Examination of Witnesses (Questions 1020-1039)
LORD HUNT
OF KINGS
HEATH, MS
CLARE CHAPMAN
AND MR
NIC GREENFIELD
25 JANUARY 2007
Q1020 Mr Jackson: So you are saying
there has not been an enormous amount of organisational change
in the Health Service since 1997? Is that your contention, Minister?
Lord Hunt of Kings Heath: The
history of the Health Service since the 1970s has been one of
a huge amount of structural change and, frankly, I think it would
have been better over that whole period if we had had less structural
change. Is the structure right now? I think it is because what
we have got is a situation where we are encouraging practice-based
commissioning, so we are giving GPs much more ability to determine
the services on behalf of their patients, on Primary Care Trusts,
I think 70% of Primary Care Trusts are now coterminous with the
local authority area and that makes a lot of sense in terms of
the interrelationship between health and social care and other
issues, and on the Strategic Health Authorities, the 10 cover
a region and, whilst those regions will not be totally self-sufficient,
they are large enough with medical schools to actually ensure
that you have got a total provision of health services for everyone
living there, so I do think we have got the right structure and
that is why I think the discretion we want to give to SHAs is
also right.
Q1021 Mr Jackson: As you touched
on medical schools, could I briefly just draw your attention,
and you may have seen the evidence, to the evidence by Professor
Sir Andrew Haines of Universities UK who said with respect to
education money as it, "being at the mercy of the SHAs, where
inevitably it is going to be sacrificed for short-term emergency
spending". How do you react to that comment?
Lord Hunt of Kings Heath: I think
it is wrong. SHAs know that working in close collaboration with
medical schools is part of their strategic leadership role. We
have made clear to them that we are going to monitor them in terms
of their long-term planning. Long-term planning in relation to
the workforce means a very close association and working relationship
with universities and other higher education institutions. I think
that is far too bleak an assessment and I do not believe it will
happen. What we have seen this year has been a response to a difficult
situation, but that will not continue in the future, and we will
monitor SHAs against it.
Ms Chapman: You asked for a real-life
discussion and it struck me that, when I went out to the West
Midlands just before Christmas, what I did see was that a way
of doing workforce planning and making very sensible decisions,
linking it both to what the Service needed as well as affordability,
was going on there. Is it wise to give that responsibility devolved
down? From that example, it suggests to me that there are places
where we can define what good looks like around the work that
happens at both the SHA and the trust level. Do I think that we
have got that level of standard across the Service? Again first
impressions would be no, but my sense is that it is not a will
gap. There are a lot of trusts that actually want to get better
at this and it is more of a skill gap than a will gap. As the
Minister said, given the structures that we have now got, I think
it is beholden on us to focus on building skills to do this rather
than reorganising because I do not think the reorganising will
solve that problem, but I do think there are examples of what
good looks like.
Q1022 Mr Jackson: Are there people
on those boards who are tasked with making sure that education
and training is protected because the drive now is towards financial
issues and financial imperatives?
Ms Chapman: Sure.
Q1023 Mr Jackson: That is my concern.
Ms Chapman: What I saw on that
board was them making a decision that linked their training money
to their workforce plans, so they were being data-driven and informed
by the numbers of people that needed to come out of it as opposed
to, "Oh, there's a budget. Let's use that to plug any gaps".
It was a very sensible discussion and a very informed set of decisions
that they took.
Lord Hunt of Kings Heath: Just
on the issue of accountability, clearly the chief executive of
the Strategic Health Authority is accountable to the board for
making sure that this is done in the appropriate way and they
will be held accountable.
Q1024 Dr Taylor: Lord Hunt, it is
good to see you here, although I am very sorry you are no longer
battling with the CSA.
Lord Hunt of Kings Heath: I am
not sure I am!
Jim Dowd: Nobody will be soon because
it is going!
Q1025 Dr Taylor: This is really just
to put a little detail on the previous question because we heard
right at the beginning of this inquiry way back in May from Judy
Curson, the Head of the NHS Workforce Review Team, that there
was very grave concern about the lack of workforce planning skills
and that one would probably lose them with the mergers down to
smaller numbers of SHAs. Can we be assured that all 10 new SHAs
do have a director of workforce at board level?
Lord Hunt of Kings Heath: I do
not know the specifics. Do you know the answer to that?
Mr Greenfield: I can tell you
that the arrangement that we have agreed with the SHAs is to define
that workforce is a key responsibility which must have a nominated
lead at board level. In some cases, it is a dedicated director
of workforce and in other cases it is merged, for example, as
a director of workforce and nursing, but we are well networked
to them all. I can also confirm that not all appointments have
yet been made because these are infant organisations. Indeed,
there is an appointment process later this week for one of those
key posts and five strong candidates.
Lord Hunt of Kings Heath: Perhaps
I can say that my answer to Mr Jackson is that the person we will
hold accountable has to be the chief executive. Perhaps I could
ask Clare Chapman to comment because one of her roles is to increase,
and develop, capacity in the general HR workforce function.
Ms Chapman: I met with the workforce
directors of the SHAs last week and it was very clear that there
was a call from them to make sure that, rather than having 10
different approaches, we actually codify what good looks like
and then do some skill-building around it. Otherwise, what is
going to happen is that it is going to take quite a long time
to learn the lessons of how to do it well. Partly I think it is,
"Let us get the right people in", and, as Mr Greenfield
mentioned, participating in the appointment process tomorrow for
one of those roles, and I think the main aim would be to get the
right people in those roles and then make sure that we do the
appropriate monitoring.
Q1026 Dr Taylor: Can I expand on
the difficulties faced by SHAs a little bit. Lord Hunt, you have
said workforce, financial and service-delivery planning have got
to be combined and you, Ms Chapman, have said that the forecasts
must be right. Even though Lord Hunt does not want to micro-manage
centrally, there have been an awful lot of changes demanded centrally,
particularly if you are thinking of sudden edicts to have independent
sector treatment centres that perhaps are not needed, but do these
changes demanded centrally not make these forecasts almost impossible?
Lord Hunt of Kings Heath: No,
and on the issue of ISTCs, I think it is absolutely right, first
of all, that they were developed to increase capacity and then
it is also right that we do encourage innovation and that no one
should feel complacent in the NHS because they do need to feel
that there is contestability. Are there implications for the independent
sector providers in relation to workforce planning? The answer
is yes. You will probably be aware that, in relation to the treatment
centres, there are certain restrictions based on the staff that
those ISTCs should recruit. Longer term, do we need to take account
of the independent sector in relation to workforce planning? I
think the answer must be yes and indeed, if we have more pluralistic
provision of services and, incidentally, of course not just health
services, but social care services too, in the social care field
there is clearly a huge proportion of people employed by independent
statutory agencies, clearly we need to have that in mind and we
need to have a strong relationship with those providers to make
sure that at the end of the day we are producing enough people.
Q1027 Dr Taylor: I think some of
the complaints we have heard have been where independent sector
treatment centres have not, if you have really examined NHS capacity,
actually been needed and, therefore, this does take work away
from the NHS workforce who could have done it, and this is going
to affect staffing levels.
Lord Hunt of Kings Heath: Clearly
those are considerations that have to be taken into account in
the development of the programme, but I think, as I have said
earlier, that there are two things here. One is increased capacity
and we have needed to increase capacity, but also we should encourage
new people to come in to provide services; that is how you get
innovation. We do have to acknowledge complacency amongst NHS
organisations, so I think of course there may be some tensions
over staffing, but we have done our best to make sure that in
the first tranche there would be no impact and I think in the
second tranche it is to make sure that you protect the shortage
specialties, so we are trying to do that in a way which has less
impact on the staffing issue.
Q1028 Mr Amess: Anne Rainsberry,
the Director of People and Organisation Development at NHS London,
as a representative of Strategic Health Authorities, expressed
frustration that they are financially accountable for postgraduate
medical training, but have no influence over the number of trainees
or the content of training. Would you answer that charge please
in 50 words?
Lord Hunt of Kings Heath: I cannot
answer on the actual details, but I am happy to write to the Committee
on it. As a general point, part of the deal really with SHAs is,
"We are placing a lot of responsibility on to you and we
expect you to sort out some of these very difficult issues. The
other side of the coin is that you then play an integral part
in the decisions we make at national level in relation to workforce
planning issues", and that is how we want it to work in the
future.
Mr Greenfield: The content of
the postgraduate medical curriculum is the statutory responsibility
of the PMETB, the Postgraduate Medical Education Training Board,
which is independent, but has responsibility to take account of
affordability and employers' views, and they could be fed into
that. On numbers, part of the workforce planning process, which
we do engage SHAs in, is to determine the number of posts for
postgraduate medical students, so I would not accept what she
has said without clarifying it.
Lord Hunt of Kings Heath: Perhaps
we might just follow this up with a written response.[3]
Mr Amess: If you could, please.
Q1029 Mr Campbell: Recently you conducted
a full workforce planning inquiry of all the aspects of workforce.
What were the changes and what was the outcome of that?
Lord Hunt of Kings Heath: I think
that this is the review by Lord Warner.
Q1030 Mr Campbell: Yes.
Lord Hunt of Kings Heath: I think
that one of the principal conclusions is what we have been talking
about in the Committee today, that, to make workforce planning
as successful as possible, we have to make sure that—
Q1031 Mr Campbell: If I can give
you some of the big issues which have just been mentioned before,
they were integration between the workforce and the service planning,
the lack of clinical engagement with the workforce, the education
and training investment "blighted" by short-term financial
considerations, that sort of thing, and that is the sort of thing
obviously we are looking at and that really is the whole gamut.
Lord Hunt of Kings Heath: You
have described my agenda for the future. Those are the very issues
which we have been debating. We have learnt a lot of lessons—
Q1032 Mr Campbell: But Lord Warner
has not come up with anything? He has looked at it, but he has
not come up with anything?
Lord Hunt of Kings Heath: No,
I do not think that is fair at all to my esteemed predecessor
who might have been before you today, but for his decision to
retire. He set in train this review. It has brought forward those
conclusions. Our job, the people here, is to make sure that we
get on and ensure that the Health Service is able to meet them.
Clearly, the discussions that we are having with the Strategic
Health Authorities, this is all designed to make sure that we
do achieve what the outcome of the review suggested.
Q1033 Mr Campbell: So Lord Warner's
inquiry still continues? Basically, that is what you are saying.
Lord Hunt of Kings Heath: Basically,
the outcome of his inquiry is setting the agenda for our work
at the moment, yes.
Q1034 Mr Campbell: And will this
Committee have an input into that?
Lord Hunt of Kings Heath: We would
be very interested and obviously the conclusions of the Select
Committee will be considered very carefully. It is not as if we
have got a hard-and-fast, "We have had the review, that's
it". Workforce planning is an ongoing process and we will
certainly take account of everything the Committee says of course.
Q1035 Mr Amess: That was, by the
way, the killer question, so we are going to look very carefully
at your answer to that particular question now you have answered
it! We had an interesting debate this week in the House about
MRSA where an awful lot was said about the productivity of the
NHS workforce. Do you think it should be a key priority, given
the current NHS financial position, the productivity of the NHS
workforce?
Lord Hunt of Kings Heath: You
mean improving productivity?
Q1036 Mr Amess: Yes.
Lord Hunt of Kings Heath: Yes,
absolutely. I think, as I have said, that the changes to the contract,
Agenda for Change as well as the doctor contracts put us in a
much better position to improve productivity. There is clearly
a real challenge for the leadership of NHS organisations to chase
down productivity. I think that the work which has been done on
productive time shows great promise, but we need to do much more
than that. Again I would say that one of my priorities and that
of Clare Chapman and the Chief Executive is to enhance leadership
skills within the NHS in order to engage with clinicians and to
make productivity improvements, so it is absolutely the right
thing to do and we are going to do it.
Q1037 Mr Amess: So the work that
you have in place, the measurement of productivity, will actually
be clearer now that you will measure productivity?
Lord Hunt of Kings Heath: Again
I think earlier I promised to write to the Committee in terms
of our assessment on productivity because of the rather technical
nature of how we describe it, but absolutely, and I think the
Secretary of State has made it clear that we want to see improvements
in productivity. I do think that the work on productive time does
show that we are getting there. I have no question at all, in
terms of the big challenges that the Health Service faces in the
future, that we have to drive up and we have to have more productive
working. We have to go for it, yes.
Q1038 Dr Naysmith: Dame Carol Black
told us that the National Health Service tends to put extra resources
into performing more activity rather than thinking it through
and thinking about how these activities can be performed more
efficiently. Do you agree with that and do you think we can break
the deadlock if you do? How would you see about doing that?
Lord Hunt of Kings Heath: I cannot
pretend to be an expert in clinical procedures, but, if one is
looking at where we want the Health Service to go, it is to take
a much more integrationist approach. We talked earlier about physiotherapists
and it is certainly my belief that the more physiotherapists and
the earlier that the physiotherapists can treat the patients,
the more likely it is that they can get better without having
heavy interventionist work. Now, I think there are any number
of examples where, in an holistic approach to patient care, you
do try to intervene as early as possible rather than simply being
concerned about the number of operations you do, and it is exactly
where we want to be.
Q1039 Dr Naysmith: I can think of
just one situation which I know quite well and it is to do with
stroke. It is quite clear, and there is lots of evidence to suggest,
that, apart from the necessity to get stroke patients scanned
to decide what sort of stroke they have had, once we have got
to the stage where that is happening routinely, there is a lot
of evidence to show that the sooner you get physiotherapy and
other things like speech therapy and so on involved, it makes
a huge difference to the outcome. Clearly, if we can do that efficiently
everywhere in the country, which we do not have to do at the moment,
that will save a heck of a lot of money in terms of aftercare
and so on for stroke patients.
Lord Hunt of Kings Heath: You
have described also the issue with people on incapacity benefit.
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