Health Committee - Minutes of EvidenceHC 6-ii

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Oral Evidence

Taken before the Health Committee

on Tuesday 24 January 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Andrew George

Barbara Keeley

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Dame Julie Moore DBE, Chair, NHS Future Forum Education and Training group, Professor Sir John Tooke, Head, School of Life and Medical Sciences, University College London, and Dr Peter Nightingale, President, Royal College of Anaesthetists, gave evidence.

Q202 Chair: Good morning and thank you for coming to see us. Could I ask you to begin briefly by introducing yourselves and telling us where exactly you come from in the system and your "stake"-which I think is the modern word-in the subjects we are discussing this morning?

Dame Julie Moore: I am Julie Moore. I have come from Birmingham this morning where I am Chief Executive of University Hospitals Birmingham. My stake in this is as an employer, but I was asked to chair the Future Forum Education and Training work group.

Professor Sir John Tooke: I am John Tooke. I am a physician, a diabetologist by background. I am Vice Provost of Health at University College London and I am the academic director for our academic health science centre, UCL Partners. I have been part of the education and training workstream of the Future Forum.

Dr Nightingale: Good morning. I am Peter Nightingale. I must apologise for my very bad upper respiratory tract infection, but I am suitably armed.

Chair: You got it from me.

Dr Nightingale: I am a consultant anaesthetist and intensive care doctor. I am President of the Royal College of Anaesthetists. I was invited on to the Future Forum because I have an interest in education, training and workforce.

Q203 Chair: I thank you for that and begin, if I may, with quite a general question, which is to ask you to reflect on where you think this process has now reached. The original scale of the changes implied by the wider changes in the health service for the education and training system caused some disquiet, both for the scale and lack of clarity of the direction. Do you feel that those have now been addressed and that we have the clarity we need or are there still important gaps in understanding as to how this is all going to land?

Dame Julie Moore: The first Future Forum report addressed that. One of the things we asked for was some speed in putting into place the arrangements, like the establishment of Health Education England. That indeed is progressing. In the second Future Forum, we would have liked it to have been a bit quicker, because they have a pivotal role to play in setting this up. That said, there are people in post now, and they are getting to grips with some of the problems. I found on the second listening exercise that people were getting some clarity and were a bit more reassured about the direction in which things were going. I cannot say to you that we went out and found unanimous consensus about everything because we did not. There was a range of views about everything and we have tried to map a course through that in our report. Things are more settled this time, although there is still some anxiety about the way things are going to end up in any change process that happens.

Professor Sir John Tooke: I would echo those comments. I was personally pleased that education and training was integral to the initial discussions. Clearly you cannot effect the necessary transformation of the NHS without attending to the workforce, new roles and, in particular, having a very clear future focus on what the learning and skills needs are going to be. This has been a solid attempt to address that. There is always vulnerability with transition, but the pace that has been injected now is appropriate. I am confident that the structural proposals can be made to work.

Dr Nightingale: I would echo that as well. There were some concerns about the exact nature that LETBs were going to take. There are still concerns about exactly how they will function, but, generally, the feeling is that, having got this far quite quickly over the last few months, people now can see the end in sight and can start looking at the important things about funding, time for training and assessment.

Q204 Chair: When we talk about an "end in sight", we are talking about clarity and permanence-in so far as these things are ever permanent-from 1 April next year and a clear map, from your perspective, to get there.

Dr Nightingale: There is now a time line, posts are being populated and documents are being produced. Some of them are still very developmental and there is still quite a bit of work to do, but we feel now that we are on the final road to getting the LETBs and the education systems sorted.

Q205 Chair: There was reference in the Future Forum report to the number of players in the system. There is nothing new in this. The education training system has always had so many players and letters that it is unclear who does what. Do you feel that there is still a concern about the number of players or has that been addressed?

Dame Julie Moore: No, it has not been addressed. I must say that you grow up used to these structures and systems so you do not realise quite how many there are until you make a comparison, but, if you think about other professions such as law, you have universities, the Law Society and the places where people practise. In medicine, there are far more and some of those roles needed clarification. It was quite interesting that at least four or five bodies thought they were responsible for quality of education, and they all had a role to play in that. One of the biggest roles in maintaining quality should be the employers, and in the past they had probably not played as full a role as they could have done. There are still a lot of players there and some clarity is needed because these are organisations that are here to stay. We need to be clear and also make sure that the burden of regulation on both education and health providers does not grow as a result of any of this, which is why one of the things we recommended was some kind of accord between the regulators to make sure that there was not duplication. I can tell you that, at times, we do feel very regulated.

Q206 Chair: Presumably, the problem arises when you have multiple regulators with incompatible regulation.

Dame Julie Moore: It can apply and it does.

Professor Sir John Tooke: If I could add a point, we need to avoid creating greater complexity with the new structures. One of the things that concerned us is this. The academic health science networks have been variously projected to promote the innovation agenda, potentially act as a host community for LETBs and are essential for innovation and for the diffusion of best evidencebased practice and so on. It is very important that we do not set up two or three identical structures and there is one coterminous structure to deliver those activities.

Q207 Chair: One of the things that the Committee was puzzling over before you came in was academic health science networks, academic health science centres and academic health science clusters.

Dame Julie Moore: The clusters probably do not exist. That was transition terminology, if you like.

Professor Sir John Tooke: I see it quite simply. There are academic health science centres. There are five that are designated as such, which are major centres of biomedical science expertise and have a diffusion mechanism to translate research into practice. The networks are taking that latter important role, which I would argue needs to be present throughout the country, to ensure that innovation is driven forward. Of course, some of those regional networks will be doing substantive amounts of biomedical research and they may qualify for academic health science centre status in the future. I can see a model of a relatively small number of globally competitive AHSCs and then a regional panoply of networks that is a diffusion vehicle for the NHS.

Q208 Chair: But definitely more networks than centres.

Professor Sir John Tooke: Absolutely.

Dame Julie Moore: Yes. One of the problems we had was that Sir Ian Carruthers’s review-he was leading this work for Sir David Nicholson-was at exactly the same time as we were doing this work. As John has said, we were keen that we did not have one structure that was this boundary and then one that was that, and so I would end up going to this meeting with 10 people and then again with a slightly different few people. Education and academic research are intimately bound together anyway and it makes sense for these to be coterminous, for there to be the one organisation dealing with that.

Q209 Dr Wollaston: Could you make clear to us whether or not you think these changes are going to change education and training for the better? You have talked about it perhaps being more complex in some ways rather than simpler. Is it going to be clear to people who are in the system, or working with newlyqualified doctors and nurses, that they will be trained better?

Dr Nightingale: I think, overall, yes. The current system is pretty good and it is producing welltrained doctors for the future. But there is no doubt that there are concerns about variability. There is variability in performance of deaneries, for instance, in education providers and there is variability in who is doing the quality management and quality control. The new structure, because it is linemanaged down from HEE to the LETBs and then out to the education providers-hopefully with the money following the trainee-then with the education outcomes framework, will have a more open ability to check that the education is being delivered appropriately. What needs to be sorted out is the slight confusion and variability regarding assessment. Is it the GMC that is working with the new LETBs or is it going to be the colleges working as agents of the GMC? There still needs to be some clarity about that. Personally, there will be a clearer structure and accountability right down, as Julie said earlier on, to the education providers, the foundation trusts, etc., themselves.

Dame Julie Moore: In theory, a mechanism existed to deal with poor placements at hospitals but it was very rarely applied. Often there seemed to be, for nonmedical education, little scrutiny of the quality of the courses going on and we had reported to us concerns over nurse education. There has been a lot said nationally about that, with employers feeling they had little influence sometimes over their local education provider, whereas this does provide a mechanism for it.

Professor Sir John Tooke: I would argue that the new structures permit a system which is more service-sensitive-the LETBs’ provider presence ensures this-but yet academically and professionally informed. The "academically informed" is incredibly important because what we have seen in medicine, of course, is the postgraduate deanery function divorced from higher education. We are the only system in the developed world that has done that and, I would suggest, at a cost, so that we are not linking in educational expertise with the training of that important professional group. These changes, in joining providers with an HEI presence in the LETBs, create a real opportunity to redress that and drive up standards.

Q210 Valerie Vaz: Could that not have been done with the structure that you have at present? It seems to me that MEE is now becoming HEE, but there are LETBs. The governance around LETBs-who sits on them and what they do-is still very unclear. Is that not something that could have developed? What I am getting at is that there is no point having change for change’s sake because it costs a lot of money. Is that not something that you could have looked at?

Dame Julie Moore: Except the SHAs have disappeared where they sat, so-

Q211 Valerie Vaz: They are disappearing because of this, are they not, because the new structure is in place?

Dame Julie Moore: The problem the first Future Forum addressed was that the strategic health authorities were disappearing, so where is the dean going to go? Is the dean going to stay? Who is going to look after education? Who is going to be the responsible officer? The status quo could not exist because it has gone already.

Q212 Valerie Vaz: I suppose that is what I am asking you. What was wrong with the system before that made you want to put it right? It seems there is a whole series of acronyms that have come up which-

Professor Sir John Tooke: In my view, the SHAs were divorced from the service front line, so that information was not being fed in first hand. The deanery was over there in the SHA and was not connected, in most cases, with the higher education institutions. That was wrong and this is a better interpretation. Also, by connecting the LETBs very clearly with HEE, central health policy, for example, moves towards more community care, can be fed through to the LETBs. That national perspective can be coordinated and fed through and yet the system remains locally responsive in precisely how it interprets those policy directives.

Q213 Valerie Vaz: Where does that information go from the LETBs? It is going to HEE, is it?

Professor Sir John Tooke: I am sorry, where does-

Q214 Valerie Vaz: The locallygleaned information.

Professor Sir John Tooke: As to the local sensitivity information, there has to be a requirement on providers and the LETB to feed back through the Centre for Workforce Intelligence and HEE so that there is some understanding of what the local need is. It needs to be nuanced by what the political direction of the Health Service is-how it is going to deal with taking that national responsibility for issues that need to be addressed at scale.

Q215 Valerie Vaz: Does this organisation have the scope to say to the Secretary of State, for example, whoever it is, that they want more health visitors and you say, "We do not need health visitors. What we need are more doctors"? Does this new structure have the ability to do that?

Dame Julie Moore: It has the ability to do it.

Dr Nightingale: At the LETB level, working through the employers, they will have a better ability to influence what kind of workforce is going to be trained. There is a limited amount of money for training. If they wish to move into one kind of practitioner rather than another, then they have an ability to influence that upwards, to get HEE, with CfWI, to make the changes.

One of the advantages I would see with the new system is that there would be more conformity. LETBs will be able to innovate and to have freedoms, but the postgraduate dean function in a LETB will be more circumscribed; there would be less variability across the country. What we need to see is more standardisation of the deanery functions. Also at the higher end, the colleges, working through HEE, need to be very clear about what they want from the QA process.

Q216 Rosie Cooper: It is going from a "could have/should have" to what actually is going to happen. Who is going to produce the workforce information that says how many doctors, nurses, or whatever, you need? Currently it is very difficult to get that information. I understand some PCTs, for example, find it difficult to extract that. It is not mandated that foundation hospitals have to pass that on. Do you think that should be a mandated part of the contract? I suppose I am trying to think it on, but, if the other part of it is that workforce planning is going to be in the clinical commissioning groups, will that cost envelope be enough to do it in a meaningful way? This is a huge jigsaw and I can hear people talking about the bid at the top, but, as a former chair of a hospital, there was, "We have too many doctors," "We don’t have enough doctors," "We have too many nurses." We were for ever on that roundabout. The theory is that the clinical commissioning groups will do it. The truth is there are not good information flows.

Dame Julie Moore: The clinical commissioning groups will not do it. They will have some input to it. Currently there exists the Centre for Workforce Intelligence, which is feeding it. At the moment hospitals do feed in workforce information. It is collated by the strategic health authorities and goes up to the Centre for Workforce Intelligence. The Centre for Workforce Intelligence will continue and that will feed information to Health Education England.

Q217 Rosie Cooper: You said it goes to strategic health authorities, not necessarily to PCTs. Will they necessarily give it to the clinical commissioning groups in the world as you see it?

Dame Julie Moore: It is shared where I am now, so yes.

Q218 Rosie Cooper: But not everywhere.

Dame Julie Moore: It might not be everywhere, but the proposal now is that it will be incumbent on every organisation to share their workforce planning. That will be fed through the Local Education and Training Board up to the Centre for Workforce Intelligence, which informs HEE’s decision making. The problem with workforce planning is I can say next year that I need more ENT surgeons, but it takes 10 or 12 years to make one and by the time you make one somebody might have invented a cure. There has always been that tension in the system and we have never ever been very good at workforce planning. One of the ways to get round that is that we believe there should be more flexibility in training so that, if somebody did invent a cure that meant you did not need a certain specialist, or you needed far fewer, then it would not take forever to retrain somebody. There has to be more flexibility in the way we train our workforce at the moment.

Q219 Rosie Cooper: You said "incumbent." Is there any mandatory bit? Is there a way that people could duck that?

Dame Julie Moore: That would be at their peril, and they would suffer. The way the funding is going to flow down from HEE at the moment, whoever has the money has the power. If the money is coming from HEE and they are not getting the information from a trust, I doubt that they would sit in the sunshine, shall we say, on that one.

Dr Nightingale: It is absolutely essential that all users of medical and nursing staff feed in workforce data. The NHS Commissioning Board will be linking across to HEE. As part of the service contracts and the outcomes framework, I am sure there will be some requirement, if you are doing NHS work, to feed in workforce data. It is essential because the electronic staff record is flawed in this way, and it is also not universal. We need to have mandated data flowing up to the Centre for Workforce Intelligence.

Professor Sir John Tooke: May I make one point? It is very important that we have a central view and central intelligence as well to integrate policy changes in the NHS and interpret that through the type of workforce that we commission but also to ensure that, for certain specialties, a national UKwide provision is protected. That clearly will not happen if all you rely on is local recognition of need. There will be some subspecialties which perhaps few LETBs would want to take on, but which are needed for national provision. That central oversight is crucial.

Q220 David Tredinnick: I want to explore accountability of the Local Education and Training Boards, if I may. The Government have agreed to the Future Forum’s recommendation that Local Education and Training Boards will be subject to an authorisation and accountability framework set by Health Education England. Can you explain the reasoning behind this and how it might work in practice, please?

Dame Julie Moore: One of the problems frequently raised with us was a lack of transparency and accountability for both the money and how it was spent. Health Education England will have the money devolved and will devolve it out to Local Education and Training Boards. They have to be held accountable for how they spend that money. Most of us have dual accountability in our professional lives. The Local Education and Training Board will be accountable to its provider organisations, the members of the board, but also there will be professional accountability for the professional people on that board and also for the spend of money up to Health Education England, which was why it was essential that that was up and running and could start coming up with the authorisation criteria. There will be differences. Some parts of the country are already getting ahead and have established shadow Local Education and Training Boards, but, as Peter has already said, we wanted some consistency and felt that Health Education England needed to start providing a steer to people so that, for example, it would not be acceptable not to have some clinical advice to a Local Education and Training Board-that kind of thing.

Dr Nightingale: Certainly the governance and financial scrutiny needs to be there. HEE will have set standards for authorising LETBs when they can show they can fulfil those.

Q221 David Tredinnick: To what extent will these training boards be autonomous?

Dame Julie Moore: That is where there will be a tension. As John has already outlined, if we needed to train a very small specialty and there are very few places in the country that could do that, that Local Education and Training Board might be asked to train five of a rare specialty, whereas there is no requirement for them in that Local Education and Training Board. That has to be a discussion with HEE. But, on the whole, for the vast majority of people we are talking about, Local Education and Training Boards will be planning for their own workforce for the future but may well be asked, in certain circumstances, to do something for the country.

Dr Nightingale: They will be large, so they should be able to take a population view.

Q222 David Tredinnick: The autonomous aspect is not entirely clear. There are still some questions there.

Dame Julie Moore: It is clear on the finance, but, if my Local Education and Training Board said, "We do not want to train any liver transplant surgeons," and, as a nation, we need more, then we might be asked to do so.

Q223 David Tredinnick: Another area that is a bit hazy is the legal status. Would you agree that the legal status of the Local Education and Training Boards is not clearly defined?

Dr Nightingale: As an outpost of HEE, I see them being held to account through that mechanism.

Professor Sir John Tooke: Right. That is how I see it.

Dame Julie Moore: Yes.

Q224 David Tredinnick: Finally, the Department stipulates that these boards must have a director of education and quality who "may also be the Postgraduate Medical Dean." How satisfactory do you think this arrangement would be in terms of transferring deanery functions to the new boards?

Dame Julie Moore: We recognise the importance of not losing expertise and experience. If the director is not the postgraduate dean, then there must be medical representation on that board. There are different patterns of deaneries currently round the country. Some are purely medical and some are multispecialty deaneries, but we would see that being a central function that would transfer over and the director of education and quality must have advice from the deans. In some places, it is more than one providing that advice there because that is essential.

Chair: Andrew, you want to move on to workforce planning.

Q225 Andrew George: We have partly covered it, with the remarks by Professor Tooke earlier. It is clearly a desire to integrate policy changes into workforce intelligence.

Professor Sir John Tooke: Yes.

Q226 Andrew George: Taking that as a theme, could I take, for example, a recent pronouncement earlier this month, in this case by the Prime Minister, about taking the initiative with regard to improving the standards of nursing and the announcement of the creation of an independent nursing and care quality forum? One of the initiatives that that will be encouraging or seeking to encourage is hourly ward rounds by nurses. The Prime Minister might be trying to break in while I am asking the question, but I did ask the Prime Minister what the consequences of this might be in terms of future workforce planning, such as how many additional nurses, if any, might be required to fulfil the requirements of additional ward rounds. I was told by the Under-Secretary of State in the Department of Health instead that the independent nursing and care quality forum will be tasked with ensuring that the best nursing practice, including hourly nursing rounds, is spread throughout the NHS and social care. So the intention is to do that.

To what extent-if you were trying to integrate policy with workforce planning-is that actually happening? Has there been any attempt to assess what the workforce implications are in terms of demand of those types of initiative and whether they are fed into the workforce planning process?

Dame Julie Moore: That one in particular has not because it has come after the work was done, but we did come across some examples where it certainly has not happened. As for moving care to the community, as part of talking to people involved in training of nurses for the community, there are very few placements to train people there at all. That might be one of the ways that workforce intelligence could feed in. Politicians might well say, "We will have more of this," but we have a very long way to go before we have enough people to do some of that.

Q227 Andrew George: Does that apply across all nursing? Are you, in effect, saying, and of course the mantra is, "We want more primary as well as acute and social care in the community and to reduce the size of hospitals"? In order to achieve that, is that a different skill set from the ones-

Dame Julie Moore: Yes.

Professor Sir John Tooke: There is a distinction to be drawn between a practical solution-the hourly ward rounds you referred to-and establishing some principles about the direction of the Health Service. There is a real danger, I would suggest, that you stifle innovation and local communities finding the solution to this problem of how you lift the quality of nursing care if you prescribe that too much from the centre. The Centre for Workforce Intelligence should be scoping the future, taking account of financial, political and technological developments that are going to impact on the workforce-the skill mix required-and deducing from that the likely pattern of staffing that is needed to broadly inform what the commissions need to look like. You must retain a local sensitivity and an ownership of the NHS values, the qualities and the aptitudes we wish to see in our trainees at a local level.

Q228 Andrew George: Do you all believe that the Centre for Workforce Intelligence, given the fact that this is as much an art as it is a science and that you cannot be precise about the future, is doing a reasonable job?

Professor Sir John Tooke: It is early days. It is an inexact science and the only question you have to ask is would you rather have no workforce planning at all or try and make an honest attempt at scoping what the requirement is? I have confidence in that process being able to operate because, up until the late 1990s, there was the Medical Workforce Standing Advisory Committee, which did quite well in terms of projecting student numbers. You could argue that the current uplift we have seen followed from the dissolution of that standing advisory committee. There was a move around the turn of the century, not based on data, when another thousand medical students, for example, were added. It is very important that we ground our projections in data.

Q229 Andrew George: An example recently of what is clearly, one presumes, a failure to anticipate a need is the shortage of emergency practitioners working in emergency centres, or A and Es. Dr Nightingale, since it flows into your specialty, do you think that is an issue that could have been anticipated?

Dr Nightingale: Many things can be anticipated. It is a case of whether they are deliverable. There is no doubt that the Centre for Workforce Intelligence has had a fairly sticky start inasmuch as it did not have good quality data on which to begin making its projections. It is improving, but it can only do a very good job if it gets very good data. That is the essential part of it. One of the advantages of the LETBs will be that the education and the service providers will be able to look at their workforce and see how it could change in the future and feed that wish list up to the Centre for Workforce Intelligence, which then can help make projections about how future multiprofessional and inter-professional training should take place. We know that in certain specialties there is a shortage of consultants, and emergency medicine is one of those. In fact there is a disastrous shortage of consultants, considering how much the emergency medicine workload is increasing. As one of the halfway houses to try to get a consultantled and delivered service in emergency medicine, practitioners have been promoted. The need is there. It is a case of whether you can find the funding and get the curricula written and the higher education institutions to deliver it forthwith.

Dame Julie Moore: It is also about how attractive these jobs are to people. One of the things that we have talked about is being flexible, but also we talked about long, wholecareer job planning, if you like, because these are very intense, very acute jobs. We have to think about whether you can continue doing the same kind of job all the way through your life, because they are so intense-middle of the night and things like that-and, partly, why do we not attract people into some of these jobs?

Q230 Andrew George: Coming back to the issue of nursing, there is evidence-certainly given to us by the RCN and others-about an unsustainable stafftopatient ratio on a large number of hospital wards at the moment. Do you think that is a question of financial pressures or the result of a shortage of nurses, or do you deny the fact that that is the case?

Dr Nightingale: From a clinician’s point of view, many of us feel that the nursetopatient ratios on the ward are not appropriate. Many of the disasters or failures of care and compassion that we hear about are due to wards not having enough nurses on them, especially at night. I personally would throw my weight behind any way that we could put the ward sister back in charge of the ward and increase the numbers of people caring for patients on the wards. They may not all be nurses, because many nurses, although they are caring individuals, have other jobs to do. But I do think there is a role for people that will care for the patients as well as nursing them.

Q231 Andrew George: Dame Julie, in part of the answer of the Under-Secretary, to which I was referring earlier, she mentioned the rolling out of the NHS Institute for Innovation and Improvement’s Productive Series "Releasing time to care" initiative, which is a bit of a mouthful. Are you aware of that?

Dame Julie Moore: Yes. It does have a shorter common title.

Q232 Andrew George: Will that help in terms of addressing issues of the effective use of staff?

Dame Julie Moore: To answer several of your questions in one point, introducing the hourly care rounds will not adversely impact on wards that are properly staffed anyway. I think it may well have an impact on-

Q233 Andrew George: If they are properly staffed-

Dame Julie Moore: We do it and have been doing it before the announcement. If you have a ward that is understaffed, it will have an impact. Both of those things are right. "The Productive Ward" is very helpful in identifying where there are wasteful tasks and steps being taken. Over the years nursing did build up a lot in its documentation that can be stripped right back down. A lot of the socalled bureaucracy is stuff that we have to do. It is recording patient observations, writing things that relatives have said and so on. It is very important to do that. Education has a key part to play in that, but so do employers in getting this right and getting quality of care right.

Q234 Andrew George: Finally, as to dependence on overseas locum and agency staff, are we in a happy place now? If we are too dependent on external resources, particularly expensive agency and locum staff, how do we address that particular issue?

Professor Sir John Tooke: If I could start, we would be less dependent if we had the most accurate workforce planning that we could. Accepting that we are not always going to get it right, I would argue-for medicine here-that it would be far more preferable to find a way of increasing the number of overseas medical students that we could accommodate, who would go back to their own country once they were trained. They would be a very significant export for us, would be good for global health, good for future relationships between our country and theirs and yet provide a reservoir of talent were we to get the numbers wrong and under-pitch in our own estimates. That is far more ethical than underproviding and then taking away people from whence they have been trained.

Andrew George: That is very helpful.

Q235 Dr Wollaston: Can I turn to the outstanding recommendations in your report, Professor Tooke, about expanding generalism and flexible career pathways? Can you explain these issues and say how satisfied you are with the Government’s response to those outstanding issues, particularly how we are going to foster generalism and help flexibility in career pathways?

Professor Sir John Tooke: Thank you, yes. The Future Forum report acknowledged that many of the principles that were espoused in "Aspiring to Excellence" are still sound ones. A deeper understanding, for example, of the role of the doctor-what the contribution is-is a starting point. Dame Julie’s point about enabling flexibility through a grounding in generalism is absolutely critical so that you do not have to go all the way up the specialty ladder-one of the myriad specialties-and then find out that you are redundant in that role and have to go back down, snakes and ladders, to the beginning again to retrain as something else. Recognising that, as the population ages, comorbidity is an increasing feature so that everybody needs to know about more things than they did perhaps a few decades ago, then that generalist grounding is critical. I do not think it has been adequately dealt with to date. We proposed in "Aspiring to Excellence" some ways of converting foundation year 2 and the early part of core training into, say, four broadbased generalist starts to specialist training. That has not been uniformly adopted and needs to be revisited.

Q236 Dr Wollaston: How confident are you that we will be able to introduce fiveyear training for generalists?

Professor Sir John Tooke: Do you mean for general practitioners?

Dr Wollaston: Yes.

Professor Sir John Tooke: Again, we regarded that as absolutely central if we were going to meet the policy requirements of more care in the community. More importantly, if you are going to meet the expectations of an increasingly sophisticated public, if you move care to the community and people have been used to highly sophisticated care in a hospital sector, they are not going to accept some lesser version of that in a community setting.

Q237 Dr Wollaston: When do you think that will be introduced? Accepting the principle that that is necessary, do you think that-

Professor Sir John Tooke: As I understand it, the Department and the Royal College of General Practitioners are working on reviewing the length of training for general practice. Again, we are fairly unique in Europe in assuming we can train a generalist-a general practitioner-in three years. We know, for example, that only half of GPs will have had relevant paediatric experience and probably the same proportion of relevant psychiatric experience. Yet those two disciplines account for a huge amount of the workload in the primary care setting. If we are going to have a top class NHS, it is one of the first things that need to be addressed.

Dame Julie Moore: We were persuaded strongly by the arguments that GP training needed to be longer and we recommended that. There had been an issue about affordability, which I think is why it had not been there, why the Royal College of General Practitioners had come up with some quite imaginative, in our view, ways of keeping the cost down and why we recommended that the Department and the Royal College work together to find a way of achieving it. But, in our view, it is essential that training is more comprehensive than it is at the moment.

Dr Nightingale: It is probably worth pointing out that, relative to many of the western nations, this country is still relatively underdoctored. One of the things that a move to more generalism will produce in the secondary sector, of course, is a reduction in the availability of specialist consultants’ advice. The only way to get round that is either to expand that section of the medical workforce or to reorganise services. That nettle has not been grasped fully yet. There is a need to put more of the specialised services in fewer numbers of larger hospitals if we are not going to expand the consultant workforce to work in more hospitals. There are a number of other areas which flow from that, one of which is to try and bring back a more teambased approach for education and training. There is no doubt that quite a lot of the service and training tension that is in there, where trainees are not adequately supervised, is due to there being too many hospitals trying to teach those specialty areas.

Dame Julie Moore: One of the other points about generalism is that generalists are often seen as, or felt to be of, a lower status than the specialist. We felt that that was wrong and needed reversing. In actual fact, you need a wider range of skills to be a generalist, and in the States they probably call them diagnosticians or something. The doctor in "House"-if you have seen the television programme-has a very high status with very few patients to look after. There is a wider range of skills there. In much the same way, we felt that education was undervalued compared with research in academic institutions. People who are excellent educators often feel they have a lower status than those who are good researchers. There is something to be said about reversing the generalist status, which should be raised, and also the value of good education and educators.

Q238 Dr Wollaston: Thank you for clarifying that. Following on from that, one of the big issues for GPs in the future is going to be their role in commissioning. Of course, currently in medical schools or in a GP’s training there is no teaching about commissioning. Do you see that as something that we are going to have as a specialist teaching aspect?

Professor Sir John Tooke: Yes. Going back to my point about the role of doctors, when we held the consensus conference following "Aspiring to Excellence", the whole issue of the doctor’s role in advising on the allocation of resources came up. In line with the public perception, the consensus was that doctors did have a role to play in partnership with policy makers and the public in determining where resources went. It has been accepted, and there is indeed an acknowledgment in the new blueprint for undergraduate medical education that doctors have a role. I see the opportunity in the new postgraduate medical, education and training area-and indeed it could extend to other professions as well-to enhance education through providing, on a modular basis, education regarding service improvement, which would take into account intelligent commissioning, research, education and diffusion of evidencebased practice. Those are the things that are going to drive service improvement. I would accept that they have not had the due recognition they deserve in curricula to date, but I am confident we can redress that because UCL Partners, which is already in effect acting as a LETB, is beginning to build in that type of postgraduate provision as part of its reinterpretation of training curricula.

Dr Nightingale: It has certainly started to appear in curricula much more frequently now.

Q239 Rosie Cooper: I have three questions. The "Better Training Better Care" plan was intended to bring about more "consultantpresent" services, taking into account the European Working Time Directive, and to make the training needs less subservient to service needs. How feasible do you think "consultantpresent" services is?

Dame Julie Moore: Peter will start, but one of the things I will say is that, in talking to people-juniors and trainees-not everybody wants to be a consultant. We had recommended that there should be more stopoff points, if you like, in a career for somebody who does not want to undertake the full range of consultant responsibilities. Peter has been very involved in "Better Care".

Dr Nightingale: The "Better Training Better Care" initiative is trying to get rid of the service training tension where trainees are often asked to do too much service in their early years and are not getting direct supervision and training on the job, as it were. As part of their training, of course, they should be developing the ability to take independent decisions, but in the very early years we know from feedback from the GMC survey that many trainees do not get adequate supervision. It varies very markedly between specialties. In my specialty, for instance, anaesthesia, a core training year 1 new starter cannot work independently for at least three to four months generally, whereas in other specialties they are expected to crack on and do whatever with more distant supervision. Trying to introduce more consultant supervision and more consultantled training early on is very important. It has an affordability factor, of course, and again brings me back to reorganisation and that perhaps not every hospital should be having trainees.

Q240 Rosie Cooper: Not every hospital should be having trainees.

Dame Julie Moore: Indeed, "Not every department within a hospital" is one of the other things we said. Within a hospital, a good department for education might be next door to one that is not so good for education. Whereas there is an expectation that everybody who receives NHS funding should train, not everybody will be deemed competent enough to train. It is part of the role of the Local Education and Training Board to say so.

Dr Nightingale: As consultant numbers go up and we get closer to the perceived balance point, the numbers of trainees that will need to come through the system will start to fall. At the moment we are starting to move into an overproduction of trainees to develop service, unless we start reexpanding the consultant or other grade.

Q241 Rosie Cooper: When do you see that balance point arriving?

Dr Nightingale: It has just arrived in my specialty. The year 2012, if you look at the graphs, is where we probably have reached the level of consultants that we set out to have. I personally do not think we have enough yet, so the bar might need to go up. But the numbers of trainees that we are producing is starting to become in excess of the consultant jobs being advertised.

Q242 Rosie Cooper: I am beginning to think I have been too long in the job as I have heard this conversation several times in my little career.

Dr Nightingale: The consultant expansion has pretty much stopped in many specialties now.

Q243 Rosie Cooper: Perhaps we will move on. The Government have accepted the Future Forum’s recommendation that the Nursing and Midwifery Council should lead on developing a properly structured postqualification career pathway for nurses and midwives. How do you see the professional body achieving it? How do you think it will affect the current NHS career structure that we are operating in Agenda for Change and the Knowledge and Skills Framework? How does it all fit in the regulatory framework? To me, it is like a giant jigsaw puzzle and I am not sure that all the bits are there.

Dame Julie Moore: We were pleased that the recommendations were accepted in full, although, being long in the tooth and a bit cynical, Sir John’s recommendations were accepted and are still to be implemented. I will wait and see what happens with all of that. One of the things that dismayed us most-and clearly I believe that nurses can add fantastic value to patient care; of course they do-is that in some places nurses were undervalued, underdeveloped, had had no postgraduate education whatsoever and nobody saw it as their job to do so. Somebody taking responsibility for it and trying to clarify it is helpful, but, like anything else, I will wait to see the results of that.

Professor Sir John Tooke: Again, from my own experience with UCL Partners, our academic health science centre is currently developing postgraduate training for nursing, recognising this need. In doing so, picking up Peter’s point about the ward sister role, it is incredibly important that nursing, in developing its profession, recognises the importance of role models. I would argue that one of the problems with the way that nurse professional education has gone is that the majority of people at the top of the profession are performing roles which are beyond or outwith the conventional view of what the nursing role is. In medicine, a trainee can look and see general practitioners and specialists as the career destination they are embarked on. If trainee nurses look northwards to the sort of role that they might aspire to, they see people doing management, or off doing some quasimedical role-

Q244 Rosie Cooper: A pretend doctor’s role.

Professor Sir John Tooke: I did not say that, but not a classical nursing role. If you develop this role model concept and have the ward sister, or equivalent, as a very strong representative of the caring profession, then we can learn from how medicine approaches things.

Dr Nightingale: That does bring us back to the question about practitioners because many very able nurses, of course, move into practitioner roles, do them very well and are very good parts of the team.

Rosie Cooper: Absolutely.

Professor Sir John Tooke: That is fine too.

Q245 Rosie Cooper: For me, and I think the general public, looking at it-Sarah will come on to this-there is a gap between the person who looks after me at the bedside and the nurse that is now theoretically behind the work station. All nurses have degrees. What percentage of that workforce needs more and more postgraduate education? Where do we see the line? We are confusing what we expect, I suppose.

Dame Julie Moore: Perhaps in the past you pointed to the fact that education has taken people away from the bedside, whereas what we are talking about is giving people better skills at the bedside. Can I reassure you that not everywhere is like that?

John has made a very good point-and we have never discussed this-about role models in nursing for people to look to. You can tell we have not discussed this, but we have ward sisters in my hospital, who are clearly the people in charge of the wards. We must make sure that that is clearly identified. But education is about, "Nothing stands still. The world moves on." Remember how years ago we did not have enough cardiac surgeons. We rapidly trained them, and then stents were invented and we did not need surgeons any more. So we had cardiologists. Then, lo and behold, five years after the stents, we need the surgeons back again. We are always going to have a problem with workforce planning and the way the cardiac surgery nurses then went to learn new skills to look after patients who had had a different procedure.

We have to keep people up to date with skills. We want to be very clear that we separate out mandatory training. People are going through their fire training and things like that, but that is not professional development. How to look after patients does change. I could not easily go back and work as a registered nurse on a ward now. I would need to do a very big course because it has changed so much. Some of the things are still the same. We want to try and get back to the fact that you need skills and knowledge to do these jobs, but you also need the right attitude and aptitudes as well. That is why we want to have more involvement from people who are clinically involved in the selection of people to undertake all clinical careers, but certainly including nursing.

Q246 Rosie Cooper: The Future Forum welcomed the Government’s announcement of a voluntary code of conduct and recommended training standards for healthcare support workers, such as healthcare assistants. You also recognised "the need for further checks and balances." I know there is a big debate on whether it should be statutory or voluntary, but why did you not recommend the statutory approach?

Dame Julie Moore: It was because, as a listening exercise, we heard such a wide variety of views and there was not a strong clear view coming through. We were persuaded of it where you had two pathways to one career in public health; so you have the medically qualified who are registered and recommended that. There was such a huge variety of views and there was strength on both sides of the argument.

Dr Nightingale: For information, I was very pro regulation. The bit I wanted to have in the report was watered down, to my mind. The reason Julie is such a good Chair is that she can take both views and come up with a consensus. I personally feel that those professions that wish to be regulated should be regulated.

Dame Julie Moore: There is ongoing work on this in the Department at the moment. We are not the Department. We can make recommendations. There was such strength of feeling on both sides of it, and of our group we were persuaded-

Q247 Rosie Cooper: Where everything is voluntary, it is all very wishywashy. For example, here the voluntary approach may be seen to be inappropriate when NHS care will be provided by foundation trusts that are independent, legal organisations. Why would you not want to statutorily require it?

Dame Julie Moore: The views expressed to us were that it is going drive out flexibility. You will register somebody within that package of jobs. Too often, when we have put a safety net in, it has acted like a net that holds people down in the NHS and people were frightened of that. There should be minimum standards below which you do not fall. Quite often we put that safety net over the top and do not let people rise above it. There was a strong view that bringing in more and more regulation and rigidity would drive out innovation.

Q248 Rosie Cooper: Do you all agree with that?

Dame Julie Moore: The Future Forum rarely agreed on an awful lot. We are all independent people coming together in that way.

Rosie Cooper: What about the panel?

Q249 David Tredinnick: Dr Nightingale, you said that those who want to should be statutorily regulated. I would like to put it to you that, now that NICE guidelines are recommending acupuncture for lower back pain, we should listen to the acupuncturists who were here in force yesterday-both the western ones and the Chinese, because it was the Chinese new year-expressing a view that they need that statutory regulation, which apparently the Government are not in favour of. Would you support that?

Dr Nightingale: I can remember the debates that went on in the council of my college when the previous senior vicepresident was the dean of the faculty of pain medicine. They submitted a very strong response to the consultation on alternative practitioners and the management of back pain, and they were completely ignored. Although the NICE guidance is out there, it does not necessarily have the full weight of the profession behind it. When we debated in the academy as to supporting complementary and alternative therapies being regulated, the general view was no, because we would prefer to throw our weight behind something that was evidence-based. We could not find the evidence for complementary medicine.

Professor Sir John Tooke: This is the problem if you sweep up all complementary and alternative medicines as an entirety.

Q250 David Tredinnick: I was not doing that. I was talking about acupuncture.

Professor Sir John Tooke: I know you are not, but, as to Peter’s point on the evidencebased approaches, I would argue that the NHS should not be adopting anything that does not have an evidence base to it. If it is proven that acupuncture may contribute and it will have a risk:benefit ratio like any treatment. If the risks are deemed to be significant, then it should be regulated.

Dr Nightingale: When I said, "Those people that wish to be regulated should be regulated," I was not including things like homoeopathy. I was including practitioners that give anaesthetics or fix broken bones in the emergency department.

Q251 David Tredinnick: I wanted to ask you about acupuncture because it is now recommended by NICE. The acupuncturists themselves have made it quite clear that they feel it would be in their patients’ interests and their interests to have statutory regulation.

Dr Nightingale: That is outwith-

Chair: We have probably covered that.

Q252 Barbara Keeley: The Future Forum report raises the issue of education and training budgets being "raided" for other purposes. How effectively do you think the new system puts an end to that raiding that is happening at the moment and what risks are there in respect of the transitional year 201213?

Dame Julie Moore: We heard a lot about how education and training had been used for other purposes in the past. We wanted it to be very transparent so that people knew where the money was going. I would like to believe that our recommendation would lead to that not happening, but I do not think I could guarantee that. Once HEE gets the money, it will go down because it has nothing else to spend it on. We were concerned that HEE was given the full sum that was available this year, which is why we made that recommendation. I was quite heartened by the discussions with HEE-or the one person that is HEE at the moment-about keeping their costs down and making sure all that money did go out to education.

Q253 Barbara Keeley: The Government plan further work and consultation on how the NHS education and training levy should be constructed. What do you think the key features should be? Can you also give your view on the levy to which private providers might be subject to ensure that they pay toward the costs of NHS education and training, bearing in mind that what we might see in future is an absolute explosion in terms of percentage of provision in hospitals that is private patients, private beds and private operations?

Dame Julie Moore: That is a very attractive proposition when you first hear it. When it was raised in the first Future Forum, the charities and social enterprises raised the issue that that would apply to them, and, if that happened, they would not be working in health at all. At the time, we were trying and still are trying to encourage social enterprise, which is why we recommended that it is very carefully modelled through to look at the numbers involved, where they might go and how it might differentially apply. You would not want to try and apply the same to a nonprofitmaking organisation as you would to a big multinational that has lots of-

Q254 Barbara Keeley: You would differentiate between a social enterprise and a very large private provider.

Dame Julie Moore: Yes. That is what we had recommended should happen.

Q255 Chair: If a social enterprise is employing people who have been through a training process, what would be the argument against them contributing, and being funded by the commissioner to contribute, to the training process?

Dame Julie Moore: They should, and that would be entirely right. The points are as follows. Do those organisations have a responsibility to train? We have said that anyone who has an NHS involvement should do so. Secondly, they have to be assessed. If they were doing that, are they contributing in that way? That is why that modelling had not brought the two together. The third point is if people are paying a levy. Pharmacists are a very good example. A lot of pharmacists go and work in the private sector afterwards. How would they contribute? It needed far more detailed modelling so that people could see the impact of that coming through. But some of the charities, particularly those concerned with palliative care, were very concerned about this as a charitable organisation. In fact, one of them said to us, "I will bring in all the nurses from abroad."

Q256 Barbara Keeley: The focus of my question was not about charities or even pharmacists, to a certain extent. The big change, if it happens, is the move in of the private providers to utilise the resources of NHS hospitals and the time of NHS consultants and other doctors. That is the key. It seems ridiculous that we are still at a point where this is so vague. The building trade has a levy system that seems to work. Other sectors seem to be able to pull together a levy. Why can’t our system pull together a levy system that would work?

Dame Julie Moore: I am sure it can, but it needs to get on and do it.

Dr Nightingale: Of course many doctors and nurses who work in the private sector also work in the National Health Service. They may work in both institutions. The training is not wasted. I fully support your proposal that, if somebody takes away full time, almost, a doctor or a nurse who has been trained by the public purse, there should be some recompense.

Q257 Barbara Keeley: It is not going to be "if," is it? If foundation trusts are allowed to use 49% of their resources for private patients, there is no "if" about it, is there? That is a very significant proportion. It would have to be reflected in a very significant proportion of the levy, I presume.

Dr Nightingale: That money comes into the trust.

Dame Julie Moore: Yes.

Q258 Barbara Keeley: It seems to make sense, because we have been in a situation where private medicine or private patients have been at the fringes, at the margins, and this proportion is not at the margins. It is almost half, is it not? It is an issue that cannot be ducked.

The Future Forum also advocates the development of a "quality premium," which would be paid where "quality outcomes in learning" are demonstrated. How do you see that working?

Dame Julie Moore: In much the same way that the quality premiums are introduced for clinical care, so people who achieve high quality standards get a premium to allow them to continue to develop their educational services. The quality premium you get now for clinical care is a bit of the budget that is held back. If you achieve it, you are given that extra and it is a low percentage, 1% rising to 2%. It could be done similarly to recognise high quality education. Of course very low quality education would be recognised by it being removed.

Dr Nightingale: The problem is finding the metric which tells you that you are developing high quality education and training, and that is the educational outcomes framework ongoing process.

Professor Sir John Tooke: It would have to start with process measures and stakeholder feedback. For example, in relationship to medicine, it would be preparedness for practice. Ultimately, of course, what you want to see is a lift in patient care quality. I think we would all accept that that is a longterm outcome.

Q259 Barbara Keeley: It is difficult to measure.

Dame Julie Moore: We did recommend that in the first report, and we are very pleased that the Department has cracked on with that.

Dr Nightingale: Of course there is nobody else in the world attempting this very difficult job, so we are leading there.

Q260 Andrew George: With such a future diversity of providers, to what extent are you confident that everyone will be making a contribution? I am still not clear that you have stated your own views on that. Related to that, do you think that those who have been trained at public expense-just as they do in a number of developing countries-are obliged to commit to public service to certain areas for a certain duration after their publiclyfunded training has been completed?

Dr Nightingale: It is very much like joining the Army, by the sounds of it.

Q261 Andrew George: It is not unusual in many national systems for this to be the case. For example, in Sri Lanka they even insist that you will go and work in rural areas where they cannot recruit. So it could go further than that. Do you think there is merit in that suggestion?

Dr Nightingale: I would have sympathy with it.

Dame Julie Moore: I would.

Professor Sir John Tooke: I think it does have merit. For example, bursaries could be used to meet some less popular requirements. The fact is that, once people have worked and trained in those environments, they often find them to be very fulfilling roles. It is the unfamiliarity, as much as anything else, that is the challenge.

Q262 Chair: If we had a universal system whereby private and voluntary sector providers were contributing to a training process, that would undermine the argument for those people committing to a particular form of employment at the end of training, would it not?

Dame Julie Moore: That is why it would need quite sophisticated modelling. If you contribute to the education, do you pay a proportion or do you pay none of the levy? That needs some financial modelling to be done, and we are not-

Q263 Chair: You are not financial modellers.

Dame Julie Moore: No, we are not the modellers.

Q264 Dr Wollaston: Would quality outcomes in learning also apply to medical schools, for example? It is very difficult, is it not, to set quality outcomes, particularly if you do not have a national assessment? You hear some comments that there is variability between the standards achieved at various medical schools and also some reports from students themselves that their feedback is not being listened to. Do you think there is a role for a quality premium in addressing those issues?

Professor Sir John Tooke: Can I perhaps correct some misconceptions? The first is that all medical schools are already reviewed on a very regular basis by the GMC. There is a quality standard that is applied. That does not mean all medical schools produce identical people. The professional range that their graduates tend to go into will differ. All medical schools in this country already have access to, and use a common assessment question bank. Within the final exams there are embedded questions from a pool which have all been validated to try and ensure consistency across the piece. It is thus a misconception that we do not have some form of national comparison. In terms of the outcomes, there is ongoing work, for example, on preparedness for practice of new graduates. Those things are largely in hand.

Q265 Chair: I have one brief supplementary on that. It is striking that this is the first mention of the GMC in this evidence session, in this highly populated group of bodies. How important is the role of the GMC in the future world as a participating body in making decisions about the education and training of doctors?

Dr Nightingale: For doctors, of course, it is the regulator and monitors the standards that colleges have set in their curricula. It is essential that it continues to do that. What I would like to see, personally, is further involvement of the colleges with quality control as opposed to the GMC working with the old deanery function to quality manage what is going on. There is no doubt that, again, it varies between specialties. The surgeons will tell you that they need to have more quality control of what is going on at the coal face in surgical training, whereas others can take a more relaxed view.

Q266 Chair: But when we have Health Education England, the local boards, the GMC and the Royal Colleges securing it, it is back to multiple regulators and potentially incompatible regulators, is it not?

Dr Nightingale: They need to be working much closer together.

Professor Sir John Tooke: The GMC role is key. One of the proposals that was rapidly adopted, of course, from "Aspiring to Excellence" was the fact that the regulation of undergraduate and postgraduate education was combined under the GMC. As you all know, formerly postgraduate education was regulated by the Postgraduate Medical Education and Training Board. Although at the time, because of the personalities involved, the principles which underpinned their processes were close, there was a very considerable risk that you could embark on undergraduate training to one set of GMC policies and then enter your postgraduate training with a different set of policies. We now have a continuum from undergraduate, postgraduate and CPD. To provide the flexibility, you need that continuum to inculcate, as much as anything, the concept that medicine and other healthcare professions are professions engaged in lifelong learning and the same standards and regulatory processes need to prevail throughout.

Q267 Valerie Vaz: I have a couple of quick questions for Professor Tooke. Your report "Aspiring to Excellence" came about as a result of the debacle around the medical training application system. Are you content that that kind of debacle will not happen again under the new system?

Professor Sir John Tooke: We have heard this morning how complex the system is. An absolute guarantee would be difficult to give. Am I more confident with this system than the previous or current evolving arrangements? Yes, I am. I think the NHS academic alliance is going to be central to that. Ensuring that the postgraduate deanery function is informed by educational expertise that resides within our universities is a way of assuring that, and being very clear about the central oversight of HEE and the local sensitivity of Local Education Training Boards provides the right balance. None of those features was really as well developed in the previous system at the time of the debacle you refer to.

Dr Nightingale: One of the reasons HEE will probably work well is that it is taking the MEE model of having boards underneath it. The medical programme board took control, with the DH, of recruitment. One of the success stories over the last three or four years has been how we have built incrementally a UK offers system now that is not quite universal, but it is getting there. It has been done by very slow, incremental "hearts and minds" tactics. My specialty is now about to go into the UK offers system for entry into core anaesthesia. If that goes well, I would expect other specialties to do that also. So by 2013-or certainly 2014-we will have essentially what was the MTAS system, but it has been built from the ground up.

Q268 Valerie Vaz: With your university hat on, we have the new training regime going on, evolving, as you say, and the higher education fees.

Dr Nightingale: Yes.

Q269 Valerie Vaz: Do you see any adverse consequences for universities?

Professor Sir John Tooke: Yes. Everybody is aware that potentially the fee level impact on medicine could be quite profound. The total debt burden for a medical student could be north of £70,000. Whereas the rise to fees of £3,000 pa-the evidence suggests-did not have a negative impact on social mobility, I believe that the relationship with fee level will not be a linear one. There will come a tipping point when families who are debtaverse will simply not contemplate that level of debt even though there are mechanisms to support them. It is just that the concept will be very challenging. That needs to be watched extremely closely, because we are committed to try and have a clinical workforce that represents the society it serves so that it has that deep understanding of societal need. It needs to be watched extremely carefully and efforts made to offset any negative impact.

Q270 Valerie Vaz: Do you see a change in this year’s applications?

Professor Sir John Tooke: Do you mean in terms of the social class data?

Valerie Vaz: Yes.

Professor Sir John Tooke: We cannot assess that until after entry, so it would be difficult at this point to say whether that is the case.

Chair: We have come to the end of our allotted time. Thank you very much indeed for answering a wide range of questions.

Examination of Witnesses

Witnesses: Professor David Peters, Professor of Integrated Healthcare, University of Westminster, Professor Ieuan Ellis, Chair, Council of Deans and Heads of UK University Faculties for Nursing and Health Professions, Professor Rajan Madhok, Chair, Greater Manchester Health Innovation and Education Cluster, and Dr Mike Farrell, Head of Educational Development, Skills Academy for Health North West, gave evidence.

Q271 Chair: Thank you very much for joining us this morning. Could I ask you to begin the session by introducing yourselves, please?

Professor Peters: I am Professor David Peters, a GP by training and an osteopath as well. I am Professor of Integrated Healthcare at the University of Westminster with an interest in innovation, selfcare, complementary medicine and inter-professional education.

Professor Ellis: Good afternoon. I am Professor Ieuan Ellis. I am Dean of the Faculty of Health and Social Sciences at Leeds Metropolitan University. I am a physiotherapist by profession. I am Chair of the Council of Deans of Health that represents the 85 UK universities that provide nursing, midwifery and allied health professions. I am also Cochair of the National Allied Health Professions Advisory Board.

Professor Madhok: Good afternoon. I am Rajan Madhok. I work as the Director of Special Projects at NHS Manchester. I am a public health doctor by training. I also serve on the Council of the General Medical Council.

Dr Farrell: Good afternoon. My name is Mike Farrell. I am Head of Educational Development at the Skills Academy for Health North West, which is part of Skills for Health the Sector Skills Council for the health sector .

Q272 Chair: Thank you very much. Can I begin by asking you the same general question that I began the previous session with, and that is to ask whether you feel that there is now a sense of emerging clarity about how professional education structures are intended to work from 2013 onwards, whether you share the sense that was expressed to us by the previous panel of optimism-I think it is fair to say, in general terms at least-that the new structures are emerging and are fit for purpose?

Professor Peters: I think so, broadly speaking. The previous witnesses gave a marvellous account of their views of how the structures are developing. The uncertainty is as to how the NHS is going to cope with the financing problems, deficit reduction and what the consequences are going to be of a very much slimmer NHS. It is hard, as yet, to see how we are going to bring down the costs of the NHS unless we do things very differently. I do not yet see the policies emerging that will help to create a greater degree of selfcare and resilience. Michael Marmot’s review-where he talked about the overarching concerns for social justice, health and sustainability-may have not yet fully emerged as shaping policies in the NHS. For some of us who are looking toward how we might educate doctors and others to have a greater sense of how they can encourage resilience and selfcare, to anticipate and prevent better and how there could be more generalists, I am not absolutely sure that we understand how things are going to develop well enough to plan adequately for, say, the 10year horizon.

Professor Ellis: I certainly think that, following recent publications, there is greater clarity as to some of the proposed architecture. As recently as yesterday, I know that the steering group for Health Education England met and I know that LETBs are starting to take form in shadow form, but we are now moving into a more detailed level of discussion. Where clarity still needs to emerge is on the way in which these changes will be transformational. There is an emerging understanding of the transactional relationship between different groups, but questions will remain for the moment over the transformational benefits of the new system as compared to the previous system.

Professor Madhok: If I may make a distinction between the "what" and "how", we are quite clear on what needs to happen and what the significant pieces of the jigsaws will be. What is, however, unclear at the moment is how they will all fit together and whether that will work. So I sit on the fence in terms of the answer to your question.

Dr Farrell: There are two perspectives from Skills for Health Academy working with the new structures. There is certainly further detail about how those would fit, but we are certainly accepting the drive of providers and employers in driving education needs. It is to be warmly welcomed. There is evidence from the participation that some of the shadow boards are already reflecting enthusiasm by employers for that role and responsibility. Of course, transition means disturbance and disturbance to current arrangements, which, in some cases, are beginning to have an impact in terms of productivity, skills development and flexibility. But there is a point about how we should not lose that momentum as we make this transition.

Q273 Chair: Can I turn particularly to Professor Madhok and ask you, in a sense, the same question I asked one of the previous witnesses as to the relationship between the academic health science networks, the clusters and a third one-and I cannot remember what it is-that uses the same phrase? You sit in one of those in the north-west. How confident are you that that provides a basis for connecting the training for the future with current academic ideas and opportunities?

Professor Madhok: I chair the Greater Manchester HIEC. In Greater Manchester we have all of these initiatives in place. We have the Manchester Academic Health Science Centre, we have the CLAHRC and we have the CLRN-the Comprehensive Local Research Network. When the HIEC came along, it was quite challenging to try and find our own niche. We did so. We managed to find a niche in terms of developing the existing workforce, so that is what we have concentrated on. Obviously, since they were set up, further changes have come along. I suppose behind your question is whether we are confident that it will all come together for us. The reason I get confidence is that at least we are talking, even though there is a lot more clarity still to come, and hopefully the next six months will be very helpful in that regard. We have continued dialogue, and certainly, as far as the HIEC is concerned, the support that we have received from the strategic health authority has been invaluable. They have made sure that we do fit in with the emerging LETBs. In our case, there is still work to be done in terms of the relationship between the academic health science networks that are proposed and the existing academic health science centres.

Q274 Chair: Do you think with the emerging LETBs it is a genuine dialogue or is there more of a "tell" relationship one way or the other?

Professor Madhok: LETBs are not there yet in the north-west and there is still some debate to be had in terms of the relationship between the arrangements that need to be put across the whole of the north-west, which was the previous footprint for the strategic health authority, and the three socalled natural health communities within the north-west-the three natural health communities being Greater Manchester, Cheshire and Merseyside and Cumbria and Lancashire. So there is still discussion to be had and meetings are taking place about what would be, first, the geographical coverage of those arrangements and also the function that they will be discharging.

Q275 Chair: NHS North West says in evidence to us: "It will be for the new provider led networks/LETBs to find funding to support HIECs"-the Health Innovation and Education Clusters-"if it is considered that they have been effective." How confident does that leave you?

Professor Madhok: I hope that they will feel we have been effective, certainly in terms of helping-

Q276 Chair: Have you had dialogue with them about effectiveness and therefore future funds flow?

Professor Madhok: Can I separate the two? In terms of the dialogue itself, yes, and that goes back to what I said a few minutes ago about the SHA being the broker. In fact, as far as the Greater Manchester proposed LETB is concerned, they have recognised that they need to do something about the HIEC. Next month, which is only the second or third meeting that the new LETB will be having, they have asked us to present the work of the HIEC. In that sense, I am fairly comfortable that communication is ongoing.

In terms of the funding, I suppose we are all waiting to hear what is going to happen, but hopefully they will be able to see the work that has been done. When all is said and done, what people will realise is that, at the end of the day-forget HIEC as an organisation as such-the function is absolutely crucial.

If I may link it back to the debate that took place with the previous panel, where there was a lot of discussion about the Centre for Workforce Intelligence and the numbers, what we need to understand is that planning is an inexact science. That is the term that was used. You need something like HIEC that can help speed up the changes that you need, which is basically modernising the existing workforce. When all is said and done, people will realise that, if we did not have them, we will probably end up creating something like the HIEC because of all the pressures that have already been articulated.

Professor Ellis: I want to add, with both the HIECs and the academic health science centres, that they have illustrated this mutual interdependency of academia in driving clinical excellence and also innovation. Innovation is an important part of workforce planning. They have also demonstrated multiprofessional, multidisciplinary and intersectoral research. The five academic health science centres were described earlier, which tend to be biomedically focused, and that is not a criticism; it is just an observation. In moving to the networks, it is important that we do not lose the intersectoral, multiprofessional research and indeed the research from nurses and allied health professions that we heard about in the previous session, and the importance of developing those clinical academic careers in order that all of those professions are able to contribute to innovation and transform the NHS.

Q277 Rosie Cooper: If I might follow on from that before I ask the question I was going to ask, workforce planning has always been problematic. We all accept that. Listening to you speaking, yes, there are lots of conversations being had and lots of details still to come. The question that shoots up at me is what assurances do you have in this time of great structural change in the Health Service-with £20 billion-worth of savings needing to be made, cutting down, if you like, rebanding nurses and losing front-line staff-or how confident are you that all of this will not impact on trainees either currently or in the next few years?

Professor Peters: It is very difficult to be confident about that. It sounds like doing more with less. My university and other universities are constantly trying to do more with less. My perception is that we are failing. Given the coming challenges and the uncertainties, I cannot see that we are going to save all that without cutting services back. My understanding of the figures is that we need to save even more than that over the next 10 years in order not to go up to the top level of the Wanless expenditure of 13%, 14% or 15% of the GDP.

Q278 Rosie Cooper: You feel that there will be impact on doctors in training now and those about to join, if you like.

Professor Peters: I cannot see how it can be otherwise. There will be less money to go round.

Chair: All our witnesses want to come in on this one.

Professor Madhok: To add to what has been said, it is not only more with less but it is more with less and faster. That is the demand being placed on the system at the moment. There is no doubt that there will be major implications because of what is happening right now. The question, however, is not about the implications. The question is how we are managing that risk. Although I am one of those as well who wants assurance at the moment, we cannot have that; so the only option is to continue the dialogue. That is why I have a sense of slight comfort that at least we recognise that there is a joint problem now and we have to solve it together. That is where the ongoing discussions are helpful at the moment. Through that process, I think we will be able to answer your question in about six months to a year’s time. That would be my guess.

Q279 Rosie Cooper: The Secretary of State does not think there is a problem with anything, so I have serious worries about whether you are going to get that answer. In the meantime, there is a risk to training and a risk, for me, to the system and to patients.

Dr Farrell: May I make a couple of comments on that? The tone and the language will be really important over the transitional phase, such as what is the common endeavour being focused on that and the different parts of the system, understanding the value that they can bring to the new arrangements. Taking our successful work, particularly, say, on the north- west footprint regarding workforce development, it has been about very strong partnership relationships, many of which will survive these arrangements, and need to if we are to sustain the momentum that we have in place. Our contribution at that particular point is also recognised. As the LETBs pick up this leadership challenge, one of their first challenges will be to set the tone for the conditions where this will continue to flourish, and needs to flourish well.

Professor Ellis: There are two ways to answer. One is: am I reassured that under the future system we will be able to deliver value for money? The signs are that, yes, that will be there. My principal concern at the moment is the transition. Many, I know, have referred to the time delay in terms of getting HEE, in particular, established. In terms of looking at some of the threats to the current workforce, you have received written evidence on some of the cuts in commissions that have been happening in nursing, in allied health professions, where there is limited oversight of that. While there are rationales as to why those are needed in the short term, currently there is not oversight of that to give satisfaction on medium and longterm planning.

There are changes happening as we speak. A 26% reduction in nursing commissions in London was announced last week, whereas in medicine there was a more sensible approach, a "no surprises" approach. There is a group chaired jointly through HEFCE and the NHS that is looking at a "no surprises" model. There are real risks that are seen in terms of some of the professions that are currently being commissioned through the transition.

Q280 Rosie Cooper: Thank you. I wanted to pick up on that because I think there is potential for a huge impact. It may be that people are happy with the future model, but it is the detail and how you get there.

I would like to address some comments to Dr Farrell about the Skills Academy for Health and how it operates in the north-west. Also we have been told about the apprenticeship scheme. Could you tell us how that operates and how successful it has been?

Dr Farrell: The Skills Academy for Health thrives on partnerships in supporting the development of the future and current workforce. Through those arrangements we support a number of activities. In terms of apprenticeships, there are two arms to that. One is into employment, a cadet scheme, something that has been evident in the north-west for many years going back to the last couple of restructures, which was primarily set up to help widen participation, particularly given some of the demographics that we face in the north-west and the need to support opportunity. Typically through that route, we will see about 400 young people between the ages of 16 to 19 coming into a cadet programme. One of the things that we have moved to, given the skills drive around the apprenticeship agenda, is setting up and piloting of an apprenticeship training association whereby, on this first cohort, 130 participants will be directly contracted under the training programme on an apprenticeship scheme and gaining work placements through organisations. As to the other arm, which has been a significant bulk of work as well, NHS North West, as the strategic health authority, has been very committed to the drive of apprenticeships and has made substantial funding available to engineer that. Through the Skills for Health Academy and our engagement with trusts, we have been able to manage on behalf of NHS North West the use of that funding in order to generate the number of apprenticeship starts that we have to date. Last year, it was just under 1,300 apprenticeship starts, and this year we are anticipating 1,400 apprenticeship starts being supported.

Q281 Rosie Cooper: That sounds fantastic. Could you quickly describe the cadet scheme?

Dr Farrell: The cadet schemes are set up on either a one or twoyear programme, with a qualification base such as a BTEC qualification or Level 2. We support the workbased element of those cadet programmes with our local employers, whereas the actual teaching and delivery is through our partnership relationships with our local further education providers.

Q282 Rosie Cooper: You are characterised as an employerled body.

Dr Farrell: Yes.

Q283 Rosie Cooper: Can you tell us how you relate to and work with healthcare employers, both in the NHS and the independent sector?

Dr Farrell: That can be demonstrated in two ways. In terms of our employers, one of the things that is very significant about the way we work is that we listen to what they need with regard to the workforce skill mix, particularly at bands 1 to 4, and also into the preemployment area. For instance, some of our programmes might be a 13week pre-employment programme as a standard offer. But an employer might say that for their area, and given the other arrangements they need, that needs to be accelerated. Therefore, we will liaise with them to adjust the programme. That would then be more specific to the local requirements.

With regard to the NHS, there is significant work around preemployment and also into the social and independent area; so that type of delivery is supported as well. Again, it is usually driven by what it is that the employer is saying they need from the offer that could be supported.

Q284 Rosie Cooper: How does that relate into the new organisations?

Dr Farrell: There is a risk with the new arrangements. There is a lot of emphasis, on the registered workforce. We know, to date, that there has been a disproportionate investment for the bands 1 to 4 workforce. It is not entirely clear whether the freedom and the flexibilities that certainly some health bodies, such as NHS North West have been of the mind to support might be supported to the same degree under the new arrangements. That is a concern. The other concern is as to the different type of relationships needed in order to support the widening participation groups, such as independent training providers. As regards the very strong Further Education base that we would work to, probably the profile and potential value of that contribution is yet to be reflected in the new arrangements.

Q285 Rosie Cooper: You are playing a full part in making sure they know.

Dr Farrell: Absolutely. What is encouraging, as Professor Madhok has indicated, is that, as part of the move to the transition, the shadow boards are asking for the intelligence on those workforce developments that are working well and that are having some impact, with a view to what is the transition-sustainable position in relation to those.

Rosie Cooper: Thank you.

Q286 David Tredinnick: I would like to ask a few questions about complementary and alternative medicine, particularly to Professor Peters and Professor Ellis. Both your universities offer courses in complementary and alternative medicine. Could you tell the Committee a bit about these courses, please, and how academic standards are set in respect of them?

Professor Ellis: I am happy to start on that. My university provides specific courses in acupuncture and herbal medicine. Those courses are running out: that is, we are no longer admitting students to those because their popularity has diminished such that there is not sufficient demand. It is not a decision based on any other reasons than demand. I would add that the standards are set in the ways that we work with other professional bodies and other regulators. In devising the curricula, we work closely with the relevant professional statutory bodies to ensure that curricula are developed in that way, subject to the quality assurance mechanisms both of higher education, if it is based on higher education, which mine is, and those professions.

Professor Peters: I have a curiously similar story. Having had a wider range-quite a big portfolio-of complementary medicine BScs, we are running most of them out. We still have BScs in acupuncture and herbal medicine, which are still recruiting, but there is less demand than ever. We do not know if those will survive.

Q287 David Tredinnick: Can you explain why you think there is less demand, please?

Professor Peters: For us there are a number of reasons. A very high proportion of our students have first degrees and are mature career changers. The new funding arrangements mean that it is not possible to get these loans on a second degree, and that was 25% of our people previously. Also, as our entry requirements go up, that has squeezed our territory. It could be entirely financial. In times of uncertainty people are not choosing a career as unpredictable as being a practitioner of complementary medicine, especially against a background of having at one time felt the NHS would be bringing in more complementary medicine and we now see it very much in decline.

Q288 David Tredinnick: What actions do you think should be taken to stop that decline?

Professor Peters: I keep hearing about the bits of the jigsaw when we debate workforce planning. I am curious about the big picture. What is the picture on the box? I hear about biomedical centres of excellence in education. I do not hear much about biopsychosocial excellence. I do not hear how this seamlessness between medical, nursing and social care is going to come about-what the models are. We know it can be done because we have done it in our own practice in Marylebone, so there are ways of not being biomedically focused in primary care. That is the way we need to go.

In terms of the models of complementary medicine, what they have in their favour is that they are based on patient experience and driven by patient choice. They address some of the problems that people find in the biomedical system to do with engagement and health promotion. It is a resiliencebased selfcare model, and people come to it on the basis of selfcare. It ought to have something to offer, but the system-the NHS-will have to move in a more resilient, sustainable and biopsychosocial direction in order to make space for complementary medicine. I hope it will and that, when it does, there will be room for CAM in the mainstream.

Professor Ellis: Clearly one of the facts that may be contributing is the debate on the scientific basis, which Sir John alluded to earlier. There will be views on that on both sides of this table. That spills over into how prospective entrants to that profession will view it and also the opportunities for employment. The complementary therapies, like many others that contribute to healthcare, are funded in different ways. Within my own faculty I have, for instance, osteopathy, which is high interest, with people still applying, even though it is not funded by the NHS. I have dietetics, which is funded by the NHS, but alongside that public health nutrition, which is not, and yet there are public health nutritionists being employed in the NHS. I also have mental health nurses who are employed and their training funded by the NHS, but I have art psychotherapists and counsellors where their training is not funded by NHS. It is part of a broader debate as to why people are applying. Clearly there is more that some of these professions need to do to market themselves so that people will apply, but also there are anomalies as to the way in which different professions who are all currently providing services as part of the NHS are funded in some cases through the NHS and in others are not.

Q289 David Tredinnick: I will ask you about that in a moment. Can I suggest to you that there are huge potential cost savings for the NHS in complementary and alternative medicine? Obviously, I have a vested interest in putting this forward because I have been Chair of the parliamentary group for a long time, and freely admit that, but this is my observation. From a personal point of view, Chair, last year I did not visit my general practitioner at all, but I had a number of minor ailments to do with eyes, stomach upsets, colds and flu and things like that, which I treated myself using a simple homoeopathic medicine box, which cost not very many pounds. I have learned a little bit about it. I think, particularly with homoeopathy we are completely out of line with Europe now where you can get these products in almost any chemist. I wonder why we are lagging behind and why it is that we are not encouraging people to try and treat themselves for minor ailments before they burden general practitioners, like my hon. Friend on my left.

Professor Peters: The system is trying to encourage more selfcare. There are campaigns about it and we know that selfcare could unburden the NHS of a vast amount of minor illness. We know that. The problem is that there are not the good costeffectiveness studies around complementary medicine. We have run pilots lately looking at acupuncture and osteopathy for back pain. The results are good. It is not clear about costeffectiveness, but patient satisfaction is high. It is a complex research issue. If we are going to wait for costeffectiveness studies, the problem is that, if we do not have services in the NHS to study, we cannot create the evidence to bring the services in. It is a problem.

Q290 Chair: If the services exist, it must be possible to produce the necessary records of the evidence of outcomes.

Professor Peters: There are a few services. There are some acupuncture and some osteopathy services, and they are doing the outcomes, but we are not at the level of having randomised control trial evidence, which is what is demanded increasingly, of course, by EBM.

Professor Ellis: In such research, one also has to differentiate between the profession and the intervention. For instance, there will be physiotherapists who will be using acupuncture as one of the tools that they use-one of their therapeutic interventions. You could evaluate the efficacy of that as distinct from evaluating complementary therapy or an acupuncturist. Part of the complexity is teasing out the intervention from the particular profession that is providing it.

Q291 David Tredinnick: Do you think that this emphasis on doubleblind trials is something that has been taken to an extreme? In the past, doctors used to operate on the basis of observation. If you take acupuncture, for example, there are approximately 50,000 hospitals in the People’s Republic of China using acupuncture and it has been around for 3,000 years. Should we not take greater note of observation and give greater credibility to it?

Professor Peters: That is not the way the system is going, but evidencebased medicine was supposed to include observation, clinical experience and patient preference. That is the nature of EBM. We are focused very much on randomised control trials. In an industrialising system where you want to be able to offer equitably an intervention across the board for millions of people, you probably need that kind of statistically valid information. The problem for complementary medicine trials is that often in the placebo arm you have very high rates of response. The problem is, apparently, that false acupuncture-sham acupuncture-seems to work extremely well. We can only attribute that to some kind of human interaction and context effect. It still means it is highly effective, but it does not mean to say that it is efficacious in the sense that a drug would be in an RCT. It is a complex argument, but at the moment the RCT rules and we have to adapt to that, I think.

Professor Ellis: Your point is well made, and I would argue that it applies equally to many of the other professions that are carrying out health interventions which cannot necessarily be measured in a clinical trial, doubleblind kind of way. If we are looking at the impact on public health of interventions from often more than one professional working with a client, then it is about looking at the ways in which we evaluate effectiveness of outcomes.

Q292 David Tredinnick: When the Committee went to Torbay, because of the new regime with personal health budgets and the expectations therein, it found that various patients, or people the Committee spoke to, were looking for acupuncture. Does that not reinforce the case that we need statutory regulation? If we are going to have a health service that embraces a wider range of remedies, surely this is a very high priority.

Professor Peters: I would agree with you if we are looking at more patient choice. We can see that, when people have the money, they will often choose acupuncture and osteopathy for back pain, but still only some 2% of the population have access to acupuncture and there are only 13,000 acupuncturists in the country, half of them physiotherapists and allied professionals. If there were a high demand at the moment, we could not meet it. I also question what was said before by the previous panel of witnesses about there being a lack of an evidence base for acupuncture in chronic back pain. The evidence base is rather good, but the NICE guideline does not push PCTs to provide it because back pain is not a high priority. If people with back pain are using the private sector, that, in a sense, unburdens the public sector to some extent but results in an equity problem. People who cannot afford acupuncture are potentially being deprived of an effective treatment for low back pain, which is an enormously costly problem.

Chair: We probably need to move on.

Q293 David Tredinnick: I have one last question on this. Do you think the Health Service should provide greater financial support for these services, given the personal health budgets and the reorganisation that we have now?

Professor Ellis: Possibly I preempted that question with my earlier answer. Patients need to have access to interventions that are effective, evidence-based and provide value for money. The current historical way in which funding from the NHS supports training is very varied for acupuncture. Working in a finite resource, there are reductions in the funding to many of the other professions that are currently funded by the NHS; so, in adding more to that, something has to give in the system.

David Tredinnick: Thank you very much.

Q294 Rosie Cooper: The Council of Deans in its written evidence to us has suggested that Health Education England must have "a power of direction" over LETBs to ensure longerterm workforce planning. How satisfied are you that such a power will exist under the plans as they currently stand? Do you support that?

Professor Ellis: To a degree. The relationship between HEE and LETBs and the governance arrangements are clearly quite crucial. That has been rehearsed in the previous session. My understanding is that the initial status of Health Education England and its relationship to LETBs is as a special health authority and they will in effect act as subcommittees of that. There is a question mark as to where that authority lies in terms of both the authorisation criteria but also the way in which the outcomes framework is used. "The power of direction" comment is more specifically about the fact that, as they move to becoming a different kind of legal entity, as a nondepartmental public body, there needs to be quite clear specification as to that relationship and the control. The example-and you may have raised this-was the question of national versus local. To take the health visitor, as a current example, if LETBs, in their totality of the 12 of them, commission based on their need and that falls well short of a national target, who wins the argument, putting it bluntly? Do HEE say, "In the interests of the national numbers that we need, you will need to commission these?", or do LETBs say, "That does not reflect what we need"? So the "power of direction"-clearly it has a legalistic meaning-is to emphasise the point that there needs to be absolute clarity in terms of those kinds of decisions.

Another example would be the cuts in commissions in nursing, given that, in order to become a health visitor, you need first to be qualified as nurse. The significant cuts we are seeing at the moment in nursing would seem to suggest you are cutting off the flow of the health visitors that are needed. It is also about ensuring that there is joining up in that system.

Dr Farrell: I have an observation on that. That relationship clearly has to be established, but one of the things which has been hard won over time is the practice of being responsive at a local level. There is a range of tools, a range of approaches, that can be used with effect to meet a local solution. One of the things in the "power of the direction" of the relationship between the HEE and LETB is not to constrain what might need to happen at a local level. There needs to be some flexibility for that to be responsive.

Q295 Rosie Cooper: Do you think it will be there? I suppose that is the real question. How confident are you-this is bits flying everywhere-in the safety net? Are you going to be able to hold it together?

Professor Ellis: My belief is that there is likely to be a focus on short to mediumterm workforce planning at a LETB level. The responsibility of HEE is to make sure there is a medium to longterm focus. Where that clarity of relationship exists, it is to ensure that there is that medium to longterm focus on workforce planning. The question, if you like, to be asked of the LETB is: how does that workforce plan meet the 10, 15 and 20year workforce projection rather than the one, three and fiveyear projection?

Q296 Rosie Cooper: Who is going to deal with the one, three and fiveyear projection?

Professor Ellis: The one, three and fiveyear projection needs to be addressed, but we have referred to the Centre for Workforce Intelligence. We will be looking at their longer-term projections as to what the workforce is going to be looking like as well as asking the local employers, "How many of those do you need in three to five years’ time?", which is, in effect, the current system.

Rosie Cooper: We could not get it right under the old system, so I am perplexed as to how the increasing complexity at this time of great uncertainty is going to get better, but there you go.

Q297 Chair: We are reaching the natural end. We had some discussion earlier on about the role of regulation of healthcare assistants and the changing demands, in particular, for generalised care provision by people who traditionally would have been called nurses and now, in some cases, are called healthcare assistants. Do you have views on the debate on regulation of those healthcare assistants? I suspect Professor Ellis may have. That is why I asked the question.

Professor Ellis: I do. I do not see statutory regulation as necessarily the way forward. There has to be proportionality of regulation. Support workers should be working under the supervision of a registered practitioner. It is ensuring the appropriate supervisory arrangements and also ensuring that there is the appropriate education and training. That in itself does not mean that they need to be statutorily regulated.

As a further comment, many of the concerns that have surfaced to do with care and nursing are care more generally. With that, I am not saying that nurses are not in all cases not to blame; there may be some fault there, but it is more generally a system failure. In some of those instances-and I know the Nursing and Midwifery Council have commented on this-when reported, it was not about a nurse but a support worker. The education, training and supervisory arrangements for support workers are crucial, but that in itself does not lead me to conclude that there needs to be statutory regulation.

Q298 Dr Wollaston: That was the question I wanted to draw on. Do you think that turning nursing to being all degree training has left us with too much of a gap between them and healthcare assistants? Should we be training healthcare assistants up further so that we lose that gap?

Professor Ellis: No, I do not. Clearly there is a kind of "too posh to wash" myth that is frequently perpetuated.

Q299 Dr Wollaston: That is a myth, do you think?

Professor Ellis: There are misconceptions about graduate nursing. At the heart of those is a misunderstanding of the way in which entry to programmes is operated currently. There have been comments recently made such as, "It takes more than a few GCSEs to become a nurse." I agree. That is why all university providers are assessing potential entrants not just on academic qualifications. It is a requirement under the NMC that there is consideration of those nonacademic requirements to make sure that entrants have the caring, empathetic skills. They are not mutually exclusive. It is a mystery to me why people feel that to be academic means to be uncaring. I do not hear that rehearsed elsewhere.

Q300 Dr Wollaston: The concern is often expressed that some people who are extremely caring, who perhaps are not academic, are feeling excluded from nursing. Whereas previously they could perhaps have become a state enrolled nurse, there is a sense that a whole group of people who would be valuable to the NHS are being excluded.

Professor Ellis: I hear that argument and this is where I would turn to Mike and say that a number of the pre-registration programmes for nursing articulate with access pathways-there are progression opportunities-universities working with NHS Employers and NHS Careers. They are raising awareness and aspiration to a wide variety of individuals about a range of different entry points so that people can progress through, perhaps, a support worker programme and then be able to progress into a preregistration nursing programme. The fact is that there is a balance between their academic entry requirements and a lot of good examples of non-standard entry requirements in order to enter such programmes, but I have to say that probably the sector needs to do more to explain that because there is this myth that it is about the academic qualification.

Q301 Dr Wollaston: Can I clarify that? You are saying that, in future, it will be possible for people who are not getting into the graduate entry level to progress on and become registered nurses without having then switched and done a degree programme, or would they have the opportunity to do a degree programme like a diploma inhouse?

Professor Ellis: There are already opportunities for progression and have been for a number of years.

Q302 Dr Wollaston: But would that be closed off to them in future once it becomes an allgraduate-

Professor Ellis: No, not at all. In fact, in Leeds we have students who are following support worker programmes, who are working with the employers, and in institutions some of those study alongside nursing students. Students are able to progress in and recognise that there are a number of ways in which one can demonstrate one’s academic potential for a career alongside having the necessary personal attributes.

Q303 Rosie Cooper: But what you are saying is that they still need to do the degree programme.

Professor Ellis: They would need to enter the degree programme, but there is the concept of stepping in and stepping out, which was talked about in postgraduate medicine. There would be a stepping-in point, which would be a matter of looking at each individual programme-because programmes will differ as to what people have done before-to decide whether they come in, as it were, at the beginning of the threeyear programme or one could give recognition to skills and experience that they already have to come in at a more accelerated point of that programme.

Dr Farrell: The biggest risk can be characterised in two ways. Certainly through our widened participation, we have seen people who have not been working for five or 10 years come into it at an entry role and, with planned progression, then feeling confident to be able to flourish and go on to widening participation programmes, and in some cases eventually leading to registration as a nurse and indeed other healthcare professional roles. We have to value that widening participation route because of the very strong values that those individuals come with. We know that, for some, there will need to be a bridge between where they may get to on a particular qualification pathway to what they then may need to be able to demonstrate in order to go on to a higher education programme. There are a number of models now being worked up, certainly by a lot of higher education institutions, and also with the support of FE. We need to look at those because the move to degree at the minute could mean that some of these potential widening participation learners get lost. The big thing that is needed, though, if we really want people to feel confident about going forward is effective information, advice and guidance. The current arrangements, both in the wider UK and the reforms surrounding IAG services, put that at risk. Although there is some clarity about what will happen with the health specific IAG services going into HEE, what it feels like for the individual and how they would access that is going to be the big question area. If participants do not get that IAG at the appropriate time in the appropriate way, they will not feel confident or supported to move on.

Professor Madhok: I want to make two general points, picking up on what has been said. The first is that we need to turn this debate upside down. All the debate is about the number of healthcare assistants, nurses, whether they are degree-trained or not. We need to turn it upside down and ask what the patient needs. The whole thrust of this reform was, "No decision about me without me", and we need to bring that debate back somehow and then build our system upwards from that fundamental premise. That is where the ultimate solution has to be some kind of a loosetight arrangement. It has to be loose enough within a national framework for people to work up these pathways. What we are talking about is creating a fundamental reform in how our Health Service works at the moment. It has to be loose enough for people to experiment and create more pathwaycentric competencies and make sure that there are an adequate number of welltrained people along the pathway who are available. Yet it also needs to be tight enough because we cannot leave it too loose. It needs to be tightened up because we are talking about scarce resources. We need to have a very tight framework from the centre that focuses on delivery but, most importantly, reinforces some of the behaviours that will be crucial in terms of delivering this vision. Those behaviours are all about interagency and interprofessional learning. That is the crucial bit.

I will finish off by picking up on, I suspect, a theme that has come through your questions, which is that you are seeking assurance. I do not think assurance is possible at the moment. Equally, we will not have any assurance unless we get past this structural debate. This structural debate is getting in the way now and people, at the end of the day, will rise to the challenge. That is where the comfort comes. There are enough people talking and there is enough leadership in the system to make these structures work. People are waiting for that to settle down.

Rosie Cooper: Can I commend our Select Committee Report, issued today, on that very subject?

Chair: That is probably a fitting note, perhaps on today of all days-unless, Sarah, you want to pursue it further-on which to draw matters to a close. Thank you very much for coming to join us today.

Prepared 22nd May 2012