Examination of Witnesses (Questions 60-79)
DEPARTMENT OF
HEALTH
2 MARCH 2009
Q60 Geraldine Smith: One of the aims
was to improve equal opportunity and diversity in the Health Service.
Do you think Agenda for Change has achieved this?
Mr Nicholson: Yes.
Ms Chapman: There is evidence
that there have not been the sorts of improvements yet that we
would want to see on that. I think it is probably a bit like the
KSF, where there is now a platform on which there will be real
opportunities to improve that. Having said that, we looked at
the report that has come out recently that suggested that our
rates were running underneath the national average in terms of
the level of discrimination that people were reporting, so my
sense is that we have made progress, there is more to be done
and we have now got a platform to enable us to do that.
Mr Nicholson: Where we have made
progress, I think, is in terms of low pay. One of the things that
was particularly relevant to Agenda for Change was tackling some
of the groups, not the qualified nurses but the people who worked
as nursing assistants in support roles. I think they got a comparatively
greater benefit from Agenda for Change and I think that has helped
the workforce considerably.
Mr Griffin: I want to mention
one small matter. The non-professional grade particularly saw
the biggest increase in their pay across the professions and is
also perhaps where the biggest change in terms of career thresholds,
which takes them up through unqualified status into qualified
roles, has been achieved.
Q61 Geraldine Smith: Can I ask finally
about the claims for discrimination around equal opportunity?
What is happening with those? Where are we up to on that?
Ms Chapman: Those are being heard
at the moment. We are waiting for the outcome of those as we speak.
Q62 Mr Burstow: I want to ask a couple
of questions around Box 3 on page 11, which sets out the success
criteria. Just running down this list, can you tell me whether
in each case there was a baseline set against which you could
measure success?
Mr Nicholson: I will do my best
on all of those. More patients being treated more quickly. We
did the calculation at the time as to the extra number of patients
you would need to treat to deliver the waiting time guarantees
at the time, which were, I think, six months for in-patient, three
months for out-patient. We calculated the volume so we could say
whether we had delivered both the volumes and the waiting times.
Q63 Mr Burstow: So there was a baseline
against which you could measure Agenda for Change?
Mr Nicholson: And there was a
baseline on which that could be done. In terms of higher quality
care, we set out our improvements both in terms of improvements
in cancer and coronary heart disease care targets and in terms
of the delivery of improved outcomes for both of those.
Q64 Mr Burstow: Can you say that
there was something against which you could say, "This is
our starting point and this programme will result in these changes"?
Mr Nicholson: I have not got a
document with it all in but I am unaware of where this is all
written down in that way. I am just going through it because I
think they were all done. In better recruitment and retention
there was a whole series, as we know. Vacancy rates were running
at about 3.5% and we knew we had to get them down to 0.5% in order
to deliver the volumes for the capacity that we needed. As for
better team working and breaking down barriers, I do not think
there was a specific measure for that, but what we did know in
order to deliver the changes we needed in terms of cancer services
to make sure we had multidisciplinary teams operating in breast,
colon and other cancers, so we worked to do that and we have delivered
all of those multidisciplinary teams. We can give lots of examples
of innovation in deployment of staff but we think we have a fair
pay—
Q65 Mr Burstow: I think the point
I am trying to get at—
Mr Nicholson: No, I understand
what you are saying.
Q66 Mr Burstow:— is that you
can give lots of examples of how it has changed and you have given
many answers to members of this Committee saying you have done
that, but one of the roles this Committee has is looking at whether
we have got value for money out of the process you have gone through
and I am not clear from what you said that there were baselines
set against which you could evaluate whether this programme had
been the contributory cause of improvements.
Mr Nicholson: This was not set
out as a programme with specifically identified success criteria
that were measured independently of everything else that we were
doing. I have said that four times now, and that is true.
Q67 Mr Burstow: And would you acknowledge
that with the benefit of hindsight that is something that if you
were setting out on this again you would not do it that way?
Mr Nicholson: No.
Q68 Mr Burstow: So you would not
set criteria again?
Mr Nicholson: We set off on a
whole series of significant changes to the NHS all at the same
time. If you are saying to me could we in hindsight have identified
the totality of that at the beginning and put it through, I would
say that we did through the NHS Plan. We set out in the NHS Plan
what it was we were trying to achieve, which was more staff, better
paid, all of those sorts of things.
Q69 Mr Burstow: The reason I started
this question was that the thing that struck me as I went through
this report was simply that on a number of occasions data have
not been collected. On a number of occasions when data have been
collected, albeit by other agencies, there is not the evidence
to support the contention of these success criteria having been
delivered. You have been able to give us lots of anecdotal evidence
but not concrete evidence. Is that a fair characterisation of
it?
Mr Nicholson: No, I do not think
what I have just described is anecdotal evidence. The fact that
we have reduced avoidable deaths through coronary heart disease,
the fact that we have delivered a whole series of significant
reductions in the waiting times for patients and access to services
generally are not anecdotes. They are substantiated in the real
world by patients.
Q70 Mr Burstow: And you can substantiate
the link directly to the general changes in the delivery of that?
Mr Nicholson: This is the dilemma
that we have. The judgment was, would we spend a great deal of
time trying to get that or would we get on with it? We decided
jointly with the NHS that it was better to look at the thing in
the round and that is what we have done.
Q71 Mr Burstow: In answer to one
of the questions Mr Bacon asked you said there was a report on
productivity due this month.
Mr Nicholson: Yes.
Q72 Mr Burstow: When might this Committee
be sent a copy of that report?
Mr Nicholson: When ministers have
looked at it presumably it will be published. I do not think it
is a secret document.
Q73 Mr Burstow: Sometimes things
take a little time after the minister has studied them before
they do get published. How soon do you think it will be published
after ministers have looked at it?
Mr Nicholson: I have not seen
it so I genuinely do not know, but I will make sure the Committee
gets it as soon as I can.[2]
Q74 Mr Burstow: Just coming back
to this point about costs, paragraph 2.21 says that data were
not collected that would be necessary to see whether the anticipated
savings could be realised. Why, given that you had put in cost
assumptions of what you would save, was there no data collection
put in place to prove that you had done that? I would have thought
that was a fairly obvious thing to do.
Mr Nicholson: The rhetorical question
is, what data would you collect? With almost everything that was
happening there was a multitude of things happening to it, so
if you take, for example, the reductions in waiting times—
Q75 Mr Burstow: But you said there
was an estimate in the programme. You must have made some assumptions
to come up with that estimate. Surely you then instruct a data
collection that would underpin those assumptions.
Mr Nicholson: As I have said,
I think people made the best assessment they could make at the
time about what the impact of it would be, but it was essentially
a top-down assessment. If you look at something like delivering
a reduction in the waiting time to within four hours for patients
in A&E, we have been remarkably successful at getting it down
to four hours. Some of that related to Agenda for Change because
some of that was done through organising job roles and particular
jobs to do particular things in diagnostics which would not have
been available, but how much of the four hours would you attribute
to Agenda for Change as opposed to increasing numbers?
Q76 Mr Burstow: That is why you are
here; that is why I am asking the question.
Mr Nicholson: We made the assessment
that it was better to look at the totality of all of the things,
the way they were interacting, ie, the quality of the way they
were implemented together as a measure, as opposed to identifying
each individual one.
Q77 Mr Burstow: One of the success
criteria is around fair pay and the report draws some comparisons
with the other two sets of pay modernisation at work which were
put in train around the same time, particularly the consultants'
contract, and this Committee has published reports on that in
the past. It suggests that the consultants' contract added 6%
to the annual pay bill for consultants. We have established here
that that is nowhere near the percentage added to the pay bill
for general changes significantly lower down. What does that send
out as a message around fairness and what does it say about the
difference in attitudes to different types of staff within the
NHS?
Mr Nicholson: In each of the groups
of staff we were dealing with quite different things. If you take
the consultant contract, for example, there was no system of measurement
and organisation of time for consultant staff in the NHS up to
the new consultant contract, so not only were we negotiating something
going forward; we were also essentially putting right something
that had been there since 1948, and the impact of getting that
right for the future will be absolutely enormous. I do not think
looking at straight percentages between one group and another
necessarily identifies the fairness of it.
Q78 Mr Burstow: But, again, because
we have no metric or baseline against which we can judge fair
pay, that is an answer that does not stack up against anything
we can measure.
Mr Nicholson: There is a whole
set of legal cases going on about fair pay at the moment, is there
not? Our judgment is that the pay modernisation scheme is a fairer
way of paying people and no doubt that will be contested in the
courts.
Q79 Mr Burstow: In conclusion, it
strikes me that in terms of 1.1 million workers, making this simplification
was a very good thing. The thing that has disappointed me from
being a member of this Committee is that when it comes to measuring
whether it has had a real effect you can offer us assertions and
you can offer us examples but linking them back to this as the
real cause of those changes is not there, is it? There is no audit
trail on deliveries.
Mr Nicholson: That is because
pay modernisation is not an end in itself, it is an enabler, it
helps you do things. In itself it does nothing, all it does is
add to the pay. It is the way in which you use the staff and the
way in which they are deployed.
2 http://www.york.ac.uk/inst/che/pdf/rp47-pdf Back
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