Health Committee - Minutes of EvidenceHC 6-ii

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Oral Evidence

Taken before the Health Committee

on Tuesday 15 November 2011

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Dr Daniel Poulter

Chris Skidmore

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Jamie Rentoul, Director of Workforce Development, Department of Health, Dr Patricia Hamilton CBE, Director of Medical Education, Department of Health, Kate Lampard, Chair, Health Education England steering group, and Christine Outram, Senior Responsible Officer for Health Education England and Managing Director, Medical Education England, gave evidence.

Q1 Chair: Good morning. Thank you for coming. I apologise for keeping you waiting. We had a couple of internal issues we wanted to resolve. Could I ask you to begin by introducing yourselves and telling us which bits of the Department and the institutions you have come from?

Dr Hamilton: I am Patricia Hamilton. I am a doctor. I am seconded, and now, in fact, full time at the Department of Health as the Director of Medical Education. My particular interests have been, obviously, with medicine but also with the broader aspects of education. I have worked with setting up Medical Education England and continue to work in the Department on policy and education.

Jamie Rentoul: Good morning. I am Jamie Rentoul, Director of Workforce Development. I have the lead on education and training, policy, funding, adult social care workforce, equalities in the NHS and size, shape and capacity of the health workforce.

Chair: What do you do in your spare time?

Kate Lampard: Good morning. I am Kate Lampard. I am, formerly, chairman of the South East Coast SHA. I am now vicechairman of the cluster of SHAs for the south of England. I have recently taken on the role of chairing the steering committee that is going to oversee the setting up of HEE, Health Education England.

Christine Outram: I am Christine Outram. I am the senior responsible officer for Health Education England, leading on the set-up of it, which I have been doing for six weeks. I am also Managing Director of Medical Education England, which is a nondepartmental advisory body advising the Department of Health.

Q2 Chair: Thank you very much. It would be very useful to the Committee this morning if we could begin by asking you to set the scene. There are obviously major changes going on in workforce planning and education of the medical and nonmedical workforce going forward. These are to a significant extent, clearly, the consequence of the service changes going through in the Health and Social Care Bill. Do you see that as an opportunity to do something which was necessary anyway, or are these changes in workforce questions simply the consequence of service changes requiring changes in institutional arrangements?

Jamie Rentoul: I will kick off and my colleagues may want to add in. First, before launching into structures and all the rest of it, it is worth restating that this is about better health and health care for people and, as in our consultation document and the Future Forum report, recognition that excellent health and healthcare depend on an excellent health workforce with both the right professional and clinical skills and the right compassion, kindness and respect for people. Although it is a selfevident truth, it is about keeping what we are trying to achieve in our minds.

In terms of the summary line for the set of reforms, it is: developing a system which is more responsive to service and employers while being professionally informed and underpinned by strong academic links. That is the summary line we have of getting the three bits right. Within that, it is: consistent with the wider set of reforms across the NHS landscape in terms of delegation of decision making, strong professional leadership, more transparency and information about quality and performance and a stronger patientcentred view. Therefore, you are taking a more joinedup view to meet the needs of patients. It is not a consequence of those reforms. It was part of the package. But the Secretary of State decided we would consult on it a little later; to have the consultation on the rest of the system reform first and then engage with people about how you get the education and training and workforce planning system to best support and enable the wider system change. The themes of stronger employer engagement, more multiprofessional building capacity and focus are also themes you have seen in workforce planning, education and training changes over a number of years. Some of the Darzi reforms were also in that direction. This set of changes moves that on further in terms of what we are trying to achieve.

Q3 Chair: Would anyone else like to comment? The question is: what are the key strengths you are seeking to preserve and take forward from the old system and what are the weaknesses you are seeking to address in the new system?

Jamie Rentoul: In terms of strengths, over the last several years there has been an investment in developing the health professional workforce. Compared to a number of years ago, we are much more selfreliant in terms of doctors, nurses and midwives coming through and having the right training package for that. With the establishment of Medical Education England and with the Professional Advisory Boards for nursing and allied health professionals getting stronger, professional advice into the system and ownership of change has improved. We want to build on that in Health Education England.

The strategic health authorities and the establishment of the Centre for Workforce Intelligence have sought to start to build more capability on workforce planning and horizon scanning-the analytical underpinnings-but we have further to go. The critical change in this is the stronger accountability and responsibility for employers within a national framework and with national leadership. Getting this right, going forward, is about employers being able to set out, much more clearly, the future service need and how the workforce goes with that: the integration of service, financial and workforce planning, at a local level, driving the system more, within a system of checks and balances and with national leadership.

Q4 Andrew George: The fact that you are talking about a new system which is more responsive and professionally informed, more transparent and more patient-centred-language you used-is all very welcome. Also, in view of the last answer, where you refer to "locally informed," how do you gather that intelligence at a local level? When you are making your assessments, are you confident, in looking at the local situation, that the trained stafftopatient ratio, particularly in the acute sector, is adequate to cope with the front-line challenges which the service faces? If you are, are you confident that you can build up a picture of a safe service where that complement of trained staff at the front line is adequate to provide the service safely?

Jamie Rentoul: I will try and answer that in a few chunks. Do you want me to talk about the new system as we will see it working?

Q5 Andrew George: Yes. You talked about "local." At the anecdotal level, people are picking up a picture of staff not being able to cope because of the staff ratios being insufficient. To what extent are you picking that up in the intelligence you are gathering?

Jamie Rentoul: Within the system, it is the responsibility of the healthcare employer to make sure they have the right suitability of staff to deliver high quality safe care. The Care Quality Commission, as part of its set of essential standards, has a set of standards about the suitability of staffing. The responsibility is clearly on the employer there. Within the system we are consulting on and seeking to develop, we are proposing that the Local Education and Training Boards-as the Future Forum called them-would bring together the local employers with the education sector to be able to say, "In understanding the service commissioning intentions of the Commissioning Board and clinical commissioning groups, this is the pattern of services we need to develop to respond to that and the workforce we need to provide the high quality care." That analysis and work will happen at a local level but within a framework of accountability to Health Education England such that Health Education England is going to be able to look at the data coming out of the Local Education and Training Boards. The Centre for Workforce Intelligence will still provide analytical information and, to a degree, challenge in the system as to whether your staffing levels are right, such that HEE can say, "We have concerns about X, Y and Z."

Q6 Andrew George: You have taken it very quickly beyond the level where the intelligence begins, which is the front line of the service itself. You were saying that it is down to the employers and the CQC to make those assessments. To what extent do you interrogate that assessment? Are you satisfied that that assessment of trained staff complement at the front line is adequate to do the job, or do you simply stand back and accept the information that is provided to you from the CQC and the employers, which I think is what you are saying? Can you confirm that is the case?

Jamie Rentoul: As to the current system, certainly the strategic health authorities, with their current duties, very much carry out that challenge function in assuring workforce plans in terms of the safety and clinical quality of care which can be provided where there are workforce changes. Again, our view is that that is an important challenge function to have in the system. You do not simply accept what is coming forward. Also, the service commissioner-clinical commissioning groups, in time-has a due diligence function to ensure that what it is purchasing for its communities meets that quality. Health Education England will have a function of saying, "Are we developing and supporting with a workforce that has the right skills going forward?"

Q7 Andrew George: You are content that that arrangement provides the intelligence you need to plan forward for the numbers of trained staff required at the front line of the service. You are not providing what you call a challenge function. That challenge function is provided by others.

Jamie Rentoul: Yes.

Kate Lampard: Can I leap in? In the new world under Health Education England, a significant part of Health Education England’s work, to begin with, will be setting up an accountability framework. This will be the process under which Local Education and Training Boards will be held to account. They will also have authorisation criteria. Part of that structure, of course, will be focused on ensuring the right decisions are being made locally for numbers and quality of training. As I see it, Health Education England will have close working relationships with other parts of the system-the National Health Service Commissioning Board, Public Health England and local commissioning groups. And there will be a twoway exchange of information which will inform how the accountability framework is put into practice, with them and the other providers, with Monitor and even the Royal Colleges. Indeed, the education providers themselves will have strong views about what sort of service their trainees are going into. Those will be the mechanisms by which we will be able to detect whether there are the right numbers and quality of staff.

Q8 Andrew George: The challenge function, it seems to me, is primarily provided by those parts of the service also responsible for managing the resource. Commissioning bodies, the trusts themselves and the managers of the hospitals are dealing with the management of a scarce resource, which is their staff-hopefully not too scarce, but certainly a limited resource. If the challenge function is provided by them as well as rationing that resource, because, clearly, it has to be limited, I am not necessarily satisfied-are you-that there is a challenge function scrutinising whether the staffing levels are adequate at the front line?

Kate Lampard: I think you are assuming that Local Education and Training Boards will only be employers. That may not be the case. There will be other stakeholders involved locally, not least the education service providers and representatives. Presumably-although this is yet to be determined-commissioners themselves will be represented. In addition, there will be this line of accountability to Health Education England which, as it were, being divorced from the service, offers a much clearer line of accountability and challenge.

Dr Hamilton: Deans and deaneries also have an important role to play, certainly for medicine. They have accountability to the General Medical Council and to Health Education England, in future, to ensure that the supply of young doctors is appropriate. They will be picking up if they are being used to provide front-line service rather than receiving their education. They are in a position to challenge.

Q9 Andrew George: It is fine for doctors, but what about nurses and care assistants?

Dr Hamilton: One would hope that the new system provides opportunities for that sort of arrangement to be strengthened.

Q10 Andrew George: You said there was a "hope" there. There is no certainty.

Dr Hamilton: There is an expectation and an intention that we will extend to multiprofessional.

Andrew George: We have gone from "hope" to "expectation." That is good.

Chair: "Intention."

Andrew George: Sorry, I did not pick up the "intention".

Q11 Dr Poulter: In terms of training and education, there are two aspects: the theoretical and the practical. We can all accept that, and everyone is nodding quite happily. On the training of junior doctors following the setting up of the MTAS system, which perhaps has benefits and negatives, one issue, which was raised by Jamie Rentoul in his evidence earlier, was about employers or hospitals-who do a lot of the primarylevel training of junior medics, except when GPs become GP registrars-investing in their staff properly. Is it fair to say that, under the current system, there is variability in whether that happens? We often have fourmonthly rotations now, as opposed to the previous sixmonthly rotations, and we have the European Working Time Directive, which often pushes a lot of hospitals towards service provision rather than training. Is it fair to say that the quality of training, both practical and theoretical, offered in different hospitals can, at best, be described as hugely variable?

Dr Hamilton: Yes. That is one issue the new system is proposed to improve. We recognise variation in training. The latest General Medical Council survey on trainees has recently been produced and while, generally, satisfaction has improved, there remains variation across teaching and training institutions. It is very important that we raise that bar of quality and improve opportunities to train in primary care and community settings. That work has already started, following two reviews: the Temple review, which Medical Education England commissioned, on the quality of training and the Working Time Directive, and the Collins review on the foundation programme. Both raised issues of poor supervision in places and also the importance of giving all trainees opportunities to train in primary care and in community settings. The curriculum is being rewritten to address that.

The important point you make about service issues trumping training is one of the things we are trying to fix with the proposed new system. That will not be contemplated or permitted in the extra checks and balances we are putting in to complement the General Medical Council’s assurance framework, which already exists, to ensure trainees have a proper opportunity.

Q12 Dr Poulter: We know, for example, that there is a finite number of doctors on an oncall rota, shall we say, or in a particular department in a hospital. We also know that, for GPs, the time they spend in their specialities in hospital is essential and what they learn there benefits their work in the community, so I accept your point about communityfocused training. It is very important the time in hospital is not compromised. I see you are nodding in agreement. But I fail to see, when there is pressure on budgets and you have a finite number of doctors in a department on a particular rota, how this is going to be achieved and how we are going to improve the quality of education. The driver with the European Working Time Directive means that there is very little flexibility for hospitals to build in training time for staff.

Dr Hamilton: As a result of the Temple review, we look at the impact of the Working Time Directive, which showed there is time, within their 48 hours, to train-but not in our current system. I agree with your shaking your head in that the way we currently run the service, with our most junior doctors providing most of the service, means they cannot train in that 48 hours. We are planning to involve consultants more, and that is already happening. As a response to that report, Health Education England has set up a programme, which Chris Outram might like to talk about, called "Better Training Better Care," in which, with a more consultantpresent service and different ways of working across and within the professions, we can provide safe service for patients without compromising training. But we have to change the system in order to achieve that.

Q13 Chair: Could I bring in Christine Outram but ask you, in this context, to address the question of what you see as the role of the GMC, the regulators and, indeed, the Royal Colleges in providing an independent view of the answer to Dan Poulter’s question? This is in danger of being too much management-led and there needs, surely, to be a strong professional commitment to standards based on regulation as well as management priorities.

Christine Outram: Indeed. Can I start with the question about the "Better Training Better Care" programme which Patricia Hamilton began to describe? Medical Education England, in the current system, commissioned the review of the impact of the Working Time Directive on training. Shortly after we had done that, we also commissioned a review of the foundation programme, which review had been one of the recommendations from Sir John Tooke’s report in 2008. As Patricia has said, both the Temple review and the Collins review highlighted the issue about junior doctors being so heavily required to be on outofhours rotas that they were missing out on training opportunities inhours from which they would undoubtedly benefit. It is the case, however, that some hospitals have managed the changing scenario with working time much better than others. There are hospitals where consultants are present much more. It does not mean that consultants are overworking, but they are working differently. Their hours are structured differently so there is greater availability of senior doctors to oversee the work of juniors and be available when juniors need particular guidance or advice. It goes without saying, of course, that it is also much better for patients that their care should be properly supervised by a senior doctor.

As a result of the recommendations of these two reviews, we have established a programme called "Better Training Better Care" which has two main themes to it. One is to support trusts across the land to increase the time available by consultant staff-the more senior staff-to support the juniors and have better supervision. The other is something we have dubbed "Make Every Moment Count," where we focus on education in the workplace in order that all opportunities for training are taken. That is a new programme. We are going to be working with trusts across the country to find different ways of improving training. In the new system, Health Education England will pick up on this programme because it is important and is supported by very senior levels across the medical profession. The way the new system will support it is through greater accountability. As well as a supportive approach, which we adopted through "Better Training Better Care," there will be the opportunity for Health Education England to set some important strategic priorities for the service. One of those, without a doubt, would be the better supervision of junior doctors. It is an issue we are all very concerned to fix.

As far as the regulators, and the GMC, are concerned we have a common interest, obviously, in quality. It is the role of the GMC, for example, to set standards for the education and training of doctors and to ensure they are met. Health Education England will have an interest completely in common with the GMC, but we will have different information we need to share. Health Education England will be allocating the money to the system to be spent on the training of junior doctors and, therefore, will have some levers in that respect. The GMC has different levers. We will need to work together and we are talking to the GMC, at the moment, about how we can use the creation of Health Education England to fix some of these issues and to strengthen the work they are doing.

Q14 Dr Poulter: I hear what you are saying. However, the point the Chairman makes is well made. We have a well-meaning but slightly utopian view being put across at the moment: a management view rather than, necessarily, the view put across, say, by the Royal College of Surgeons. You will be aware of the very real concerns they have about medical training. What the Chairman was asking, and what I was trying to drive at as well, is this: it is very difficult on the ground, in a small district general hospital, to rearrange rotas. There are real practical problems in you saying that, within a 48hour working week, you can do service provision and training and free up consultants out of their outpatient clinics or their time in theatre to do all this extra training. I think a slightly utopian view is being painted. Certainly there is concern, among the colleges, that what is there at the moment does not work and we need something much better in the future. I am not hearing anything other than "management-speak" coming across about how this is going to change. When the Royal College of Surgeons have been expressing real concerns about the training of surgeons and surgical trainees, what are you doing to make sure those concerns are addressed and that the training of surgeons is improved?

Christine Outram: I am not describing a utopia I have imagined. I am describing practices I have seen in hospitals, which I could take you to, which I have visited.

Q15 Chair: But you have acknowledged-or your colleagues have acknowledged-there is too much variation.

Christine Outram: I do acknowledge there is too much variation. It is hard. We are tackling a system that has grown up over decades in the way we organise the training of junior doctors. It is not easy for hospitals to change. Small hospitals have particular issues, but so do large hospitals.

Q16 Chair: With respect, you are compounding my concerns. You are saying there are some examples of excellence, which we acknowledge, and then you are telling us how difficult it is in smaller hospitals. That is the problem. Where is the cutting edge?

Christine Outram: There are examples of excellence in smaller hospitals, too.

Q17 Chair: I accept that.

Christine Outram: Large and small hospitals have taken different approaches. The approach we are taking, at the moment, is to spread the use of these good practices and encourage hospitals to look at the way they organise themselves to improve what we all acknowledge is an issue. The Royal College of Surgeons are involved in the work that we are doing. They do have concerns. We have to be particularly careful with the training of surgeons to ensure that people have enough time in operating theatres, for example, and are not spending all their time elsewhere. That takes organisation and focus.

Jamie Rentoul: At the risk of lapsing slightly into management-speak, some of this is about recognising that good education and training cannot be left to an individual provider, small or large, but is a collaborative effort in terms of the right rotations, the right support and so on. Therefore, these Local Education and Training Boards are about employers coming together, working with postgraduate deaneries and increasingly across professional groups to say, "What are the quality standards we are going to make clear everyone has?" They will be held to account by Health Education England with better information, transparency and focus over time. It is not a quick fix-these problems have been around for a long time, haven’t they?-but it is about a system which sees this as critically important to sort out.

Q18 Valerie Vaz: How are you going to encourage them to use the money for training for that purpose? There is already raiding of the budgets going on now, is there not?

Jamie Rentoul: Not to a great extent. In terms of Health Education England allocating money to Local Education and Training Boards, the deal is about specifying the outcomes, quality of training, numbers trained and so on in return for the funding flow being received and, over time, building up a better set of information which gives you the accountability in the system. One of the issues at the moment is that the information about quality and so on is rather weak. We need to build it up so that the Local Education and Training Boards are genuinely held to account for what is being achieved.

Q19 Valerie Vaz: I do not know if we are moving on to architecture, but they are not set up yet.

Jamie Rentoul: No.

Q20 Valerie Vaz: Who is on them?

Jamie Rentoul: At the moment, Patricia has professional accountability for postgraduate deans in terms of quality of educational training. We work through the strategic health authorities now in terms of the quality expected but we want to see, going forward, stronger employer ownership of this.

Q21 Valerie Vaz: But they would not be down at a local level.

Jamie Rentoul: Again, as you know, we have not made policy decisions on this yet and the Government have not published details. The size and shape of them are still to be determined. The discussion going on at the moment is that they are of sufficient size to be able to take a broad view of the workforce in an area and have economies of scale, but also to have the clout to take action where there are concerns about quality.

Q22 Valerie Vaz: Will they be outposts of Health Education England?

Jamie Rentoul: As I said, the Government have not published yet. We are waiting for the Future Forum. The Secretary of State will determine that in what we publish shortly.

Chair: We might have some recommendations.

Q23 Dr Wollaston: Concerns have been expressed about the scale and pace of this, another major untested system change. Could you clarify what was so bad about the existing system-that is still not clear to me from your answers-that it could not have been fixed under the existing arrangements? As you have mentioned, we have variability but examples of very good practice. What, in the existing system, would have prevented you addressing that variability adequately to justify this scale and pace? Also, how confident are you that the time scales can be met?

Jamie Rentoul: On the scale and pace, you will know that we consulted in December last year and then the Future Forum did its first round of engagement and produced its report. As a result of the forum’s first report, the date of the abolition of strategic health authorities got pushed back a year. Their strong recommendation, which the Government accepted, was that we needed more time to make sure we were building the right local relationships, thinking about the development of the Local Education and Training Boards and giving people enough time to form new relationships and have clarity of role. That has given us some more time in terms of pace of change, and people are more comfortable with it.

In terms of what needed fixing in an organisational sense, first it is about establishing national leadership and focus with Health Education England: rather than having a set of functions sitting betwixt the Department of Health and strategic health authorities, having Health Education England at arm’s length from the Department providing that national leadership. Secondly, within the Local Education and Training Boards-

Q24 Dr Wollaston: Could you go back? Are you saying Health Education England did provide national leadership?

Jamie Rentoul: It did not exist. Medical Education England was an advisory group to the Department. It provided advice. It did not have executive responsibilities or funding allocated through it. It was medicine, dentistry, pharmacy and scientists, not nursing, midwives and allied health professionals. Health Education England will encompass all the professional groups in its remit. The proposal in the consultation was that the central funding will be allocated through it. In bringing together the employer view, the professional view, commissioners, regulators and the education sector in the Health Education England decision-making, it has funding flows that go with it and give it, therefore, grit in the system in terms of outcomes achieved.

The second bit is getting more employer engagement and ownership of workforce planning, education and training, which is where the Education and Training Boards come in.

Q25 Chair: Can I explore this question of the relationship between HEE and the regulators a bit further? You were implying that everyone’s interests were the same. I am not quoting you directly, but the sentiment coming out was, "We are all in this together. We are all going to the same destination. There are no choices to be made." Life is seldom like that in reality. I would like to understand how you think Health Education England will relate, in particular, to the GMC and the medical regulatory bodies.

Christine Outram: The GMC are involved now with Medical Education England and are a key partner for us. They are on our boards. When they do work on particular issues we are invariably involved in some way, and vice versa. I know that that will continue. It is not that we are all in this together, but we are looking at the same hospitals and the same issues.

Q26 Chair: But you might come to different conclusions about a given set of circumstances. That is the key point, is it not?

Christine Outram: We might, initially, in which case a productive relationship with the regulator would be one where we had a dialogue. In Health Education England we brought our information. They have an enormous amount of indepth information which is extremely useful in dealing with the sorts of questions we have discussed. For example, the survey of junior doctors provides an awful lot of information about their experience-what they are going through.

The way I see it, Health Education England will have information that comes through a particular management line and through the perspective of an organisation that holds the funding, sets some national strategy, reports and is accountable to the Secretary of State and is concerned to have the particular priorities the Government wants it to have. The regulator is looking at the standards of education and training, in this case, constantly and consistently with that focus. Both parties have something to bring to the table in terms of information. The GMC, obviously, registers doctors and accredits training courses. HEE will allocate funding for the local partnerships to spend on training. Health Education England and the GMC have different levers to make things happen. For the various scenarios you could picture, there may be some where the GMC’s levers work and some where Health Education England, through strengthening the accountability in this new system, can make things happen that the GMC have not been able to. We have regulators who do a very good job, but the world is not perfect now. There is still work to be done.

Q27 Chair: What concerned me in the way you presented it the first time-and it is slightly different now-was the implication that there was no tension. It seemed to me that, between a commissioner with budget responsibility in the form of HEE and a regulator with professional standards responsibility and, ultimately, no accountability for money, there is inevitably, and should be, tension. I would be more comfortable if I felt that was something being explicitly recognised and welcomed rather than shuffled under the carpet.

Christine Outram: I do acknowledge there is a tension, but tensions, if they are going to be helpful, need to be worked through.

Chair: Of course.

Jamie Rentoul: The GMC or others will make their decisions on whether standards are met and HEE has to live with them. They are statutorily responsible for that decision-making. Sometimes those will be uncomfortable decisions, but then HEE and the employers will have to respond to them and take action. That, again, is part of what you were talking about earlier in terms of another challenge function outside the management line which you need in the system.

Chair: But it is interesting that it is coming into the conversation in response to questions rather than being volunteered. That is the point I am seeking to draw out.

Q28 David Tredinnick: I would like to move on to the multiprofessional approach to education and training. Does the Department intend there to be a more multiprofessional approach to education and training, breaking out of professional silos? If so, what form will that take in practice?

Dr Hamilton: When deaneries, as we have discussed earlier, move out of the SHA aegis at the end of March 2013 and into the new system architecture, the intention is that this will be the time to make them truly multiprofessional. Clearly, there are obvious economies of scale and economies to be made in backoffice functions being shared and so on. More importantly, it will bring us multiprofessional training. That is not, necessarily, training within the same classroom, but learning with and about each other. Instead of only training expert teams-and we do train expert teams-we train them to work together, not each being an individual team.

A lot of work is already being done on training in a multiprofessional way. For example, using simulation, the various professions all train together in putting their skills into practice in emergency situations and so on. Working together, the deans can, as we do not do now, learn about innovative ways of education and training from each other, using the spread and adoption of research and education. We need more research in the other professions to encourage research in nursing as we need to foster it in medicine. We can work together to learn from and train each other, and to encourage junior doctors, for example, at times to learn from specialist nurses or others working in the community.

Q29 David Tredinnick: Does anybody else want to come in on that?

Jamie Rentoul: The other thing to add, again thinking back to what you are trying to achieve in this, is that, as you think about changing demography, patterns of service and more people with longterm conditions, it is about getting that bit of the service, financial and workforce planning together and saying, "What is the right skill mix to provide appropriate integrated care for people in later life?" Then you go back to, "Who do we need to be delivering those skills in the provision of care?" rather than saying, "We are starting with an X and we need lots more of these with this set of things." Again, it is addressing perhaps some of the longerterm challenges about sustainability.

Q30 David Tredinnick: Earlier on, you were talking about patientcentred views. Patient choice is critical in the Bill and this is what we are hoping to achieve. We are also getting better regulation of some therapies which have not been available. For example, herbal medicine is about to be regulated by the Health Professions Council. We have acupuncture now available through NICE guidelines. Are you considering whether there needs to be better training or more extensive training for those disciplines? Do you see a relationship with this new provision in the work you are doing, please?

Dr Hamilton: We certainly need to be aware of the different therapies and ways in which patients would choose to be treated, and the place in which they need to be treated. For example, we have asked the Centre for Workforce Intelligence to look at patient pathways: to look at the various ways in which patients present to the Health Service and the various options they might have for meeting different sorts of therapists in different ways. We can then help plan and train the workforce we think they need. That means starting from home all the way up into hospital so that we will take account of all those various options.

Q31 David Tredinnick: I have raised this before in sessions, but we have a huge expansion in Chinese medicine and it is about to be better regulated. I am suggesting to you that you need to factor this in. There is also another group of people who are now regulated by Act of Parliament, the chiropractors and the osteopaths. Have you had any thoughts about how you can make better use of them and take the pressure off orthopaedic surgeons?

Jamie Rentoul: It links back to the point we are making-as employers think about responding to services and services’ commissioning reflects patient or community views-of being in a position where the employers, working together, then think about appropriate training to deliver that care. Some of that will need a national perspective. You may want common training standards, for which you need to consider the right professional body to provide that advice and who is going to oversee it. Thus, care assistants-something being discussed a lot at the moment-getting the right training standards such that the Health Professions Council can then think about that in voluntary registration. There is a degree of wanting to see the bottomup drive of what services we want to offer, the mix of skills and therapies to do it, and then how we respond to that in terms of the training and education needs. It is a generic response, I appreciate, and maybe there are specifics we will need to pull through that.

Q32 David Tredinnick: I think there is going to be a change in that patients are going to start asking for different services, now they have choice.

I would like to move on now, if I may, please. One of the Department’s key objectives is to widen participation in health professions so that all groups of the population are properly represented. What is the scale of that challenge? How do you think the proposed reforms will address it, please?

Dr Hamilton: Certainly from a medical side, it is a real challenge. It is one of our stated objectives for the proposed changes for the new system that we aim to widen and improve participation. We do not underestimate the challenge, perhaps particularly for medicine but for all the healthcare professions. There is good practice going on, and one of the aims we hope to get out of the new system is the swifter spread and adoption of good practice. We know, for example, that King’s College has done a great deal to not only increase participation and the uptake of medical students from a wider section of society but to support them through the first year of training. That is often where they drop out because people think, "Job done. We have recruited them," when in fact they need further support. Our statistics still show a greater proportion than we would perhaps like to see-no disrespect-of public school people attending. In medicine, it is still very high and we do not have as much participation as we would like. It is, as I have said, a stated objective of the reforms. It is, I imagine, something of a challenge for Health Education England to get better statistics, better availability of information and better spread, and encouragement and expectation that people will adopt the sorts of good practice that we have seen in various locations.

Jamie Rentoul: I will add to that. Within the current system, and working together with the Department for Business, Innovation and Skills, we have the Higher Education Funding Council. Quite a lot of these issues are joined up across the two in terms of people coming into education as health students and then coming into the Health Service. Discussions are now about appropriate student support through the NHS bursary, which has meanstested and nonmeanstested elements, and, "Is that being best targeted to support widening participation goals?" As to the service level agreements the Department currently has with the strategic health authorities, there are the widening participation aspects in terms of the training commissions and so on. As we move into the new system, what are the different ways, in terms of financial support and expectations on the contracts with education institutions, that we can build on to try and address the objective?

Q33 David Tredinnick: I have one other question I would like to ask. Although it has become controversial, homoeopathic medicine has been part of the Health Service, pretty much since its inception, through the regulation of doctors through the Faculty of Homoeopathy. When you look at the broadening of scope, do you think you will be considering whether it is necessary to have better assessment of this particular discipline and how you will be able to respond to the increased demand from the general public now that they are being given more choice? That is my last question, Chair.

Jamie Rentoul: We should probably offer to write to you on that, consulting colleagues in the Department, if that is okay.

David Tredinnick: You would like to think about it. Very well.

Jamie Rentoul: Yes.

Chair: Write to me and I will circulate it. It will be read with particular interest by Mr Tredinnick.

Q34 Andrew George: First of all, my apologies. I have to attend Questions to the Deputy Prime Minister in a moment. Coming back to the theme I was inquiring about earlier on workforce planning, as I understand it, under the new structure, the Centre for Workforce Intelligence will be retained as such which will obviously provide intelligence on future planning of the workforce. To what extent will it be publishing and informing both the public, but also itself, on what it believes the skill mix and skill needs of the service will be and the extent of that need?

Jamie Rentoul: It is core to its role to get that information published so people can debate it, prod and poke it and say, "You have not thought about X, Y and Z in that bit of modelling." Again, as successive reports have said, good workforce planning and horizon scanning and so on is very hard to do, but doing it is better than not and you need to get it as good as you can. You have Peter Sharp coming in the next evidence session. That is a critical part of their role.

Q35 Andrew George: Coming back to or, if you like, going further in the direction of the questions I was asking earlier, when you were talking in terms of interrogating the assumptions underlying that data, are you content that there will be sufficient interrogation of the skill mix needed literally at the front line? In other words, will there be any assumptions made at all about trained stafftopatient ratios at, say, ward level at hospitals depending on the acuity of the patients on that ward? For example, will that be left entirely to the managers of those services?

Jamie Rentoul: We want challenge at a sufficiently granular level that people are able to do something with it. The national average information does not help you a lot of the time in delivering local services. As a way of working, part of the purpose in having the Centre for Workforce Intelligence contracted but out of the system is that they are doing the analysis. It is their analysis for the colleges, professional bodies, patient groups, commissioners and employers to have a go at, to get it as good as it can be, and give that challenge. To choose something topical, to deal with maternity care workforce as a whole you have to do that at unit level in terms of complexity of case mix-age of mothers and so on-for them to be able to aggregate up and say, "What is the future need in terms of training commissions?"

Q36 Andrew George: As to what level of assumptions will be provided, taking the case of midwives, if the intention of Government is to offer choice, including home delivery-in which circumstances, at second stage, you probably need to have two midwives present-that appears to imply a need for more midwives. Will the assumptions underlying the numbers that are provided at the national level provide a commentary which will inform those numbers and advise people as to how you have arrived at them?

Jamie Rentoul: Yes, that is certainly the intention. It comes back to that clear articulation of service commissioning reflecting patient views-mothers’ views in this case. What is the range of services between a midwife and their junior at a home birth and an obstetric unit that is going to be commissioned for a local community? What is the right skill mix and what are the implications for doctors, midwifery, midwives and maternity care practitioners that you need to deliver that with the safety, quality and mother’s experience you want to get to? It has to be quite granular.

Q37 Andrew George: Thank you. That is very helpful. Finally, in relation to overseas and agency locum staff within the service itself, is it the view in the service that the use of agency and locums is, by implication, a failure of workforce planning?

Jamie Rentoul: The view is that the level is too high. Generally, it is useful to have some because it gives you flexibility and so on, but the NHS is spending too much on agency staff at the moment. As I said at the start, we have seen significant growth in terms of the number of people in different professions coming through training such that you would expect us to be making progress in reducing agency usage, though not seeking to eliminate it. I do not think that would be the right goal.

Q38 Dr Poulter: I want to put a question to Kate Lampard. Can you explain your role-what you will be doing-as steering group chair of Health Education England?

Kate Lampard: I am going to be leading, or chairing, the steering group. The steering group is designed to ensure that, from the outset and at the early stages where we are designing and setting up Health Education England, we get the involvement and the perspective of a wide group of stakeholders. They will be able to ensure that all those whose interests need to be taken account of in workforce planning and the provision of education and training are heard and ensure that we do not lose what is good and what needs to be preserved about the system as we presently have it. The stakeholder group is going to meet on a regular basis. In practical terms, we will be providing the leadership to ensure that we set up the new system, the new architecture, appropriately, so that it takes account of the views of the stakeholders, and to offer support, encouragement and challenge to the staff as they set up Health Education England. In due course, we will hand over, to a formal board, Health Education England.

Q39 Dr Poulter: I put it also to Christine Outram. How will the existing professional programme boards and advisory boards be integrated into Health Education England? Will there be similar structures created for other healthcare professions?

Christine Outram: Medical Education England has four professional boards covering doctors, dentists, pharmacists and scientists. In addition, the Department of Health has established two groups, which Jamie referred to earlier, covering nurses and midwives, on the one hand, and allied health professionals, on the other.

Pretty much across the board, those groups have done some very useful work and have ensured that all aspects of education, training and workforce development being led by the Department of Health and the SHAs have been informed by some coherent professional input and opinion. For those reasons, the White Paper stated, right at the start, that Health Education England’s advisory structure would build on that which had been developed in Medical Education England in the Professional Advisory Boards. As far as I am concerned, we need to ensure a smooth transition of those arrangements. All the groups are doing some very important work, from the sort of work I talked about on medical education to some changes to the undergraduate pharmacy curriculum, which will improve the training of pharmacists. All of them have important work going on. They bring all the stakeholders to the table: sometimes there may be disagreement but there is a place for those disagreements to be worked through, rather than the Department being advised by conflicting parties. We will need to ensure a smooth transition of those arrangements into Health Education England.

In terms of the individual programme boards, that will not be too complicated to achieve and the professionals round those tables expect to come into the future. There are a few professions which are not yet covered within those different boards and we certainly need to make sure that all the health professionals have some means of their interests being represented through the advisory structure. We have not worked out how we are going to do that yet, but we certainly intend to do so.

The missing bit comes back to the discussion we had about the multiprofessional debate. At the moment, the main board of Medical Education England brings the four professions within Medical Education England’s remit to the table and has done some useful work on looking at healthcare issues in a crossprofessional way. Health Education England will need to ensure some means for it to have strategic multiprofessional advice that finds solutions to the workforce problems of the future. Again, that is in discussion. I do not yet know exactly how we will do that, but we certainly will do it in some way.

Q40 Dr Poulter: In terms of the relationships and responsibilities of Health Education England and the need for educational boards or local skills networks, it will be more at a national level than a local level. How do you see that?

Christine Outram: You have to do some things at a national level.

Q41 Dr Poulter: What are they?

Christine Outram: They are national functions. There are very small specialties, for example, where branches of some of the professions need very few people-types of medicine where you might need about 10 people across the country. There is no sense in that kind of workforce planning being done at a local level. HEE will need to make sure there is a national view that keeps an eye on those smaller specialties, for example. Another example, also in relation to medicine, is about the recruitment of junior doctors for the different specialty training paths. At the moment, that is led by a partnership of the strategic health authorities with the Department of Health and Medical Education England. There is an understanding that, to get that planning right, you need to take a national view. Again, HEE will need to make sure that there is a national view, which is safely transferred from the old system to the new.

Much of the strength of the new system that is being proposed will depend on the involvement of providers, professionals and employers on the ground locally. A large part of their workforce plans will be made up on the basis of what those particular primary care practices and hospitals believe they need for the future. There has to be a balance. I do not believe that HEE will start to specify hundreds of different outcomes to be achieved in a particular year, but it will set some standards and some priorities.

Q42 Dr Poulter: I want to follow up on that, and this is very much what Jamie Rentoul was saying earlier about local service providers and healthcare providers having much more of an interest in the education, development and training and having much more of a voice in that than perhaps they do at the moment. In terms of the training of doctors, a lot of the essential training, historically, that provides the basis and the basic knowledge for community care and general practitioners’ care is provided in the hospital setting, initially, in terms of paediatrics, obstetrics and gynaecology and psychiatry. That used to be six months and is now four months since the European Working Time Directive came in. That is a great amount of clinical exposure, experience and training that has been lost to general practitioners. Do you think there needs to be a review of that in a national setting?

Christine Outram: I will ask Patricia to start off.

Dr Hamilton: The Department has worked before with the Royal College of General Practitioners to look at enhancing and potentially extending the duration of training for general practitioners, which currently stands at three years in total. The case is being relooked at presently by the Royal College and will be submitted, in the spring, to Medical Education England for consideration. There are two things to be considered. One is the strength of the educational case and the other is the cost-benefit analysis, balancing the inevitable costs against the benefits that we have. Those cases will be considered early next year.

Q43 Dr Poulter: I have one final question. It is at a slight tangent but it will be of general interest, I am sure, to members of the Committee. There is a growing wish, in particular, for simulators in training and multidisciplinary working and training in emergency scenarios that go on in hospitals. That is being developed at a local level. I know the Chelsea and Westminster Hospital has this in obstetrics. Is the Department of Health looking at how that education and training could be beneficial to the agenda, for example, that we have in areas like obstetrics and gynaecology or emergency medicine to overseas aid and development; how the Department and our training programmes here can link in better overseas; and how our doctors could benefit and help-a symbiotic relationship to their training and the overseas aid programme-by improving education in that respect?

Dr Hamilton: It is an enormously important topic. Technologyenhanced learning generally, a combination of the simulation techniques and Elearning for healthcare, can be-and we anticipated that it must be-an important part of training both here and, as you say, with potential for distancebased learning. The Department is about to publish a strategy and framework for technologyenhanced learning. We also believe that the new system would be an excellent one. This is the sort of innovation and good practice which is potentially expensive and needs to be used wisely, but can be used as part of a network very constructively. I strongly support what you are saying. We are supporting it, too.

Q44 Dr Poulter: I have a quick supplementary to that. Concerns are sometimes raised, for example, by doctors who are linked with the armed forces, and also doctors who want to go and spend some of their training overseas. They have difficulty in negotiations with the deanery, even though it would be very beneficial to the countries they are going to, and indeed to the armed forces, as well as beneficial to their training and British medicine when they return. There are difficulties with the deaneries in this respect at the moment. Is that something you will be looking into?

Dr Hamilton: We will. We have looked at it with the Ministry of Defence. I know that the Royal College of Surgeons runs a very intensive simulation programme for doctors going overseas into warfare situations. With the armed forces themselves, there is not a problem. Certainly, one thing we want to do in working with the deans and deaneries is to ensure there is consistency generally on the issues of study leave and out-ofprogramme training and experience.

Q45 Chair: Before we leave HEE, can I ask about the intended relationship between HEE and the other home countries and the extent to which this is a UKwide brief? All the questions we have discussed about the links with the regulators, the development of training and so forth, are clearly UK questions. They are, in particular, in relation to smaller specialties but not only in relation to them.

Christine Outram: They are indeed, and that is obviously the case now. With Medical Education England, therefore, we have been very conscious that we have to take a UK perspective on anything we do, and work with our colleagues in the devolved Administrations. We are a very small advisory body, but we have established good links with Scotland, Wales and Northern Ireland. HEE will need to continue to do that because you cannot make changes to the training of our major healthcare professionals within an Englandonly context, particularly, as you say, in some of the smaller ones. We will establish and build on the relationships as we have them now.

Q46 Chair: You are seeking to develop a UK view before you move. You said you could not do it without taking the others with you, which was quite a strong statement.

Christine Outram: Perhaps my language was not tight enough. I do not think HEE has to take a UK view, but it has to bear in mind that the labour force it is working with-the market it is operating in-is UKwide. For example, if it was to cut the number of healthcare scientists it was training, in my opinion, it should not do that without discussing it with the devolved Administrations. It would be pointless. They are all involved.

Q47 Chair: There is a bit of a tradition of Scottishtrained doctors in England.

Christine Outram: Indeed.

Jamie Rentoul: Some of the Scottish numbers are now reducing and, therefore, that has a potential impact on England. It is about having the exchange of information so that we each understand what is going on.

Q48 Dr Wollaston: If you increase the time of training for GPs to five years, would you only be able to do that if there was a similar change in Scotland?

Dr Hamilton: We are working with the devolved Administrations on this. When we are discussing this, we are discussing it with them as well.

Q49 Dr Wollaston: Would you not go ahead with it unless it was across national boundaries? There is a real concern that we might see inconsistency here. Doctors, of course, are constantly moving across boundaries.

Dr Hamilton: It would be a real shame if we could not get agreement with the DAs, and we will work very closely to make sure that whatever agreement we reach is compatible across the borders. You are right in that we do not want to disadvantage trainees. Clearly, we each have to recognise each other’s CCTs. It would not derecognise a training that was of a different length, because we are part of the European Community, but we would prefer to go ahead with agreement from them. Scotland has already piloted a fouryear GP programme, so we are hoping that, whatever solution we come to-and we have not yet made that decision as to whether it is four, five or whether we can justify the extension at all-we will be making it in conjunction with representatives from the DAs.

Q50 Dr Wollaston: Further to that, on the point of GPs, there is a concern that we are not training enough GPs considering that we are moving to a primary-careled service. Is that something the panel shares a concern about?

Dr Hamilton: We do share that concern. It is one of the issues we think the system is here to be cognisant of and try to fix. We have been aware of a specialist drift and that we are training more specialists than generalists. That includes general practitioners but, also, general surgeons, general paediatricians and general physicians. We now have the accurate numbers. We have made more general practitioner places available in the recruitment rounds over the last two years and have increased and intend to continue increasing that proportion.

Q51 Dr Wollaston: One problem, of course, is that those places are often not filled. How are you going to drive a change so that trainees have realistic expectations? They cannot all become renal specialists. As people go through medical school, they tend to have very much a hospitalbased focus, and I wonder what plans you have to change that.

Dr Hamilton: You are absolutely right. Every year we publish the competition ratios. I write an article in the BMJ about careers saying, "Be aware, if you are applying for surgery, these are the competition ratios," but, still, they apply. We know that we need to address this issue at several levels. There is the expectation when you apply to medical school- the hidden curriculum, the subliminal messages that are given-that, if you are doing well, you ought to be a specialist at medical school. Also, we have been working with the Royal College of General Practitioners on our career websites to give positive podcasts to try to attract young people into general practice.

Finally, we have a big project called "The Shape of Training," looking at the shape of postgraduate medical training, in which we are trying again to take forward some of John Tooke’s recommendations. We are starting with the option of a more broadbased training, following foundation, which includes paediatrics, general practice, psychiatry and medicine. For those who are undecided, they can get experience and training in those specialties and then can transfer the competencies and skills they have acquired across to their final chosen specialty. They do not have to start again at the bottom of the ladder.

Q52 Dr Wollaston: That is a very important point, yes.

Dr Hamilton: We are hoping that we will attract young people into psychiatry and general practice, which are both underrecruiting at the moment.

Dr Wollaston: Thank you.

Chair: Still we have a discussion about whether there should be competition in medicine.

Q53 Valerie Vaz: I want to turn to the new architecture, where HEE fits into it and how you are going to interact with the different bodies; for example, Public Health England, the commissioning groups and, as Mr Rentoul mentioned, employers. That has come up quite a few times. How would you see it all working in terms of education and training, for example, now that we have Hinchingbrooke Hospital being taken over by Circle? Is that what you meant by employers?

Kate Lampard: As far as the other organisations, and where HEE fits in the new architecture, are concerned, it is important that it acts as an integral part of the system and that it has working relationships with the NHS Commissioning Board, Public Health England and regulators, CQC, Monitor, the professional regulators and the Royal Colleges. Unless one understands the priorities of those organisations, one is not going to make much sense of the workforce planning and be able to address that in delivering the numbers of trainees to fulfil the priorities from those organisations. On a general level, I see this as a twoway communication and involvement. It is not simply about HEE having to be apprised of the priorities of those other organisations. Equally, of course, HEE will have information about how employers and the service generally are fulfilling their responsibilities to train the right staff.

Q54 Valerie Vaz: Are you capturing data in some way? Is there a mechanism for capturing data?

Kate Lampard: As I see it, there will be. If we have an authorisation system and criteria, and if we have an ongoing accountability, we will have to gather the information to assure what they will tell us. I hope we will also gather very soft information, for instance, bout students’ or trainees’ experiences. That sort of information should be handed on to the other parts of the system having responsibility for policing the system as much as we do. It is that sort of general view.

Jamie Rentoul: In terms of the employers-healthcare employers generally-you want a system, to take your example on Hinchingbrooke, that should be part of the training and education system. Therefore, you want thirdsector providers-Macmillan or whoever-to be involved in your Education and Training Boards if they are providing NHSfunded services. We are thinking about the training needs in the round.

Q55 Valerie Vaz: Do they sit on a board or a local group?

Jamie Rentoul: I was being less specific than that because we have not yet published the Government response. In terms of the Education and Training Board, you would expect that to have healthcare employers represented and the academic health sector and the education sector represented as a detail of that representation. You cannot have them all on it, but you need employers to have confidence that their needs and interests are being taken forward in the work of the board.

Q56 Valerie Vaz: Does anyone have anything to add?

Christine Outram: Perhaps the other relationships to think about, which are particularly important, are those with the Commissioning Board and Public Health England. Both will have strategies for services and for public health that need the right staff. Those are crucial relationships for Health Education England to get right and to nurture. We cannot allow the agendas to diverge. The service needs particular staff. Health Education England needs to understand the strategy for the service and it takes a long time to train some healthcare professionals-anything from two or three years to 15 years. The sharing of thinking about the future is very important in relation to both the Commissioning Board and Public Health England. All the relationships are going to be important, but those are particularly major ones.

Q57 Valerie Vaz: You mentioned the students. The deaneries are quite good-or so they say-at picking up what the students say about a particular hospital in terms of their training. Are they going to be involved in it, too? Do you have a role for the deaneries?

Dr Hamilton: Most definitely. The dean should be part of the board, because it is crucial that they represent the quality of education and training, and also the relevant higher academic institutions, such as the Academic Health Science Centre, so that the research and innovation sector is also represented.

Q58 Valerie Vaz: I will give you a scenario. We have had women dying in hospital while giving birth, and there has been a shortage of midwives. How is that picked up in terms of training more midwives? There is also a Department of Health initiative saying that there must be more health visitors. We are not sure we need health visitors. Whose job is it to say to the Secretary of State that we need more midwives, not health visitors?

Jamie Rentoul: Within the system, the Secretary of State will give a mandate to the NHS Commissioning Board, in terms of service outcomes in return for the money allocated. That will cover maternity care and, indeed, the offer to families and under-fives which health visitors then help deliver. He will also, in a similar way, have a mandate to Health Education England with some resources attached to it which says, "You need to go and make sure that the mediumterm workforce is going to be able to respond to these commissioning intentions." There is a working together in the system to make sure that, for maternity care, health visiting and, indeed, the other areas, you are developing the right set of skills going forward. There is a fixed pot of money overall, but you have to make choices about the right balance there. Again, the set of reforms says that a lot of those choices are best made locally with employers, commissioners, patient groups and communities working together to say, "What is the right answer for us?", which you can then aggregate up, have the challenge we have talked about in coming to the decisions and the flow of money is there.

Q59 Valerie Vaz: That is spoken like a true, good civil servant. I am thinking more along the lines of HEE having a separate responsibility. You know you need more midwives, because that is going to plug the gaps, than you do health visitors. How does that get fed into the system, into the Secretary of State and into that pot of money? You will get the soft and the hard evidence, will you not, that there are not the midwives out there?

Christine Outram: Yes. You would probably do both things. If a Secretary of State-this is all speculative now-had a particular priority because of a national situation, HEE would need to take that on board. It is accountable to the Secretary of State. It will have a mandate-an agreement-with the Department that will be reviewed, over time, to deliver certain things. If Health Education England was aware there was a real shortage of midwives coming up and supposing-I know it seems unlikely-the Department of Health had not realised that, it certainly would be Health Education England’s role to make sure the Department of Health was aware of particular problems brewing and, therefore, the action it would propose taking. The money, of course, goes through Health Education England. It would need to agree how it is going to spend it with the Department of Health, but different priorities can all be met and have particular-

Q60 Valerie Vaz: Do you have the framework for that in terms of passing down the money and the training? Do you have the framework to set up what is needed?

Jamie Rentoul: To a certain extent, it is building on where we are now. The strategic health authorities-and you have Tim Gilpin coming next-will, if you take the maternity example again, think about what is happening with the birth rate, complexity, age profile and so on, in terms of service need. For example, "What do we need to do in terms of doctors, midwives and maternity care practitioners to deliver safe and high quality care? What does that mean for numbers of training commissions when we understand attrition, participation rate, retirement patterns and so on?" That is leading to SHAs, at the moment, commissioning education training places, keeping a tight eye on completion of courses and people getting into jobs after them. Therefore, the new system is building on what we currently have in that respect.

Q61 Chair: Do you know yet how many Local Education and Training Boards there are going to be across England?

Jamie Rentoul: No, not yet. The SHAs, working with local employers and education institutions, are discussing it. Pending the Government publication, which gives you function and some decisions on form, that work is going on and will be taken forward after we publish.

Q62 Chair: I am all in favour of form following function, but you have put the emphasis on "local" and links with employers. How many of these bodies there will be, and what shape they are going to take, is not an unimportant detail, is it?

Jamie Rentoul: The discussions at the moment suggest they are going to be quite big-10 to 15 across England, not 200.

Q63 Chair: That is roughly the same number as there used to be SHAs.

Jamie Rentoul: It is perhaps 10, and deaneries is 12.

Q64 Valerie Vaz: Is that a general figure, or are you suggesting that is what might be the case?

Jamie Rentoul: That is what some of the discussions at the moment say. The Secretary of State has not made a decision yet.

Q65 Chair: That is the level of local engagement rather than one training board per acute trust under discussion.

Jamie Rentoul: Yes. The general view in consultation with people is that that sort of level is too local and you do not get the right scale to think about experience, right rotations and so on and so forth, and you have issues in the system about the right running costs.

Q66 Chair: I can understand that and have a lot of sympathy with it. The counter argument will be that local engagement, from a commissioner point of view, at a regional level has always been quite difficult to establish.

Christine Outram: The issue is that you would be looking at too small a scale to do it locally. The challenge is going to be getting the employers involved, which perhaps comes back to the balance of power discussion that we had and getting that right.

Chair: We are very short of time now, but there is a question on deaneries, and we should not avoid funding.

Q67 Dr Wollaston: I will ask very quickly about deaneries. The Department has said that the functions of postgraduate deaneries are going to move to the local skills network. Could you explain how that is going to work and what it means for the survival of deaneries themselves? There are many people who feel that deaneries do a very good job and are concerned about them disappearing.

Dr Hamilton: They are very important and their function is essential. We have done a lot to assure their continuation during transition and the intention is that they continue beyond transition with, probably, many of the same staff. We have to talk about functions rather than individuals, but those functions will continue into the new system architecture.

Q68 Dr Wollaston: They will not lose any of their functions but will probably expand their role and become more multiprofessional. Is that how you envisage it?

Dr Hamilton: Yes, absolutely.

Dr Wollaston: Thank you for clarifying that.

Q69 Chris Skidmore: Mr Rentoul, in one of your earlier answers, you mentioned there is a fixed pot of money. Obviously, in terms of the funding for the multiprofessional education and training levy, at the moment, for 201112, that is flat in cash terms, but I imagine a decrease in real terms. Also, there are reports that the levy itself is being cut by 15% over three years, if I am right. I was wondering what the reasoning behind this was. Might you be able to shed some light on it?

Jamie Rentoul: I do not think you are right on the cut point. The multiprofessional education and training levy-central funding-is broadly flat cash, a 2% cash increase with dentists’ vocational training going into it. That is the kind of position.

Q70 Chris Skidmore: I will blame Healthcare Finance for the error. It is not my own.

Jamie Rentoul: We had discussions with the strategic health authorities when we did not know what the spending review settlement was.

Q71 Chris Skidmore: None the less, at the same time, there will be an increased burden on the MPET in terms of not only midwives’ but also health visitors’ increased training. Do you not see there is a mismatch? Even a 2% increase in cash terms is not necessarily-

Jamie Rentoul: Certainly, there are pressures on it regarding health visitors. Improving access to psychological therapies is another pressure area. Equally, there has been progress made with some of the lowering of attrition rates from courses. You do not need to train quite as many people if you are managing to hold on to them well. In some SHAs there has been a small drop in nursing commissions in making sure they have the balance right.

Q72 Chris Skidmore: We have had reports of universities that their commissioning is decreasing by 10% to 15%. We can talk about it, but the information we have had is that if there are cuts, they are being front loaded to the first year. In some universities they have seen 50% cuts in midwifery courses. I do not know if you would recognise that at all.

Jamie Rentoul: I would not recognise the midwifery numbers because the commission numbers in midwifery are still at near record levels. Some of the nursing numbers have gone down, a reflection of us having gone from a period of significant overall NHS funding growth to a more constrained position such that it is about getting a balance. You do not want to be producing so many nurses that you are creating unemployed nurses.

Q73 Chris Skidmore: Regardless of this position, we are going to have a significant shift from the MPET towards tariffbased funding. That looks like it is coming on the horizon. Again, what was the rationale for that? Was that a flaw in the MPET system itself?

Jamie Rentoul: Within the multiprofessional education and training budget, money goes out to real people in three ways. First, it goes through the NHS bursary, administered by the NHS Business Services Authority. That supports the living costs, essentially, of health students. Secondly, it goes through the benchmark price with universities for nonmedical courses-nursing, midwifery and AHP. There is an agreed price, which is, effectively, a tariff such that the competition is on quality of what is being provided. Thirdly, it goes to support clinical placements, either through the service increment for teaching for undergraduates or the medical and dental education levy, as it is called-I am lapsing into managementspeak jargon-for the postgraduate. It is that clinical placement bit that, at the moment, is not a fair tariff across the country. It reflects historical allocations. That is what we are proposing you should have: a fair tariff so that funding follows the student trainee equally and, therefore, the additional costs of providing clinical placements are met.

Q74 Chris Skidmore: How this tariff will operate is still under consideration at the moment. Is that right?

Jamie Rentoul: Yes.

Q75 Chris Skidmore: Are there any particular options that you are still considering and have not made up your mind on?

Jamie Rentoul: In the consultation the Government said it was committed to the principle of tariff but recognised that we should move with care in terms of funding flows. In anything like this, where you are trying to get an equitable tariff from the previous position, you get winners and losers. You need to make sure people have enough planning time and clarity about where they are going to be able to make the adjustment in terms of their overall finances.

Q76 Chris Skidmore: Within the framework of the tariff, there have been two issues that we have certainly been made aware of. One was quite recently on the Health Service Journal website, "Private sector warns of training levy danger," as to there being a disproportionate levy placed upon the independent sector. Their argument is that the independent sector does provide sufficient training, if not more than is recognised. Obviously, they are worried. They also claim that they have been deliberately excluded from the Future Forum. I do not know if you have any comments on the role of the independent sector and the fact they may be facing a heavier tariff burden.

Jamie Rentoul: Separating out tariff, which is how the money gets allocated to training providers, from levy, which is how the money gets collected in the first place, at the moment, the multiprofessional education training funding is a top slice from the overall allocations. What we consulted on was whether-in terms of transparency and people understanding the actual costs of education and training and having all those receiving the benefits of it contributing to the cost-there would be merit in moving to a levy for all healthcare providers such that a percentage of whatever figure you choose on income would be levied from them to contribute to the costs and then be allocated back out through tariff. In the consultation, we said that is quite a big shift. It needs careful thought, modelling and thinking across the NHS, the independent sector, the third sector and the implications on people coming in from the EU and so on. We should take our time to do that. That is the next step on this path, and for the Secretary of State’s confirmation.

Q77 Chris Skidmore: The other issue, very quickly, is that the new levy would not cover postregistration training and continual professional development. Instead, that cost would be met by the employers. What is the rationale behind that?

Jamie Rentoul: In the current system, the multiprofessional education and training funding is very largely for the development of the next generation. SHAs have some flexibility to say that there are particular issues on bands 1 to 4, training or continuing professional development or other aspects of innovation, which they think would be strong value for money to carry out. In the consultation, we said perhaps we should restrict the multiprofessional education and training levy and reinforce the employer responsibility for CPD investment, which would give better transparency about what is happening there. That is a key bit of right skills of the workforce. There was a pretty strong view coming back in consultation that the flexibility is valuable. You do not want to get locked into a professional or nonprofessional line but you do need employers to have the flexibility to think about the right skill mix. Again, we will be reflecting on that in the publication.

Chris Skidmore: I wonder if anyone else on the panel has any comments on the concerns I have raised. I know there were several there.

Chair: That probably concludes this session. We have had witnesses who have been waiting for half an hour now for us to get through what has been a very full session. Thank you very much indeed.

Examination of Witnesses

Witnesses: Peter Sharp, Chief Executive, Centre for Workforce Intelligence, and Tim Gilpin, Director of Workforce and Education, NHS North of England Strategic Health Authorities Cluster, gave evidence.

Q78 Chair: Thank you for your patience, and I apologise for keeping you waiting. Could I ask you, briefly, to introduce yourselves and tell us where you come from?

Peter Sharp: Hello. I am Peter Sharp, Chief Executive for the Centre for Workforce Intelligence. By profession, I am a psychologist and was Chief Psychologist in Southampton till 10 years ago when I moved to the private sector. I have worked as Director of the National Healthy Schools Programme before becoming Chief Executive of the Centre for Workforce Intelligence.

Tim Gilpin: Good afternoon. My name is Tim Gilpin. I am Director of Workforce and Education for the northern cluster of strategic health authorities, which was brought together about a month ago. That encompasses Yorkshire and the Humber Strategic Health Authority, the North East and the North West. I have spent most of my career working within the NHS in hospitals, community services, mental health services and, more latterly, at strategic health authorities.

Q79 Chair: Thank you very much. I would like to start by directing some questions at Peter Sharp about the Centre for Workforce Intelligence. This is obviously absolutely central to workforce planning processes. Could you tell the Committee a bit about the work that you do and also cover the slight oddity-possibly-that you are an organisation within the private sector owned by a private sector company?

Peter Sharp: Yes. The centre’s primary purpose, a bit like Jamie said earlier, is to improve people’s lives. What we are about is not only producing intelligence to inform better decision-making. It is decision-making that ultimately improves people’s lives. In essence, it came into being following your last Health Committee report, and I paraphrase, that said there had been catastrophic failures of workforce planning for 15 years. A lot of the system distrusted the advice that it was getting. The centre was created as a contract which was tendered openly and competitively, and both public and private sector bodies tendered for it. It could have gone either way. We were appointed to run the centre and we have been in existence now for 16 months. We opened our doors in July last year. We also TUPE transferred most of the NHS Workforce Review Team into the Centre for Workforce Intelligence. While we are private, we have a number of the workforce planners that were in the NHS Workforce Review team working with us.

Q80 Chair: How many of those are there and where are they?

Peter Sharp: There were 28 who transferred across to us. We have maintained the Winchester office, where their Workforce Review Team sat, rebranded as the Centre for Workforce Intelligence, we have a Westminster office, across the road in Matthew Parker Street, and we have a small office in Leeds near the Department of Health.

Q81 Chair: In terms of how you work, what is the source of the data you are using, who are the customers for the data and how do you relate both to source and customer?

Peter Sharp: There were lots of questions in there. As to sources of data, we analysed, on appointment, nearly 100 sources of data that were available to us. We looked at what the previous Workforce Review Team had used, which was a smaller number of data sets than we currently access. We are not a data warehouse. Our job is not to house data. It is to use data and turn it into intelligence. Primary sources include the NHS Information Centre data they furnish and ESR, the employment records. We work with the GMC. We work with the Royal Colleges. We have an expansive stakeholder map of people who hold that data. We have tried to do the equivalent of "Trip Advisor" on it as to its relevance, value and whether or not you would want to use it and so on. We are in the process of categorising data, which we think has great merit.

I should say that the centre is responsible for health and social care, so it looks at integrated healthcare, not just at health. We also access the national minimum data set for social care, which has the virtue of being a genuine national minimum data set, although only about 50% of employers currently complete their returns on that. There are issues about data that have always plagued the veracity and accuracy of workforce planning. There are two aspects to that. One is about completeness. The second is about quality. We have been working closely with the Information Centre and the GMC to look at how both of those might be improved. We are not only a customer of those organisations, in terms of using data they supply, but an influencer in the fields in which data is collected. As the centre evolves, it would be our hope to see the construction of a core national minimum data set for health and social care.

Going back to earlier discussions, there needs to be collection of local data. We already take that, currently, from SHAs, PCTs and, indeed, foundation hospitals. We have all those sources of data in health. Within social care, there are 44,000 employers and we have started to negotiate points of entry for collecting data even from the private sector employers within that. We talk to the private sector employers in health as well.

Q82 Chair: Are you developing your information based on the data you collect in response to questions asked of you by key customers, or are you sending information at large and hoping somebody uses it?

Peter Sharp: I do not think we send information at large and hope that people will use it. Our intent is to look at how the quality of the intelligence that we furnish impacts behaviour. I can say-and I know you are aware of this-that there were three or four years of data each year saying where there were shortages in particular specialties of doctors. There was oversupply of some specialties, and the numbers were not regarded. When we produced our first set of data, in August last year, we looked at which of the strategic health authorities implemented the advice and guidance-and that is the status of what we produce-and implemented it. In nine out of 10 cases, it was to the number. We worked closely with the tenth case to tell them that, the following year, the numbers they had not regarded would go into the numbers for 2012. So they would compound the problem by choosing not to follow or have due regard to the advice. We are more interested in impact of reporting and we certainly are not simply publishing and then travelling in hope, as it were. Our ambition is to work closely with the stakeholders to make sure the advice and guidance we produce is tailored to their needs. To that end, we are working more closely with the employers than was the case, for example, in the Workforce Review Team.

Q83 Chair: Presumably, you have quite an important customer sat on your left.

Peter Sharp: I do indeed, yes.

Q84 Chair: How would you characterise the value the centre has added to your work?

Tim Gilpin: For us, it is fair to say that it is early days with the centre. As Peter has said, it was established a little over 15 months ago. A lot of the work has been nationally specific, particularly around medical staff, for the reasons that Peter has said. But we welcome the arrival of the centre, particularly for those national and, indeed, international issues they can bring to our attention that help inform local workforce planning. We welcome their arrival and employers, in general, do as well.

Q85 Chair: Can you put your finger on instances where you are making decisions now on the basis of better information than you used to? You have been in this field for some time.

Tim Gilpin: Yes, I think there is a lot more rigour around the medical workforce planning model. Peter liaises very closely with the Royal Colleges and other national colleagues to understand both the supply of doctors into the system and what is coming through our plans, but also alongside the Royal Colleges. The quality of that information and the first report that was produced, which went into all the different medical specialties, was a lot better informed than we have had in the past.

Peter Sharp: We published, again in August this year, for the 2012 numbers and, on the back of that, each of the 62 medical specialties had individual liaison with us. We are much closer to the mark now in understanding what the view and perspective is. Where, for example, a college disagrees with us, we put that in the report and say why they disagree. Then, if we are maintaining a recommendation which is in disagreement, we say why. In the past, what tended to happen was that there was more horse trading and a number went in. What we try to do now is say what the evidence base is that leads us to the recommendation or the conclusion that we have. That is a significant shift in the way it is done.

Q86 Chair: To understand one of the implications of the earlier discussion, are you making recommendations about numbers of different types of skilled person independent of the training budget?

Peter Sharp: Yes. Let us take the three broad areas that the centre works on: leadership, intelligence and planning. Until now we have concentrated on intelligence, which is very specific, at the end of the day: how many people should there be, what should they be doing at what level and where should they be doing it. In addition, we do thought-leadership pieces where we look at it, for example, from the patient service user or citizen perspective-patient for health, service user for social care and citizen for public health. We try to look through the lens of what they are in receipt of, work backwards to who might provide the service and try to be agnostic as to how it should be provided, and not go with how it is provided now and prorate the numbers. We are taking, in thought-leadership terms, a fundamental shift in the way we look at how services should work.

In December, the Department will publish our report, styled as a leadership report, called "Starting the Debate" where we have put in "What if" scenarios: "What if we had a consultantpresent service in medicine?", "What if consultants were striated as a profession from consultant, senior consultant, principal consultant, director, group director and national director?", "What if the pay bands were different from where they are?" We have had those through workshops and discussions with all the stakeholders, not only doctors but employers and, indeed, patients.

Chair: Thank you. That is interesting.

Q87 Valerie Vaz: Mr Gilpin, how do you plan for the NHS workforce in the north of England and how far ahead are you looking?

Tim Gilpin: In terms of the way that we plan, we have had quite a good discussion this morning about how medical workforce planning is co-ordinated nationally. From the bottom up, the way that we work, first of all, is to start with the provider workforce plan. The provider workforce plan will have workforce finance and activity as part of that plan, but it is the workforce element, obviously, that we are interested in. We take a fiveyear outlook for nonmedical staff. There are all sorts of pitfalls in all of this, which we may come on to. Nevertheless, that is our starting point. We take that into a dialogue with commissioners, in particular, so that while the provider plan should reflect commissioner intentions, we think it is very important-indeed, local health communities do-that they work on these things together.

As we look at the QIPP challenge and things like that, we are seeing reconfiguration of services, more integrated care and planning much more along a pathway rather than within an institution. We think it is very important that commissioners are involved in shaping that plan. We also take the national priorities, the things that we talked about earlier, in terms of health visiting and access to psychological therapies-any of the national drivers that we have in the system and which, in future, may come through HEE. We are taking care of that as well. Basically, we then prepare a regional development plan that aggregates those things. It also takes into account any regional initiatives. For example, under the Darzi review of two or three years ago, every SHA published a strategy. That was along certain themes. It may have been around trauma or endoflife care, but things that, as an individual provider, it is not possible to plan for. Those are things that we need to take care of regionally. That is how we do it, basically.

We base our commissions with universities on that as well, and the CPD elements that Jamie Rentoul talked about earlier. The one thing I would emphasise about this is that it is all about dialogue, relationships and talking through the issues the particular providers and health communities are facing. There is no substitute for that. It is okay filling in a plan on a piece of paper with numbers on it, but we think that is a critical role for the SHA in working with employers and local communities to take forward. That is how we do it.

Q88 Valerie Vaz: What if your local plan differs from the national priorities?

Tim Gilpin: It seldom does because the national priorities are fairly limited in terms of what they ask of us. This year, the only national "must do" issue relates to health visitor numbers and that is what we are working on anyway. The other thing that seems to happen is that themes develop, both sequentially and in parallel, in terms of what clinical issues are facing the country. Often, the bottomup plans are what people would have expected to see anyway in terms of some of the clinical developments that are occurring in hospitals and community services.

Q89 Valerie Vaz: How do you see that fitting into the new system?

Tim Gilpin: The way I see it, and, certainly in the north of England, the way that we are talking about setting up the local skills networks, which you have heard about, is that they will be coterminous with the current workforce directorates that work very closely with the providers and commissioners along the lines I have said. To some extent, this is as complex as people want to make it. If we have good relationships now, if the strength of our plan is tested by, "Do we have big surpluses or big shortages of staff?" and the answer to that is, "We do not. We think we are getting it roughly right," it should be a relatively straightforward transition into the new. The relationship with the centre, I would hope, will be much as it is at the moment with the Department. One has to accept that there will be-and quite rightly-a dialogue and an overview from HEE in terms of quality, national standards, national career frameworks and things that, realistically, can only be done nationally.

Q90 Valerie Vaz: As to the good relationships that you have, who are you having them with now and are they going to be different people under the new architecture?

Tim Gilpin: I do not think they are.

Q91 Valerie Vaz: Are they all still there?

Tim Gilpin: Yes. They are largely with employers and now, as we have reframed the system, it is with PCT clusters as commissioners. Looking forward, they will become the embryonic parts of the NHS Commissioning Board. Personally, I do not see a massive change in that. But, of course, the governance arrangements will change depending on the guidance that is issued on the skills networks and how they would work.

Q92 Chair: There is an issue, is there not, over the rate of change? You describe a system where everyone knows roughly where they are going. But if the Nicholson challenge is going to be met, one of the things increasingly talked about is the need to change the way care is actually delivered, which will have implications for skills requirements in the system. Is keeping the workforce aligned with a faster rate of change more problematic than perhaps you are suggesting?

Tim Gilpin: I do not think it is problematic if employers get engaged to the extent that the reforms would see them getting involved. For me, the people that have to be fast on their feet, agile and understand what commissioners wish to do have to be the employers that employ the staff that we educate. Yes, you are right. If the system does not change, the speed at which it can respond may not be fast enough to keep up with the challenges you have suggested.

Q93 Chair: Going back to the subject we were exploring earlier, one of the potential breaks in that process is professional conservatism.

Tim Gilpin: Yes. I think that is right.

Q94 Chair: With a small "c".

Tim Gilpin: I think that is right. As to the way you characterised it earlier, I do not see this as good and bad. It is healthy tension in a system that needs checks and balances within it. Neither part of the system should dominate, in my view. You are right that sometimes people out there-employers-would say, yes, the professions are conservative with a small "c".

Peter Sharp: Can I add to that? My tutor, when I trained as a psychologist, John Bowlby, said, "There is no progress without conflict." You alluded, earlier, to tensions between different organisations. There is, of course, constructive discontent and constructive conflict and then there is destructive of both varieties. What I see starting to happen, which I think has come about with the pace of change, is that you can have a conversation and a genuine dialogue. I am not saying, necessarily, people agree. Why would they? But what is happening is that we are talking about things discussed in rooms but not properly aired. We are talking about role extension, role substitution, different ways of working, new categories of workers, different striation of career structures and so on. All of that is now out in the open, which can only be a good thing.

The second point I would add, on the back of what Tim was saying, is that, apart from local workforce plans, what we need to do is have a much longerterm focus on workforce planning. Hitherto, it has tended to be one, two and three years and driven largely by finance. What it needs to be is 10, 15 and 20 years and, based on what the needs will be over there, work backwards from that. Otherwise, what you tend to be doing is constantly looking at what is happening now, next year and possibly the year after. That is part of what our initiative on horizon scanning is doing. That involves groups of universities and stakeholders from health and social care. We will be publishing a whole series of policy briefs about each of those areas on longterm and longrange planning.

Q95 Valerie Vaz: Do you have much flexibility about length of time- the flexibility to be looking over 10 to 15 years?

Peter Sharp: I am not sure what you mean by, "Do we have the flexibility?"

Q96 Valerie Vaz: I mean the flexibility to know when things are changing.

Peter Sharp: First of all, there are ways to look at what they call "megatrends" and "wild cards". A megatrend would be obesity or ageing population or things that are known, and we even have a good handle on by how much. We know what the demography will look like in 10 and 15 years’ time with a good degree of accuracy. We know, based on the last 20 years of what has been going on with obesity, it is not likely to turn around in the next three to five years. Those things we have some handle on.

Christine Outram talked about trying to look ahead because it is 15 years from your A-levels to being a consultant, and that is on a good year-having no absences, electives or whatever. You have to look 15 and 20 years ahead in order to have the right number of consultants because they are in the system now. We have to know what is going to happen in 10 and 15 years.

Q97 Valerie Vaz: I want to go back to my midwife point. It took women dying, and not having enough midwives, for people to realise that you needed more midwives in the training system.

Peter Sharp: I do not want to disagree entirely, but I would say there are midwives often in the wrong place and not prepared to move. There are midwives who have left. When we look at the number that there are-

Q98 Valerie Vaz: But there is a problem there, is there not?

Peter Sharp: There is a problem of getting-

Q99 Chair: Forward planning has to discount for the fact that you are employing human beings.

Peter Sharp: No, on the contrary. I would say that the finer tuning of the workforce planning is getting a handle both on the numbers and then on the regional, sub-regional and locality levels. The number of midwives is at its most difficult in London, but there is a surplus of midwives in Manchester, where there also happens to be a training centre, where very many are trained. It is very hard to get them, for financial reasons, to want to come and work in London. Part of the workforce planning has to be about reexamining where we put the training, not just the global numbers of how many midwives there are.

Going back to an earlier question about Local Education and Training Boards and how many there are, one part of our work in 201213 is to get from national down to regional-or whatever word is used instead of "regional"-and then local and hyperlocal. We have a project where we will have GPS plotting right down to a hospital level where we will say where there are shortages. We will have a "red, amber, green" of any of the professions, whether doctors, nurses or midwives. We have a plan to put in place a system that can show local issues around workforce planning and highlight it back to the system.

Going back to Christine Outram’s point about very small specialties, for example, some of these things are hyperlocal because there are only 15 of those hyperspecialist people in the country and there is no service available in the north of England if that specialist retires.

Tim Gilpin: My comment would be that all of this is an art. It is not an exact science where you are going to get it right all the time. The other thing I would say is that about 60% to 70% of the staff we have currently will be working in the service in 10 years’ time. We are concentrating an awful lot on commissions from universities or doctors when, in fact, quite a lot of investment has to go on with the current workforce.

There are some things it is very difficult to predict. If we think about cardiac surgery 10 years ago, and about what interventional cardiologists and radiologists can do now, the clinical scene does move. The technology and the pace of change is so fast that we need to look-I know Peter is looking at this nationally with colleagues-at how we build flexibility into systems as well to say, "It is not a linear path that we can see exactly what is going to happen in 15 years. Perhaps, in the way we train doctors, we need to have a position where people can step on and off a training programme if the demand for that specialty at CCT level changes."

Q100 Chris Skidmore: Mr Gilpin, I am sure you are aware that, since about 200506 when the ring-fencing was removed from education and training budgets, strategic health authorities have raided those budgets, in the past, in order to achieve financial balance. I am not saying that happens in your local area, but I wonder if you have had any experience of that and its effects generally?

Tim Gilpin: I have not, and I can say, in the north of England, that has not happened. What does happen, which I think happens around the country, is this. If you think about Yorkshire and the Humber, which is the area I am best acquainted with given that I was doing that job until a few weeks ago, we have an MPET budget of about half a billion-£500 million. It would not be prudent or sensible not to hold back some money for eventualities that will occur during the year.

Q101 Chris Skidmore: What sort of eventualities would those be, generally, within the SHA or particularly regarding education issues?

Tim Gilpin: There could be an issue in terms of a particular demand, say, where you have a shortage of staff or where we want to promote a particular issue. It could relate to a return to practice.

Q102 Chris Skidmore: Would it still be within the workforce?

Tim Gilpin: Yes, definitely. But then what happens, when we create a reserve, is that can be used to offset. It is called control totals in the NHS, but it is a budgetary issue. That helps, but it is never taken out of workforce, certainly not in the north anyway, and spent elsewhere. We get that money back the next year. That goes to the point about the flexibility we need to use that money as we see fit. In the last two years, by carryover and prudent use of money year on year, we have £15 million. That has been spent in clinical skills development and simulation centres, throughout Yorkshire and the Humber, that are used on a multiprofessional basis. Certainly, my experience is that it is not used elsewhere. Yes, reserves do accrue, but that is quite a deliberate thing, from our perspective, in order to help either in things that may come up midyear, as I have said, or to spend on big capital developments.

Q103 Chris Skidmore: It is tiny-one third of a per cent.

Tim Gilpin: Yes.

Q104 Chris Skidmore: I was interested to read your comments in the Healthcare Finance magazine in March 2011 because I did not realise the difference in the figures. You have mentioned, "At some London teaching hospitals the income per student for a placement per year is between £70,000 and £100,000, whereas in newer medical schools such as the Hull York Medical School it would be around £36,000."

Tim Gilpin: Yes.

Q105 Chris Skidmore: Obviously, if this proposed tariff came in, you would be a tremendous beneficiary. If you could deliver education costs at almost half of some of the bigger London teaching hospitals and the tariff was as mentioned in this article, about £35,000, you would be doing very well. You would have a movement of students to your area, would you not?

Tim Gilpin: Not really. That comment about the country applies within an SHA as well. What we are talking about here is a payment that is essentially made for clinical placement. Traditionally, that has only applied to undergraduate doctors in training. Those costs are so embedded, particularly in large teaching hospitals-that is no one’s fault, it is history-there is no transparency. When you do the sums-if we are talking about Yorkshire and the Humber-in Sheffield teaching hospitals it is about £70,000 per medical student that they would get, in Sheffield Children’s Hospital it is about £120,000 and at Leeds teaching hospitals it is £70,000. But all of the DGHs and other hospitals, apart from the HYMS, which I have quoted in there, are much less. That could be as little as £10,000.

For me, the underpinning processes this new system is trying to put in place are critical to getting employers engaged. There are two aspects to that, which Jamie Rentoul mentioned earlier. One is a fair and transparent tariff that follows the student wherever they go. Therefore, people are rewarded for good education because you could move students around if education was seen not to be at as high a standard as you wanted. The other side of it is-and I understand this is a very complex thing to do-a levy that says, "This is your money that we are going to use in education and training." For me, those two things would add transparency. They would bring employers to be really interested. Therefore, it is not only about the system, it is about the processes and incentives.

Q106 Chris Skidmore: It is very similar to the Any Qualified Provider model.

Tim Gilpin: There are parallels with Payment by Results, the tariff that works in the general NHS. There are parallels with what is called the best practice tariff, which you may have heard about. We could then incentivise places, say, in primary and community care, where, at the moment, training is largely concentrated in hospitals. Having accepted that that is necessary, if we are going to create an NHS that is more based on community and primary care, it would seem logical to me that the systems we produce to underpin it incentivise education in those environments.

Q107 Chris Skidmore: They seem tremendous advantages. Are there any disadvantages, in your own mind, that arise?

Tim Gilpin: Yes, there are. One of them is-and it is back to the Chairman’s remark-about the pace of change. If we were to reduce the income, which is effectively what we would be doing for the two hospitals in Sheffield and the Leeds Hospital, in Yorkshire and Humber, that could destabilise them. Any proposals would have to be worked through over a long timescale so that they were managed properly. Personally, I do not think everything can be "tariffed" because, particularly in education and training, we need resource for flexibility, whether it is clinical skills facilities that I have mentioned or elearning or other methods of learning we are just discovering and researching. If everything is tied up in tariff you are not going to have any money to spend on that, so there are disadvantages, but the advantages far outweigh them.

Q108 Chris Skidmore: On that point about workforce planning, Mr Sharp, I have read your memorandum and it certainly sounds like, in the past two years, there has been a great deal of work on the supply side of the workforce. Do you feel that the pace of change with this tariff might disrupt some of the good work that has already gone in intelligently planning for the future workforce?

Peter Sharp: I do not think it will disrupt the work. There has to be more work done about doing the full triangle of workforce planning. You talked about supply and demand. Most of the workforce planning in the last 15 years has been stock and flow and supply-led. What does that mean? It means that people say, "How many have we got? How many do we need whenever-next year, three years?" Demandled modelling, looking at future demand and what people need, and particularly if you introduce the element of choice and you introduce the possibility of them having different ways of having their needs met, will shift the need for that supply.

As to the third leg of workforce planning-supply, demand and then cost, cost effectiveness and affordability-the centre concerns itself with cost and cost-effectiveness and leaves affordability to-

Q109 Chris Skidmore: If you have a flat tariff, does that not negate any understanding of where the demand might be?

Peter Sharp: Not necessarily. I will give you a worked example. We have been asked to look at a business case for NHS Global: the possibility of UK plc using some of its spare capacity for teaching others in healthcare and social care. There are clients-other countries- waiting for that. It is not that their workers would replace ours. It is that they want them for their own country. There is a shortage of doctors across Europe of nearly 1 million. We have worked with the WHO, OECD and the European Commission and represent the UK at what is a threeyear joint action programme on workforce planning. That takes us into an area that says if there were distortions, because of a local way of transacting business, it is possible, with longer term planning, to mop up, for example, spare capacity if one area of the country suddenly found itself deluged with applicants.

Q110 Chris Skidmore: You were both here for the earlier sessions. Do you have any comments to make on what the Department said about funding and possible funding cuts to the MPETs? Did you have any understanding of what might be happening in the next couple of years, whether it was flat cash or a 2% rise in cash?

Tim Gilpin: The answer you got was the right one; we did get flat cash this year. There was an increase in the dental vocational training budget, but, to be fair, that was offset by the pressures around things like access to psychological therapies and health visitor number increases. The net result was that we got flat cash and that is what we have been asked to plan for next year.

Peter Sharp: The only comment I would make is that we have been asked to and have produced for the Department a report called "Workforce risks and opportunities." For example, we have indeed identified risks as to midwife and GP shortages. We would look, in the coming year, at any impact, according to financial settlements, of 0.5% flat cash versus whatever inflation is currently-4.2%. There has to be consideration given to what is the net effect of that over a period of time, with it being unlikely that inflation is going to drop.

Q111 Dr Poulter: Mr Gilpin, you made the point about having a demandmet service. There has historically been a tension between that and what have sometimes been shorterterm political priorities, shall we say, and specifically perhaps the trend to training for acute medicine, whereas we see the medical admissions ward or the surgical admissions ward are often an A&E bypass rather than necessarily being a service that exists for its own sake in some hospitals. What I am driving at is this. Have you had concerns in the past-when we look at the bigger demographic challenges that we face in obesity and the ageing population-that shortterm political initiatives have interfered with the longerterm workforce planning?

Tim Gilpin: I have not detected that, I have to say. The big tension we have talked about a little is the balance between the longterm interests of workforce planning, in terms of the supply of the regulated workforce, and shortterm necessities from providers who are just managing workload and peaks in demand, in particular. If you want to, give me some examples of where you may have seen that.

Q112 Dr Poulter: I did give you one with acute medicine. Previously, you would have had an A&E department that would have dealt with the majority of admissions. Then, because of the waiting targets, a lot of hospitals set up almost an A&E bypass with a medical and surgical admissions unit. There was a drive for the acute position, if you like, which would have been a job covered by the A&E doctor, historically.

Tim Gilpin: I see. I do not have any insight on it. All I would say is probably organisations would say that they were streaming the patients more appropriately and so say, "If you have arrived and you have a surgical issue, then you can be seen in surgery and medicine according to your need." I do not think it has been a major issue in workforce planning terms. You are back to that flexibility and where people can be deployed.

Chair: Not only have you got past the GP, you have also got past A&E and straight on to the ward.

Q113 Dr Poulter: Exactly, and without being treated as well, very sadly, in some cases. There is another issue about how we plan for workforces. It is almost a slightly different point rather than on the targetdriven distortion of how workforce planning can occur, and we do see that in hospitals. As we see medical care improving, we also see, for example, that we have fewer generalists. For example, we know that angioplasty is the gold-standard treatment for someone having a myocardial infarction, a heart attack, so what we do is set up a cardiology rota. Previously, however, some of those cardiologists may have done general medicine in a hospital as well, so while the specialist rota is a great benefit, you lose their generalist expertise. The earlier witnesses commented about the need to have more generalists, be it in hospital or in general practice. Is there a concern that we are creating more and more specialists, and that we should take into account the need to maintain general medical skills and generalism in workforce planning?

Tim Gilpin: It is two sides of the same coin. I think you are right. There is no doubt that increased specialisation has led to those pressures in hospitals in terms of rotas. It is an issue of training curricula and other means of educating doctors in specialist areas to take account of the needs of the generalist as well as the specialist. As you say, that would then impact on longer-term workforce planning, in particular for medicine. I do not know whether Peter would like to add anything.

Peter Sharp: We have held workshops where we have looked at the shape of the medical workforce. Some of the things suggested that would, at least, begin to answer some of the issues you have described are: better triage and a consultantpresent service so that the first diagnosis is more accurate. The more junior the doctor in making the first decision, the more likely they are, allegedly, to get it wrong. That is what clogs things up and sends people in the wrong direction, and so on.

Part of what we have put in the report that will be published in December is talking about what are the benefits, first of all, for patients and then, potentially, cost benefits. Although it is more expensive to deliver a consultantpresent service, it is argued that you get it back by not sending them to the wrong place or giving treatments they did not need. That is certainly part of what that document is trying to do, to get that debate to the surface. We have looked both at emergency medicine and at the acute sector and discussed, with the colleges, about how getting the first diagnosis right matters most for them.

Q114 Dr Poulter: This would be about the consultant on call perhaps taking the referrals rather than one of the junior doctors.

Peter Sharp: One thing that clinicians have said to me is that they should not be on call. They should be there.

Chair: We will not start that debate at one minute past one. Do you want to ask a quick question?

Q115 David Tredinnick: Chairman, I am always apologetic for starting a line of questioning after one o’clock and I know my friend over here has sent me some fairly powerful signals about not speaking for too long. I would like to ask a couple of questions about the scope of your intelligence and data collection. I am thinking about the supply of services, which services you are monitoring. I will start by saying you have mentioned integrated healthcare twice and that your second goal is planning for the whole health and social care workforce. Integrated healthcare may mean one thing to you but, for me, as the chair of the parliamentary group for integrated healthcare, it means something else: integrating what we used to call complementary and alternative medicine into mainstream healthcare-Chinese medicine, acupuncture, herbal medicine and homoeopathy-which has been part of the Health Service almost since it began with the Faculty of Homoeopathy regulating homoeopathic doctors. We now have other groups that are performing services. I will quote one. At George Eliot Hospital, in my constituency, we have aromatherapists who, at the request of the doctors who are delivering babies, have helped with pre and post natal care and made it easier for them to focus on their core work. I am suggesting to you that you should have a register of what these services are, be aware of them and try and have some intelligence about the scope of their use. In particular-this is my last point and I am not going to ask lots of subsequent questions-now that one of the core objectives of this health Bill and the Health Service is patient choice, a lot of patients are going to demand these services. I would like to throw that to you as the last ball of the day.

Valerie Vaz: Yes or no. [Laughter.]

Peter Sharp: I will answer very quickly by saying that the Centre for Workforce Intelligence is agnostic as to which services it considers. It wants to look at it through the lens of the patient or the service user. If we find evidence that patients and service users are expressing a preference for a particular service, we would feed that into a report that says that. We would be honour bound to look at the efficacy and the evidence base for the outcomes of those treatments and to look at the literature, particularly high quality doubleblind literature, to say whether it was a treatment that workforce funding and training should be shifted into. We have to be evidence based. Although my colleague said we were an art-and some say a dark art, workforce planning-we also like to see parts of it as properly scientific. We would want to be sure that we had an evidence base for whatever we were recommending.

David Tredinnick: I have a tiny supplementary. Doctors for years have also used observation as a method of assessing whether a treatment is effective. I hope you are not going to exclude that.

Chair: That was a very skilful answer. Thank you very much for your evidence. It has been a useful experience of the real world. Thank you very much.

Prepared 22nd May 2012