Examination of Witnesses (Questions 1040-1059)
LORD HUNT
OF KINGS
HEATH, MS
CLARE CHAPMAN
AND MR
NIC GREENFIELD
25 JANUARY 2007
Q1040 Dr Naysmith: Yes, it is exactly
the same.
Lord Hunt of Kings Heath: For
far too long people get on to IB and, once they are on it, often
very many people stay on it for years, yet, if you could have
got early intervention right from the start, you would have prevented
them getting on incapacity benefit in the first place. We know
the life and health outcomes of people on IB are very, very poor,
so it is a no-brainer really, and the more we can get upfront
investment as early as possible, the better. That is why, if I
may go back to the issue of physiotherapists, I am concerned about
the position and why clearly we need to do everything we can to
try and resolve it. I think there are other examples where early
intervention helps. Of course NICE, in some of the guidelines
that they have been producing, give very good guidance to the
Health Service in that regard and I would expect NICE to continue
to do that.
Q1041 Dr Naysmith: It also relates
to what we were talking about earlier about needing a flexible
workforce and being able to build in this ability to change as
needs change.
Lord Hunt of Kings Heath: Yes,
and I think in Agenda for Change, for instance, on which almost
all the non-medical and dental staff have now been assimilated,
is an approach which actually encourages that by measuring the
job evaluation process. It does allow you to reward people for
the skills that they bring and it does allow you to encourage
and incentivise people to develop their skills into the kind of
flexibility that you want if you are going to get the kind of
change in service provision which you have suggested.
Q1042 Dr Naysmith: So is changing
the culture a priority in the National Health Service then? Everything
cannot be a priority, I know that.
Lord Hunt of Kings Heath: Everything
is a priority, but, thinking about the scale of the challenge,
let us pay tribute to the staff of the NHS; they have done a hell
of a lot in the last few years and we have seen a lot of improvements.
We now have to kind of step up a bit because, if we are going
to meet the real challenges, the demographic challenges of the
future, more monies come in, but we have be smarter at the way
we do things. That means a change in culture. The job of those
of us responsible for workforce planning is to take these incredibly
committed and skilled people and give them every opportunity to
enhance their skills, develop their skills and use them to the
fullest. That of course is about a change in culture, but I think
that we also need to give our leadership at the local level every
support and encouragement to lead that process. That is why, if
you are asking me what is one of my top priorities in workforce
planning, it is in enhancing leadership skills of people in individual
organisations so that they lead this change
Ms Chapman: If what you are striving
after is efficiency, then I think that flexibility that you talked
about is important. I am absolutely sure though that the other
piece is about engaging staff because inevitably the people who
know how to redesign it so that it is most efficient are the staff
themselves. What I saw before Christmas, going round a cancer
unit that had just been redesigned by the staff, was that both
the physical layout as well as the way the treatment was being
delivered was more satisfying to work in because people actually
felt they were wasting less time, it was far more effective for
the patients because they were not waiting around so much and
overall, when you looked at the productivity of the whole unit,
it was improving, so, as part of the leadership challenge and,
as you mentioned, Minister, the culture, I am completely sure
that engaging staff to find those efficiencies is absolutely the
right way to get at them fast.
Q1043 Dr Taylor: I am very glad you
have said that; it is absolutely crucial. I really want to go
on with flexibility a little bit. We have heard a lot about the
advantages, but what are the disadvantages of flexibility? Are
there any?
Lord Hunt of Kings Heath: Do you
mean in terms of individual members of staff or of the Health
Service?
Q1044 Dr Taylor: In terms of the
ability of staff gaining competencies in other things and doing
other things.
Ms Chapman: I have a general point
to make on that and that is that my experience is that one of
the big satisfiers at work is the opportunity to get on, so often
flexibility is one of the ways that you make sure that you provide
that ongoing challenge for people in the workforce. I think that
where flexibility can be combined with a career ladder so that
it is genuinely an opportunity to get on, then it is positive.
Where it can be negative is where you actually get a dilution
of skills or your get confused roles and that is where I think
it requires very careful working through because what you do not
want is everyone doing everyone else's job because (a) that is
not satisfying, and (b) it is not productive. What you also do
not want is people doing roles that they are not prepared for.
I think flexibility has to come with quite thoughtful work around
both of those areas.
Lord Hunt of Kings Heath: Of course
paramount must be patient safety in that sense. The issue about
people doing jobs for which they actually do not have the competency
is a very important factor here.
Q1045 Dr Taylor: So, as a way to
promotion, I would agree, that is absolutely brilliant to look
at it like that. One of our witnesses previously pointed to some
disadvantages and said that, "...when you substitute a nurse
for a doctor, nurses tend to consume more resources than physicians
but generate the same high quality of care output; but as they
consume more resources, that eats into the savings you get in
their salaries, so the overall effect tends to be cost-neutral".
Lord Hunt of Kings Heath: Well,
I am not sure that we have evidence of that. I will certainly
find out whether there are some indications, but I suppose in
a sense nurses, when they are given greater clinical discretion,
tend to work under protocols and my understanding is that nurses
work very well within those protocols, so I am surprised by that
and I am not sure that that is borne out in practice, but I will
see whether the Department has any information about that.
Q1046 Dr Taylor: I think the only
illustration I can give of that is if nurses are doing screening
clinics, then they would have a whole battery of investigations
that perhaps, if it was done by a doctor, they would reduce the
list. That has been suggested.
Mr Greenfield: I think that the
evidence we have of the different application of skill mix at
the moment is very patchy. One of the streams of work that we
have identified the need for within our productivity agenda is
actually to look at the 100 or more new roles that we have introduced
and to actually evaluate the business case to see, from the perspective
of value for money, whether the patient experience and whether
the benefit to the Service overall has improved. Where, frankly,
we have an overwhelming business case, a good example is the emergency
care practitioner which has enabled us to reduce pressure on primary
care, convert the ambulance service from what many people perceive
as a patient transport service to actually a front line of first-contact
healthcare; that would be a strong case. However, in some of our
other new roles, the case is not well understood, not well made
and it is that sort of evaluation that we need to do, to assess
the business case and then promote it through the SHAs so that
the commissioning reflects what is proven.
Q1047 Dr Taylor: Yes, emergency care
practitioners, we have had a lot of evidence to say how effective
and accepted they are. Turning to healthcare assistants, increased
training for them towards promotion is absolutely crucial, yet
these appear to be one of the groups that are hit worst by the
cuts in the training budgets. This is why I was so pleased to
hear you, Lord Hunt, say that these cuts were one-off cuts because
your predecessor at a previous session implied that this was going
to go on for some time.
Lord Hunt of Kings Heath: Let
me just comment on that. Of course the SHAs have to make their
own decisions within the framework that I have already suggested.
I cannot say that an SHA in the future will not make some reductions
in some training places because clearly they have to make their
own judgments. What I am saying is that, as a broad response,
we have had to deal with a very, very difficult situation this
year in terms of financial deficits and that has meant that SHAs
have had to make some very difficult decisions. We expect SHAs
to get back on an even keel and that short-termist decisions in
relation to training, et cetera, will not have to be made. What
I agree with you about healthcare assistants is that they do a
fantastic job and also there has been great success in helping
healthcare assistants, who have a lot of experience, in training
to be professional nurses, and clearly we would not want to inhibit
that. I can assure you that one of the key planks that we will
be monitoring SHAs on in the future is their ability to be able
to progress those staff. I cannot say to you that there will not
be any changes in the future in terms of number of healthcare
assistant places for nurse training, but I can say to you that
I have always considered that healthcare assistants know what
being in the Health Service is like and they have all that experience
of working with patients, so they are ideal people to then, for
those who wish to, encourage to become nurses.
Q1048 Dr Taylor: So you will feel
able to put some pressure on SHAs to protect those sorts of training
posts?
Lord Hunt of Kings Heath: I have
no problem at all about putting pressure on SHAs and, if anything,
ministers have to be very cautious about that. What I have said
is that I want to give them as much discretion as possible because
I think ultimately that is the only way you get the harmony between
money, services and staff, but their commitment to long-term workforce
planning, including encouragement of existing staff to go in for
training, particularly in relation to healthcare assistants, is
one of the important indicators that we will monitor them on.
Q1049 Dr Taylor: Can I just come
back to another example of flexibility downwards, which has been
mentioned already, and this is where we come back to the specialist
nurses. What is going to be so difficult for you in giving us
more information about this is to discover which specialist nurses
are being actually employed part-time and doing ordinary nursing
duties. So we really would like this information but it is going
to be very difficult to get, and we do not just need the numbers
that have been made redundant because redundancies are a very
small proportion of the staff reductions because most of the reductions
are vacancies that have been frozen where people have left, so
when you do look at specialist nurses somehow we want you to cover
all those groups of staff reductions.
Lord Hunt of Kings Heath: We will
do the best we can to get the information that is available. Again,
I say I do not think that it will be in the long-term interest
of individual organisations to impact on the ability of specialist
nurses to do the job. In terms of the future and in terms of our
debate about the need to be able to change the services to meet
new circumstances, they are just the sort of people that we need
to encourage.
Q1050 Dr Taylor: But I am sure we
have all got anecdotes that for part of their time they have been
shoved on to a ward to do the basic nursing.
Mr Greenfield: It is perhaps worth
also pointing out that historically our access to that level of
detail of information of the workforce of 1.3 million has been
very patchy and the bureaucracy of actually obtaining such information
is significant. However what we are doing at the moment is rolling
out a new electronic staff record system. We have it in place
now for over 505,000 staff, almost 300 separate organisations,
and by the end of this month we hope to have it out to over 600,000
staff, and it will be fully rolled out by April 2008. The level
of detail within that system will help local management to actually
identify the skill-sets that it has and we would hope support
their more effective and efficient use and it will also enable
us to access details of the current workforce from a central data
warehouse which will improve quite significantly the information
and the timeliness with which we can provide it.
Q1051 Dr Taylor: This is more up
to schedule than the whole of the NHS IT system?
Mr Greenfield: This is a separate
programme which is on target and on budget.
Dr Taylor: Brilliant.
Q1052 Charlotte Atkins: The NHS plans
to move 5% of hospital activity into primary care and increasingly
the Government wants to ensure that healthcare is delivered locally,
but we have heard from the Council of Nursing Deans that this
move is very much undermined by both lack of funding and career
pathways within the primary care sector. What would your comment
be on that?
Lord Hunt of Kings Heath: I am
disappointed to hear that because clearly we are committed and
we are going to make sure that primary care does more work in
the future, it can do more work in the future, and indeed I would
argue that the GP contract is one of the foundations for ensuring
that that happens. I am not aware of problems in relation to career—I
assume this is for nurses in primary care—
Q1053 Charlotte Atkins: Absolutely,
we are talking about nursing deans here, yes.
Lord Hunt of Kings Heath: Certainly
it is something that I would be very happy to look into.
Q1054 Charlotte Atkins: I hope you
will because certainly the impression I get and indeed those of
who campaign hard about our Primary Care Trusts do see that within
the primary care structure there is not a great career path for
nurses or indeed for other staff. Yes of course you have the GP
contract, but primary care is more than just about GPs and clearly
there is a whole range of professions and allied occupations which
are crucial within primary care which do not seem to get the recognition
that they do in hospitals. It is very much again hospitals being
the tail that wags the dog.
Lord Hunt of Kings Heath: The
reason I mentioned the GP contract is because of the way it rewards
GPs for their patient performance and use of nurses can be very
much an integral part of that. We all know I think from personal
experience just how much more is done in the primary care setting
by nurses. I also think that the development of people like community
matrons and other specialties is an indication of what can be
done, so it is disappointing to hear if nurses in primary care
feel that they are not being recognised or do not have career
pathways. I am certainly very happy to look into that and perhaps
come back to the Committee in that area.
Q1055 Charlotte Atkins: Can I pick
you up on the community matrons; certainly within my own patch
they do a great job but, as I understand it, the evidence does
not demonstrate that they do substantially reduce, for instance,
emergency admissions into hospitals. Is that not the case?
Mr Greenfield: I believe you had
the Chief Executive of Kingston PCT here and my understanding
of the evidence he presented was different to that, so I would
have to go back and look at the evidence of the impact of community
matrons on admissions.
Q1056 Charlotte Atkins: I have not
read the evidence but I understand that what tends to happen is
that those community matrons tend to find additional jobs that
have to be done within the community rather than actually reducing
the amount of admissions into hospital. I would certainly be interested
to see your evidence on that to see whether that is in fact the
case.
Lord Hunt of Kings Heath: My experience
of talking to many nurses working in the community is that they
are thoroughly enjoying the extra responsibilities that they have
been given. I just mention nurse prescribing as one excellent
example where their abilities have been recognised. There are
so many new opportunities for nurses in the community, so many
areas in which they are developing that I would have thought that
it does present opportunities and, if anything, I have come across
many nurses who have left hospital and gone into the community
because they feel they are given so much more autonomy in the
community, which is a lesson perhaps that hospitals can learn
in relation to their own staff, so it is disappointing to hear
that. As I say, I would like to look into that and perhaps come
back to you on it.
Mr Greenfield: I am familiar with
some of the work we already have in stream in this area. I think
it is true that traditionally when nurses have graduated from
diplomas or degrees they have tended to go into the trust environment
and we have had work going on in this area in Camden and Islington
PCT where they have developed programmes that help support the
initial placement straight into primary care, safely and well
supported. We have also got through the Chief Nursing Officer
a programme recently launched in the last quarter of last year
which is about modernising nursing careers and within that there
are workstreams that include defining more clearly the career
path in primary care, which I think has traditionally not been
the case, but also recognising many of those posts in primary
care are not NHS employed, they are GP employed, which adds a
complexity, and also to support the move for nurses and other
professionals out of large acute trusts to provide care closer
to home, which is consistent with the direction of the White Paper.
That last stream of work is only just beginning but it is one
of our priorities.
Q1057 Mr Campbell: We were told by
some of our witnesses the other week that the quality of managers
is highly variable and that there were no minimum standards for
them. Of course, there are no minimum standards for MPs but at
least we are assessed every four years!
Lord Hunt of Kings Heath: I think
chief executives would say that they are assessed because of course
one of my concerns is the rapid turnover rate of chief executives
in the Health Service. There are clearly some issues here about
leadership. I have put this down as one of the areas that I particularly
want to focus on, as has the Chief Executive of the NHS. There
is a sense in which the great NHS tradition has been to have administrators,
they then began to be called managers, and I think that there
is clearly a capability issue about whether all our managers have
the capability and the skills needed to drive through some of
the changes that we want to see. It is very easy to knock managers
in the Health Service but they have a hell of a difficult job
to do. Many of them are absolutely brilliant, and you have had
one or two appear before you, but there is clearly a variation
in quality. There are issues about what kind of people ought we
to recruit at a young age into the Service. There are issues about
the graduate training programme and whether that is fit for purpose.
These are the matters that we want to look at. David Nicholson,
the new Chief Executive of the NHS, who was chief executive in
the West Midlands, had started a programme in the West Midlands
of identifying about 160 future leaders and starting a very intensive
programme with them. He now wants to develop that throughout the
country. The interesting thing about the West Midlands programme
is that a lot of clinicians have been identified and are taking
part in it. I am convinced that alongside the excellent lay managers
we have got to encourage more clinicians into senior leadership
and managerial positions, and I am sure that that is the way to
get greater ownership amongst clinicians for changes. You had
Sir Jonathan Michael before you in a previous session and he,
surely, is the kind of role model that we would wish to see developed
in the future.
Q1058 Mr Campbell: One thing that
was in the news last week was where they were going to put business
managers into schools; would that apply to hospitals?
Lord Hunt of Kings Heath: The
Health Service has gone through various phases of encouraging
people in from outside. Some Members will recall when in the early
1990s a lot of Service people came in for a brief period of time.
I very much welcome people from other fields coming in. Clare
Chapman's appointment from Tesco to the Health Service is an excellent
example of that and we want to see more of that happen. It is
not as if one would say everyone needs to come from outside. We
have got a lot of highly skilled people who we want to grow and
develop but yes, let us get people in from outside as well, people
from social services also have a lot to offer, and let us remember
that this is a hugely challenging task.
Q1059 Mr Campbell: In many ways it
is a team job as well. You have got managers who will be clinicians
and you have got managers like yourself, Clare, and it is a team
effort really—I would have thought that anyway.
Lord Hunt of Kings Heath: You
do not really have a completely hierarchical managerial set-up
where the chief executive can simply tell clinicians and everyone
to go and do what the chief executive wants. Clearly the chief
executive has to set the framework and the job plans for consultants
are a very good way in which the chief executive can have a grown-up
discussion with individual clinicians. Running a hospital for
instance, it is a highly complex organisation, you need to do
it with great skill, there is team work, but in the end you have
to hold the chief executive accountable for what happens in that
institution, and what we need to do is to make sure they have
got the tools of the job to discharge that accountability. I wonder
if I could bring Clare Chapman in to give some more specifics
about the kind of programmes that we want to develop in this area.
Ms Chapman: One of the things
that the Chief Executive has asked me to look at as a priority
is what are the things that a manager or chief executive need
in order to succeed in their role. If we are very clear on that
then in the same way that we had the discussion just a moment
ago you can make sure that those experiences are actually achieved
and the standards are assessed as part of that. I am completely
sure from the few people I spoke to before Christmas that managers
would welcome that too because I think people thrive when they
are clear what is expected of them and also they get the skills
at the right time. I think as a matter of priority it is let us
be clear what people need in order to succeed in those roles and
then let us work with the managers themselves to make sure that
that is programmed in.
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