Examination of Witnesses (Questions 920-939)
PROFESSOR CHRISTOPHER
FOSTER, MR
PHIL GRAY
AND MS
LOUISE SILVERTON
18 JANUARY 2007
Q920 Jim Dowd: Ms Silverton, I think
you referred to an increasing birth rate in this country. I thought
that in common with most of Europe, certainly northern Europe,
we had a declining birth rate.
Ms Silverton: We did have a declining
birth rate; it declined from 1996, but we are now back up to 1996
levels. There has been an increase of about 8% over the past five
years. The increase is greater in London because it has a younger
and different population. There are far more non-UK-born women
who come with their own needs. We will face significant problems
because we find that with PFIs maternity units are smaller; each
time they are replaced they become smaller. Women are told that
they will be going home four or six hours after birth, essentially
whether or not they like it. That puts increasing pressure on
midwives. I also echo what my two colleagues have said about people
being encouraged into midwifery. The average age of student midwives
is 33 and 75% of them have dependents. Having been trained over
three years at a cost in excess of £45,000, they find there
are no jobs for them. With respect to the six-point plan for midwifery,
that was cut off at the end of 2005 and nothing has replaced it.
Q921 Jim Dowd: That is linked to
the next question which involves Mr Gray. Is it the contention
of either or both of you that anybody trained in a medical school
has an automatic right to a job in the National Health Service?
Ms Silverton: My answer is that
anybody whose training has been paid for by the NHS should work
first and foremost for the NHS. I say that because 99% of births
in the UK take place in the NHS. The market in private maternity
care is very small; the number of births undertaken by independent
midwives is 0.07%, so from a midwifery standpoint my answer is
yes.
Mr Gray: We do not say that people
have an automatic right to a job. What we do argue is that in
terms of trying to ensure that a huge investment by the British
taxpayer is not wasted it makes sense to think about giving new
graduates something like a one-year job commitment, after which
they are on their own and they have to look after themselves.
We understand that in medicine there is effectively a two-year
guarantee of employment after qualification, and in Scotland there
is something like a one-year guarantee for nurses. There are precedents
for that. However, after that there should be no commitment. The
primary issue is how to deliver better and more effective and
efficient patient care. The issue as to whether or not we need
them is predicated on that patient need.
Q922 Jim Dowd: A former Secretary
of State for Health came up with the idea, again from the point
of view of protecting the taxpayers' investment, of requiring
all trained doctors to spend a minimum period with the NHS. I
hear that that got absolutely nowhere, largely because of the
opposition of the royal colleges of which you may understand I
am not a fan.
Mr Gray: The Chartered Society
of Physiotherapists is not one of the royal colleges and it takes
a different view. We estimate that the cost to the taxpayer per
physiotherapist, taking purely NHS figures, is probably in the
region of £30,000. If the estimated 1,300-odd physiotherapy
graduates of last year's output still do not have a job that is
a loss of something like £40 million, which is a huge waste.
The real issue here is that we are hit by short-termism which
is substantially to do with financial deficit reduction. To be
clear, financial deficits have not just been hitting in 2006,
though in that year it was much worse, but, as you found in your
previous investigation into NHS deficits, it also hit 2005 and
2004. That hits significantly jobs that junior physiotherapists
can do. It is often in those grades where there is the greatest
turnover, so those are the posts that fall vacant and become frozen
when the portcullis comes down. What is not centrally featured
in that are the needs of patients. We know from our own evidence
that waiting lists particularly in outpatient physiotherapy, which
are hidden because they are not recorded substantially in the
18-week wait assessment, are going up significantly. The evidence
we have put before you shows that in some cases it is going up
to something like four months. That guarantees that people end
up not getting their injuries at work dealt with quickly and effectively;
they end up on incapacity benefit and with a huge amount of employer
cost in sick pay, but the failure of joined-up thinking does not
link the cost or saving to the NHS compared with the cost to the
employers, the cost to the Department for Work and Pensions and
the lives of the individuals affected in that way.
Q923 Jim Dowd: We also discovered
in our deficits inquiry that as a proportion of total NHS spend
the deficits in 1997 were much higher than they are today, or
in recent years.
Mr Gray: Yes.
Q924 Jim Dowd: Turning to the royal
colleges, we received evidence from the NHS Partners Network to
suggest that the role of workforce planning should be to meet
the business expectation of commissioners and not the diktats
of the royal colleges. Do you agree with that proposition? What
role do you think the colleges currently play, and how can it
be improved?
Professor Foster: As the representative
of the Royal College of Pathologists perhaps I may answer that.
You have not provided any evidence for the stance you have taken.
I have already said, and can demonstrate, that the Royal College
of Pathologists, far from being defensive, is playing a very proactive
role in interacting with members of the Department of Health across
the board. We look not only at our own members—in other
words, the medically trained members—but we also integrate
the professional bodies of clinical scientists and members of
the IBMS to look at the totality of workforce requirements, so
there is no protectionism there. We certainly do not defend medics
against scientists and technicians. The evidence which is demonstrable
is completely contrary to what you suggest.
Ms Silverton: For the record,
although we are the Royal College of Midwives we are not a medical
college and we do not control the numbers that come into our profession;
they are commissioned by the NHS. At the moment we have a situation
where people have been commissioned to come into midwifery to
meet shortages but they cannot get any jobs. If we take the University
of Salford as an example, last year 34 midwives got jobs; this
year 12 did and there are unfilled vacancies, which means that
women in labour find that no midwife is caring for them. One midwife
is running between three and four women at the same time. It is
not that we are protectionist; it is to do with the quality of
care and women not being able to see midwives because there are
not any.
Mr Gray: I do not wish to comment
on the royal medical colleges, but in the case of the allied health
professions and physiotherapy we genuinely start by looking at
patient need and what is required to improve the delivery of service
to patients all over the country. An example of good connectedness
of both vision and decision was the NHS plan in 2000. Quite a
lot of work was done on that at the time and immediately after
in trying to forecast the then changes in policy and direction
of travel. One result was a government decision announced several
times in Parliament that the workforce in physiotherapy over 10
years would increase by 59%, that is, about 8,000 additional staff.
We were approximately half-way through that process when it changed,
despite the fact that since then there have been many other policy
proposals and changes, not least of which is the increasing elderly
population, the changes in the delivery of community services
and the need to be responsive to patient choice. Clearly, all
of that indicates a need for an increasing number of physiotherapists.
Our problem is not one of defensiveness but short-term cuts leading
to long-term problems in the delivery of healthcare.
Q925 Jim Dowd: This Government has
put more money in the health service than any other and the judgment
is that collectively we are approaching the point where the nation
is making its maximum investment in healthcare provision generally.
I do not think that we can increase its share of GDP much beyond
what it is. You refer to short-term cuts, but this is just financial
discipline, surely?
Mr Gray: We have no quarrel at
all with and warmly acknowledge the very substantial commitment
and investment that the Government have made and the way in which
things are being delivered. The shortening of waiting lists in
which physiotherapists and other HPs have played a significant
part is an exemplar of what has happened in that respect. It is
not a question of the money disappearing into a black hole; it
has delivered much higher levels of care, but that does not detract
from the damage which has been done as reflected in the report
of the Health Committee on NHS deficits in terms of short-term
decision-making. If I am being completely cruel about it, the
short-term decision is almost one where they plan to produce more
physiotherapists, and most of the senior decision-makers you talk
to will acknowledge the continuing need for those physiotherapists,
but the service will say to those graduating, "We are terribly
sorry. We did intend to do this but it is just not convenient
at the moment." For people who are very bright, able and
committed that is disillusioning, but those same people have the
opportunity to go somewhere else. The average physiotherapy student
going onto a course has the same high A-level score that is required
to get into medical school. If those same bright people do not
find jobs in the NHS they will eventually find jobs not just in
McDonald's and short-term positions where they are now but in
the City and in companies that will use them outside healthcare.
In a couple of years' time we will be scratching our heads and
asking what the heck happened to all the physiotherapists.
Q926 Jim Dowd: Our local McDonald's
in Forest Hill closed down last September.
Mr Gray: That was not because
of the physiotherapists, hopefully.
Ms Silverton: We recognise that
significant money has been put into the NHS. However, when one
looks at the proportion of that money spent on maternity services
it has fallen from 4% in 2000-01 to 3% in 2003-04.
Q927 Jim Dowd: But in cash terms
it is a much higher figure, is it not?
Ms Silverton: I agree, but when
one looks at the significant increase in the number of nurses
in the NHS, which is 20% to 25%—the Department of Health
does not disaggregate midwives from its nursing figure—the
increase in midwives is less than 5% and they have been asked
to do much more in screening, meeting disadvantaged groups, assisting
breast-feeding mothers, dealing with domestic plans and with an
increase in the birth rate.
Q928 Jim Dowd: The NHS workforce
review team works with you and other organisations. Is it effective
and useful? Is it of any benefit?
Mr Gray: I believe that the workforce
review team does a good job but within severe limits. Its work
is now much more effective in looking at the supply side; in other
words, how many staff are in the service, how many people are
coming in and what is the likely wastage rate from the service
and so on, but there are still big gaps. For example, in physiotherapy
and other AHPs the system does not collect any information about
the speciality and grade mix. It can tell you how many physiotherapists
there are but not how many senior ones there are, and it certainly
cannot tell you how many of those seniors are involved in delivering
care for older people. There is a gap on that side but the bigger
gap is on the other side. I make very clear that workforce planning
is inherently very difficult. If it was easy everybody would be
doing it. From conversations that we have had with them—I
respect their expertise—their big gap is the forecasting
of demand. First, experience shows that when you start off with
decisions at local level, where they have to be, you have to take
account of the population's needs. We are told by the workforce
review team that we cannot really deal with patient needs; all
we can deal with are expressed demands from employers. Whether
they reflect the needs is quite another matter. Second, the information
that they get is extremely poor. In our evidence we have cited
the fact that we got so irritated by the last set of figures from
the workforce review team—again, this is not their fault;
they get it locally and from SHAs—that we made a Freedom
of Information Act disclosure. First, we demanded from every SHA
all their figures on physiotherapy workforce demand. We were appalled.
Out of the then 28 Strategic Health Authorities, 11 put in no
information. Five were the London SHAs, the largest employers
in the country, and there was no information from them leading
to future projections. Second, a number of the SHAs had no physiotherapy
breakdown; they had an AHP figure. That is a bit like saying that
a physiotherapist is a radiographer, is a pathologist, is a dietician,
is a biomedical scientist. Of course they are not; they are very
different and need to be looked at differently. When short-termism
comes in the problem is compounded. At a purely practical level,
when people fill out forms in trusts and indicate how many nurses
or physiotherapists they will need in five years' time when faced
with very big short-term financial directions their horizons are
reduced. Whether it is a junior person in an HR department filling
out that form—frequently in the past it has been—or
a senior one, the inclination to do the digging and true investigation
that is needed is not there. For all these groups, the medium
size and smaller professions, in the health service there is a
major gap in terms of information for the future. With the best
will in the world, the workforce review team with all its skills
is handicapped by that lack. They tell us that they simply must
reflect what the SHAs tell them they believe they need.
Professor Foster: I agree that
there is a big problem in the Strategic Health Authorities in
terms of commissioning. We work very closely with the NHS workforce
review team on almost a continuous basis. Until last year the
WRT made recommendations about the NTNs—national training
numbers—required in the various pathology specialties to
be able to maintain the services as they saw them expanding, but
there is no mandatory element there. Strategic Health Authorities
can choose either to accept or ignore that advice, and they will
not put money into training if they have budget deficits elsewhere.
As we have seen in the past year, the MPET moneys have been unbundled
and are no longer ring-fenced and so there is a very real risk
that training will be compromised. The other element at the start
of the discussion was the difference between numbers. I believe
that part of the problem of workforce planning in the United Kingdom
is that for too many years we have concentrated on whether we
have replaced the numbers of individuals there at particular levels
in the past. Bearing in mind what I said earlier, the Royal College
of Pathologists is looking holistically not just at the medical
workforce but also the scientists and technicians. We put together
a group under my chairmanship which also involved the NHS workforce
review team, the Audit Commission and the Keele clinical management
group. The reason was my desire to develop an algorithm by which
we could look at the workload of individual laboratories around
the country. What is the amount and type of work and what is the
expertise required to deliver on the work that is coming in? As
clinical services develop, as they should, and are underpinned
by pathology then one can predict the types of people one needs.
In that integrated manner one can not only transfer skills between
the groups, as Sue Hill wants to do, but look also at joint training
and education, about which Charlotte Atkins asked in the previous
session. At the moment we are hampered by the way the Strategic
Health Authority particularly does not interact with us and commissions
work. We think that that is too na-£ve, restrictive and parochial.
Q929 Dr Naysmith: In pathology about
10 years ago one of the things that was happening was the privatisation
and out-sourcing of pathology services, not so much clinicians
but the other two strands that you talked about at the beginning.
Has that continued apace, and will it not have an influence?
Professor Foster: Of course, privatisation
is something that has come to the fore both through pathology
modernisation and, more recently, discussions around the Carter
report. At the end of the day, one needs to specify which type
of pathology one is talking about. If one is running a private
clinical chemistry laboratory where there is a very high automation
rate compared with manpower and one can run machines 24 hours
a day 365 days of the year one benefits by taking on work from
almost any source because it becomes more efficient. One cannot
do the same with histopathology, for example, or something that
requires a much higher manpower/unit workload ratio. Looking at
the latter, the number of histopathologists available in the country
who are able to report is relatively small. At some point during
the day they need to stop what they are doing and take a rest.
That is where the European Working Time Directive comes in. When
that is fully implemented it will be illegal to work 40 hours
a week in the NHS reporting histopathology and then to do another
40 hours elsewhere. I believe that that was where Sir Jonathan
Michael was na-£ve in saying that one would just recruit
from outside. The Royal College of Pathologists tried to do that
on a number of occasions. We do not believe that it is legitimate
to take pathologists from, say, third world countries where they
should be employed more effectively. We have stopped that as a
policy. But in addition those people are not there and we need
to train them. The money needs to be put in early because there
is a lead period of something like 13 years between identification
of the need for a pathologist and the training of somebody who
has those skills and can practise independently.
Ms Silverton: We work extremely
closely with the workforce review team and it has been quite a
satisfactory arrangement. However, we suffer quite badly from
what local information is fed in. Heads of midwifery will ask
what has been sent in about their need for midwives and a junior
person in HR has looked at the age profile and decided that four
will retire in the next two years and that is it. That takes no
account of service changes and increased part-time working. We
have also been hit by what is, I suppose, the double-whammy of
two routes into midwifery. There is the three-year route which
is paid on a bursary, and in England there is an 18-month route
post-nursing. Those people are paid from the NHS salary bill.
The number of commissions in some areas has been cut by up to
one third, which means that in 18 months' time there will be a
third fewer student midwives coming out. We have some suggestions.
We would like to see all units use the Birthrate Plus workforce
tool every three years or when they reconfigure their service
and change their model of care. We would also like to see the
information on workforce numbers for midwives disaggregated from
that for nurses. We are talking about 24,000 whole-time midwives
in England and hundreds of thousands of nurses. We just need to
be able to produce specific figures.
Q930 Charlotte Atkins: I think we
are all agreed that the number of staff in the NHS has massively
increased. There has been an increase of about 24% between 1999
and 2005. From what you have said, I suspect that if I asked you
about staff numbers in your own areas you might not be able to
give me exact figures. Ms Silverton said that midwife numbers
had increased by 5%.
Ms Silverton: There was an increase
of 896 between 1997 and 2005, so it is an increase of less than
5%.
Q931 Charlotte Atkins: I do not know
whether Mr Gray can give a comparable figure.
Mr Gray: In physiotherapy the
increase has been just under 5,000 since 1999, which is about
33%.
Professor Foster: As to pathology,
yesterday I obtained the figures and compared them with data from
the health and social care information centre on the web. Overall,
the increase is 5.2% but that also includes a deficit of something
like 3% in chemical pathology and 16% in immunology, so there
has been a fall in some sectors. Overall, there has been no increase
greater than 8%.
Q932 Charlotte Atkins: What would
be the overall increase?
Professor Foster: It is 5.2%.
Q933 Charlotte Atkins: What I would
like to ask you, not so much about your own areas because obviously
the increases are relatively small, is whether you think the increase
in staff numbers has been effectively managed within the NHS.
Professor Foster: Do you mean
within pathology?
Q934 Charlotte Atkins: I was going
to ask you about your own sectors but also your impressions of
the increase in staff outside those areas.
Professor Foster: I do not think
I have the data to be able to tell you the position outside my
own sector, and it would be presumptuous for me to try to do that.
Q935 Charlotte Atkins: In that case,
perhaps you could comment on your own sector.
Professor Foster: I think that
pathology, which is very much a self-motivated group of specialties
straddling science and the medical/clinical field, has been over-managed
to focus upon delivering service with relatively little resource.
We accept that there has been an expansion, but what you have
not asked about is the expansion in the workload. Laboratories
generally work on a geometrical expansion of 13% per annum, so
if you set that against an overall arithmetic change of 5.2% in
workforce numbers the disproportion, irrespective of the increase,
is enormous.
Q936 Charlotte Atkins: What about
the deficit areas that you talked about? You said there was a
16% deficit in immunology. What impact has that had?
Professor Foster: It is enormous.
One hears in the media frequently that accurate diagnoses and
investigations are being long delayed, not because the individuals
concerned are not working to the maximum but because there is
a mismatch between the resource and their workload.
Ms Silverton: With respect, unfortunately
it has been very badly managed. The six-point plan came in with
a great trumpet fanfare and there were lots of things about continuing
professional development for midwives. That ended totally at the
end of 2005. There is now no funding for midwives' return to practice
or for adaptation of overseas midwives who could gain entry to
the register and who are far fewer than in nursing. The total
number of midwives, which is the number that the NHS likes to
use, has increased slightly. However, now 55% of midwives work
part-time, whereas in 1997 the figure was 43%, so they are delivering
fewer hours and fewer babies. The manifesto demands have not been
looked at with respect to resource requirements. Given the increase
in older mothers who need more midwifery care and the number of
teenage mothers, I think the whole thing is a bit of a mess. We
probably need to go back to the drawing board and have a look
at what can be done to manage this. In about 2000 the Secretary
of State said there would be 100 consultant midwives. As of 2005
there were 50, since which time there have been redundancies and
an even further reduction in posts. I am afraid that payment by
results does not help because the basis on which the costings
have been made locally is flawed and it appears that all trusts
want to do is reduce the number of midwives as much as possible.
We have seen some very significant increases in the number of
healthcare assistants. The college is much in favour of having
appropriately prepared maternity care assistants as part of the
team, but our evidence is that they are being used to substitute
for midwives. Birthrate Plus shows that for an average DGH you
can substitute approximately 9% of midwifery time primarily in
postnatal care, but you cannot substitute anywhere else without
loss of quality of service.
Q937 Charlotte Atkins: Mr Gray, in
your evidence you wanted to focus on heads of content as well
as head count. Therefore, when you answer the question about your
particular area perhaps you can also elaborate on that issue.
Mr Gray: I take a different view
from Ms Silverton in that in terms of employed staff it has been
managed very well and has been very successful. There is a different
answer, to which I will return, when we come to the issue of how
well the large number of unemployed graduates has been managed.
Just looking at what has happened to the additional staff employed,
it has worked tremendously well in terms of prevention and treatment,
real innovation in the way services are delivered and the locality
in which they are delivered. They are highly productive changes
that have reduced waiting lists and improved the delivery of care.
To quote just a couple of examples, for the past several years
in physiotherapy there have been more and more places, but still
not all—the Prime Minister did not say that about exactly
the same issue a few years ago—on orthopaedic surgeons'
waiting lists. That has resulted in something like a 70% reduction
in their waiting lists which are the longest in the NHS. That
is done by experienced specialist physiotherapists reviewing the
whole of the waiting lists and directing up to 70% of the people
on those lists either into physiotherapy or other forms of treatment
and allowing the other 30%—people who are likely to benefit
from surgery—to go forward. That saved a huge amount of
time and money. As to the delivery of services for older people,
there has been a significant expansion in relation to the national
service framework that came out in 2003. We can always think of
lots more things that can be done, but in terms of physiotherapists'
contributions to enabling people to get out of hospitals and hospital
beds reasonably quickly and restoring their ability to go back
to their homes and normal lives, not ending up unnecessarily in
nursing home care with the huge cost that that involves, they
have played a big part in that. One of the recent developments
is in patient self-referral systems, enabling patients as part
of patient choice when they have an injury to refer themselves
directly, instead of going to a GP, to a physiotherapy service.
Referring to the Health Service Journal awards that took
place only a few weeks ago, physiotherapy self-referral systems
in Scotland got the prize for the best innovation in terms of
access. There have been a lot of very significant changes, but
there are gaps. One classic gap is the lack of joined-up government.
A major issue about which the Government are concerned is how
to reduce the number of people on incapacity benefit. How does
one reduce the 680,000 people who go onto that benefit per year?
One answer is to try to provide treatment for those people who
are on incapacity benefit, but a much better one is to decide
how to get rapid access to effective treatment. Patient self-referral
systems do that. Unfortunately, although the Department for Work
and Pensions and the Government overall want that the NHS is not
investing in it. Joined-up government would help.
Q938 Dr Taylor: Before I go on to
deal with training funding I just want to reassure Mr Gray that
we are aware of a huge lobby of unemployed physiotherapists. Ms
Silverton, in your evidence you said that perhaps there were some
newly-qualified midwives who were not able to get jobs. Do you
have any idea of the numbers? Is it a major problem?
Ms Silverton: That has become
an increasing problem since September of last year. It is quite
hard to find out. In Salford in 2005 35 midwives got posts. The
University of Salford trains for a number of the Manchester hospitals.
This year 12 have got posts and we understand that there are sufficient
vacancies for all of them. As a proxy, in November and December
of last year we had 350 fewer moving from student to core membership.
That is indicative of the fact that it is a major problem. I think
that we might have been much happier with the Government on how
things had been done if, like the physiotherapists, we had had
an increase. We called for 10,000 more midwives which would have
been an increase of a third; we have had just under 5%.
Q939 Dr Taylor: To go back to training
funding, in the deficits inquiry that we have just undertaken
we were horrified to find how training budgets had been affected
so severely. It relates particularly to non-medical rather than
medical training. Turning to Professor Foster, obviously pathology
includes medically trained doctors, clinical and biomedical scientists
and other staff. Is the difference in the training funds available
for the medically qualified and the others very obvious to you?
Professor Foster: I think that
that depends on the individual specialty. Across the board we
are short of funding, but the landscape has changed this year.
Medical training was protected by the MPET levy but it is no longer,
so we will not see the effects of that. In any case, we have faced
a shortage of people wanting to come into pathology because within
the undergraduate medical curriculum in the majority of schools
pathology is no longer a core component. This comes back to my
comment at the beginning. If there is no profile you are hardly
likely to want to choose such an occupation for a future career.
The answer to your question is that when you compare the scientists
and medics the factors affecting recruitment are very different.
The quality of non-clinical scientists and technicians who predominantly
are now recruited from universities—so they are graduate
entrants—is extremely high. The problem until recently,
which I believe Sue Hill is trying to address, is that there has
been a mismatch between the time to registration and its requirements
and the funding available for registration so that numbers of
the non-clinical scientists would come in at the required four
years but they would do three years. They would not get money
for their final year before registration and would leave and go
into industry, which would mean a huge drain on resources from
the NHS. We estimate that it would amount to somewhere between
£80,000 and £100,000 per person dropping out at that
point. The funding has been there but it has not been structured
correctly in terms of career structures, and that is being addressed.
On the medical side, the problem is lack of profile so we are
not recruiting because we have little or no presence across the
board in the undergraduate medical curriculum.
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