retain public confidence, the way our contracts work
probably does limit our scope slightly, so for instance we can
only utilise doctors who are on the specialist register. Therefore,
I think generally the ISTC companies have not implemented all
of the overseas innovations they might have done because it is
reflecting the Department's concern about the ability to ensure
the public have confidence. It is easier to tend to replicate
what has happened rather than bring in too many new things. Certainly,
I know that the companies in the network which are involved in
the diagnostic contracts tend to utilise the radiographer changes
that Skills for Health led over the last few years, I think those
changes will come in. Advantages ISTCs could have in that certainly
so far they have tended to be greenfield operations, so that you
are not encumbered by having a change management process from
somewhere you would prefer not to be starting, you do at least
have the opportunity to start something new and, therefore, you
can design in new ways of working right from the beginning instead
of having to persuade people that it is a sensible thing. I think
the other thing is that increasingly in the second wave of contracts
we are seeing contracts where in order to keep the care local,
in line with the new White Paper, we are seeing some quite small
centres, so there might be only seven or eight staff delivering
something very local, and obviously for the independent sector
there the ability to multi-skill those staff to do a number of
tasks outside traditional boundaries would be very attractive.
I think probably we could not hold up a lot of evidence yet to
say we have done all the innovation that perhaps we would like
to, but I think that is certainly the direction of travel. In
the NHS, from my experience, there are always some fantastic examples
of extended roles, but it is very difficult to disseminate them
across the Service as a whole.
Q804 Sandra Gidley: What needs to
happen to realise this huge potential then?
Mr Highton: I think that the competences
that Skills for Health have developed need to sit alongside qualifications,
particularly vocational qualifications, that are recognised by
employers and therefore portable between employers. Historically,
there have been issues where employers made up their own competency
frameworks and a member of staff moved 50 miles down the road
to another employer and they would not have necessarily recognised
what the previous employer had done. I am a very strong supporter
of Skills for Health, because it gives recognisable currencies
between employers. With the strength and public recognition of
the existing professions, the scope is at the assistant practitioner
level using vocational qualifications and at the advanced practitioner
level, where people have a professional registration and then
are able to acquire new skills, perhaps from other professions,
to expand their range and flexibility to their employer, I think
it would not be realistic to say that one could replace the registered
professions. We need to adapt them at the margin, ie the level
perhaps just below assistant practitioner and the level above
where people could acquire a new and wider range of qualifications.
Q805 Sandra Gidley: Is there anything
you want to add?
Mr Stansbie: I think I would agree
with what David said. There are good examples in the NHS and good
examples in the private sector. Just recently we had a meeting
hosted by BUPA with 10 of the big private independent hospitals
and they are very keen to use the work that we are doing. The
good thing about that of course is, again, the commonality and
transferability so that you can move between different parts of
the sector and UK. I think increasingly we are moving to a mixed
economy and from our point of view what is important is that transferability
is there so that the skills are in the workforce at all levels
and we can use them to deliver what we need for the patient. There
is a real potential. The other thing of course to say is, as you
have said all morning, the workforce is 70% of the costs and,
therefore, it is critical that we get this right. Also, my personal
belief is that in health it is a personal issue and, therefore,
the workforce are the people who look after the people. We have
got to get this right and make a difference. I do not think it
is either/or, it is both and the potential to move across is what
is really important.
Q806 Chairman: Do you think that
skill mix changes are cost-effective? Have you any evidence of
that?
Mr Highton: I think they certainly
can be cost-effective if they are planned well and, as the Health
Service moves perhaps to having fewer large acute hospitals and
more care being moved out into settings, work that perhaps might
be done by doctors in large acute settings can be done by other
professionals in the other settings, but you need to train staff
to be able to do some of those extended roles. Obviously the out-of-acute
hospital settings will not necessarily be able to have the same
24/7 medical rotas which large hospitals have got and therefore
one has to find other ways of covering the care in a way that
the public will retain confidence in. I think the challenge for
the whole health care sector at the moment is to retain public
confidence in the set of changes which are likely to happen.
Q807 Chairman: When we looked at
ISTCs in our report obviously the additionality affected any sort
of cross flow of workforce between the independent sector and
the NHS but we are told that will alter in phase two. We are not
sure how many will go ahead with current press reports. Do you
envisage that will affect this skill mix change, that you could
see somebody coming in and operating a little bit differently
in the independent sector and then potentially going back to the
ways that they have operated before? I do not mean operation,
just the way that they worked before.
Mr Highton: I think the additionality
has been relaxed somewhat in the second wave. Clearly, the additionality
rules relate back three years to when the demand was outstripping
the supply and therefore it was felt important to demonstrate
that the new capacity was not draining or poaching from the NHS.
I think we have now moved into a situation where the supply is
probably outstripping the demand, certainly at the newly qualified
level and work permits are now required for the newly qualified
nurse grade equivalent, yet, companies like mine will still have
contracts that have additionality clauses relating. I think there
is a catch up needed, there is a realignment needed of the additionality
clause and our submission said that ultimately we think we should
move to a free labour market. I think we understand why it was
needed three years ago, I think we are less clear why it is needed
now.
Q808 Chairman: It is not clear at
this stage. We did visit an establishment which was BUPA in Redwood
and they had a situation where the National Health Service and
BUPA staff were working alongside one another on elective surgery
teams. Do you think that is likely to happen in any phase two
ISTC?
Mr Highton: I think, speaking
for my company, we expect that to happen in some of the centres
that we have got, that a proportion of the staff will be transferred
from the local hospital and a proportion will be new staff employed
by us and we would expect them to work alongside each other effectively,
which I think is a management challenge we feel sure we will be
able to deliver.
Q809 Dr Naysmith: To do some training
as well, that has got to come into it.
Mr Highton: Absolutely. There
are two types, the first one required in the contract is, if you
like, we are making sure that we offer training capacity, so 35%
of our theatre lists have to be offered up for training and then
obviously, as an employer, we will invest our own funds in the
continuing professional development of our own staff. There are
two types there, one that we are funding and the other we are
providing the capacity for junior doctors and student nurse placements
which the existing system can utilise but we are certainly pleased
to be doing that.
Q810 Dr Taylor: Following up on that,
I think you said in Canada you had got integrated training going
already. Is that what you said?
Mr Highton: The hospital group
in Canada, the University Health Network in Toronto that we are
partnered with, utilise maybe four theatres with a block group
so there is a consultant anaesthetist putting in the blocks but
in the theatre there is an anaesthetic assistant monitoring the
patient. There is a doctor present but there is not a doctor in
each individual theatre.
Q811 Dr Taylor: I thought you were
referring to training issues.
Mr Highton: I was talking about
service issues there. Those respiratory therapists that they have
in the hospital who want to become anaesthetic assistants do go
through a provincially accredited training system.
Q812 Dr Taylor: There are some specialties
which still remain on the additionality list, like orthopaedics
and anaesthetics. Can you see those being eroded and you getting
more integration on both sides?
Mr Highton: I think anaesthetics
is very difficult because I think the current workforce planning,
and the reason it is recognising the shortage speciality, assumes
the current paradigm. Unless there is an acceptance, I suspect
at a national level involving the Royal College, that paradigm
can change, then the workforce planning will carry on much as
it is at the moment. If every anaesthetised patient, whether general
or local, has to have a doctor present then the current paradigm
will continue. I do not think it is in our power as an employer
to change that.
Q813 Dr Taylor: Picking up on Peter's
point about emergency care practitioners, was the figure you said
£56,000?
Mr Stansbie: Yes, that was an
estimate from one of the south-west ambulance trusts, that is
£56,000 savings to the health economy and that did not include
any savings in bed days. It did include a significant saving in
people having to go to A&E, a significant saving in terms
of mileage and transport costs. Then the extrapolation is the
number you get. These are not our figures, this was a trust working
these out, even if they are 50% too high, it is still very substantial
savings.
Q814 Dr Taylor: At the moment, who
is doing the training of the ECPs?
Mr Stansbie: It is a local training
scheme using our competences and, of course, the beauty of that
is that becomes a transferable scheme because our competences
are recognised and transferable.
Q815 Dr Taylor: Which budget does
the training for ECPs come out of?
Mr Stansbie: I would guess it
is MPET but I am not an expert in those budgets locally.
Q816 Dr Taylor: If it is MPET it
could be targeted like everything else?
Mr Stansbie: It could.
Q817 Dr Taylor: I think one of you
implied that it was difficult for new jobs to appear. Is that
because with the cut in NHS training budgets it is the innovative
training courses that get cut first because they have to go on
with the old ones?
Mr Stansbie: I think there are
a number of issues about new jobs and new roles. First, we are
quite conservative as a health sector and therefore—and
I think it was said this morning—you have got to get clinical
buy-in to this. I want to stress that clinical buy-in is about
the whole clinical team and that takes time and by far the best
way of getting it is from the bottom up. Secondly, some of our
systems and processes mean that even when you have identified
the jobs, the competences and everything else then you have still
got quite a lot of work to do to make that a reality. Thirdly,
the education and training which we deliver is still quite bound
by what education provides, both further education and higher
education. I think John Sargent was saying in Manchester when
they tried to build a very substantial scheme for assistant practitioners,
they realised how long it took to get the education sector up
to delivering that number of people. I think you have got all
three of those things as factors.
Q818 Dr Taylor: Are either of you
qualified to say whether the independent sector are better at
preserving training budgets if they are hard up, or have they
not been hard up?
Mr Highton: I think part of what
we do is provide capacity for the NHS budget to utilise the work
we do for the post-graduate doctors to train on and also to provide
places where pre-registration nurse placements from the universities
can take place. We are contractually bound to deliver that training
capacity, it would be the budgetary situation within the NHS that
decides how much of it is taken up. I think in terms of our own
continuing professional development budgets, it is clearly in
our interest to continue to invest in the development of our own
staff but it is like any business, every bit of expenditure is
up for review annually, of course.
Q819 Charlotte Atkins: You both argued
in your written evidence that the independent sector should play
a greater role in workforce planning. How might that be achieved
and why do you think that is important?
Mr Stansbie: I think it is becoming
increasingly important because the percentage of the workforce
employed in the independent sector is growing and, therefore,
we would be most unwise not to take account of what is a growing
percentage of the workforce. In terms of how that is done, it
is even more complicated than in the NHS because a lot of independent
sector providers are very small and, therefore, it is about how
you can make sure that you are hearing those voices and bringing
what they are saying to the whole issue of the workforce. The
way we are approaching that is we have something called a "Sector
Skills Agreement" which all Sector Skills Councils are developing
which is basically an agreement of how you develop skills in the
sector and we have one of those for each of the UK countries including
England, which is actually agreed. It is a set of deals, but we
are taking that one stage further and looking at doing regional
skills agreements. I think it is at regional level that we stand
the best chance of involving the independent and voluntary sectors.
It will not be perfect and I do not think any of us would pretend
that, but it does, I think, give us the opportunity at a more
local level to listen to what the needs and requirements are and
also about how we can use the independent and NHS parts of the
sector together and, indeed, the voluntary sector. The voluntary
sector is not insignificant and some of the big employers in the
voluntary sector are quite substantial in local settings, so it
is about bringing all of those together. Of course, if we can
do that we get some real added value in terms of the capacity
that the independent sector can provide but also generally in
terms of driving new roles, systems and approaches, so that is
what we are hoping to do. That is from our point of view, as a
Sector Skills Council. There is then an issue about how we bring
that together with people, like WRT, National Workforce Programmes,
the Department of Health and others, who are very big players
in the workforce planning scene. I wish I had all the answers,
but we have got some of the questions I think now and we have
started to put some mechanisms in place which can help, simple
things, like working with David, the Independent Healthcare Advisory
Services, the regions and having meetings with the private sector,
as we had the other week, hosted by the private sector is a big
move forward from where we were.
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