Examination of Witnesses (Questions 940-956)
PROFESSOR CHRISTOPHER
FOSTER, MR
PHIL GRAY
AND MS
LOUISE SILVERTON
18 JANUARY 2007
Q940 Dr Naysmith: Professor Foster,
one of the matters you referred to in your submission was the
need for flexibility in the whole pathology workforce. How does
that tie in with what you have just been talking about?
Professor Foster: As I said at
the beginning, what we do in the college is to look across the
three sectors—the medically trained, the non-clinical scientists
and the technicians—and consider two questions. First, is
there work being performed by one of those sectors that should
be performed by another? We do not see that as being static but
constantly in flux. Many things which only a few years ago would
have been done only by medically trained persons for whatever
reason have now been cascaded down and are being done perfectly
competently by clinical scientists or those at a technical grade.
I am not being pejorative when I use either of those terms. At
the same time, we are looking towards core training so that within
those training grades we will have medically trained young pathologists
together with non-clinical scientists in training and biomedical
scientists or technicians taking core components of their training
simultaneously.
Q941 Dr Naysmith: What I am trying
to get at is whether you ever come across a situation where you
cannot implement new technology and the barrier to it is the lack
of adequately trained staff?
Professor Foster: Yes, we are
facing that. One of the current drives is for pathology modernisation.
My committee on modernising pathology careers and blue skies horizon
scanning for available technologies that can be introduced finds
that we can bring in new technologies and train individuals only
if we have time allocated in order that they should undergo education
and take time away from delivering the service within all of the
sectors of pathology. It is too tightly tied between the activities
of the pathologist or scientist at the bench, microscope or wherever
and the delivery of service and there is no slack whatever. Any
slack that there might be is perceived to be non-economic. I believe
that that view has to change, because to take in individuals,
transfers skills and bring in new technology so there is constant
evolution and education must be an investment for the future.
We do not have that at the moment.
Q942 Dr Taylor: I think you said
that the specialties within pathology were differently affected.
If you take biochemistry as an example, is it right that there
are very few medically qualified biochemists working now?
Professor Foster: Not entirely.
This is very interesting. We go back to what I tried to say earlier
about different roles. In many ways within the college it is probably
inappropriate to keep people who are medically trained within
the laboratory, unless they want to do that as a career, so that
the clinical skills that they have gained are not used and developed
for the management and care of patients. When we were at the Westminster
together chemical pathology was, if you like, a fixed entity,
but it has now changed. We now have specialties like clinical
chemistry and metabolic medicine. There are those trained in the
deep science and understanding of the chemical bases of diseases
who are perfectly competent and who are beginning to manage patients
and use those skills, devolving the strictly laboratory non-clinical
skills to non-clinical scientists. That is a very good example
of one of the matters to which I referred earlier.
Q943 Dr Taylor: You also said that
the workload was going up by 13% per annum.
Professor Foster: We use 13% as
a pretty good geometrical figure; in other words, the 13% next
year is based on the 13% that has already occurred this year.
Q944 Dr Taylor: It would seem that
as a result of a lot of technological changes the actual demands
for staff, even though the workload is going up with increased
automation, might even be going down?
Professor Foster: That is correct
if you look at the groups. It depends on how you want the medically
trained pathologists to interact, let us say. There is no doubt
that within medicine pathology harbours a deep understanding of
the science of medicine. Since pathology and science is no longer
taught as part of the undergraduate curriculum pathologists are
the only people who still retain that information. The motto of
the college of pathologists is that it is the science that underpins
healthcare. If one looks at how many medically trained staff one
needs to run an increasingly automated service the answer is relatively
few compared with the increase in workload, but one needs more
scientists and technicians. On the other hand, if one looks at
histopathology where one needs interpretation and a deep understanding
of the clinical relevance of the observations one needs far more;
one needs to keep expanding those.
Q945 Dr Taylor: Has the decline in
the post-mortem rate had an effect on reducing the workload?
Professor Foster: Not so much
in terms of the workload, because the surgical material that is
coming in is going up enormously, but as far as concerns feeding
hard data and information into medicine and management of patients
and the critical evaluation of clinical procedures and how patients
are managed, I think that we are in an appalling situation. One
of the most fundamental audits of the effectiveness of clinical
services has just been cut away from underneath us.
Q946 Dr Taylor: So, post-mortems
are no longer used for training medical students?
Professor Foster: No. I understand
where your question comes from. I tried to answer the question
at one level, but I believe that the deep implication which I
have tried to explain when I talked about the science—you
now ask about autopsy—is the fundamental understanding of
disease. Our understanding is not static; it is not that which
was present five, 10 or 15 years ago; it is evolving so that there
are new types of management, sub-divisions of diseases and the
development of biologically appropriate ways of treating or not
treating patients. Malignant disease, cardiovascular disease and
metabolic disease are all affected.
Q947 Dr Taylor: One of the witnesses
mentioned payments by results. Should there be an element in the
tariff for training? At the moment I believe that it is funded
separately, is it not?
Ms Silverton: There should be,
certainly with respect to continuing education for midwives. Last
year's survey showed that 70% of midwives received fewer than
two days' training each year, and 36% got time off but had to
pay for and organise their own training. It has become far worse.
A survey that we did just before Christmas showed that 40% of
units had cut their training budgets, and in 20% of cases the
cut was 100% and there was no training at all. Two of those units
are doing some training using endowment and charity funds. We
are not talking about having a nice day off; we are talking about
mandatory training for midwives that affects lives. For example,
if one thinks of the assessment of foetal heart rate and the practising
of drills when things go wrong in labour wards, unless one practises
them when something goes wrong one does not know what to do. For
some of these things one has to do it once a year or twice a year,
and they are being cut. What does that do for quality of patient
care? There is a shortage of midwives. We want to introduce the
midwife as the first point of contact. We want midwives to move
from hospitals into midwife-led units. They are skilled and competent
midwives but currently, to use an analogy, they are driving an
automatic car. If one gives them a car with gears they need to
learn how to drive it. They understand road sense but they have
to feel confident about doing it. There is no backfill for them.
How on earth will they deliver an agenda set by the Government,
which we fully support, that puts women at the centre of care
and planning it? I am now beginning to despair.
Q948 Dr Taylor: Is one answer to
have payment by results and alter the tariff?
Ms Silverton: It needs a proportion
for funding and training, in the same way as the Birthrate Plus
tool kit.
Mr Gray: I add that there is a
need to widen that because the government are looking at changes
not only in the provision of services by current NHS providers
but also by diverse other providers. We need to make sure that
there are elements built into that and that the independent sector,
which will be increasing in future, plays an active role both
in commissioning and sharing responsibility for providing post-qualification
training for others.
Q949 Dr Naysmith: We feel that we
sorted that out, or at least contributed to it in our report.
Mr Gray: But we and AHPs have
seen training budgets slashed. The answer to the earlier question
is that there should not be two separate budgets for medics and
non-medics; there should be a single one determined according
to need. We cannot have a beggar-our-neighbour situation; if budgets
are being slashed they hit everybody.
Q950 Mr Amess: We are coming to the
end of this fabulous evidence session. In a way, it would have
been interesting if our three witnesses could have shared the
platform with our three previous witnesses, and even more so if
we could get you back to share the platform with ministers at
the end of the inquiry, but perhaps that may not be possible.
Ms Silverton, you have delivered over 1,000 babies which is an
incredible achievement.
Ms Silverton: For the benefit
of the inquiry, I should say that most of them were in Scotland.
As you can tell from my accent, I am a Scottish midwife.
Q951 Mr Amess: When you retire perhaps
you will write a book on it. I am sure that, like Dr Finlay's
Casebook, it would be interesting. You said that the bursary
for midwifery students had been increased to £10,000. Can
you explain to the Committee why? Can you also tell us whether
you think that other healthcare students would benefit from bursaries?
I am sure that they would. How important do you think these bursaries
are in persuading people to enter the service?
Ms Silverton: It was two years
ago that we launched our campaign for a bursary of £10,000.
I am sure that we should be looking at increasing it now. It is
a nice round figure, but one needs to look at the issue of a non-means-tested
bursary. The profile of student midwives is quite different from
many other groups that come into healthcare. The average age of
students is 33 and 75% of them have dependents, so they have experienced
childbirth themselves and then they come into midwifery. They
struggle very hard on the bursary; they do not have university
holidays; they are looking at six to eight weeks' holiday a year.
It is very hard for them to work as well as be students. They
are delivering service and are working shifts in hospitals and
in the community and they are on call. Those with dependents have
their own homes so they have to keep their homes running. The
way that the bursary is currently calculated means that if their
partners earn more than £13,000 or £14,000 a year they
are regarded as contributing and often they find themselves on
those salaries subsidising someone who receives £5,000 or
£6,000 a year. There are very silly rules. Because of the
nature of midwifery and there is not a maternity unit everywhere
many find that for a period of their training they move from their
home unit to another one. If they choose to avail themselves of
accommodation at the second unit that is not reimbursed; if they
choose to drive each day it is. We find that midwives drive from
Plymouth to Exeter and back each day and try to keep their families
going. The peak time for midwives to drop out of training is towards
the end of the second year. We have invested £30,000 in them
and they have invested a lot of time, and for them often it is
the straw that break's the camel's back.
Q952 Mr Amess: You are Scottish and
probably for those reasons loans would be a big disincentive?
Ms Silverton: We would like to
look at that. We would not rule it out. Perhaps a loan that is
automatically repaid after a certain time if they have given service
in the NHS might be a way round it. That would keep midwives working
and contributing to the NHS, and it might galvanise the minds
of those who commission training to try to sort out some continuing
practice for them when they qualify. But they are a scarce resource.
Most of the people who come into midwifery regard it as a second
career; they have very good transferable skills. We have midwives
with PhDs who come into midwifery because they want to look after
women. It is a shame that they cannot get jobs, and we need to
address it.
Q953 Mr Amess: I do not have a quote
for Professor Foster to comment upon, but he should not regard
it as a sleight because he certainly made his presence felt at
the start of this session. I have a quote for Ms Silverton and
Mr Gray. Ms Silverton, you spoke about skill mix changes in midwifery
to combat budget pressures rather than as a way to improve care.
What is your evidence for that?
Ms Silverton: The evidence is
that the council of deans of the nursing and midwifery programmes
have done extensive surveys on education commissions. The fact
is that commission numbers have been reduced despite the forthcoming
NSF and the requirement for more midwifery time, and hospital
managers have said to us that they are cutting the number of 18-month
student midwives simply to reduce the salary costs and are spending
salaries on those who are directly delivering care. More worryingly,
we find that where a healthcare assistant has been seconded to
do three-year training—that is a well-known route into midwifery—there
have been major problems in re-employing them once they have qualified
because there is no money for that. Some of them have found themselves
qualified as midwives but are still paid as maternity care assistants.
Q954 Mr Amess: I am not a QC, so
I shall let you off with that answer. Mr Gray, you said there
was no evidence that change in roles would reduce demand for existing
staff overall. Does this mean that staff in new roles are creating
another tier of care rather than replacing more expensive staff?
Mr Gray: No. We think that the
very clear evidence is that physiotherapists are relatively inexpensive,
are productive and clinically effective and deliver major changes
in care. Within that, skill and grade mix matters. The problem
is: what is happening with that? At the moment we think there
is a danger that an almost inverted pyramid will appear with very
few junior posts and many senior ones being created. One significant
effect that emerges from it that the Committee may look at is
the tendency towards lazy workforce planning. We have been very
successful in demonstrating through research and elsewhere the
effectiveness of this change in roles. The tendency of NHS trusts
has been to seek senior physiotherapists rather than junior ones
with a complete lack of connectedness. They have commissioned
so many in previous years, but what are they doing about creating
jobs for those juniors to enable them to become progressively
the seniors of tomorrow? Instead, what has happened in physiotherapy—the
comment by the chief executive of St Thomas' about the abandonment
of workforce planning and leaving it to market forces raise more
than one or two questions in my head—is that we have been
drawing in from overseas increasingly large numbers of very able
physiotherapists. Our survey showed that in 1999-2000 the state
registration body registered 500; in 2005 that went up to 1,300,
which was an increase of well over 200%. They were filling the
gap which is demonstrated by that statistic. The qualified physiotherapy
workforce between September 2003 and September 2005, according
to the Department of Health's figures, increased by 2,000. The
increase in student numbers over the same period was about 500.
Where was the gap filled? It was done by drawing in people from
overseas. When as part of that we are pulling in people from poor
African countries—large numbers from Zimbabwe, South Africa,
Zambia and Nigeria—with comparatively few physiotherapists
to treat their needy populations to start with then lazy workforce
planning and free market forces become a scandal, because on the
other side this year we have 1,300 graduates who do not have jobs
and next year we may have a larger number. We have another 200
graduates coming out in the first three months of 2007. I think
it is crucial to plan that investment by the taxpayer properly
and productively in the service instead of simply looking for
short-term lazy solutions. Therefore, skill and grade mix really
matters.
Q955 Dr Naysmith: My experience is
that there are quite a lot of antipodean physiotherapists. How
long do some of these overseas physiotherapists stay employed
by the National Health Service? Do you have any figures?
Mr Gray: Yes.
Q956 Dr Naysmith: I suspect that
it would be a relatively short period for Australians and New
Zealanders.
Mr Gray: Australians, New Zealanders
and some South Africans—not others—used to come here
in sizeable numbers on holiday work permits. They would work primarily
and substantially for agencies doing temporary jobs. The recent
figures we have seen show a falling off in that number. Since
the Department of Health and the Home Office removed junior grade
posts from the shortage list which enables people to get work
permits there has been a reduction in those numbers, but the opportunity
for people from overseas occupying senior posts is wide open and
there are still very sizeable numbers of those. There is turnover,
but our evidence is that very substantial numbers from other countries,
including African ones, stay and do not go back home after a short
time.
Dr Naysmith: I interrupted Mr Amess.
Mr Amess: I think you have made your
case extremely well. I am sure that what you have just described
will be seen in many other sectors.
Dr Naysmith: I thank all three of you
for your contribution this morning. We have heard some very interesting
statements and comments. We hope that our report will be published
before Easter; if not, certainly very shortly after it. You will
be able to read your contributions and our deliberations in that
report.
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