Examination of Witnesses (Questions 1060-1068)
LORD HUNT
OF KINGS
HEATH, MS
CLARE CHAPMAN
AND MR
NIC GREENFIELD
25 JANUARY 2007
Q1060 Chairman: I am interested in
your plans for attacking the high turnover rate of chief executives.
Have you any plans for attacking the high turnover rate of ministers?
Lord Hunt of Kings Heath: I will
try and stay here for as long as possible!
Q1061 Dr Stoate: At least the current
Minister does not have to worry about being re-elected!
Lord Hunt of Kings Heath: Not
yet!
Q1062 Dr Stoate: I have worked in
the Health Service for a long time, as you know, and I have been
saying for many years that the NHS is chronically under-managed
and chronically over-administered. In this inquiry and in the
previous one on NHS deficits, I have been very disturbed by the
enormous variation in quality among managers. You have mentioned
a couple today who are obviously first-class but we have also
seen evidence of managers, frankly, who have been extremely underwhelming.
We heard from PCTs when we had evidence on the NHS deficits inquiry
and some of them seemed to have lost complete control over their
finances and seemed to think that was just the way it is. My worry
is that there is no set down qualification to be an NHS manager,
there is nothing specific about the chosen requirements, they
have not got to be revalidated or reassessed every five years.
Obviously they are assessed by their boards and they can be removed
if they do not perform, but that usually only applies to the chief
executive. My concern is that there remains far too much variability
and far too much unpredictability and in the end, let us be honest,
it is the Government that pays the political price when an institution
fails in its duty to manage adequately the money that it has been
given.
Lord Hunt of Kings Heath: I do
not disagree with your analysis of a variation in the quality
and expertise of the managerial cadre and clearly I have already
stated that I see that as one of the areas where I have a great
interest in sorting this out. What I am clear is that the reduction
in PCTs and in Strategic Health Authorities is very important
in terms of ensuring that you have got a smaller number of organisations
with greater expertise. There is no question that we need to enhance
commissioning skills. On the hospitals side too, we need to make
sure that the managers we have got do have the right skills and
expertise for what I am sure you would agree is a very demanding
job. I hope I can reassure you that we do see this as important.
The fact that David Nicholson has a good track record in actually
resolving some of these problems in the West Midlands, where I
would say that by and large we have a very good health system,
indicates that we are going to take this seriously, and we do
very much accept the points you make.
Ms Chapman: Can I just make a
point on that, in terms of that variability I think you described
brilliantly what needs to be done, which is define what is needed
and make sure that you design the programmes and experiences to
get that. One of the things that really attracted me to the NHS
was the size of the talent pool. One would assume given over one
million people that within that number there are some extraordinarily
good managers or people who have got the capability to be extraordinarily
good managers. The issue is spotting them, so as well as the development
programmes that the Minister has just described and you have outlined,
I think it is also pretty critical to make sure that it becomes
a priority not just to engage staff but also to do some very active
talent-spotting because if we do not have the talent with over
one million people then many companies have got a number of problems.
Q1063 Dr Stoate: It is not just talent-spotting;
it is ensuring that those who do not meet the grade are either
re-trained very quickly or moved somewhere else because it is
very disappointing when a local institution can effectively let
down the entire local health economy and ministers have very little
control over that situation, but certainly the local Members of
Parliament know it and they very often pay the price.
Lord Hunt of Kings Heath: I think
it is also worth pointing out that the system reform of incentivising
hospitals that do well through payment by results is clearly designed
to get the levers in to reward good performance and penalise poor
performance, so hand-in-hand with managerial improvement goes
the system that we are developing.
Mr Greenfield: Perhaps I could
offer some comment too about work that has been going on with
the foundation trusts to monitor where they have been developing
programmes to assess fitness for purpose for transition into foundation
trust status, and as part of that the tests are about the executive
and non-executive quality of the teams. We have been developing
work mirrored around that to support the development of PCTs in
a fitness for purpose assessment which is about our reconfiguration
and by reducing from just over 300 to around 150 we are assessing
them for fitness to practise which includes the assessment of
management skills.
Dr Stoate: As long as you are tough on
the outcomes because we do not want the fitness for purpose problems
that the Home Office has had. Clearly there is no question that
some PCTs in the past have not been fit for purpose and I am now
hopeful with the configuration that that should be a thing of
the past.
Q1064 Chairman: Could I ask you how
we determine the future NHS workforce. The think-tank Reform has
told us that they believe that what the NHS needs is a smaller
but more highly skilled workforce. The Chief Medical Officer giving
evidence to us told us that the UK medical workforce should be
expanded as it is still smaller than the OECD average. You may
be tempted to say that they are both right but I just wondered
how is the future size of the NHS workforce going to be determined
when we have these not necessarily conflicts but issues around
about what should happen in the NHS?
Lord Hunt of Kings Heath: That
is really our collective responsibility here before you today
to determine how to do this in the future. I think it is very
much about trying to ensure as far as we can what the likely future
requirements on the Service are, to make sure that we produce
the numbers of staff that are required to meet those requirements
but then to have the flexibility to make adjustments if it looks
like the figures are not bearing this out or there are big changes
in practice in the Health Service. As I said earlier, no-one could
sit here and say with confidence that we know exactly what the
workforce requirements will be in 10 or 15 years' time, but we
can make as reasonable an estimate as possible building on all
the experience we are developing. As I say, the key thing there
is the monitoring, making sure that we have got up-to-date information,
making sure that we are in close discussions with Strategic Health
Authorities, and then being able to make the adjustments, and
that is really what we seek to do.
Q1065 Chairman: Can I ask you about
something that we have briefly touched on this morning but not
in any great detail. It was mentioned earlier about where there
have been gaps in the workforce in the past that overseas recruitment
has been a way of bridging that gap. We come really to the issue
of the ethics of doing this, particularly recruiting from the
developing world which in itself has far less of a structure of
formal healthcare than certainly we have in this developed economy
that we sit in now. What are your views on that not so much in
terms of the past but in terms of the future?
Lord Hunt of Kings Heath: I would
of course refer to the ethical policy that we adopted in relation
to international recruitment. Essentially much of that international
recruitment was to help us deal with the immediate, short-term
shortages in staff. What is now happening (and we have seen some
of the products of it in terms of the issue with nurses and physiotherapists)
is we are becoming self-sufficient so that would suggest that
we have much less requirement for international recruitment in
the future.
Q1066 Chairman: What about the issues,
and I am talking not so much about nurses at this stage but the
issues of doctors and potentially surgeons who will come here
not to work permanently but come here for probably six months
or even up to two years, where they would actually be working
inside the National Health Service and be salaried but also effectively
getting skills and then after their term taking those back to
the developing world. What does the Department think about that?
If we are going to have a market-place of doctors, is that likely
to end?
Lord Hunt of Kings Heath: I will
ask Mr Greenfield to comment in detail, but as a general principle
I would draw a distinction between going abroad to bring in staff
to deal with vacancies that we have here and of course what is
absolutely essential is the continued link between our NHS and
healthcare services overseas because in terms of UK plc it is
absolutely critical that we keep that link. Would you answer on
the technicality?
Mr Greenfield: As the Minister
has pointed out, we are moving from significant dependence on
international medical graduates (for whom we have been very grateful)
to more self-sufficiency, which is fairly unique within the modern
world. For example, we understand America and some other English
speaking countries are currently planning to train doctors to
provide 75% self sufficiency. I can also confirm that we were
approached by the Royal Colleges to say that they wanted us to
protect the arrangement for people to come here from other countries
for short periods of, say, up to two years so they could develop
specialist skills and so that we could maintain our professional
reputation in the world for very strong medical training and give
them skills to take back to their communities, and we have agreed
those arrangements with the Home Office and that scheme will continue.
Q1067 Chairman: That has been agreed,
has it, because the Home Office are currently out for consultation
on a migration advisory committee that they are setting up and
that quite clearly could interfere if it is not sensitive to the
needs of what I would loosely term assisting the developing world
in enabling that to happen. Could I move on to nursing because
this is an area where I was told by ministers many years ago now
that there is no direct recruitment of nursing from abroad in
terms of what I would call the sensitive and the developing world,
and that could be the Caribbean and it could be many African countries
as well, but that does not stop somebody coming in and working
for six months in the private sector and then coming into the
National Health Service. As opposed to that, we have got countries
like the Philippines which trains nurses so they can be effectively
exported, for want of a better expression, and earn money and
send it back home. What is going to happen in the future in these
particular areas?
Lord Hunt of Kings Heath: I think
it is worth saying—and you mention Philipino nurses—clearly
the number of nurses who have come into the UK in the last few
years has been large and they have been incredibly helpful in
dealing with the shortages, but we have this express desire to
make the UK more self-sufficient. That is where we are at the
moment. We have been discussing the issue of newly qualified staff
and we are seeing the impact on self-sufficiency, so inevitably
as a general point we are going to rely less on overseas staff
in the future.
Q1068 Chairman: If there were nursing
grades that were coming for the type of training we are suggesting
surgeons or doctors may be doing for the short term to improve
their skills and then to take them back, then presumably they
would be looked after as well, would they? I do not know if that
is the case, Minister, I have to say, but I just pose the question
in view of the assistance that we can give to other parts of the
world.
Lord Hunt of Kings Heath: The
general point is this: clearly we are going to reduce the number
of people coming in, but what we do not want to do is inhibit
the kind of exchange programmes which are helping developing countries.
Equally, as I have said, because the UK's health position, our
pharmaceutical industry, our medical devices industry is so strong,
from a UK plc point of view it is essential that we continue these
international links and we want people from overseas to look to
the NHS as a model for them to review, look at, and take back
to their own country.
Mr Greenfield: We have recently
in the last six months asked Lord Crisp, a previous Chief Executive
of the NHS, to undertake some work with colleagues in government
to look at the impact of our changed ethical policy to international
recruitment and the impact of greater self-sufficiency on those
developing nations, and I understand his report is due in the
springtime.
Jim Dowd: But these are all peripheral
activities of the Health Service, are they not, they are not mainstream
activities.
Chairman: But important in terms of elsewhere
in the world. We should have done a bit of housekeeping before
you came in which we did not do and that is that the Committee
should agree that we publish the written memoranda that we have
had on our Patient and Public Involvement inquiry that starts
next Thursday; is that agreed? Minister, could I thank you and
your two colleagues very much indeed for coming along and giving
us what hopefully is going to be the final session in this inquiry.
We hope that we will have the report out by about Easter, we are
looking at the logistics of it at this stage, so you can take
it away along with other reports that you have got to look at
and hopefully employ it in workforce planning in the National
Health Service.
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