Examination of Witnesses (Questions 260
- 264)
MONDAY 8 MARCH 2004
MR GERRY
SUTCLIFFE AND
MR JOHN
HUTTON
Q260 Lord Colwyn: Let us go back to junior
doctors. When I was a medical student in the early 1960s, we rather
looked forward to the two years when we were going to spend hours
and hours working and that is when I always imagined you picked
up the greater part of your training. In fact, we are hearing
already about worries regarding training. I do not have the figures
in front of me, but junior surgeons could possibly be getting
only one sixth of the sort of training they used to get. Whether
that is right or not, I am not sure. The BMA are worried and they
say that, when the 58-hour working week comes in, they are going
to lose the equivalent of 3,700 junior hospital doctors and then,
in 2009 when it is a 48-hour week, they are going to lose something
between 4,300 and 9,000, which is a wide spectrum there, of doctors.
Do you see this as a crisis or do you think it is something that
is going to be controllable eventually? If I may just go on about
the BMA, we understood from them that they feel that perhaps too
little has been done about preparing the Health Service for these
changes. We have known about it rather longer yet we have been
doing anything about it and I wonder whether you agree with that.
Have you had conversations with the various departments, the BMA,
the Department of Health, NHS trusts etc?
Mr Hutton: Yes, we have had quite a few conversations
with the BMA about this. In relation to that latter point, I know
it is a very easy accusation to chuck around that we have not
properly prepared for this and I really do not believe that to
be true. I say that for a number of reasons but, first and foremost,
if you actually look at the headline, if you look at how hours
for junior doctors have been reduced in the last ten years or
so, I think there is every reason to be confident that we could
have met the 58-hour week maximum working week for juniors in
training by this August. Ninety-five per cent of junior doctors
in the NHS currently work 56 hours a week or less. That is because
of the New Deal, the agreement that was reached in 1991 with the
BMA for junior doctors. So, we were making very good progress
and I do not think that is where the main challenge for us actually
lay. We have been diverted from all this through SiMAP and
Jaeger. It is when the European Court came to its particular
interpretation of the definition of working time and its comments
in Jaeger about when compensatory rest had to be taken that we
found ourselves in the predicament we are in and, with the greatest
of respect to the BMA, I am not sure that they predicted that
we would be in this position themselves. So, we have had to change
course; we have had to change tack and try and accommodate the
impact of those two judgments in how we have set about the job
of tasking the NHS with the job of implementing the Directive
and that has been immensely difficult. In relation to the total
number of junior doctors and doctors' hours, I am not really sure
that I fully understood the BMA's point in relation to the argument
that it was making. Remember, we already are making progress towards
the new deal and reducing junior doctors' hours and what we are
doing is actually increasing the number of junior doctors in the
Service very substantially as well as increasing the number of
consultants working in the NHS. The Government's ambition ultimately
is to have a largely consultant-led service. We are not there
yet, not by any means. We have 100,000 doctors in the NHS in total,
about 30,000 are consultants, 30,000 are GPs and the rest are
junior doctors, so clearly doctors in training at various points.
Clearly, we have a fair old way to go. I would simply say that
we can reduce junior doctors' hours and we are doing that without
impacting on the quality of healthcare and, crucially in relation
to training which I think is a really, really important issue,
I think the guarantee of all of this is that these changes have
to be overseen fundamentally by the Royal Colleges, by the Academy
of Medical Royal Colleges and now the Postgraduate Medical Education
and Training College. These are all bodies with substantial independence
from Government who will be ultimately looking and quality assuring
the training regime that is in place for our junior doctors. One
of the things that we have to avoid doing—there are two
key things here if I can just very quickly refer to this—is
substitute tired juniors for tired consultants. I really do not
think that is a very sensible way forward. That brings me back
to the work we are doing to look at the whole scheme of things
and the whole way in which we staff hospitals at night. The other
thing that we have to be sure about is that we do not compromise
on safety and training. It is absolutely not part of the Government's
approach to dealing with the problems of forcing and implementing
a directive to imagine that what we have to chuck out of the window
straightaway is any concept of, this is training time, these are
doctors in training. Having said that, like you, I have met many
junior doctors who say that the actual quality and training available
to them by doing a resident on-call rota is not necessarily terribly
high given the impact of working late at night in a hospital.
At 2.00 in the morning in a hospital, you are not likely to obtain
any quality training experiences, yet we have a particular way
of staffing our medical teams at night that has built up this
culture of assuming that this is the only way in which you can
do it. I do not think we should be afraid to challenge some of
those practices if, in the process, we can provide better training
and not poorer training for junior doctors.
Q261 Baroness Greengross: Can I just comment
on what you have just been saying because I agree with you that
we have to question all our practices but one of the important
things about being near or near enough to a DGH is that you can
get all the specialists there and, in a trauma unit, for, let
us say, a stroke, we know that we are not as good as we might
be because we do not always get stroke patients immediately. So,
I am a little worried about the idea of not having people there.
I represented the Committee with some MEPs and people from the
Commons last week at a meeting and we were discussing why we cannot
do what has been done with the other person in the lorry in transport
policy, the one who is not driving, who is available for work
but is not actually driving which does not count as work. Has
anybody thought of doing that? When you are on call and you are
asleep, you are available for work but you are not actually working?
We need some commonsense solutions to these problems and I just
wondered if you had thought about that as being one of them.
Mr Hutton: We certainly have and that would
be a very common way of staffing out-of-hours medical and surgical
teams in most of our hospitals in England at the moment. There
would be the junior doctors who would be resident on call and
they will spend some of their shift asleep because there is no
need for their services, but there would be the back-up of more
senior consultants who would be actually at home. Under the SiMAP
ruling, that will not count as working time. It is when they are
actually asleep close to or probably on the site of where they
are working that the difficulty has arisen. So, that would be
part and parcel of an effective solution to some of the problems
we are facing as well as the very important work that the Academy
of the Medical Royal Colleges has led for us on developing what
are called cross-cover arrangements where more generally qualified
or doctors can provide cross-cover for a range of specialties
in hospitals. I agree that this is new territory for us in the
UK and we do have to tread very carefully on all of this, but
I am glad to say that the Academy of Medical Royal Colleges has
approved in general a way of staffing that sort of out-of-hours
medical team at night which allows us to have fewer resident on-call
rotas and not drop the quality of care that we provide which of
course is important. In relation to your last point about DGHs
and stroke care, clearly we have a lot of ground to make up on
stroke care and you will obviously be aware because of your commitments
in the House of the Government's determination to ensure that
there is a dedicated stroke care unit in every district general
hospital as part of the national service framework and we are
making good progress on that, but I think also we should not lose
sight of the fact that, in relation to the National Health Service
now, ie pre-August and pre the impact of the Directive, there
are some hospitals that simply do not provide a full range of
trauma and speciality out of hours 24 hours a day because it is
simply not possible to do that and patients will be referred to
specialist tertiary referral centres now as part of providing
high-quality care because the profession locally and the Commission
have agreed that is the safest way to deal with medical emergencies
that occur late at night. It is something of a myth that every
hospital will have every type of specialist cover 24 hours a day
now. That is not the case.
Q262 Baroness Greengross: I know that there
are hopes for negotiated settlements and adaptation and you have
just spoken about changing the Directive in some way, but there
is that highly sensitive issue about importing doctors from overseas.
Do you think that if this is not negotiated to accept some of
the UK's points, we would just have to import more and more people?
Mr Hutton: We are not going to do that. We are
not going to do that really because I do not think the doctors
are there, firstly. If we simply approach the problem of trying
to make sense of SiMAP and Jaeger by recruiting
more doctors, as we made clear to the European Commission in the
autumn, we would need several thousand, anywhere between 6,000
and 12,000 doctors. I do not believe that is a sustainable strategy
for us to pursue in the timescale that is available and I think
that we would struggle to recruit that size of workforce, even
if that is the right thing to do. I do not actually believe that
it is the right thing to do because all that would simply do is
just carry on exactly the same level of staffing hospitals at
night that we currently have and I really do believe very strongly
that there are issues there that we should be pursing in terms
of efficiency and proper use of medical and surgical expertise
at night that we should not lose sight of. I think those are things
that we should be doing. Whatever the outcome of the discussions
at European Union level are, that is not a solution that is going
to fly because I do not think the doctors are there and one thing
that we are not going to do is solve the problems of the NHS in
this particular regard by plundering the healthcare systems of
other countries. That would be quite inequitable and something
we are certainly not going to do.
Q263 Baroness Howarth of Breckland: In the
way that the conversation has gone, I would just like to phrase
my last two questions differently to the way we have them on the
paper following through some of the conversation rather than just
putting the questions. It has been suggested in much of the evidence
that we have had that the Working Time Directive has sort of put
a bomb under some people in the Health Service—and I simply
reflect the way in which the evidence has come out—in that
it has made people change the way that they are working. How much
do you think it is due to the Working Time Directive and how much
do you think the opt-out, which is where we are trying to focus
in terms of some of our thinking here, might in fact impede that
development? If I can just throw that in and just say that the
Manchester research, which no doubt you have seen, identified
a number of ways in which NHS trusts—Mr Hutton, I think
you were referring to the pilots and the way there have been attempts
to tie in different ways, particularly teams—have been
somewhat impeded because some stakeholders are not really keen
to change the culture of change particularly. The report says
that there are some consultants who do not want to face cultural
change. How long do you think it is going to take for this to
happen and do you really think that the opt-out has been a pressure
to move some people forward in some of those plans?
Mr Hutton: In relation to the first part of
your question, there is no doubt at all in my mind that the impact
of SiMAP and Jaeger has been a big wake-up call
in relation to this issue about how we staff hospitals and how
we train healthcare workers. There is no doubt at all. I think
those changes would actually be for the benefit of the National
Health Service because I think that we can do so much more with
more staff than we currently have. For many people in the NHS,
you get qualified and, almost immediately, hit a glass ceiling—you
cannot go anywhere else and you cannot do anything else and your
pay is stuck. That is hopeless for encouraging and motivating
a workforce. There are some very positive things that will come
out of this that we should seize as opportunities and run with.
You are quite right, Manchester University will be doing a review
of the pilots—and we look forward to that—on how we
can implement the Working Time Directive. There are some very
exciting things that are coming through that. One of the specialties
where we will have a difficulty with the Working Time Directive
will be anaesthetics and that is generally recognised here and
in other parts of the European Union too. I know, for example,
the work of my own NHS trust, the Morecambe Bay NHS Trust which
is one of the largest acute trusts in the country with three large
DGHs, one in my own constituency, which is recruiting and training
up nurse anaesthetists to assist the work of anaesthetic anaesthetists
in the operating theatre. I think this is a very, very encouraging
development. It has been in the United States for several years
and we have been a little slow here in the UK to pick up and run
with those sorts of opportunities. Of course, coming back to the
second part of your question, undoubtedly these issues present
cultural challenges for many people in the NHS and not just surgeons
but managers and maybe patients too. So, I think there is a lot
of work to be done and not much time to do it in in terms of engaging
with the clinicians, the public, the NHS and so on about the need
for this type of change. I think that we are making progress.
The Working Time Directive pilot sites are demonstrating ways
of working and, in my experience of the NHS, it is a science-based
service. Fundamentally, it goes on what works, it goes on the
evidence of what works. If we can show that this is a sensible
way of working, then the NHS will pursue it vigorously because
it not just about dealing with this particular opportunity, this
is part of a much wider effort to re-engineer the way in which
we do our business and it can provide perfectly safe and reliable
care more efficiently and effectively and those are very big gains
for the NHS. Chairman, finally on this point because this is really
right at the hub of all of these questions, what I am trying to
say is that we have a particular pressure with SiMAP and
Jaeger and we are working very hard to solve it, but I
do not think we will be able to take action that is a quick fix.
We have the problem of 1 August and how we deal with that but
what we are actually talking about is the long-term future of
our hospitals and how we want to staff them and the people who
work in them and how we want to provide for as much local access
to services as we possibly can and that is why, Lady Greengross,
your question about recruiting more doctors—and I know it
was rhetorical—to occupy existing roles in medical on call
and resident rotas is not the right solution. It might help us
in getting to that quick fix but it is not the right thing to
do for the NHS and I think we must not lose sight of the needs
of the NHS in the future. This is not just a here and now problem.
What we do around the Directive will affect the quality of provision
for years and years to come, so this is a very, very important
long-term agenda for the NHS to get right.
Q264 Baroness Howarth of Breckland: You
mentioned care workers and we have not discussed care workers
very much in this Committee, although I come from a social care
background and have some understanding of that. Whereas a hospital
is a large institution with a large number of professionals working
together which sometimes makes amalgamation easier in terms of
the Working Time Directive, do you see particular issues where
people are working in small units with the same sorts of professionals
with trying to meet these issues?
Mr Sutcliffe: In the private care sector but
also in the local authority care sector in terms of pressure on
local authority budgets and issues around that. As I said earlier,
there are other emergency services, the police for instance, and
then there are problems relating to the horizontal amendment directive,
people like off-shore home workers and things like that which
could be affected by the definition of all aspects of the judgment.
Mr Hutton: In relation to social care, I am
not sure that I can provide any hard and fast quantification of
the scale of the problem. I think you are right and our intelligence
indicates that the two rulings of the European Court are likely
to have the biggest impact on small care homes and they are overwhelmingly,
I would say almost entirely, run by small private firms or in
the independent and voluntary sectors. The larger care homes will
tend to have staff awake on duty at night rather than resident
on call and are all in the statutory sector. So, I think it is
a problem for the small care homes and it is a problem therefore
for the independent and voluntary sector and I think there are
some very serious issues there and I think again that it does
confirm very strongly the need for flexibility around the issue
of opt-out.
Chairman: Can I thank you very much indeed
for your evidence. We said that we would try to get through the
session in an hour and we are only two minutes over the hour,
which I take responsibility for as Chairman. As I said, there
will be a transcript and, if you could let us have that back rapidly,
that would be much appreciated. You have to go back to your Ministerial
duties and we have to go back to deciding whether or not we dispense
with the Lord Chancellor, which is the subject of our work today
in the House of Lords! Thank you very much.
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