Health Committee - Minutes of EvidenceHC 6-ii

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Oral Evidence

Taken before the Health Committee

on Tuesday 6 March 2012

Members present:

Mr Stephen Dorrell (Chair)

Rosie Cooper

Dr Daniel Poulter

Mr Virendra Sharma

David Tredinnick

Valerie Vaz

Dr Sarah Wollaston


Examination of Witnesses

Witnesses: Rt Hon Simon Burns MP, Minister of State for Health, Jamie Rentoul, Director of Workforce Development, Department of Health, and Dr Patricia Hamilton CBE, Director of Medical Education, Department of Health, gave evidence.

Q401 Chair: Thank you very much for coming to join us, Minister. Could I ask you, first, briefly to introduce your two colleagues so that we know the area of expertise that is there for you and for the Committee?

Mr Burns: Thank you very much, Chair. It is a pleasure to be here this morning. On my right is Jamie Rentoul, one of the officials who is expert in workforce issues within the NHS. On my left is Dr Patricia Hamilton, who is an expert in education and training.

Q402 Chair: Thank you. I would like to begin at a very general level, if I may. There is a lot of institutional change going on in the whole healthcare system and, of particular concern to us in this inquiry, on education and training. Focusing on education and training, it would help the Committee to understand what the problem is that we are trying to solve. Why is there this desire to change all these arrangements?

Mr Burns: To start with, I should explain that the reforms are necessary because they are helping-aiding and abetting-to achieve the Government’s vision as outlined in the Equity and Excellence paper back in late 20102011. Services need to become more responsive to the needs of patients and local communities, and the NHS workforce are obviously central to achieving that. We believe that education and training is integral in shaping the values and calibre of the staff and needs to keep pace with technological innovation, developments and opportunities for further improvement of the nation’s health outcomes. We also think it is crucial that accountability and decision making need to sit with employers, who have told us, time and again, that they want greater autonomy and accountability for planning and developing the workforce. Primarily, those are the overriding reasons for the concept of the whole modernisation programme, as has been outlined in the White Paper.

Q403 Chair: If you are looking at the difference between the performance of the system when all these arrangements are in place and the performance of the system prior to 2010, what are the changes that you are looking for? What is the improvement of performance of the management of the education and training system that is the justification for the case? What is the case for change measured against the criteria you have described?

Mr Burns: The overarching one is to make the workforce more accountable and more relevant to the changes within the treatment patterns and the innovation within the NHS. That is the overarching thing. Where there are specific crucial areas, there does need to be far greater accountability-and I assume this will arise in future questioning-through the LETBs. There is greater local ownership of education and training where local employers, the local health economy, universities and local authorities can all come together to identify and plan the workforce they need, ensuring that they get the training that is required for them to be a highly qualified, firstrate workforce. If you take the funding arrangements-again, an area you may wish, during the course of today, to come back to-there needs to be far greater transparency. At the moment, we are basing the funding on historic criteria and we need it to be more flexible and more adaptable to local conditions and local LETB areas. That is a significant change.

Q404 Chair: Do you think there is a clear view in the system about a change in the way care is delivered that is necessary and is leading to a change in the training requirements for the workforce? It is something the Committee has talked about in some of its recent reports-the need for a more integrated communitybased service that relies less on acute care delivery. If you do agree with that requirement to change the way care is delivered, what are the implications of that for workforce planning and how is that going to be transmitted back into workforce planning in the system that is being developed in the future?

Mr Burns: There are changes afoot at the moment, and I think they will continue. What is crucial is that the setting for care has to be the most appropriate care. All too often in the past the natural assumption was that people would go to an acute hospital when it may well have been more appropriate for them to be cared for in a home or community setting. You will see, as we have seen in recent years-and this will gain pace-that far more is being done to provide community and home settings for care. You will see, with the figures for emergency admissions to hospitals, that last year saw, for the first time, a 0.5% reduction in the number of admissions, certainly compared to the previous 10 years of figures that showed increases each year. We will see more of that. For that to continue to be developed, we will have to see changes in the workforce because there will need to be a more highly skilled, trained workforce working in the community setting rather than in an acute hospital setting, even though there will still be a very important role for acute hospitals. That is where the LETs will have a particularly crucial role because, being locally based and locally focused, they will be able to take decisions on planning and the prerequisite training to ensure that need is properly met.

Jamie Rentoul: If I could add a little to the Minister’s comments, the other point is as to the relationships between Health Education England nationally and the Local Education and Training Boards more locally with the commissioning system. This will mean the National Health Service Commissioning Board being able to set out the strategic service commissioning intentions for the system and having that relationship between it and Health Education England in setting an overall framework for workforce planning, education and training. Similarly, at a local level it will mean having the Local Education and Training Boards talking to and consulting with the clinical commissioning groups such that workforce planning intentions-the education and training plans-reflect those commissioning intentions in terms of the sorts of service changes you are talking about.

Q405 Chair: There is a tension, is there not, between a clear national view, in the form of the NHS Commissioning Board transmitted to Health Education England, and the bottomup approach which may not get or attach the same priority to that service change agenda?

Jamie Rentoul: Yes. Again, part of the change is to strengthen that bottomup view in the system so it will be a less topdown system than the one that currently exists. Inevitably in this system, as in any other, there is that nationallocal tension about a small number of national priorities that people need to pay attention to.

Q406 Chair: It is an interesting question as to whether the bottomup approach is more or less-small "c"-conservative than the topdown approach. In other words, which is the most effective way of driving change through the system?

Mr Burns: There is a combination, but what is crucial about the local approach through the LETs is that these are local businesses-local NHS and universities-and because they are in a far better position to be able to identify local need, they will be the driving force. That will be the stimulus within local communities for meeting workforce numbers and requirements for the provision of healthcare there.

Q407 Chair: We need to move on, but at the heart of these questions, it seems to me, is whether you achieve the change through a planned approach or whether you do it through the accumulation of small local decisions.

Mr Burns: Yes, but it is a combination of both. Health Education England has an overall view and responsibility to improve, enhance and secure the proper workforce and the quality education which will then-through the streamdown to its committee on the ground, the LEPs-be delivered in each local community, fitting local requirements. It is a twopronged attack-or approach, rather than attack.

Chair: Our plan has lasted 10 minutes and is in ruins already. We will have questions from Sarah, Valerie and then move on to David.

Q408 Dr Wollaston: How local will they be? How many LETBs are we going to have?

Jamie Rentoul: I will start on that one. Having published the guidance document on 10 January, we are now in the process of working with the strategic health authorities and the local employers on their plans for what we have described as shadow Local Education and Training Boards to start from this April. They will have a year in shadow running before going into full operation in April 2013.

Q409 Dr Wollaston: How many will there be?

Jamie Rentoul: We have not yet signed off the proposal. They have not yet formally submitted proposals for the exact geography.

Q410 Dr Wollaston: But it is crucial, is it not? If we are talking about it being local and there only end up being, say, four LETBs, that is not going to be local by most people’s definition. How many would you anticipate?

Jamie Rentoul: When I came to this Committee in October I said something like 10 to 15 as a kind of estimate.

Q411 Dr Wollaston: Is that still your view?

Mr Burns: The estimate is 12 to 16.

Jamie Rentoul: There is quite a lot of active discussion locally on what they see as the right footprint, relationships, scale and leadership capability for them, and so on.

Q412 Dr Wollaston: We are quite far down the line now, are we not, not to know what the structures are? It is very difficult to discuss how local this kind of thing can be if you do not know what size they are going to be.

Jamie Rentoul: A number of places have been operating with committees pulled together-the members of a LETB-already. They are well advanced but there are still some discussions about "Do we want one covering this area or two?", that sort of thing, and "Does this bit of service want to associate with this area or another?" So they are well advanced but not yet finalised.

Q413 Valerie Vaz: Minister, thank you very much for coming. This is a joke; I flag this up because you do not always laugh at my jokes. You called these LETBs "LEPs" and I am wondering if that is going to be your new Ministry-if there is a Freudian slip there-but they are LETBs, are they not, Local Education and Training Boards?

Mr Burns: Yes, they are Local Education and Training Boards.

Q414 Valerie Vaz: You were calling them "LEPs", were you not?

Mr Burns: Listen: the initials are so odd that I thought long and hard before coming to you to work out what it was. I thought the easiest thing was to call them what tripped off the tongue easiest because you, being intelligent people, would all know what I was talking about.

Valerie Vaz: Thank you.

Mr Burns: But it is an odd one.

Q415 Valerie Vaz: This whole process is odd. There are so many acronyms that I have had to do a flow chart about everything, the funding-

Mr Burns: From the day I walked into the Department of Health, in May 2010, I found that and I thought, "Why can’t people just talk in plain English rather than acronyms that are meaningless to new people?" But that is not really the question, is it?

Valerie Vaz: So it is not your new Ministry.

Chair: It is beyond the power of this Select Committee to achieve that.

Q416 Valerie Vaz: Can I confirm this, because we have a lot of different intelligence coming out? Do the LETBs exist now? Could you confirm how many exist?

Jamie Rentoul: They do not exist now. There are SHAs establishing essentially, subcommittees of the strategic health authorities-sorry I lapsed into another acronym-at the moment to bring the right people together to form the Local Education and Training Board. What we have said is that from April this year they should have shadow arrangements in place, which will still be subcommittees of the strategic health authority, because the strategic health authority will still have the statutory duties and responsibilities up till the end of March 2013. Then, during the year, as Health Education England gets up and running, it will run an authorisation process with the shadow LETBs to ensure that they are fit for purpose to go in April 2013.

Mr Burns: Would it be helpful on that-

Q417 Valerie Vaz: What will be the governance of these LETBs and would they be on a statutory footing?

Jamie Rentoul: The Local Education and Training Boards will be committees of Health Education England. Health Education England, subject to parliamentary approval, will be set up as a special health authority. The Local Education and Training Boards will be subcommittees of that special health authority with formal schemes of delegation for what they are being asked to do.

Q418 Valerie Vaz: But Health Education England does not exist at present, does it?

Jamie Rentoul: No.

Mr Burns: No.

Q419 Valerie Vaz: You have the LETBs forming and then you are going to get Health Education England coming on afterwards. Is that right? Is that a good way round, do you think?

Jamie Rentoul: Again, we have a transition team for Health Education England at the moment working within the Department of Health and a senior responsible officer for Health Education England transition who was involved in the process of talking to the strategic health authorities and the employers about the shape of Local Education and Training Boards. Then we will have the formal authorisation process once Health Education England is established.

Q420 Valerie Vaz: What if Health Education England does not like what is happening on the ground-they do not like the LETBs? What happens then?

Jamie Rentoul: In terms of the authorisation process, you will have a degree of delegation agreed through that according to the demonstrated capability of the shadow LETB. So if the Local Education and Training Board is not demonstrating it has the right governance, financial controls or partnership arrangements, then it may be that it does not have as much delegated authority as somewhere that is able to demonstrate that.

Q421 Valerie Vaz: Who do you see as members of these LETBs? Do you have a list?

Mr Burns: Yes. What they are going to have, first, is an independent chair. They will derive their board membership from a range of healthcare and public health providers, so that all types of healthcare are included and their views can be considered. What the board will also have is representation from local education providers who will agree in the developing of local public health workforce and research, as well as local government-the new academic health service networks. They will set up advisory arrangements to reflect the breadth of local interest and ensure that the decisions that are taken are reflective of the needs of local communities.

Q422 Valerie Vaz: What about more specifically?

Mr Burns: More specifically?

Jamie Rentoul: What do you mean by "more specifically"?

Q423 Valerie Vaz: Who is actually going to be on them?

Mr Burns: Representatives of the groups I have just told you about.

Q424 Valerie Vaz: Will it be academics? Can you not give me names? You must know if they exist already.

Mr Burns: If you are asking can we give you names of individuals-

Q425 Valerie Vaz: What about groups of organisations, roughly?

Mr Burns: I thought I had done so, with respect. There will be representatives from local education providers.

Q426 Valerie Vaz: Such as?

Jamie Rentoul: Universities.

Mr Burns: Universities and colleges in the area. They will be from local health providers, public health, but we cannot give you individual names at this stage because that is too premature.

Q427 Chair: How many members do you think there will be on a LETB?

Jamie Rentoul: We have not said "You must have X number."

Q428 Chair: Are we talking about 10 people, a committee or a parliament?

Jamie Rentoul: We are talking about a board that is able to make decisions, therefore not a very large number. A number of them-again, in their current development stage-have a board, which may be 12 to 15, but also a wider partnership council that involves the wider range of stakeholders, to make sure the range of interests is represented.

Q429 Valerie Vaz: Where do you see the deaneries fitting in?

Jamie Rentoul: We see them fitting in as part of the Local Education and Training Board and their operational team.

Q430 Valerie Vaz: Do you consider the system that you are setting up in the future to be sufficiently flexible? For example, if there is a need for midwives in a certain area and someone at the Department of Health-or even the Prime Minister-makes a reference to, "We are going to have 4,000 health visitors", what happens in terms of accountability when someone in a LETB is crying out saying, "We need many more midwives but you are talking about health visitors"?

Mr Burns: They will have the flexibility to identify how many midwives they need for the area that they cover. When you talk about a political figure-you used the Prime Minister-as saying-

Q431 Valerie Vaz: He has made an announcement, has he not?

Mr Burns: Yes, but he did not pluck a figure out of the air.

Q432 Valerie Vaz: Really.

Mr Burns: Yes, really.

Q433 Valerie Vaz: That becomes committed spending.

Mr Burns: I know it will come as a surprise to you, but no, he did not.

Q434 Valerie Vaz: It becomes committed spending. Maybe you do not understand that. The Treasury will see that as 4,000 health visitors. That is committed.

Mr Burns: Yes.

Q435 Valerie Vaz: Right. So it is committed spending and you do not need it.

Mr Burns: Yes, but he will not have plucked the figure-

Q436 Valerie Vaz: You do not need health visitors. You need midwives.

Mr Burns: No. If we are going to be historic for a minute-if you will allow me-the Prime Minister identified two areas, when we were in opposition, where he strongly believed that there needed to be more staff within the NHS to deliver the services. That is why he gave that commitment.

Q437 Valerie Vaz: "Staff" is different from "health visitors". That is specific.

Mr Burns: It is playing around with words.

Q438 Valerie Vaz: I am trying to work out the accountability line, Minister. People on the ground-like, for instance, a radiologist-will tell me that we need more consultants and other people will say we have too many consultants. But, clearly, there is a move to consultant presence, so maybe we do need more consultants. I am saying that people on the ground sometimes know differently from us at the top. That goes for me too. I am trying to find out how flexible this new system that you are going to have is.

Mr Burns: The LETBs will be identifying the needs for the local community. Also, an overarching monitoring of the workforce requirements of the NHS will be done partly through the work and advice of the Centre for Workforce Intelligence, which was set up at the back end of 2010. It is there to look at, in so far as one is able, the anticipated workforce requirements of the NHS over the coming decade.

Q439 Valerie Vaz: Can I quickly turn to the Workforce Directorate-this is my last question-and then I promise I will shut up? I want to ask what is happening to the Workforce Directorate. I understand it is going to be disbanded.

Jamie Rentoul: Do you mean the Workforce Directorate in the Department of Health?

Valerie Vaz: Yes.

Jamie Rentoul: In changing its structure, the Department of Health is setting up a new directorate called the Directorate of External Relations, which will include those functions currently in the Workforce Directorate that continue in the Department. There will continue to be a Department policy remit and sponsorship of Health Education England, for example, within the Department, but a decent chunk of what is currently in the Department, in terms of education and training policy, would move across as a function to Health Education England.

Q440 Valerie Vaz: Are the staff still there, have they left or are they going to move across?

Jamie Rentoul: We have not carried out the moves yet. There is a process of Health Education England setting out its structure-the policy for transition of people-such that we then take that forward in terms of the moves of individuals.

Q441 David Tredinnick: Minister, I am not as brave as Valerie to try and make a joke out of acronyms but I thought it was very commendable to do that. I also think that choosing "LETs" was a pretty fair way to determine your thought process on this knotty subject.

Mr Burns: It seemed easier to trip off the tongue.

Q442 David Tredinnick: It seemed to be reasonable. I would like to ask you a few questions on the organisational structures, some of which have already been touched on. The first one is that the Secretary of State-I think clarification would be helpful, continuing the theme we have had-has advocated that "form follows function". Could you elaborate on that, please?

Jamie Rentoul: In terms of the rationale for the reforms and setting up Health Education England as a dedicated body, it is to give focus and national leadership for workforce planning, education and training, running through into the system. That then gives, at a local level, the employers, local professionals and education providers coming together-again, in a board-a focus on this area. You give it the attention and specialised expertise it needs as a system, if that is what you are getting at.

Q443 David Tredinnick: Health Education England must be "employerled". How far is that part of the Government’s plan? I will expand a little on that. The NHS Employers have said in evidence to us that Health Education England must be "employerled". How far is that part of the Government’s plan?

Mr Burns: I am not altogether sure that I have the question right. The focus of Health Education England is to provide national leadership and oversight on strategic planning and development of the health and public health workforce. It will allocate the education and training resources to meet those ends. Therefore, to my mind, what is driving Health Education England is that overarching responsibility to ensure that it succeeds in its aim. It will have a number of functions, which I am sure you are familiar with, but to my mind, that is the driving force of HEE. If you could elaborate a bit more on what you mean by workforcedriven-

Q444 David Tredinnick: This came up in evidence that we have been given and I wanted to have your comments on it.

Jamie Rentoul: In terms of documents that the Department has published, we have said that Health Education England needs to carry the confidence of employers, the education sector, professionals, patients, the commissioning system and, indeed, regulators. In terms of setting it up, it needs to be established in a way to do that. This is about bringing together a range of different perspectives and making the system work effectively.

Q445 David Tredinnick: Health Education England is going to be set up as a nondepartmental public body. Why is that, please?

Mr Burns: First of all-if it would be helpful to give the time line-it is going to be set up as a special health authority because it will require primary legislation to set it up as a nonGovernmental body. It will be up to the business managers and those who put together legislation for future parliamentary sessions as to when there will be a slot for primary legislation for that. It can remain as a special health authority for up to six years, so from 2013 to 2019. No doubt at some point, sooner or later-I cannot anticipate the powers that be who determine the Queen’s Speech-there will be legislation. The reason it is going to be at arm’s length from Government is that we believe that is the most effective and efficient way to deliver, particularly within the general philosophy of an NHS that is not micromanaged and politically controlled from the top.

Q446 Chair: Can I ask a question about the relationship between HEE and LETBs? There was a discussion document that the Department published last autumn, Education and Training Reform, and there was a stakeholder event on 19 September 2011, which talked about the relationship between HEE and LETBs as being a contractual relationship so that the performance of LETBs would be defined in contracts, with penalties to flow if the LETBs did not perform to contract. Is that still the model that the Department is expecting to implement?

Jamie Rentoul: Not quite. That reflected the original consultation document of December 2010 when we were consulting on the Local Education and Training Boards being autonomous bodies, whether statutory or hosted by another NHS body. Following the consultation and Future Forum exercise, the policy, as set out in the January 2012 document, is that the Local Education and Training Boards will be hosted by Health Education England, as I talked about earlier. In employment terms, you would expect people to be employed by Health Education England, so a contractual relationship is not the right relationship. It will be more of a service level agreement and a formal scheme of delegation.

Q447 Chair: It will not, in truth, be as independent as is implied by a contractual relationship. It will be a subset of HEE, basically-a subsidiary of HEE.

Jamie Rentoul: It will be formal subcommittees of HEE with the level of delegation reflecting the authorisation process, again, with the intention of more delegated, devolved decision making.

Q448 Chair: If the starting point was a contractual relationship, you could argue that the model, as it has emerged, is less delegated, could you not?

Jamie Rentoul: In practice, you are going to be holding the LETBs to account from HEE centre, whether they are hosted by it or they are contractual bodies.

Q449 Chair: Do you envisage a single formula for the relationship between the HEE and the LETBs or is that, in reality, going to be a service level agreement negotiated one by one between the centre and the locality?

Jamie Rentoul: If I have followed your question, there will be some common elements to the agreement between HEE and the Local Education and Training Boards in terms of the outcomes expected for the funding flow that will go to them. The detail will obviously reflect what the local education and training requirements are.

Q450 Chair: Will those be public, transparent documents?

Jamie Rentoul: Yes.

Q451 Chair: But potentially, at least, every one of them different.

Jamie Rentoul: They will have a common framework.

Chair: With a common core-

Jamie Rentoul: A common core.

Chair: -but, potentially, reflecting different-

Mr Burns: In parts, yes.

Q452 Dr Poulter: I want to pick up on a couple of points that have been made. Obviously there is a desire that there will be "any willing provider" in the workplace. If it is the case that contractual arrangements between providers will be over a fiveyear period or a 10year period-whatever it may be-and different providers could be coming in to perform different parts of what is currently perhaps one hospital specialty at the moment, how would you envisage that impacting upon the workforce training?

Jamie Rentoul: I will start off on that. In the passage of the current Bill through the Lords, there is an amendment, which the Government accepted, of having a duty on all providers to cooperate in the planning and provision of education and training. That will also be a standard term in the NHS contract. In terms of the Local Education and Training Board having oversight and leverage to make sure that training placements are where they need to be across the providers of healthcare services, you have the mechanisms to make that happen. Clearly, if you have a high volume procedure, such as cataracts, which goes off to a particular provider, you need people to have the experience of providing that service. Therefore you need arrangements to make sure that they get that experience as well as other bits of their wider experience.

Q453 Dr Poulter: Where other providers of services at the moment are being used or have been used by the NHS to reduce waiting times and the like, how would you describe the training arrangements that have been set up, or that have previously been in place, with those providers? Has there been any training taking place alongside the provision of, say, cataract operations provided by another provider to reduce waiting times or, for example, heart bypass operations?

Jamie Rentoul: Are you talking about the current position?

Q454 Dr Poulter: Yes. Historically, the previous Government introduced private sector providers to reduce waiting lists. Was training any part of using those providers? Was that an inherent part of their use?

Jamie Rentoul: I am sure Patricia will add more detail. If you talk to people around the service, it has been pretty patchy. There are some good practice examples and there are some other areas where it has not been properly addressed in the contracting arrangements.

Dr Hamilton: We have good examples where people have taken trainees into the private providers to gain training and experience, but it has been an issue, particularly with these high volume, low risk procedures, that our trainees do not always get enough experience. That is going to be an advantage of having the deans and deanery part of the planning of deployment of the workforce. They can plan the training alongside the planning that is going ahead for the service so that we can make sure the training is spread properly throughout the service provision.

Q455 Dr Poulter: We have heard, as a Committee, that in a number of hospitals-partially due to the EWTD and for other reasons-service provision sometimes has gone ahead of training. If you have the functions of a particular department being performed over multiple sites, inherently that would make service provision more challenging, but it could also make training, in particular, more difficult as well.

Dr Hamilton: That is why it is very important to preserve the function of the deans. We would expect the LETBs to be able to demonstrate that the dean can act independently of the conflicts of interest that may arise, particularly with service and training, in making sure the quality of training is preserved and not sacrificed to service and yet not compromising service either so we get that balance right.

Q456 Dr Poulter: Would you accept that one of the weaknesses of the current system is that, very often, the arrangement between the current deaneries and local hospitals can mean, in some cases, you have a very good accommodation of training but, in other places, service provision is prioritised at the great expense of training? Is that a fair comment?

Dr Hamilton: It is a fair comment and it is one of the things that we are trying to address, to reduce that variability to make sure that we do have high standards of quality.

Q457 Dr Poulter: Where contracts for providers come in-perhaps that are not private sector providers, but otherwise are coming in-are you looking at making sure that, inherently, as part of that contract, trainees are specifically addressed in a holistic way?

Dr Hamilton: Yes. We are building checks and balances into that system so that providers will have to demonstrate they are meeting the educational outcomes framework being drawn up at the present time. Not only do they have to meet the process requirements of the GMC, as before, but there are also metrics and indicators being drawn up whereby they have to demonstrate that they are meeting those provisions. With the increasing transparency of the funding flows, it gives Health Education England and the Local Education and Training Board itself the power of holding the money.

Q458 Dr Poulter: You are confident that making sure training is inherently written in as a part of the new contracts by the providers is a way that could potentially enhance the quality of training available, which was not done in the past, I believe.

Dr Hamilton: Yes. That will be part of the duty to cooperate.

Q459 Dr Wollaston: Can I follow that up with a supplementary to Dr Hamilton? It is not only an issue with postgraduate training but, I understand, for undergraduate training as well. Where certain services have been, if you like, sent out entirely to the private sector in some areas-for example, provision of services for drugs and alcohol-medical students are being denied access to those sites where they are in the private sector. Is that something that you are concerned about and have plans to address?

Dr Hamilton: We would want to address that. We are increasingly trying to make undergraduate and postgraduate training much more of a seamless process. We are looking at, particularly, the final undergraduate year at the moment to make sure that they do get the breadth and depth of experience, not only in content but in context, as you are implying-that they experience different contexts of training as well.

Q460 Dr Wollaston: Do you envisage for the private sector-not just the private sector but perhaps social enterprises-that it would be a duty for them to have to accommodate medical students if that was not available in the usual university and NHS setting?

Dr Hamilton: It would be up to some local determination as to what is suitable. They still have to meet the curricular requirements of the GMC, so I am not sure that the duty to cooperate would absolutely specify exactly what each place has to do. However, if the deans, in conjunction with the higher education institutions, feel it is beneficial to the student or the trainee’s education, then that should be worked through.

Q461 Dr Wollaston: Is it something that you recognise, at the moment, as a potential problem, that students are sometimes being denied access to experience in areas like, for example, drug and alcohol? Do you recognise that as an issue?

Dr Hamilton: I think it is an issue. There are still many things we could improve in education and training, and that is part of the purpose of this work. It is something that we need to look at. They certainly need to be aware of drug and alcohol problems and we do need to be able to give them that experience. It is always difficult getting everything into the curriculum, but having broader representation across a LETB and bringing those people to the table may help to increase the experience that is available to the trainees.

Q462 Chair: Am I right in thinking that one of the amendments in the House of Lords to the Bill is to require a provider of care, in response to an NHS commission, to participate in the training system?

Jamie Rentoul: Yes.

Mr Burns: Yes.

Q463 Chair: There is a gap between legislative commitment and reality, of course, but the requirement is there in any commissioned service to the NHS.

Mr Burns: Yes.

Jamie Rentoul: It is, and it is expected to be a standard term in the NHS contract from April this year.

Q464 Rosie Cooper: My comment was going to be in that direction, in essence. I heard from your previous answers that it would be in the contracting process. I was wondering whether foundation trusts may consider some of that information to be commercially sensitive and, therefore, not want to share it. Is there any possibility that that would happen?

Jamie Rentoul: Again, there is a requirement in the current Bill about the provision of information which covers that. There will need to be processes within the Local Education and Training Board that it is able to take in some commercially sensitive information and handle it in terms of the workforce plans. But the requirement on all the providers to provide the information will be there.

Q465 Rosie Cooper: The Centre for Workforce Intelligence suggests that there is a risk of having too many hospital consultants, given the number we have in the pipeline. How do the Government intend to address that?

Mr Burns: There will be changes. As you are aware, in recent years there has been a 60% increase in consultants in the NHS. As we see more treatments and care being carried out in the community rather than in an acute setting, there may well have to be adjustments to the workforce to cater for that, where relevant, and at other levels as well possibly. That is something that would have to be identified locally within the local providers to make sure that there was the right level of staffing for the treatment of patients in whatever setting it is.

Q466 Rosie Cooper: Minister, I understand the Department is already looking at how to handle consultant numbers and redundancies or whatever. Could you be a bit more open about where you are?

Dr Hamilton: I could help to build on that. We have asked the Centre for Workforce Intelligence to look at this because we are predicting a continued increase in the number of consultants. Obviously there are the dangers of oversupply and issues around affordability and so on. Therefore, the centre is looking at planning the whole workforce and at scenarios to cope with that.

Q467 Rosie Cooper: Thank you. You are looking at the provision as of now. The Bill will drive more services into the community. Mike Farrar, for example, is very clear about, and a number of people have talked about, the number of hospitals that will close. Therefore, there will be much less need for consultants. Are you already looking at areas where you think there will be overprovision, where hospitals may close and that kind of thing?

Mr Burns: Can I say-and I will get my colleague to elaborate further on your question-

Rosie Cooper: Well rescued.

Mr Burns: -that part of your question had a statement as if it was fact about hospital closures. It is local decisions that determine the provision of the local health economy. I am not convinced that we get very far forward with somewhat vague suggestions of hospital closures, with all the associated emotive language.

Q468 Rosie Cooper: Where is the massive overprovision of consultants going to come from?

Mr Burns: There will be changes in provision. If, as I said earlier, one is going to see more care being appropriately provided in the community, then, yes, local areas will have to look at the layout of the way in which they are providing care at the moment. But that has to be driven at a local level.

Q469 Rosie Cooper: In short, hospitals will close. The premise is the same. I understand that if you are driving more services into the community there will be gaps. This morning I have been to an allparty group on health and they were talking about CCGs becoming system managers. If you are going to provide more in one part of the system, there will be less in another. That is likely to be the acute sector. We can already envisage an overprovision of consultants, but if units close then that will become more acute quite quickly. Where are your plans currently, at the Department of Health, to manage that?

Mr Burns: First of all, we are not-to use your words-driving care into the community. What is driving the configuration of the provision of care is: What is the most appropriate care for the patient? It is not a question of driving it, like herding cattle.

Secondly, the NHS, as you well know, is constantly evolving. We have seen throughout the history of the NHS, with changing medical practice and changes in medical procedures, wards closing and other wards opening to reflect those changes, that evolution and local needs. That will continue. But it will be-as I get back to my basic point-down to the local health community to determine the best configuration of services to meet the needs of the local community.

Q470 Rosie Cooper: That may be that, in your view, the hospital will close.

Mr Burns: I am sorry, but I am not going to fall into the trap that you keep pushing me towards. I will not go over the edge.

Rosie Cooper: I am quite happy. My point is made. I was not going to go on very much longer.

Q471 Mr Sharma: I want to ask that if we are-not driving, but certainly whatever phrase you would like-

Mr Burns: The most appropriate care setting for the patient.

Q472 Mr Sharma: Will those communitybased services be provided by the third sector or do you think there should be a new sector created to provide the services?

Mr Burns: They will be provided by a variety of different providers, as they are now. The NHS will provide some of it, as may the voluntary and charitable sector.

Q473 Mr Sharma: Is it "may" or "will"?

Mr Burns: "May". I cannot anticipate, in a local community, who is going to be the provider of certain types of care because that is up to the commissioners and the local communities. As you know, now there are a variety of different providers of NHS care within a community as well as within a hospital setting. You will be familiar with the fact that the last Government dramatically increased the input into NHS care by the private sector. We have seen myriad different types of care provided for NHS patients based on the core principle that it is free at the point of use for the patient.

Q474 Mr Sharma: Do you not agree that that will lead to closure of some hospitals in some areas?

Mr Burns: No. I will get back to my original point because I can see where you are hoping I am going to go and I am determined not to. The fact is-

Mr Sharma: But you will see the-

Mr Burns: Let me finish. The fact is that the provision of services in a local community-the configuration and the reconfiguration of services in a community-must be driven by that local health economy and the commissioners. That is what has happened in the recent past. That is what will happen in the future. It is local decision making to make sure that the services provided are those that are relevant and needed for the local communities.

Q475 Rosie Cooper: What potential do you see to make use of noncareer grades-specialty doctor and associate specialist grades? I always had problems with this when I was at the Women’s Hospital. They were much admired by the general staff, but consultants maybe did not rate their colleagues too highly.

Dr Hamilton: We recognise that we have not valued this cadre of doctors as we should have done. Increasingly-they have already had their terms and conditions changed-we are looking, for example, at some of the work that we are involved with in emergency medicine, where we know that we need more staff to look after the emergency departments, and we have not been using and valuing them enough. We have been using them but not in a way that values them. As part of the whole new system, locally and nationally, we need to increase their value, job satisfaction, career progression and continuing professional development. There are many ways in which we can use their skills, particularly when we will need to reduce the numbers of trainees. We can very much weave in the skills of the associate and specialty doctors.

Q476 Rosie Cooper: When you talked about reducing the number of trainees, how do you see that spanning out over the next 10 years? How many do we have in training now? How many do you see in five, 10 or 15 years?

Dr Hamilton: We are working, as I said, with the Centre for Workforce Intelligence on three areas, starting with undergraduates but also with the specialty trainees. The centre produces an annual report that shows that each year we have reduced slightly. We have come down from an intake of 7,000 per year to about 6,500. We are not planning to reduce dramatically more but we are trying to direct more trainees into general practice. We have, at the moment, a slight excess of specialists and not enough people in generalist training or in generalist specialties.

Q477 Rosie Cooper: Thank you. I was about to ask you about Sir John Tooke’s recommendations and whether the message to send out is that the career structure within medicine is changing and changing quite dramatically.

Dr Hamilton: Yes, indeed. We are taking forward Sir John’s recommendations, and we have been doing that piecemeal. We have been looking at some of the things that he suggested in terms of having broader-based training and being able to be more flexible about changing from one training programme to another. We are about to start a big review on the shape of postgraduate training in which we are looking at changing the career path to make it more responsive to the needs of the service and patients, but also to the needs of trainees. We have, in fact, developed a broadbased programme which includes paediatrics, psychiatry and general practice so that the trainees in that programme get an experience of those specialties. They can then go into the specialty of their choice without having to go-snakes and ladders-right to the beginning of training, but can carry some competencies with them as they move from one to the other.

Q478 Rosie Cooper: This is my final question. Should all hospitals be involved in training and, if not, how does that impact on the plans you have? How does the jigsaw all start to fit?

Dr Hamilton: I think all hospitals should be involved in training, but that does not mean the traditional "SHO, middle grade, nearly consultant" rota we have had in the past. We know that we are going to have to reduce the numbers of trainees and we know about the European Working Time Directive, but also, particularly, there are the reports that have come up from John Collins and John Temple that show we are not supervising trainees properly. We have to rethink the way we deliver training, which is not to use them as purely service-learning on the job-young doctors, including in the middle of the night, but that they get properly supervised targeted training, where we make every moment count and every clinical encounter a training experience.

Q479 Rosie Cooper: I am not talking about overall, but in that case would you not need a slightly raised number of consultants available in order for them to be there almost round the clock?

Dr Hamilton: Absolutely.

Q480 Rosie Cooper: How difficult is that?

Dr Hamilton: That is what we are working on at the moment-having a greater consultant presence. Someone already referred to the "consultant present" service. We think it is better for patients to have the consultants nearer the front line and earlier in the patient pathway, but it is also good for training.

Q481 Rosie Cooper: When I was chair of the Liverpool Women’s Hospital, we had a huge consultant presence in the hospital, but that was so difficult to achieve. In the wider sphere, I am sure, and in the different specialties, that will be incredibly difficult.

Dr Hamilton: It will, but we have the-

Rosie Cooper: We should do it.

Dr Hamilton: We have large numbers of trained doctors coming through so we will be able to expand the traineddoctor workforce.

Q482 Rosie Cooper: Will you be able to afford it?

Dr Hamilton: That is what we are looking at. Of course, at the moment, a lot of them are paid to work extremely long hours and you can have more doctors working slightly shorter hours. There are ways you can look at this. You can look at the career structure through a consultant career pathway, which will, of course, be much longer because they get to consultancy earlier and are going to carry on working later. That is what we are asking the centre to model at the moment. As well as a consultant presence for greater periods during the day, we are looking at developing the sevenday week hospital. We will need more consultants to staff that as well. That does cost, but it will mean that patients get some of the routine care on Saturdays and Sundays that they expect during the week.

Q483 Rosie Cooper: That would be easier to provide, more cover in a smaller number of units, would it not?

Dr Hamilton: It would.

Rosie Cooper: I look forward to following that. Thank you.

Q484 Chair: Is there not a tension emerging from the questions of the last quarter of an hour between the following two views? One view, articulated by Sir John Tooke’s report, is that we need more generalist, communitybased care provision, training, manpower and workforce planning to reflect that changing model of care. The other view is that articulated by the Minister in response to Rosie Cooper, that this is all about local decision making and there is no national view about how the care model is going to change. I wonder whether there is a clearer national view and if there might be some value in articulating what that view is about the shape of what future care needs to look like. It would enhance both patient and public understanding and professional understanding about what the new service needs to look like five or 10 years hence.

Mr Burns: On the narrow point of the questions from Rosie Cooper on reconfigurations, the thinking behind that question was a little wider than the tensions you highlight in your question. One got the impression that she was desperately tempting me to say something on reconfigurations and hospitals that was-

Rosie Cooper: I was genuinely trying to understand the global view on consultants and where that excess was coming from. I would not dream of tempting you into telling the truth.

Mr Burns: I think I am a bit older than to be reassured totally by-

Chair: We seek crossparty truth on this Committee-

Mr Burns: Indeed you do, but I am not going to be tempted down any culdesac-

Chair: -in a political minefield-

Mr Burns: -that will come to haunt me.

Chair: Could I tempt you to answer my question?

Mr Burns: Yes, absolutely, on the tension one.

Mr Sharma: Truthfully.

Mr Burns: They always are, sir.

Dr Hamilton: I hope it is a creative tension; all these tensions are. There is a difference between strategy and strategic leadership. Health Education England is set up to provide some of that leadership in developing innovation or encouraging innovation from local LETBs. The way in which that strategy is interpreted and implemented locally is up to the LETBs.

Q485 Chair: I understand that, but is it not part of national leadership to create the space, and indeed the leadership, to encourage local rollout of that vision at a faster pace than might occur if it was left to local initiative?

Dr Hamilton: I am sure it is, and I would hope that Health Education England would demonstrate its leadership in that way. As you know, we are trying to develop leaders through the Leadership Council to encourage and foster innovation. I would have hoped that one of the purposes of the system is to get that flowing, perhaps both ways, more easily with a shorter distance than it has hitherto.

Chair: Thank you.

Q486 Dr Wollaston: I have a followup question to Dr Hamilton. Where should training to be a commissioner come into this? Should that happen at all levels of medical education and postgraduate education or do you envisage it coming in at a particular part of training?

Dr Hamilton: Some understanding of the business of commissioning should come at all levels of training, and I think it should start in undergraduate years. My remit is slightly more for postgraduate and we have put in that all colleges have to include in their curricula some competencies that we have developed with the National Institute for Innovation on leadership and management. That included some understanding about the commissioning process. That is in the core generic curriculum so that everyone has to have a basic understanding of how that process works.

Q487 David Tredinnick: How will the voices of the smaller nonmedical professions and the smaller sectors and employers be heard in the new system, please?

Mr Burns: Can I ask what your definition of smaller is?

David Tredinnick: Not as large as the others.

Chair: He is there before you, David.

Q488 David Tredinnick: I am thinking about my long interest in complementary and alternative medicine, in particular. I would like to suggest to you that at a time when we are trying to increase choice in the health service, there is, broadly speaking, an inconsistency in the provision of other services which are outside the mainstream health service that we have been talking about this morning but, nevertheless, assist doctors and provide alternatives for patients who may want to take a different route from the conventional biomedical route.

Mr Burns: Thank you for that. I thought that was what you meant but wanted to clarify so that we were talking from the same hymn sheet. The fact is that, as you know, the Department of Health does not maintain a position on any complementary or alternative treatments. However, decisions on whether to commission and fund complementary and alternative medicine treatments are made when they have satisfied themselves as to safety requirements and clinical cost-effectiveness, as well as the availability of suitably qualified and regulated practitioners. It is a matter decided on a local basis within that framework.

Q489 David Tredinnick: We had Professor Ellis in front of us, the Dean of the Faculty of Health and Social Sciences at Leeds and Chair of the Council of Deans of Health. I recall him saying that one of the problems at the moment is that demand for courses at universities is high, for example, for osteopathy, which is not currently funded. However, there are other disciplines such as 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 by the NHS, but I have art psychotherapists and counsellors who are not." He was suggesting that we have a lot of anomalies here. Would it not be possible for the Department to look at ways of having a more consistent arrangement?

Mr Burns: Do you mean for the provision of courses in our universities?

Q490 David Tredinnick: For the provision. Another point related to this is acupuncture, which is now recommended by NICE guidelines for lower back pain. In another answer we heard that only 2% of the population have access to acupuncture and there are only 13,000 acupuncturists across the country. Now that the Health Professions Council is to regulate herbal practitioners and now that we have a regulation that is related, through Chinese medicine, to acupuncture, would it not be possible to have a policy of the Department to provide a wider scope for these treatments on the National Health Service? There could be significant cost savings there.

Mr Burns: If I can deal with the first point, then I will ask my colleague to come in on your second point. The first point was about the provision of courses at universities. I know from past evidence given to this Committee and your questioning that you were concerned about what has been happening at Westminster university.

David Tredinnick: That is right-Professor Peters.

Mr Burns: The straightforward answer is that it has to be up to the academic institutions to determine what courses they are going to put on for students to attend rather than any direct involvement by the NHS. On your second point about this whole area of medicine and the NHS, I will ask Patricia to give you detail.

Dr Hamilton: Certainly as far as training and regulation is concerned, herbal medicine has gone on to a statutory register because of a European law which means that they cannot practise without being part of a register. As to training, our curricula are being increasingly driven by service need and employers. We have not included these alternative and complementary medicines in the curricula at the moment because there has not been the drive for that. They work on a slightly different framework than the more scientific, evidencebased framework from which we compose the rest of the curriculum.

David Tredinnick: Thank you very much. I would like to return later to one of the elements to do with the funding of students, which we will cover in another section.

Q491 Chair: Can I pick up the slightly broader question of the smaller nonmedical professions? It is not just about alternative and complementary medicine. It is also about the broader range of nonmedical specialisms in healthcare. There is a concern in some of those areas about the degree to which their voices will be heard in a training system that appears to be, to some extent, the son or daughter of MEE. Therefore, there is a danger that it is medically led without adequate voice for the nonmedical clinical professions.

Jamie Rentoul: We have been pretty clear in the documents we have produced that this is about a whole workforce view and it is not a medicallyled system. It is a multiprofessional system we want. If you look at some of the nonmedical numbers on nursing and allied health professions, they are very big numbers. The issue, then, is that you have some smaller groups within that and are they going to get enough attention at Local Education and Training Board level? Again, we have said we will be looking to Health Education England to have particular regard to smaller professional groups. In terms of some of those, you will need more of a national view of the numbers. You will not be able to do your workforce planning at a Local Education and Training Board level, but you may have a Local Education and Training Board looking at it on behalf of all the others. That is a clear part of the brief to Health Education England.

Q492 Chair: That is a specific option that will be developed, is it? One LETB would be the lead commissioner, for example, for physiotherapy training.

Jamie Rentoul: That is the one. Whether physiotherapy, where there are still quite significant numbers-

Q493 Chair: Let us say occupational therapy training then.

Jamie Rentoul: They are smaller numbers there. Yes.

Chair: Thank you.

Q494 Dr Poulter: I come back to the current quality of training available to doctors, nurses and other healthcare professions. If you expand the number of training places, there is obviously a finite number of existing professionals who can train them, or if you expand the number of medical schools and the number of medical students, for example, there are only a finite number of hospitals they can do their clinical placements at. Do you have a concern that the quality of the clinical experience in clinical training available to medical students, nursing students and midwives is reduced by these factors, that there is an increasing number of students but the structures have not expanded adequately to train them?

Dr Hamilton: There is concern at the moment that we have too many students and trainees in the system. We are looking, with the other devolved Administrations and with the Higher Education Funding Council for England, at medical student numbers at the moment with a view to thinking that we might need to reduce them. Clearly, we are thinking very carefully before we do that. Certainly we are very careful to try to match the number of good training places to the numbers of trainees coming through the system. Again, one of the aims of this whole plan is to make sure that we do get the deans and deaneries involved in planning the workforce, the placements and the programmes within and across the LETBs to ensure that everyone who is in the system gets a good quality of training and a good experience of different content and contexts of training.

Q495 Dr Poulter: Turning away from medical training directly, we know there has been, as the Minister said earlier-a political message, and on the ground that is borne out by what the Royal College of Midwives would say-a shortage, for example, of midwives in some units. Yet we know that there are increasing numbers of midwives being trained, for example. We also know that there are increasing numbers of midwives who want to go back to work. Having left the profession, they want to go back in. There seems to be a disconnect here between the employer and the workforce planning that is going on; if you like, the acknowledgment by Government and by workforce training that there is a service provision gap but, at the coal face, these people are not necessarily being employed once they have been trained. Why do you think that is happening and how can that be addressed?

Mr Burns: Can I start? You have identified one area where there is a need for more staff. The NHS has worked hard in the last year or two to try and reduce the disconnect and increase the numbers to meet the needs. You rightly identify that, for the last two years, there have been significant numbers of people in training. In the current year there is a record number. I think it is 2,507, off the top of my head, or 2,573-one of the two figures. Also, since May 2010, there has been an increase in the total number of midwives of 869. That is a step in the right direction, but there is far more that needs to be done to identify the problems that you have highlighted. More has to be done on retention but also on encouraging those who have taken a break-for a variety of reasons-to reenter the workforce and the profession, to help with building up the numbers to fill any pinch points there might be throughout the NHS. To get some greater detail, I will ask Jamie if he can elaborate on that.

Jamie Rentoul: We have also done a bit of work with the strategic health authorities on the future plans that show further growth both in the midwife workforce and the broader maternity team workforce. As the Minister said, near record levels of training numbers are continuing. That is a problem that is well recognised and is being addressed. Indeed, in the new system, we are getting employers closer to this, a closer alignment of the responsibility for then employing the people coming out of it.

Q496 Dr Poulter: The thing I am driving at is this. Clearly there has been a commitment to the training, but is there an issue that local employers-local hospital trusts-have to make that commitment to employ those trainees to fill these workforce gaps and make the financial commitment at a local level? Do you feel that is happening as much as you would like it to happen?

Jamie Rentoul: Again, as the Minister said, we have had a growth of nearly 900 in the midwifery workforce since the coalition Government came in. Within the processes-at the risk of lapsing into jargon-the integrated planning process that the SHAs currently lead is about drawing together both your view of future demand and activity and the workforce planning, education and training such that you get that commitment to the jobs for people coming out of training places.

Q497 Dr Poulter: Is there a place in this to ensure that employers employ those people who are being trained to meet that demand, and that there should be, shall we say, mandatory staffing ratios or levels? Is there a case that that may encourage employers towards doing that, or good practice in what staffing ratios ought to be, both to encourage adequate training of healthcare professionals but also to meet that service provision and make sure that people who have trained because there is a demand actually have somewhere to go and work and meet the demand they trained to meet?

Jamie Rentoul: Yes. We would be supportive of your latter position about good practice and people making the right local decisions, professionally informed, rather than setting stafftopatient or mother ratios that do not take account of different case mixes, how care is provided and the overall shape of the maternity workforce team. It is about people making the right decisions, professionally led, and about the staff they need to deliver good quality outcomes of care.

Q498 Dr Poulter: Having some knowledge of maternity, generically it is fair to say that you would expect a labour ward, be it in Bradford, London or in rural Suffolk, which I represent, to have the same standards of patient care. We ought to be saying, and I believe the view at the Department is, that every woman should have a dedicated midwife through to delivery. But is it a case of making sure, where we know that is what the policy objective is, and we are training and getting more midwives in place, that those trusts at a local level ensure those things happen? That is where the disconnect appears to be.

Mr Burns: Yes.

Rosie Cooper: It costs a lot of money as well.

Q499 Dr Poulter: It is also a question of local spending priorities and how we make sure that the trusts, the managers and the boards put that workforce to the use they have been trained for and meet those national policy objectives of good care. That is what I am driving it.

Jamie Rentoul: Yes. That links into the other bit of the system around CQC as well. As professional regulators have CQC as a regulator saying what the essential standards are as to suitability of staffing, that you have the right numbers of properly trained staff to provide the care. That, again, needs to reflect the good practice that is required.

Chair: Hopefully, the commissioner might take an interest in that one day.

Q500 Rosie Cooper: Listening to Radio 4, I heard nursing leaders insist that nurses needed degree level training because they had so much patient contact. Yet most people would say that the group that has the most contact with a patient would be healthcare assistants. The Government do not even wish to regulate that group of employees in spite of a strong body of view in favour of it. Can you explain the reasoning behind the fact that you do not want to regulate healthcare assistants?

Mr Burns: Yes. We have said that our response should be proportionate. As you are aware, we are setting up a register. We think, at this stage, that is a proportionate response. We will obviously look at it when it has been in place and we have an opportunity to analyse the impact it has had and whether it has been effective or not. Depending on what comes out of that, we will be able to consider the way forward. It may well be that a register is the appropriate way forward rather than the regulation that you are talking about. If that is the case, it is the preferable alternative.

Q501 Rosie Cooper: How are you regulating standards of healthcare assistants now and how do you think that a voluntary register, almost, will bring a solution?

Mr Burns: At the moment, as you know, both health and social care sectors are subject to numerous tiers of regulation which are there to safeguard the health, safety and welfare of patients and service users. As Jamie said in answer to Dan Poulter’s question, there are also the requirements under CQC. Ultimately, if employers think it is appropriate, they have the use of existing systems, such as referrals to the Independent Safeguarding Authority, if there are problems with individual people.

Q502 Rosie Cooper: But it does not drive up the standard, does it?

Mr Burns: No.

Jamie Rentoul: I have a bit to add to the Minister’s comments. We have commissioned the relevant sector skills council, Skills for Health and Skills for Care, to do a joint piece of work on both code of conduct and minimum training standards for support workers. As part of that, we will need to think about the transparency and information provided on those training standards being met and, therefore, the obligations on employers and Local Education and Training Boards.

Q503 Rosie Cooper: For the person who has the most contact with the patient on a daytoday level, all we are doing there is minimum standards.

Mr Burns: I would not quite go along with that rather loaded question.

Q504 Rosie Cooper: That would be as I take it. You are setting minimum standards, but that is it. It is not about driving quality. It is not about raising it up. It is not about giving it any value or making it the important role that it really has to be because it has the most contact with the patient during the day.

Mr Burns: Yes, it is an important role and no one is downgrading that role or suggesting otherwise. The question of driving up standards will come, in addition to what Jamie and I have just said, from the whole working ethic of the hospital-the standards and quality that are provided there.

Q505 Rosie Cooper: Mid Staffordshire?

Mr Burns: You are picking an exception-a sad exception-and it is being looked at now, awaiting the publication of the second Francis report and the recommendations he comes out with. But for every Mid Staffordshire-fortunately there are very, very few of them in the NHS-there are also dozens and dozens of hospitals around the country where a dedicated staff, day in and day out, are providing absolutely A1 healthcare for patients. What I am saying is that it is the responsibility of the hospital to be there to drive up standards within that hospital environment. I do not see how, per se, simply throwing regulations at an issue is going to make any difference. Rather than rush in with the full panoply of regulation and all that that entails, we should see what the impact is going to be with a register.

Chair: Could we have one more on this, Rosie, and then move on?

Rosie Cooper: Finally, I was going to ask about what you were doing about bands 1 to 4.

Q506 Mr Sharma: Could I add briefly, Minister, that I have some knowledge of working in the field in the past so I understand what the needs are, although the statutory regulation may not be very important, if you look at the previous experience and the hue and cry from the people working in the field, they demanded it, which means the previous practices did not work effectively. That is why there is a demand-this body of opinion in favour of it-to set up this statutory regulation for the healthcare assistants. Can you not see that we can move forward on this basis rather than waiting for the voluntary register and then come back after five years and say "This did not work"?

Mr Burns: No, because, as I said earlier, the response has to be proportionate, targeted and consistent with securing the safety and confidence of patients and service users. I would like to go down the road that is proposed at present rather than immediately imposing a whole new regulatory system that may not achieve the aims and the aspirations of those who support it, but by that point, it would be too late because there would be a full regulatory regime there. I would be hesitant at this point and would want to see more about the evidence of other alternatives to going down that route.

Q507 Mr Sharma: Very briefly, if I take it that this is a pilot, how long will you give to it?

Mr Burns: I think it is a year.

Chair: One more, Rosie, because this is on education and training and not regulation of health assistants. Then we will move on to Valerie.

Q508 Rosie Cooper: What is your current view of the professional development, appraisal and training of staff in bands 1 to 4 and what is being done to improve it? Overall, my involvement in the health service has meant that I am very into the boom and bust-too many of them, not enough of them, too many.

Mr Burns: The what? Did you say boom and bust?

Rosie Cooper: Would I say such a thing?

Mr Burns: I thought I heard it.

Q509 Rosie Cooper: We have too many gynaecologists, then not enough, and all that kind of thing. There are two questions there. What are we doing about bands 1 to 4 and the overarching view of how you stop-

Mr Burns: -boom and bust. On the last point-and I will ask Jamie to come in on your first point-the measures that are being taken, first of all, the creation of the Centre for Workforce Intelligence and the work that it does is crucial. The work of HEE-when it is established-through its committees will also help to minimise that. You are never going to eliminate the problem 100% because of the everchanging needs of the NHS, some of them very rapid, given the time scales for training some of the staff. But with careful, strategic and intelligent overviewing planning you can help to minimise the problem. Through HEE and the LETBs you can also have a positive impact on seeking to minimise the problem, though you will not be able to eliminate it altogether, for the reasons I have given.

Jamie Rentoul: On bands 1 to 4 we have been clear, again in the remit to Health Education England, reflecting what people told us in consultation, that it should have a whole workforce perspective and not only be about the registered professions. Clearly, quite a lot of the central funding support is about registered professions but, again in response to the consultation, we have said that there will be the ability for the Local Education and Training Boards to use some of that money to support innovation and pump priming of development for bands 1 to 4 and care practitioners and that sort of thing. It is not going to be something where you say "There is a big new pot of central money that is going to support it", because it is primarily an employer responsibility, but there is that leadership role for HEE and the Local Education and Training Boards and some flexibility in terms of the resources available to them to support innovation.

Q510 Rosie Cooper: So we will not expect to see too much too soon.

Jamie Rentoul: Again, it is about driving the leadership of it-transparency focus-within the new system. The evidence from staff experience is that if you have wellmotivated and welltrained staff, you deliver better patient care. That is what we expect HEE and the LETBs to be pushing forward.

Rosie Cooper: We will no doubt come back to this.

Q511 Valerie Vaz: Minister, could I ask what reassurances you can give to people, particularly in the transition period, about the education and training budget, whether it would be protected-ringfenced-and if perhaps certain specialties could be ringfenced as well?

Mr Burns: As you are aware, the current budget for this year is £4.9 billion. It is not ringfenced. We are working at the moment on the new budget for the next financial year under the changes and, at this stage, I cannot tell you what the figure will be because it is too early visàvis the consultations we are given. What I can tell you in one way-hopefully this is a reassurance-is that we want a far more transparent system so that people can see what the money is delivering. Also, there has been a problem with the existing formula for setting the finances because it is historic, outdated and inflexible. It cannot move properly to meet adapting changes. One is hoping to build into the new system and the new way of calculating and handing over the money a system that has more flexibility to take those factors into account, and certainly more transparency. It will not be ringfenced, but what will be crucial is that, of course, the education outcomes framework will be published. That will basically be a statement, among other things, of how we expect the money to deliver the training and the education, which one can look at. That will be the pressure point for delivery of what is expected for the money.

Q512 Valerie Vaz: As a followup, how do you protect the education and training budget from being raided by the SHAs currently while we are going through this transition? That is usually the first one to go, is it not?

Mr Burns: Yes, but it has not been, thank God. To me it is always a false economy that you raid education and training, not only in the NHS but across the world. When it comes to a time of economic hardship, or whatever, to cut back on the investment for the future is a false economy.

Q513 Valerie Vaz: Perhaps Dr Hamilton could help us as to how you protect it in the transition.

Dr Hamilton: In the future, Health Education England will be holding the LETBs to account for the use of the money to make sure that it is being used for the purpose for which it is intended. In terms of transition, Jamie might be better than me to answer.

Jamie Rentoul: At the moment, we have a service level agreement with each of the SHAs for their MPET money with some key performance indicators and what they have to deliver for it. We monitor and track progress. For the 201213 financial year, we will continue to do that to protect the money. As the Minister said, the allocations for 201314 are currently being worked on and that reflects the evidence base about the pressures that we need to meet.

Q514 Chair: The SHAs have form, do they not, for raiding this budget?

Jamie Rentoul: People talk about that a lot. When you push for the evidence, it-

Q515 Chair: I thought there was some evidence from the predecessor Committee in-I think I am right in saying-2005, which was acknowledged by the Government at the time.

Jamie Rentoul: Yes, but I am saying in recent years there has been less of it.

Mr Burns: Life has moved on.

Q516 Valerie Vaz: Can I confirm what plans you have for getting rid of MPET, SIFT and MADEL and all those horrible acronyms that we cannot get used to?

Mr Burns: We struggle with them.

Jamie Rentoul: Yes, there are lots of acronyms. As to the multiprofessional education and training moneys, essentially there are three ways we are using it. One is on support to nurses, midwives and allied health professionals for their tuition costs at universities. That is a benchmark price and, again, is set as a tariff, essentially. Another is through the NHS bursary support, which is for living cost support for healthcare students. The other bit is the clinical placement support, particularly service increment for teaching and the medical and dental education levy. It is that third bit for which we are saying we are going to develop a tariff such that it is fair across the country and, in due course, funding fairly follows the trainee student in their clinical placement. The current system was built up over time and there are different amounts of money depending on where you are in the country, which is not equitable. We recognise that there is a complex transition in moving from where we are now to where we want to get to. It is going to take some time and we are working with the strategic health authorities over the next few months to develop transition plans for moving to a fair tariff for that bit of the multiprofessional education and training moneys.

Q517 Valerie Vaz: MPET, as we know it, will not exist any more.

Jamie Rentoul: Once you have an acronym, it is quite hard to get rid of, isn’t it? There will be tariff support to clinical placements. Whether Health Education England chooses to call it something different, because it is different, I do not know. That might be quite a good idea, but the service tends to keep acronyms.

Q518 Chair: Do the Government intend to accept the recommendation of the Future Forum that there should be a quality premium built into that tariff system?

Jamie Rentoul: Yes. We are supportive of that.

Q519 Chair: Have you worked out how it can be done?

Jamie Rentoul: It is work in progress.

Mr Burns: It is still being worked on.

Jamie Rentoul: Again, it links to the education outcomes framework the Minister talked about, of having a better set of metrics and indicators that support being able to benchmark performance. In this area we are behind, I think, service quality in terms of the indicators that support a view of quality of education outcomes. You do that-and there have been various bits of work in the last few years on commissioning for education quality and metrics-to try to be able to say, for some of those, "Actually, you will have something which is a little bit like commissioning for quality improvement"-if that is what CQUIN stands for-on the education side, but you have a premium for higher quality delivery.

Q520 Chair: Do you intend to involve the GMC and other professional regulators in that process? They have a statutory responsibility in this field that is always notable by its absence in these conversations.

Jamie Rentoul: We have talked a bit about the GMC today.

Q521 Chair: I think it has been mentioned once so far.

Jamie Rentoul: We are talking to all the professional regulators, and indeed to the higher education stakeholders as well, about information flows in the system. There is a big review going on in higher education about health information because there are quite a lot of information requirements on universities. It is about getting a good set of information. The regulators have quite a lot of it and some of that could be used-GMC trainee doctor survey outcomes, for example - as part of what you are looking to reward.

Q522 Chair: It is particularly relevant, is it not, if you are looking into assessment of quality? Presumably that is exactly what the GMC is interested in when it approves training schemes.

Jamie Rentoul: Yes, absolutely.

Q523 Dr Wollaston: I want to go back to a point we touched on earlier, the role of the independent sector. Where are you with the possibility of the independent sector contributing to the new levies, and what options are under consideration in that regard?

Mr Burns: There is not a lot I can tell you at the moment, for reasons that will become apparent. There is consideration of a possible levy, but no decisions have been taken. We are still looking at it prior to evaluating the pros and cons.

Q524 Dr Wollaston: Are you able to elaborate on the options you are considering?

Jamie Rentoul: There is not a great deal to add to what the Minister has said. We have a lot of work to do with stakeholders.

Mr Burns: In the broadest concept, what has been thought of is a levy of a type. There is a considerable amount of work that needs to be done before working out whether that is the best way forward and, if it is the best way forward, how it can be fine-tuned if need be. It is too soon to be able to give you anything meaningful that would move the thing forward.

Q525 Dr Wollaston: Are you at least able to say whether there will be some kind of levy on the private sector?

Mr Burns: No. Part of the consideration is whether a levy is the best way forward or not.

Q526 Dr Wollaston: You are considering the difference between, say, a levy and mandating that they have to take a formal role in training in the areas we touched on, particularly where there is no possibility of receiving-

Mr Burns: Yes. Regardless, there will be requirements through the contracts to take part in it. As to whether there will be an actual levy decided upon at the end of the day, it is too soon to reach a decision because of the ongoing work that is being carried out.

Q527 Dr Wollaston: It is very important because it matters to people outside this place. I understand the most recent figures are that 66% of NHS consultants undertake some work in the private sector, and I would be grateful for your thoughts about whether that is the most uptodate figure, but there is a sense, if they do, as to whether we are providing a subsidy to the private sector and there should be a formal recognition of the role that the NHS has had in training those consultants.

Dr Hamilton: During consultation there was a lot of support for that concept. However, it was also pointed out in the consultation that an unintended consequence might be that it would be detrimental to the voluntary or third sector, such as Macmillan nurses, who also provide services. If the levy were to apply to them, that would seem to be unfortunate. That is one of the reasons why it has gone back to be thought about in more detail.

Q528 Dr Wollaston: Is there not any mechanism for distinguishing between the voluntary and private sectors?

Dr Hamilton: That is one of the issues being looked at.

Mr Burns: That is one of the things we are looking at.

Q529 Dr Wollaston: Incidentally, are you able to say whether 66% is the most uptodate figure of NHS consultants undertaking some private work?

Dr Hamilton: I am not able to say. I do not know is the answer to that.

Mr Burns: We do not know.

Q530 Chair: In terms of when that decision will be made, can you give us any idea about time scale, and also who makes it? Is it a matter for HEE or for the Government?

Jamie Rentoul: We have said we would need to consult formally, if we were going to move to a levy, because of the effect on businesses and so on. We think it is for the Government to develop the policy.

Q531 Chair: It would be a decision that the Department would reserve to Ministers rather than delegate to HEE.

Jamie Rentoul: Yes.

Mr Burns: Yes.

Q532 Rosie Cooper: Minister, the Deputy Chief Nursing Officer for England recently acknowledged that despite Government rhetoric about the need to transfer care from acute settings to community settings, the number of district nurses has dropped below 10,000. He admitted that it was a weakness and could not explain why it had such a priority focus, other than that the Prime Minister had pledged to recruit 4,200 health visitors. I understand the Prime Minister’s wish to have more health visitors, but could you explain what the policy is behind the situation we find ourselves in, how we have arrived here and what you intend to do to resolve the issue around the reducing number of district nurses, which will be fundamental to the future as you see it?

Mr Burns: Did you say district nurses or health visitors?

Q533 Rosie Cooper: You have reduced the number of district nurses while the Prime Minister wishes to increase the number of health visitors.

Mr Burns: Yes. The ambition is for 4,200 more health visitors over the lifetime of this Parliament.

Q534 Rosie Cooper: While district nurses are being reduced as we go. Would you like to tell us, as you see it, the difference between a district nurse and a health visitor?

Mr Burns: I do not actually have the-

Q535 Rosie Cooper: Perhaps we will start at the bottom and work up.

Mr Burns: I do not have the figures in front of me on the number of district nurses.

Q536 Rosie Cooper: The Nursing Times.

Mr Burns: Ah, that important source of information.

Rosie Cooper: It does not really matter. The facts are-

Mr Burns: It would be quite nice to ascertain whether it is factually correct. I am not disputing the Nursing Times, but as I do not have the figures in front of me of the number of district nurses, and I would be very grateful if any of my colleagues do-

Q537 Chair: Would you like to write to the Committee with those?

Mr Burns: Thank you, Chair. That is very helpful. I can tell you what we are doing about health visitors, but on the specific point of the numbers of district nurses I will come clean.

Q538 Rosie Cooper: Yes, the Prime Minister has said he is having 4,200 more but the rest can go hang.

Mr Burns: I do not think the Prime Minister said that, certainly. It is not his style.

Rosie Cooper: No. It is mine, though.

Q539 Chair: There is a serious question that is raised in the Nursing Times-the suggestion that there has been a depletion in the number of community district nurses and that that is attributable, at least in part, to increasing the numbers of health visitors. It would be interesting to the Committee to know whether the Department accepts that is true and, if it is true, whether it is desirable and whether something needs to be done about it.

Mr Burns: I am grateful. I can give a guarantee to the Committee that we will write to you, Chairman, and to all your colleagues.

Chair: Thank you very much.

Q540 Rosie Cooper: Could I almost go back to basics? Last week’s Delivering Dignity report said "Student nurses, medical students and other trainee health professionals need to have dignity instilled into the way they think and act from their first day". Why is that not happening in every case, every day now and how will these reforms fix that problem? If you are out there talking to members of the public, or reading any newspaper, this is core to how you will be treated if you are in hospital. We have to get that right.

Mr Burns: I could not agree with you more. It is crucial. There has to be kindness, compassion, care and making the right amount of time available to deal with the individual to help them at what is an extremely vulnerable and difficult time in their life. Everyone in this room would share that and is saddened, and in some instances appalled, at the experiences of what has been going on in some of our hospitals-too many of our hospitals-in recent years. That is why there is a huge challenge for the Commission on improving dignity in care.

Q541 Rosie Cooper: Minister, the question is how will your reforms fix it?

Mr Burns: There is a twopronged approach. First of all, if I could carry on about the Commission doing that sort of work, that is one way of moving forward: getting back to basics with nursing and making sure nurses have the time to be able to interact with patients-that the glass of water or the food is near to them, that the patient is able to eat-and provide all that sort of care. That is why we are waiting to see how the Commission will translate into action what needs to be done from their point of view.

Secondly, many of the solutions lie within the NHS, the local NHS, itself. Sharing best practice, bringing people together and putting in place the right systems will help to minimise the problem that you highlight.

As to the point on the other side of your question-"How will the reforms make a difference?"-you may not agree, but my view is this. One of the core purposes of the reforms is to put the patient at the centre of care and because GPs-who have the best knowledge and understanding of their patients-will be commissioning the vast majority of the care, they will be concerned that their patients are getting the right quality of care from the providers they are commissioning. They will be active watchdogs on behalf of their patients to make sure that what they are commissioning is the appropriate care but also of the highest quality. Those things together, a more focused approach in making sure that it is the patients’ needs and the outcomes of treatments for patients that are at the core, will help.

Jamie Rentoul: Can I add something on the education and training changes giving employers clearer responsibility and ownership? A lot of this-certainly in terms of who you are recruiting, getting the right training placement support and getting the right firstyear experience-is about the partnership between the employer and the university. There are lots of really good examples where that works well now, but it is not working well everywhere, Through this, it is getting those relationships stronger and holding people to account.

Q542 Rosie Cooper: Thank you. I do agree with that but the question is how it translates to the front line. I absolutely agree with the Minister that the patient is at the core of everything we deliver. If we did not have the patient and their best interests at heart, what is the point of doing anything else?

You made comments about making time available for the patient-making sure all the communications are right and all those associated things-and I totally agree with that. But I wonder whether you see a basic contradiction between asking for a lot more value added, a lot more input from nurses and nursing, while, at the same time, as a consequence of the reforms-even before we have reached 2013 and really implementing them-we are already downbanding nurses and reducing the number of nurses. Do you not think that those kinds of things will make it even more difficult to achieve the quality you are talking about?

Mr Burns: No. If one takes the issue of downbanding, which I know is a subject that is very close to your heart, it is not a downbanding of the individual nurse. It is a downbanding of the position that an individual nurse may hold. There is an inevitability in an evolutionary health service that where you are seeing changes in the way in which care is provided, one of the offsets is that you will see changes in the nursing requirements, in particular, where you have to make changes. In one area you may change and down-band-to use your phrase-the position that the nurse holds because of the changes in the provision of care. But, of course, the nurse herself may wish to then move to another job within the nursing role of the provider that is in a position that is not being downbanded for the reasons I have given.

Rosie Cooper: Minister, perhaps it would be useful to look at the number of roles-and they are senior roles-that are downbanded and how they affect different hospitals. The reality of what is happening is that most hospitals are reducing some of the banding of senior nurses, and, where they may have two or three band 7s, or whatever, they are reducing them to one. That means the morale drops, their pay drops and the nurse is expected to do more for less. The nurse will care about the patient but the truth is that the morale and how the individual feels will be affected by this. Then we are saying to them, "We need to make sure that everything you do"-which, absolutely, it has to be-"is top quality, but we expect more of you." There is a contradiction there and I will not go any further with that. But we need to care about how these kinds of decisions impact on the very people we depend on.

Chair: That is a statement rather than a question.

Rosie Cooper: Yes.

Mr Burns: I took that as a statement.

Q543 David Tredinnick: We are nearing the end, but I have a few questions on interprofessional issues, higher education issues and, finally, the Department’s attitude to self-care. The Government wants a more multiprofessional approach to healthcare education and training. We accept that. Can you describe what this will look like in practice, please? What will a more multiprofessional approach to healthcare and education and training look like?

Jamie Rentoul: I will start on that. It is about taking a whole workforce view when you are thinking about workforce planning so it is not all done in little silos of different professional groups but you look across the whole and the right skill mix. Also, it is about-I think this might be borrowing one of Patricia’s phrases-building expert teams, not teams of experts, so that people in different professional roles understand what the other professions bring to it and they work well together, effectively. It is not about everyone being trained all the time together-because you need your deep professional training-but it is about making the linkages between the professional groups where it is sensible to do so. Do you want to add anything, Patricia?

Dr Hamilton: No. I hope we have already started that, but we have been very clear throughout the document that one of the aims of the new system is to get people out of silos and working much more interprofessionally.

Q544 David Tredinnick: Following on from that, within this new system postgraduate deaneries will become "truly multi professional". That is from one of your documents. How will that happen, please?

Dr Hamilton: The function of the postgraduate deanery has to be retained. As to the role of the postgraduate medical dean, we absolutely need to keep those. Up to now they have been working only in medicine. Bringing them into the LETB gives the opportunity to broaden and to share some functions. For example, there will be opportunities to share backoffice and other functions that they have in common and also, when planning the team, to share the competencies that can be shared. It does not necessarily mean that nurses and doctors will train together, but they will put into practice what they have learned in a much more constructive way than we have done previously. That will be overseen by the leaders of education and quality within the LETB.

Q545 David Tredinnick: Fair enough. Perhaps we will go on to the higher education issues. What effect will the new university fees cap have on the NHS training budget, given that the NHS pays tuition fees for nonmedical students and contributes towards those paid by medical and dental undergraduates?

Jamie Rentoul: I will start. For nonmedical students, as you say, the NHS pays the tuition fees. We have a benchmark price, which has been agreed in negotiation with the higher education sector, and that continues going forward. That is the intention. For the support we give in the latter years of medical and dental training, we have made some arrangements for the 201213 entry year that we have agreed with the Department for Business, Innovation and Skills and we are in discussion with them, having made it clear that was an arrangement for that year. As to what the future settlement will be, we have not yet made decisions.

Q546 David Tredinnick: What impact will this regime have on prospects for widening participation in the medical and dental professions?

Dr Hamilton: That is an issue that concerns us. One of the major educational outcomes areas that we are setting is to widen participation. We still have not managed to achieve wider access into medical school. While we hope that what we have put in place will help participation, there is a wider issue of selecting it right back into medical school, which almost means influencing at school, for expectations of people-that they could apply to medical school-to be raised. We know, obviously, that the coalition Government are very interested in this; I represented medicine at a seminar held by the Deputy Prime Minister. Quite a few professions are battling with the same issue. This is a bigger issue, a much wider issue, than just fees, but clearly that is an important part of it and we still need to do further work on it.

Q547 David Tredinnick: I will finish off by looking at self-care. Part of it is to go back to the earlier theme that I had on complementary and alternative medicine and refer to the point you made about the university of Westminster. Given that universities such as Westminster have already reduced the number of complementary and alternative medicine courses they offer, which they have had to do-this is principally due to the difficulty students are facing with funding, not because of lack of demand-do you think that the university fees regime, which requires up to £9,000 a year in fees, will affect this sector? What impact has it had, and so on?

Mr Burns: The straight answer is that this is a matter more for BIS than the Department of Health. But if one is looking at it logically, off the top of one’s head, then courses, regardless of the cost, will attract students who are particularly interested in benefiting from increasing their education and getting a qualification in whatever the subject is. They will take into account, however much the level of the tuition fee, whether it is going to be value for money for them and their future career prospects in whatever career they decide to take.

Q548 David Tredinnick: A lot of these people, if they graduate in the CAM field, will be looking to teach people how to look after themselves. Can you tell me what the Department’s attitude is to self-care generally?

Mr Burns: There are still areas where there is not enough proven evidence of the outcomes in this field, but I would hate to tread on anyone’s toes in an area which is beyond the NHS, strictly speaking.

Chair: It is a broader interpretation of education and training to take on education and training for self-care.

Q549 David Tredinnick: It is, but this is-

Mr Burns: There are two types of self-care, and I know where you are going.

David Tredinnick: I have not got there yet.

Mr Burns: No, but I know where you are going, because there is another area of self-care which, of course, is to do with people looking after themselves when they have a cold or whatever. We are all in favour of people selfprescribing over the counter medicines to seek to minimise the health impacts of those sorts of medical complaints.

Q550 David Tredinnick: Thank you. You have walked straight into the space I set you.

Mr Burns: Yes, because I know where you are coming from. But the trouble with the area of self-care that you are raising is that there is not enough evidence, to my mind, with suitable outcomes. That is why that whole area has been at arm’s length from the NHS, by and large.

Q551 David Tredinnick: That is a very important area, that there is not enough research. With the emphasis on doubleblind, placebocontrolled trials, rather than observation, which used to be the case, we need more evidence. On the self-care issue, Professor Peters, who came before us, said "self-care could unburden the NHS of a vast amount of minor illnesses". You raised the matter of colds. I had a chest infection two weeks ago. I have a small box of homoeopathic remedies-I have used the system for 20 years-and I successfully treated this complaint using a couple of remedies. I stayed off antibiotics, avoided going to the doctor and saved the NHS money. It is this kind of self-care, of people taking responsibility for themselves, that is fundamentally important if we are going to reduce the costs on the health service at a time when there are increasing demands. I would like to suggest to you, Minister of State, that this is an area that you should address. What we need, even if the NHS is not providing the service, is a proper availability of practitioners in these fields so that people who opt to go to them should be able to get those treatments and reduce the burden on hardpressed doctors.

Mr Burns: You raise a very interesting point. I am neither medically nor ministerially qualified to the depth that you are, but I do have, if it helps the Committee to make progress, what I hope will be a positive suggestion. As my colleague Anne Milton has responsibilities and greater knowledge in this area, it might be sensible if you engaged with her on the whole area that you are raising at this Committee hearing this morning.

Q552 David Tredinnick: That is a very helpful suggestion, but perhaps you would use your officials to send her a briefing on what we have said so that she could write to me and respond on that issue when she is at liberty to do so.

Mr Burns: I will certainly arrange for that to happen, though it may be a few weeks before she replies, due to her own personal circumstances.

David Tredinnick: We understand exactly what is going on. Thank you so much.

Q553 Dr Wollaston: Can I return to the fees cap and raise the issue that there is a discrepancy of funding between the newer medical schools and some of the older medical schools whose funding has been based on historic levels? Do you see that the introduction of a fees cap may even out some of the funding discrepancies?

Jamie Rentoul: Can I clarify that you are talking about funding from the Higher Education Funding Council for undergraduates?

Q554 Dr Wollaston: Yes, medical school for undergraduates, or do you think there is already good parity between the funding level for undergraduates between the various institutions? Do you think having tuition fees is likely to even that out or not have any effect because so much extra funding comes from the Department?

Jamie Rentoul: The Higher Education Funding Council are also consulting on their funding at the moment. I do not want to add to the list of things to come back to you on, but I do not want to talk on their behalf because they are the funders for undergraduate medical schools.

Q555 Chair: It is outside the remit, I think. Are there any other questions? Thank you very much, Minister, and your two supporters.

Mr Burns: Thank you.

Chair: Thank you for coming. We will reflect on what you have said and other evidence that we have gathered. Thank you.

Prepared 22nd May 2012