Select Committee on Public Accounts Minutes of Evidence

Examination of Witnesses (Questions 120-139)



  120. Is not the reality—going back to my confusion with the figure provided in Box A—that if we start with 1995-96 let us say, when the figures started to rise above 50 per cent, the figures had been falling to that point, had they not? Were we starting from a low base? Had the figures been falling before that?
  (Mr Crisp) Let me see if I have that number here. I am sorry, I do not have that number here.

  121. You quoted for Mr Griffiths the number of funded commissions in 1996.
  (Mr Crisp) That is right.

  122. You said there were 14,984.
  (Mr Crisp) Yes.

  123. Have you got the figures for 1992-93?
  (Mr Crisp) In 1992-93 there were 16,338. This is commissions for training. It fell 1,400 over that period.

  124. There was a fall in the early 1990s and then the figures started to rise again.
  (Mr Crisp) They started to rise again from 1996-97[10].

  125. I want to follow up what both Mr Steinberg and Mr Griffiths asked you about which were your comments about inaccuracies in planning in the early 1990s because, like Mr Steinberg, I am not really happy or satisfied with the answers that you gave to Mr Griffiths. I think I am right in saying the report mentions specifically that in the early 1990s the transfer of responsibility for training went from the NHS to higher education and talks about the reduction in numbers. Are we right to make a link between the two?
  (Mr Crisp) Actually I do not know is the answer to that. The intention of moving the training from being trained within the NHS to being trained within the university setting was for reasons about making sure that we actually provided a proper training environment for nurses and did not use them as, if you like, cheap labour.

  126. The two things happened at the same time, did they not?
  (Mr Crisp) Yes, but a lot of other things happened at the same time as well.

  127. Is it not the case in many institutions that if there are, for example, restraints on funding or profit then one of the first victims is training? Training is usually low on my list of priorities from the outset but top of the list of priorities if there are cutbacks.
  (Mr Crisp) In the early 1990s it was a mix of some decisions at the centre, some regional input and some input from the local trust, so it was a mix. Actually in the early 1990s it was still being controlled through the regional health authorities at the beginning of the 1990s but it shifted on.

  128. The report also specifically mentions, and the Audit Commission report picks up on this as well, a lack of common data about training, a lack of planning, particularly in the early 1990s, but that is actually exacerbated, is it not, by the fragmentation of the NHS? The phrase you used earlier was over localised, I think.
  (Mr Crisp) What has happened in terms of both this aspect of planning and other aspects of planning is that we moved from a very centralised system to a more decentralised system. We are now moving to getting a balance between the centralisation and the decentralisation and that is precisely what has happened and those are the succeeding policies here.

  129. During that period the number of people going into nurse training declined but is rising again?
  (Mr Crisp) In the early 1990s it did for those three or four years but I also note that a National Audit Office report published in 1992 actually concluded that the transition you started your questioning with, the transition from moving nurse training from within the NHS to higher education, the NAO report published then concluded that the early indication was that this was having a positive impact on the service and that implementation had gone well. That was the NAO's look at it in the early 1990s.

  130. It began in 1989 and then it moved on to the 1990s?
  (Mr Crisp) That is right. I do not think you can equate the change in that system to the other issue.

  131. I am not sure that is how I read the report. I want to move on to the problem raised by, I think, the Chairman earlier about the shortage of therapeutic radiographers. You quite rightly said that they are an important group of staff although in terms of numbers relatively small. The reality is that in terms of their importance in, for example, the NHS Cancer Plan they are absolutely crucial, are they not?
  (Mr Crisp) Yes, they are.

  132. Because their effect on local treatment can be quite crucial.
  (Mr Crisp) Yes.

  133. For example, a lady in my constituency, who unfortunately suffers from breast cancer, came across this very problem. The treatment that she is getting in one of our local trusts is certainly within the bounds of clinical acceptability but it pushes her towards the higher risk end of any possible side effects. That is a very serious problem, is it not, for people on the ground?
  (Mr Crisp) I think there is a serious shortage, yes.

  134. You have already outlined what you are doing, but are you convinced that you are doing enough to address that problem?
  (Mr Crisp) Can I make two quick points. Firstly, we are increasing the number of training places and by what is really quite a significant number but the issue is getting people in. We need to understand when we get them in why we have got this high attrition rate. It is interesting here that the top reasons why people are leaving are that they have made a wrong career choice—and that is perhaps partly about not recognising the stressfulness of this particular occupation—and, secondly, poor academic performance is the second highest reason. Both of those are issues which obviously you need to try to sort out in the selection and by getting more people coming through as well, but this is a difficult area. We have done a certain amount. The last thing, as I said, was in mid-February we sent out this joint letter to lapsed members to try and get them back into the profession. This is something we have got work under way on. Whether it is going to be enough or not is why I said it is one of the areas that worried me.

  135. The attrition rate for radiographers is 27 per cent, and a third of the people drop out on academic grounds, and this goes back to what Mr Steinberg was saying earlier about the qualifications one needs for certain jobs in the NHS but I was surprised to read at the bottom of case example 2 on page 20 that: "A number of universities have introduced continuous assessment to target learning support more effectively and in the belief that some students will find the smaller components easier to handle." If some universities have arrived at that decision they are probably about a decade or a decade and a half behind, for example, most sixth form colleges and A-level courses which have been doing this for quite some time, and yet we hear that only some universities may have done that.
  (Sir Brian Fender) I think each university clearly needs to make a judgment about what best support it can give its students and its best assessment processes. I do not think I can make an easy judgment about how they should do that. The question of attrition in radiography obviously has some particular aspects to it. What we try to do is make sure that institutions are supporting students at an individual level in the way that best suits them. We have got a lot of studies going on about how best to do that. We have not focused on the particular issue of radiography, that is true, and it may be that one of the consequences of this report is that we do need to look rather more finely at some particular subjects.

  136. I hope that you will because it does seem it is a problem that is not only serious but has been going on for some time. Mr Crisp, when the Secretary of State very graciously opened my new accident and emergency department (or, rather, emergency care centre) he and I spoke to a student nurse who was on placement at the general hospital but concerned about the lack of good quality practice placements. Why is that such a problem?
  (Mr Crisp) There are two reasons why it is a problem. The first one is, of course, we need to increase the number of placements very significantly because of the number of additional commissions. They have gone up 30 per cent and we need to increase those[11]. That is the first point. The second point is that when it was not a problem we did not pay much management attention to it, if I can put it that way. Now we are recognising it as a problem we have to address it. Again, there is an example in here of one of the case studies which is showing how people are within a confederation appointing somebody in a specific role to do this, including may I say in the private sector. We are securing placements in the private sector and in a wider range of fields than there would have been otherwise. At the moment that is a bit of a bottleneck that is being worked on to make sure it does not stop us.

  137. Does this not take us back to where we were a few minutes ago because again talking to a nurse at the weekend, who is a very experienced nurse, she was complaining about the lack of opportunity for people to have placements on wards because of the lack of experienced staff to train them. The NHS has a very good record of older nurses taking younger ones under their wing and showing them the ropes. So it is part of that problem, is it not, and it is not really helped by the number of agency nurses that the NHS depends upon?
  (Mr Crisp) We have got a very difficult balancing act in managing the NHS. We are trying to keep the service going, we are trying to increase the service and we are trying to increase education at the same time. This is pretty tough and it is pretty tough for the sort of nurse you were talking to who probably wants to do more education but is finding that the service is going on at the same time. That is a balance that we have to keep looking at and we will do some relatively short term things to make sure we can keep training people at the same time as we are running the service and that may mean putting people in different placements we have not looked at before, but it is a difficulty.

  138. How effective has the "Return to Practice" programme been and also overseas recruitment in terms of numbers?
  (Mr Crisp) This was the number I failed to find earlier, I am afraid. They have both been effective, they are both continuing, they are both worth doing. They are part of what will contributes toward that 20,000.

  139. The BMA report today, of which no doubt you are aware, says that two out of three doctors are not interested in going on to be GPs and most of those are women who want career flexibility. One of the complaints I get from would-be nurses is, "Yes, I would return to the profession but I need child care and I need to be able to work part time or job share or whatever." What sort of effort is being made centrally to encourage trusts to go down that route?
  (Mr Crisp) I have just found the figures that you were asking about. 4,181 nurses, midwives and health visitors have returned to employment in the NHS in England and another 2,000[12] are preparing to join them. Over 60 per cent of those who have returned so far have taken up part-time posts, which demonstrates how the NHS is providing more flexible, family-friendly opportunities for people who want to work. It is precisely that point and offering them part-time opportunities is one of the attractions we can use to bring them back. So 4,181 have already returned[13].

  Mr Campbell: Thank you, Chairman.

  Chairman: Mr Edward Leigh?


10   Note: The number of funded commissions rose from 1995-96, not 1996-97. Back

11   Note by Witness: The number of placements are due to increase by 30 per cent, they have not, as stated, taken effect already. Back

12   Note by Witness: The figure is, in fact, 2,020, not 2000. Back

13   Note by Witness: 7,513 persons have returned to the nursing profession. Back

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