Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 700-719)

MS ANNE RAINSBERRY, DR MOIRA LIVINGSTON AND MS SIAN THOMAS

24 JANUARY 2008

  Q700  Dr Naysmith: Which impinged on some people who were training that year?

  Ms Rainsberry: That is correct, but it was not to training numbers, it was around the infrastructure, and that has now been restored.

  Q701  Dr Naysmith: Let me get this absolutely right. It was not to do with reducing training numbers?

  Ms Rainsberry: No.

  Q702  Dr Naysmith: But it may well have influenced the quality of the training process that took place that year.

  Ms Rainsberry: Yes.

  Q703  Dr Naysmith: By spending training money on something else.

  Ms Rainsberry: Things like CPD were affected, so study leave budgets would have been affected, but not the core infrastructure.

  Q704  Dr Naysmith: I will go on to the question I was going to ask you. During our workforce planning inquiry you told us that the strategic health authorities had little influence on the development of MMC. Do you think that is the reason why the disastrous transition took place in the new system in 2006? If you had had more influence, would it have gone better?

  Ms Rainsberry: Yes. I think hindsight is a wonderful thing, but in terms of development of policy, as you get nearer and nearer to implementation, it is extremely important to gauge those people who are interacting on a daily basis with the service, because one of the complexities (and that played out last summer) is when you get into difficulties you have got difficulties around doctors' careers, their aspirations and training, but also very real service risks around that and, therefore, all of those competing risks and priorities need to be properly looked at and balanced, and I think that going forward it is important to have that service view. I, together with an SHA chief executive, sit now on the MMC England Programme Board that has been planning a round for 2008, and I think that that view has been heard and has been balanced against the medical profession, and we have certainly, I think, as a board produced a framework that, to date, is working well for 2008.

  Q705  Dr Naysmith: Is that the same in your area, Dr Livingston?

  Dr Livingston: Yes. If I can address your previous question in terms of cuts to training, just to clarify for the North East that no such cuts were made in terms of access to training and study leave and that the way in which we managed the reduction in the allocation was through working very closely with the service through a bundling of funding approach and a quality monitoring of delivery to ensure that no such cuts were made. I would also add that, at times when phrases such as "raided the budget" are used and "cuts were made to training", it is important to understand that, as part of effective workforce planning, there will be changes made to the commissions that we make with higher education and we have a contract which allows flexibilities within that. When we did reduce the contract for the number of diploma nurses, for example, in the North East, that was done through full consultation and also was done as a result of effective workforce planning. I think sometimes that is misunderstood and is taken as evidence that budgets were raided. In fact, it was exactly what we think we should be doing, which is effective workforce planning and collaboration with higher education and the service.

  Q706  Dr Naysmith: Thank you for clarifying that. In the north-east we had some evidence, clearly in my own area, where cuts were made by the Strategic Health Authority which had really disastrous effects on the local university which was training nurses, and it happened virtually overnight. Not everywhere is the same. Thank you for that clarification. What do you think about the involvement of strategic health authorities in this whole area going forward, given that you commission the trainees?

  Dr Livingston: Going back in time, and certainly my knowledge is within the North East and particularly within the area of MMC that I worked in, I would say that there were attempts made at engagement, and I think when you look back it could always have been improved. There was a responsibility on us—at that time I was working in the deanery—to engage with strategic health authorities, so early on in the process of MMC development we were involved in the Workforce Planning Committee set up by the Strategic Health Authority so they could fully understand the implications of MMC at a local level. At a national level the SHA Chief Executive representative was on the MMC Programme Board throughout the process. For me, where I'd like to get to is, I think, full integration of education, training and service delivery. I do not think that they can be separated out. I think it is a core function of the NHS. I think it is essential that we see it as the core purpose of all our service delivery organisations, and in that sense understanding the needs of employers as we move forward is essential to get to the structure right for training. I do think that the structures now in place are going to be very effective. The evidence that we have seen so far, in terms of the signing up to agreements and the workforce planning embedded within the training thinking, is a really positive step.

  Q707  Mr Scott: This is a question for Mrs Rainsberry and Dr Livingston. Is it correct that only three of the ten strategic health authorities have non-executive directors from a higher education background and, if so, is this not short-sighted, given your responsibilities for commissioning education?

  Ms Rainsberry: I cannot comment. I have not done a survey of strategic health authorities.

  Q708  Mr Scott: I am told it is correct.

  Ms Rainsberry: Okay. Certainly in London we then would be one of the ones that does have an academic representative as a non-executive director on our Board. We also have a Workforce Strategy Board, which is a formal sub-committee of our Board, so I think you can take from that that we would obviously take the view that it is important to have that reflected on your book, but, there again, it is important to understand that of the 4.4 billion that is spent on training and education in England over a billion of that is spent in London. So, clearly, we have a very large responsibility in that regard.

  Dr Livingston: Within the North East we have two non-exec directors who are both from higher education and a third who is a non-exec director on a Higher Education Organisation Board. We do see it as very important, and I think it reflects the priority that we give to workforce development. It is important that we do not see that as a solution to the engagement of higher education, which I think needs to be there throughout the system. I think, as Anne was mentioning in terms of her workforce board and engagement with higher education, we need to ensure that a proper debate happens at all levels within the decision-making process at a regional level with higher education, and the board membership signifies that interest and commitment, but the work has to be done throughout the system within the region.

  Q709  Mr Scott: Do you think one answer to it in areas which do not have people is if postgraduate deans were co-opted onto local strategic health authority boards?

  Dr Livingston: I think the structure at the moment is that the postgraduate dean is accountable to me and, in that sense, therefore, the deanery is fully represented through to the board. I think that the postgraduate dean needs to sit on the decision-making committees about workforce development and workforce planning, but their presence on the board I am not sure would be the right way forward.

  Ms Rainsberry: I would agree with that. What is the problem we are trying to fix? If the problem we are trying to fix is to make sure that there is proper advocacy of education training issues, then I think it is legitimate to say: where on the board is somebody who has that in their brief and to ensure that there is a proper alignment with the dean. I suppose a strategic health authority could appoint their dean director as their director of workforce in some areas, but I think the principle is a good one, that you should have somebody on the board who is advocating, particularly when a large part---. Normally, in most strategic health authorities, the largest part of their budget is their education training budget.

  Mr Scott: Thank you.

  Q710  Charlotte Atkins: Sian, do you feel that your organisation and employers in general had too little influence during the development of the MMC, and, if that is the case, what sort of problems did that cause?

  Ms Thomas: I think we gave written evidence to you and in that evidence made it very clear that our views were that we had very little influence at the beginning. We were a fairly new organisation when MMC commenced, and it is very difficult to cohere the view of 500 separate employers, but increasingly we are, and were, doing that. I would see our role in three phases. Before February 2007 we had a very peripheral role. We were probably regarded as a peripheral stakeholder in the process and, therefore, our influence was limited. We had no role on governance and had very limited engagement in implementation and design. In fact, I would say a great majority of the design decisions were made without employer input. One of the lessons learnt, I think, is that a great deal of expertise across the NHS in medical staffing departments and HR department was not, in fact, taken into account by the people designing the process, so we would agree with you. The second phase, which was during the latter part of 2006, we began to have engagement with the department because we were anxious about the lack of communication to the service and, indeed, became aware that the potential of mismatch between applicants and posts was greater than we had probably anticipated. We never knew what the numbers were, those numbers were not shared with us until the spring 2007, so we began road shows with employers and tried to engage with employers more during that time. Then, as has been alluded to today, at the beginning of March we realised there were grave problems, and that was when our active and full participation began through membership of the review group, and I would have to say since that date we are more engaged. I still do believe actually that employers need to be more centrally involved in this policy area and more employer views need to be taken into account in the design especially of the recruitment processes, because at the end of the day these are our employees who we will be employing for 30, 40 years and the end product of this process is important to employers on the ground.

  Q711  Charlotte Atkins: The new MMC Programme Board has got two large employers on it, I think. Is that adequate?

  Ms Thomas: It is adequate at the moment. We are giving a balanced view, and both of the people who attend the Programme Board are backed up by a system which means that over 100 employers' views are fed into that debate, but that is the only engagement we have on MMC at the moment.

  Q712  Charlotte Atkins: In parallel with that, do you think that the department recognises the need for more employer input into medical education.

  Ms Thomas: I think it has been acknowledged by the department and also by the Tooke Report that that is needed to be developed further.

  Q713  Charlotte Atkins: Do you think at the moment things are improving?

  Ms Thomas: They are improving.

  Q714  Dr Taylor: We are moving on to NHS Medical Education England. If you were here for the first part, you would have heard all our three witnesses give a ringing endorsement to this. One of them actually said that he thought that recommendation 47 was the most important in the whole of Tooke. Would you agree with this or do you see alternatives or disadvantages?

  Ms Rainsberry: I agree it is the most important recommendation, but I do not agree with it.

  Q715  Dr Taylor: Let us have the counter view then.

  Ms Rainsberry: I was here for that evidence, and you were talking to those witnesses about the 87% level of support and, just as a point of clarification, that was a new recommendation that has not actually been consulted on, so there is no benchmark, if you like, as to whether 87% of people who responded agreed.

  Q716  Dr Taylor: Let me be absolutely clear. To those last two recommendations that were added, there was no comment, so the 87% support did not apply to those?

  Ms Rainsberry: That is my understanding.

  Q717  Dr Taylor: What you were saying is you would have been one of the large per cent who disagreed?

  Ms Rainsberry: Yes, that is right.

  Q718  Dr Taylor: Why do you disagree?

  Ms Rainsberry: First of all, I think that it fractures the relationship between service and education. At the end of the day, we are in the business of training doctors to deliver care to patients and at the moment strategic health authorities are the only part in the system where the balancing of service, long-term strategic planning and education align, and I think, by taking medical education off-line in that way, it would fracture that relationship. I think it adds another layer of bureaucracy by setting up an independent body and I think it would make SHAs in how they discharge their accountabilities in terms of the strategic development of health services and maintaining the integrity of the system, the health system, particularly as we move more towards foundation trusts, more challenging: because you have to have some body that has an oversight of a particular health system that is looking at where the service is developing and whether there are proper workforce plans in place to deliver that. So, I would be quite strongly against it.

  Q719  Dr Taylor: You may remember that our workforce planning inquiry actually recommended that planning functions should be given to SHAs?

  Ms Rainsberry: Yes; so I see it as being contrary to that recommendation.


 
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