Examination of Witnesses (Questions 211
- 219)
WEDNESDAY 3 MARCH 2004
DR GILL
MORGAN, MR
ALASTAIR HENDERSON,
PROFESSOR HUGO
MASCIE-TAYLOR
AND MS
RACHEL ALLSOP
Q211 Chairman: Thank you very much for coming
along. We are trying to do a lot of work in a relatively short
time because the Commission has set a deadline for consultation
and we want to get our views in before the end of the consultation.
I will just remind you that the session is open to the public
and may be recorded for broadcasting, and you will get a verbatim
transcript at the end which, of course, you can correct but please
send it back fairly rapidly in view of our timing. Would you like
to introduce yourselves?
Dr Morgan: If I could start, my Lord Chairman,
I am Chief Executive of the NHS Confederation. The NHS Confederation
is a membership organisation which any NHS organisation can join,
and we currently have over 93 per cent of NHS organisations in
membership; that means virtually every large and small acute trust,
as well as over 90 per cent of primary care trusts. We also cover
all four countries—we are a United Kingdom-wide organisation.
We represent the management—professional managers, doctors,
nurses, everybody involved in managing organisations—rather
than any individual section of the management.
Mr Henderson: I work at the Confederation and
I am currently the Acting Director for setting up our employers'
organization, which is going to be taking on the responsibilities
for employment issues from the Department of Health.
Professor Mascie-Taylor: I am Medical Director
in the Leeds Teaching Hospital Trust having passed up in clinician,
physician and geriatrician. I am Director of Commissioning in
Leeds and Acting Chief Executive. The Leeds Trust is a large teaching
hospital trust—in fact, the largest trust in the United
Kingdom—employing almost 600 consultants and over 800 junior
doctors.
Ms Allsop: I am Director of Personnel at Leeds
Teaching Hospital Trust, the same organisation.
Q212 Chairman: Thank you. Would you like
to make an opening statement?
Dr Morgan: In terms of an opening statement,
the NHS Confederation is very clear that there is quite a lot
of work to be done around European Working Time Directive. If
we go through the questions you have set us I think we will cover
all the issues we would want to raise so, rather than take time
making an introductory statement, we will go into the questioning.
Q213 Chairman: Thank you, and thank you
for your written submission; it was very helpful. You have said
that in a way there are two matters: there is the SiMAP
judgment and the Jaeger judgment on the one hand and there
is the bringing into effect of the Working Hours Directive in
relation to doctors in training. I think you took the view that
the NHS could have met the original requirements by August 2004.
Some others have said to us that they did not think that was entirely
realistic and that it is perhaps more a matter of timing because
the changes would also be quite considerable in the organisation
of medical services, and the BMA has quoted to us figures about
the number of junior hospital doctors who would be needed in due
course to meet the new situation. Would you like to comment a
little bit further on that?
Dr Morgan: Yes. You have to put the European
Working Time Directive before SiMAP and Jaeger.
If we put those two separately and just take the simple Working
Directive, with the opt-out which the Government has put in for
junior doctors, the NHS for some time has been working to a deal
done between the medical profession and the Government called
the "New Deal", which basically required NHS organisations
to move junior doctors to 56 hours in the working week. The Working
Time Directive would allow 58 hours in the working week so, if
you look at the implementation of the New Deal, it ought to give
a very clear answer about how near to hitting the overall deadline
we would be, and the latest figures we have are that 95 per cent
of NHS organisations are New Deal compliant and therefore it can
be assumed, if they hit the New Deal, they would have achieved
the old-style Working Time Directive.
Q214 Lord Colwyn: Can you just remind me
about the New Deal? I thought the actual deal was a 48 hour week
by August 2009, is that incorrect?
Ms Allsop: By 2009, yes.
Q215 Lord Colwyn: So the New Deal just goes
up to the 56 hour week?
Dr Morgan: No. Going back a stage, there has
been long term concern in the United Kingdom about junior doctors'
working hours, and even before the European Working Time Directive
came into being, we had been working within the NHS to what we
call the "New Deal", which was a negotiated contract
between the junior doctors and the BMA and the Government, and
it is a New Deal which is nothing to do with Europe which is 56
hours. If you look at the European requirements it is 58 hours
from August and 48 hours from 2009, so the New Deal is just the
name of a contract within the NHS.
Q216 Lord Colwyn: We have taken evidence
from the BMA and have heard a lot of evidence about the number
of doctor hours that are lost and have been given figures, and
they, of course, are blaming the Department of Health and feel
that not enough has been done. This has been in the air for a
long time; can you tell us what consultations have taken place
between yourselves and the Department and the BMA about these
changes, because it did seem to us that it was total unpreparedness?
Mr Henderson: Probably it is fair to say that
everybody would perhaps wish that we were further forward than
we might be at this moment—trusts, the Department of Health,
and the BMA—but just simply blaming the Department of Health
I do not think is actually terribly helpful or necessarily terribly
fair really. I think there has been quite a lot going on and certainly
in terms specifically of consultation there has been quite a lot
of that. There is a national expert group that does bring together
all the medical Royal Colleges and the BMA, the Department and
the Service, and there is an implementation board that meets six
weekly and has done for about 18 months. Frankly I am not sure
it is more consultation and discussion that we want, it is about
implementation in local organisations and we may need more time
for that. I do not think it is discussion at a national level.
Dr Morgan: It is important to recognise that
there are two ways to deal with this: one is by having more doctors,
and that is a very long lead time and, over the last five years,
the number of medical school places has been substantially increased.
That does not help us for the August deadline but certainly by
the 2009 deadline it will have made a significant impact. We have
brand new medical schools and have also increased the numbers
of doctors training in existing medical schools, so that is one
half. The second half of what the Service needs to do is very
much more about reorganising work because the NHS recognises,
and has done for some significant time, that if you looked at
the distribution of work between different professionals, it has
happened because it has happened historically, not because that
is the way you would design the system now if you started from
scratch. So the Department has been working quite hard with organisations
in the NHS to experiment with ways of changing matters, partly
looking at whether you can run hospitals more safely at night
by doing things differently and partly at doing pilots about how
we transfer responsibility from one professional group to another.
The problem with that is it needs a great deal of confidence in
a professional for another individual to take over those responsibilities
and that is quite a significant cultural change for people, so
the task is how rapidly you can produce cultural change because
doctors and any other professionals cannot work within a situation
they regard as unsafe, and they therefore need to be convinced
that the new systems will work and be safe before they will produce
the change. Now, those pilots are quite active.
Professor Mascie-Taylor: It is important in
addressing the question to look at this in a sequential way: what
have we done about 58 hours, what we will need to do about 48
hours, what are the potential effects of SiMAP and what
are the potential effects of Jaeger. To address your question,
there has been a great deal of discussion and consultation about
58 hours and a great deal of work has been done, and the compliance
which various trusts are meeting is quite well known and we can
certainly tell you of our experience in Leeds, so I think if your
question about consultation and discussion and future planning
is about 58 hours then it seems to me that that which has needed
to be done has largely been done. If your question addresses 48
hours, SiMAP and Jaeger, then those are quite different
issues and we would need to deal with them separately both in
terms of implications and in terms of planning which is required
to deal with them. If it would be helpful we can certainly give
an account of our thinking around 58 hours and the implications,
we think, of 48 hours. We can add to that SiMAP and
Jaeger, but they do produce quite different effects and different
issues.
Q217 Lord Colwyn: In your written submission
you talk about these remarkable findings in the Department of
Health's Hospitals at Night project. I assume from that this is
something that has been in on-going discussion for some time?
Dr Morgan: Yes, indeed.
Q218 Lord Colwyn: Could you elaborate on
that a little bit, and tell us how you think it will improve junior
hospital doctors' conditions, without of course bringing any harm
to the patients which is most important?
Mr Henderson: Shall I say a little bit about
the national Hospital at Night project? What this has been doing
is looking at basically what really goes on in—unsurprisingly—a
hospital at night and, in effect, what it is trying to do is ensure
that care out of hours is really going to be delivered by a single,
multi-disciplinary team working out of hours rather than the various
layers of hospital doctors that there have been. What the studies
have found is that—and none of this may be a great surprise—only
a very small proportion of the out-of-hours work is related to
patients in a life-threatening situation. A significant proportion
of that night-time work is non-urgent and could be brought forward
into the day, and a reduction of clerking and better administration
could probably reduce the medical staff workload by up to a half,
which is fairly substantial. So from the pilot it was found that
there were benefits to patients from more timely care to higher
quality care, better co-ordinated care, not being seen by tired
doctors, and equivalents in benefits for the staff themselves.
So there are some exciting potentials there although there are
some caveats. There is the slight danger of thinking that Hospital
at Night will solve all the world's ills: it will do quite a lot
but there are problems that it will not work in every specialty,
but it can be developed. The logic that is there can be developed
throughout the service.
Professor Mascie-Taylor: If you forgive me,
let me go back a stage to what are a whole list of potential solutions
to having fewer junior doctors' hours available, because there
is a long list, of which Hospital at Night is but one—it
is an important one potentially but not the only one, and the
solutions include clearly just simply having more doctors and
perhaps more consultants—and those are in the pipeline:
changing cross cover arrangements between doctors, both horizontally
at the same grade and vertically within a specialty: re-organising
the service, both within departments, within hospitals, within
trusts, and importantly within localities, so there is a huge
agenda here about service reconfiguration: and then finding other
people to do work which is currently done by doctors. So there
is a list of potential solutions. As far as service re-organisation
goes that would involve potentially changing the scheduling of
work, reconfiguring what doctors do, and I think Hospital at Night
fits neatly into that in my classification for what one might
do, so to come to Hospital at Night, which is potentially but
a small part of the total solution, what has been demonstrated
I think very effectively is that a great deal of the work that
is done at night is of a generic nature—that is to say it
does not require highly specialised or trained doctors. It is
also clear that in many institutions, although not all by any
means, the amount of work done, say, after one in the morning
and before breakfast is quite small. That leads you to the conclusion
that you could cover those hours quite effectively with a smaller
number of doctors. It throws up, though, the question of how you
would cover more specialist units and the need for, if you like,
more senior opinion. So Hospital at Night, I hope I have explained,
is part of a solution across a whole range of solutions. I do
not think it has yet been anything like fully explored, and there
will be difficulties, both real and imagined.
Q219 Earl of Dundee: Following on from what
you are saying, if you begin with Hospital at Night and think
of all the other good and constructive pilots which are being
deployed at the moment, in spite of strong evidence from all of
them and the suggestion that it would be a good idea to extend
them right through the Health Service, what are your own thoughts
on two matters: firstly, what the level of resistance might be
within the Health Service, obstinate resistance preventing anything
which is perhaps called from happening, and even if that is not
the case but particularly if it might, to some extent, be the
case, it might take ages and ages really for that which is very
good within a pilot to be properly extended as necessary throughout.
Professor Mascie-Taylor: There is no doubt that
there will be, as in any other organisation, resistance to change—it
goes with organisations—and there has been resistance to
change towards both the New Deal and the 58 hour target, and as
has been explained they are broadly similar. Of course again,
typical of most organisations and people, the activity which has
led to the 58 hour problem very largely being dealt with has occurred
towards the deadline. People become more prepared to change when
they recognise that this is real, that it will happen, and that
we have to find a way of dealing with it. Both Rachel and I have
sat in meetings where we have had to be very clear with colleagues
that these changes are inevitable, and we would be best turning
our attention to how we might deal with them as opposed to working
out ways of avoiding them. So you are right, there will be resistance,
and it is certainly our experience that we have successfully very
largely worked towards the 58 hour target but, as I said earlier,
there will be different discussions to be had about the 48 hour
target, SiMAP and Jaeger. They are different problems.
In terms of how you might roll out pilots, it is a combination
of people seeing that pilots that are being done are relevant
to them and their working lives and have not been selected in
areas where you predicted that people seem to achieve success;
it is partly making people see that a certain solution is required,
that is to say that changes cannot be resisted; and it is perhaps
the facilitation of those changes by skilled management and skilled
leadership amongst doctors.
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