Examination of Witnesses (Questions 20-39)
DEPARTMENT OF
HEALTH
2 MARCH 2009
Q20 Chairman: Has anybody read it?
Mr Nicholson: I think probably
Mike has.
Mr Griffin: Yes, I have.
Q21 Chairman: Or is it like the Schleswig-Holstein
question, that only two people have read it and one is mad and
one is dead, or something? The third is you, is it?
Mr Griffin: It is to be dipped
into, not to be read from cover to cover.
Q22 Chairman: Oh, I see. The third
one did not know what the question was. Why has it not been implemented
across the NHS? It is absolutely crucial to all this, is it not?
Mr Griffin: It is. It is a very
innovative piece of work. It is a complex piece of work and it
came in part way through the implementation of Agenda for Change.
In itself it would have been a major piece of change to implement.
I think coming straight on the back of Agenda for Change made
it particularly difficult for trusts to focus on it. However,
it is an essential part of Agenda for Change and one of the real
areas for benefit comes from successful implementation. It provides
a way of analysing our work. It provides us with a way of having
performance management discussions with our colleagues. It provides
a development framework within which people can plan their future
careers. It has been a hugely important piece of work. The fact
that it has been slow to be fully implemented is not a reason
for despair but a case for greater perseverance in completing
the implementation of it.
Q23 Chairman: Lastly, we have looked
in detail at the doctors' and consultants' contracts. Are they
the real winners from Agenda for Change in terms of their pay?
Mr Nicholson: No, they are not.
I would argue that the real winners from the entire programme
of pay modernisation are essentially our patients. They have got
the benefit from the improvements in quality that we have seen
across the service. They have seen the benefits from the improvement
in quality in primary care. They have seen the benefits of being
able to manage the time they consult medical staff, the increased
amount of time that consultants spend on clinical care and the
amount of time that GPs spend with their patients, which has gone
up as part of it.
Q24 Chairman: But how much of this
has come from Agenda for Change? That is what I am asking you.
I am not denying there have been improvements. I am asking specifically
on Agenda for Change what has been achieved. You have got to come
up during the rest of this afternoon with what Agenda for Change
has achieved.
Mr Nicholson: As I say, it is
very difficult to try and explain what the benefits are of what
is essentially an enabler. Agenda for Change helps you do things.
It enables you to make your arrangements so you can design a job
without going through a huge bureaucracy to deliver individual
patient benefit.
Q25 Mr Bacon: Mr Nicholson, I must
say I am puzzled by all this. You went to a lot of trouble to
set up an all-embracing, all-singing and dancing pay system reform
and yet you cannot tell us anything about what it has done although
there were some fairly specific assertions made at the time. For
example, you referred earlier, in answer to the Chairman, to this
1.1-1.5% year-on-year rise in productivity. A rise of 1.1-1.5%
in productivity was an assertion that the department made at the
time, in 2002, when Agenda for Change was launched. That is a
very specific thing. How could that assertion have been made without
it being known what it would look like if it were achieved, without
your being able to attribute it to the thing you were doing?
Mr Nicholson: Additionally, of
course, at that particular time decisions were taken to increase
the size of the NHS by nearly a third. As you will know yourself,
it is extraordinarily difficult to deliver productivity gains
when you are expanding a service in the way that we were at that
time. All that I can say is that to get through the complexity
of that we decided to look at a package of things working together
and see how that would give us the indication. As I say, it does
show that we made £3 billion worth of savings as part of
the process that we adopted, and we think that is a reasonable
return on what I think is a very complicated thing.
Q26 Mr Bacon: This 1.1-1.5% year-on-year
rise in productivity was a very specific assertion and that 1.1-1.5%
rise in productivity was specifically related, was it not, to
Agenda for Change?
Mr Nicholson: Yes.
Q27 Mr Bacon: I am looking at paragraph
f on page 9, where it says, "Agenda for Change was expected
to achieve specific and measurable benefits,"—
Mr Nicholson: And it has.
Q28 Mr Bacon:— "but there
has been no formal assessment of the programme by the Department
or by individual trusts". Surely, if you came along with
any programme that was designed to achieve specific and measurable
benefits you would say, "What are these benefits? How specific
are they and how do we know whether we have got them?". It
is basic, is it not, and yet you do not seem to be able to do
that?
Ms Chapman: I think we can do
that in that, of the four areas we said we would get improvements
from, part was productivity, part was the increased staffing for
in-service staff and also the reductions in drift and the improvements
in care that were being looked for, particularly in terms of improved
waits, et cetera, so we knew the areas. Rather than go off and
measure whether we got the £1.3 billion anticipated savings
in those four areas, it was recognised that at the time the service
had two other areas where productivity was being looked for in
terms of the technology that was being put in and the service
framework.
Q29 Mr Bacon: Sorry, hang on. When
you say the technology was being put in are you talking specifically?
Ms Chapman: There were a number
of pieces of technology that were being introduced at the same
time along with the service frameworks.
Q30 Mr Bacon: Such as what? Which
technology?
Ms Chapman: I was not here at
the time.
Mr Nicholson: If you look at the
things like the electronic staff record, if you look at the new
arrangements we were putting in place for GP connectivity with
their IT systems, these things were all being developed at the
same time.
Q31 Mr Bacon: Hang on a sec—GP
connectivity?
Mr Nicholson: Sorry, I meant the
community systems like RiO and all of these systems that were
being implemented.
Q32 Mr Bacon: When you say "GP
connectivity with their IT systems", do you mean GP connectivity
among GPs? I do not quite follow you.
Mr Nicholson: Yes, sorry; I was
referring to community services. I was not referring to GP services
at all.
Q33 Mr Bacon: You were not referring
to Choose and Book?
Mr Nicholson: No, no.
Q34 Mr Bacon: My father-in-law had
an experience with Choose and Book the other day. He was sent
home with a phone number to ring. He could not book it. When he
phoned the recorded message said that the service was not available,
so it certainly has not increased productivity, has it?
Mr Nicholson: I am sorry he had
that experience, but there are lots of examples where Choose and
Book has worked extraordinarily well for the patient.
Ms Chapman: The reason I was explaining
those was that if you talk to a trust it is very difficult, given
that there were three areas of improvements in productivity going
on at the same time, to try and measure the productivity improvements
from each one separately. Actually, they looked at productivity
improvements in the service. Therefore, there was a programme
initiated centrally called the Productive Time Initiative, which
was looking very much at whether the benefits were delivered?.
The benefits of Agenda for Change were consolidated in there and
that is what Mr Nicholson has already described in terms of the
improvements being in the region of £3 billion, which was
slightly better than the £2.9 billion target that was set
up in the Product Time Initiative arrangements.
Q35 Mr Bacon: The trusts individually
have to implement all this. How will you, going forward, hold
trusts accountable for productivity?
Mr Nicholson: From now on, you
mean?
Q36 Mr Bacon: Yes.
Mr Nicholson: The major way in
which the centre holds individual organisations to account for
productivity is through the tariff and the way in which the tariff
is set. For example, for this year the tariff is set in such a
way that individual trusts are expected to deliver a 3% cash-releasing
productivity improvement in their arrangements. We have planned
to make that probably 3.5% next year. That is the way in which
we drive the change with the individual organisations, so we do
that on the one hand. On the other hand we provide organisations
with the tools to enable them to do it. Agenda for Change is one
of those tools, so we have a pay system now which is much simpler,
much more flexible, much more able to respond to the individual
needs of organisations than the old Whitley system was in the
past, and individual organisations can make those changes at a
local level. We provide them both with the incentive, or penalty,
if you like, through the tariff and the tools to enable them to
do it.
Q37 Mr Bacon: You mentioned that
you have commissioned York University and others to do work on
improving productivity measures.
Mr Nicholson: Yes.
Q38 Mr Bacon: When was that commissioned
from York University?
Mr Nicholson: It was commissioned
some time last year and is due to report this month.
Q39 Mr Bacon: What I do not understand
is, knowing that the measures of productivity as you have described
them were inadequate (Nigel Crisp used to tell us this) at the
time Agenda for Change was being introduced originally, and these
assertions were being made about the way in which it would increase
productivity, why did you wait six or seven years until last year
before commissioning work to do something about getting better
measures?
Mr Nicholson: I think we were
trying to work with the measures that we had and improve them.
We have been working with the Office for National Statistics over
the last few years and they do include some small quality improvements
within them but we do not believe enough, so we have been working
with the ONS to make that case a reality. In practice what we
have been doing is getting on with implementing Agenda for Change,
consultant contracts, GP contracts and delivering benefits for
patients. That is essentially what we have been focusing our attention
on. As I say, we have been working with the ONS. We have not quite
got to the place we wanted to be with them so we have commissioned
our own work now.
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