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 usat that time I was working in the deaneryto
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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