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Health Committee - Minutes of EvidenceHC 6-ii
Taken before the Health Committee
on Tuesday 21 February 2012
Dr Daniel Poulter
Mr Virendra Sharma
Dr Sarah Wollaston
In the absence of the Chair, Rosie Cooper was called to the Chair
Examination of Witnesses
Witnesses: Dean Royles, Chartered FCIPD, Director, NHS Employers, David Worskett, Director, NHS Partners Network, and Sally Taber, Director, Independent Healthcare Advisory Services, gave evidence.
Q304 Chair: Good morning. Thank you very much for joining us. My apologies from the Chairman, who is attending a funeral in his constituency. I am a pale reflection of him for today. Your presence is very much appreciated. Can you begin by telling us your organisations and who you represent, please?
Dean Royles: My name is Dean Royles. I am Director of the NHS Employers organisation. We represent employers in the NHS across the plethora of workforce issues, things like pay, pensions, employment practices and education and training.
David Worskett: I am David Worskett. I am the Director of the NHS Partners Network, which is the association of independent sector providers of healthcare working with and in the NHS.
Sally Taber: I am Sally Taber. I am Director of Independent Healthcare Advisory Services, the trade body for acute independent healthcare providers; I also look after the cosmetic surgery providers; I run the Independent Sector Complaints Adjudication Service as no private sector patient has access to the Health Ombudsman; and I am doing some work with the Government on introducing a selfregulation scheme for Botox,® dermal fillers and lasers used for aesthetic purposes.
Q305 Chair: Thank you very much. Can you summarise how each of your organisations views the Government’s reform plans set out in "Developing the Healthcare Workforce" and in the recent update, "From Design to Delivery"?
Dean Royles: As the employers’ organisation, we broadly welcome the direction of travel. In particular, we welcome the idea that employers and providers are more directly involved in the planning of education and training. We like the idea of a national body responsible for overseeing multiple professional education and training. In terms of the direction of travel, we know broadly where it is going. The train has left the station, we are laying the tracks ahead of it and there are still some things in play in terms of this coming to fruition. We need to see to what extent, for example, the Local Education and Training Boards are autonomous. Are they going to be allowed to make decisions that are in the best interests of patients, and are they supported in doing that? In terms of the education environment itself, there is a danger that we could look at education in isolation from other workforce practices, like pay and regulation. These things are interrelated and impact upon the way that the staff do their job. It is not always only an education solution to things. I think those are still in play-in particular, how we look to cover the entire workforce, especially bands 1 to 4, given the crucial role that they play in patient care. As we look at it in the Local Education and Training Boards, will they be able to have a look at that whole workforce and make good and efficient decisions that deliver better care for patients?
David Worskett: From an independent sector perspective, the first thing to say is that this discussion has moved on slightly since we embarked on it, in that the Government have now published a strategy. Broadly, that is pretty satisfactory from our point of view. We think it has come out in very much the right sort of place. It is important to say that most independent sector providers-certainly all those of repute-place quite a high importance on staff training, although it is sometimes a different sort of training to that done elsewhere. I do not know of any of my major members, certainly, who do not regard training and development of their staff as a very high priority, which, in a sense, is what you would expect in organisations that need to train people and look after patients properly in order to survive.
If we have some concerns-and they have been partly alleviated by the latest Government paper-it is more in the area of people not understanding the training our members do, and how intensive that is and how committed they are to it, and not fully appreciating the value of it. The world has moved on quite a long way since the first independent sector treatment contracts when, for reasons unknown to us, the then Government prohibited independent sector treatment centres from undertaking training. That prohibition was removed quite quickly, and we now have a very much healthier situation in regard to participation in training and people moving between organisations-public and private sector-for training purposes.
Sally Taber: I go back as far as the Workforce Development Confederations. We achieved local involvement there including the involvement of the independent sector providers, and sharing of training programmes and so on. The LETBs could be like that. It is great that we can really get back to local involvement. How you get the private sector representative on there needs to be discussed. My organisation has now been contacted by UCL Partners running the central London ones. We have also been invited to do a pilot with NHS Midlands and East. We are already part of that. A few years ago, when there were Workforce Development Confederations, I coordinated the independent sector representation throughout the 28 of them, and we achieved a lot then.
Q306 David Tredinnick: I would like to start with looking at the new organisational structures, and I raise this with Mr Royles to start with. The NHS Employers has said in its evidence to us that Health Education England must be employerled. On that basis, what specific form do you think it should take and which employers should be involved in leading it, please?
Dean Royles: When you look at education and training, employers are very well placed to understand the needs of patients. They deal with patients on a daytoday basis. They see the needs of patients; they see training and services; they have active engagement with their patients, with their local population and the boards that they have in place; and they also speak very freely to their clinicians about how services are developing. From our point of view, we welcome the idea that, if you put new architecture in place, you do not just get a lift and shift of the old system into the new system and say, "We have a change in NHS architecture, let us make sure we get education and training that works in there." This is an opportunity to get a fundamental rethink about how we look at what are the needs of patients and how we plan our workforce into the future. To enable that, you need Local Education and Training Boards that have good employer representation on them and feel as if they have autonomy and authority to make decisions based upon the evidence they would use to come to that. The Government have put forward that that would be overseen by Health Education England. There was a variety of different models they could have gone for but they chose that particular model, and I understand why they have done that. In so doing, there could be a tendency towards centralisation. The natural order of these things is if you set up a central body it looks to centralise and make decisions on a central basis.
Given that we need to get that sort of authority for Local Education and Training Boards in there, and to make sure that happens, we need employer representation, employerled, with Health Education England so that if there are disputes, conflicts or issues people have trust in that system. That might be about bringing people into Health Education England who have particular expertise in this area and who also happen to be employers and, maybe, medical directors, nursing directors, HR directors and chief executives. We think we have a role as an employers’ organisation. We are active on the ground in looking at what good practice is; the things that people are doing; innovation; sharing what works with people; and lessons learned, so we have a role to play in that as well. That employer role in there is important.
Also with Health Education England we have a tendency to think of things like Medical Education England as a committee. This should be an organisation that has engagement at its heart-not a series of meetings that makes decisions-that is seeking information and evidence in order to run its business and affairs. It has something like £5 billion worth of education and training funding to deploy and we should be able to make sure we can use that efficiently and effectively if we get all the right voices in the right place.
Q307 David Tredinnick: Thank you very much for that. In the new system, as it is planned, the Local Education and Training Boards will be employerled. What capacity and capability will employers need to assume this role and how ready are they to assume it?
Dean Royles: Employers have been engaged in education, training and workforce planning for a number of years. Many of the NHS organisations are large organisations in their own right, with 5,000, 6,000, 7,000 and 12,000 people in some cases, with a board of directors of workforce people involved in there looking at what patients need and bringing in clinician expertise in terms of planning those services. So people have been engaged in that workforce planning.
There is something of a paradigm that has developed that suggests employers are not really that interested in education and training and it is best left to the professions who understand. My experience is that employers are very passionate about wanting to provide the best quality staff they can for the patients they serve. In terms of a willingness to do it, they actively want to get engaged. We want them to get engaged in those Local Education and Training Boards where they feel as though they have authority and decisionmaking powers to be able to do that. If we can deliver that for them, then it will not be a capacity issue because there will be the will there. They will want to bring in the use of expertise from things like the Centre for Workforce Intelligence, they will want to bring in information about what is happening on the ground and they will want to share ideas of good practice. But the capacity and the will is there if we can construct a system that shows them they can be approved to make appropriate decisions for their patients in their constituencies.
Q308 David Tredinnick: So the will is there. That is very reassuring. Can I ask David Worskett and Sally Taber to come in at this point? How satisfied are you that independent sector providers will be sufficiently covered by the remit of the local boards and adequately represented on them?
Sally Taber: What we need to create in the independent sector, first of all, is very much an awareness of the LETBs. There is not total awareness yet. I hope it is not going to be like the last Workforce Development Confederations where there were some excellent examples but, also, those that perhaps did not engage the independent sector. There must be, almost, a mandate for all the LETBs to have an independent sector representative on them. As I say, we have a pilot about to start with NHS Midlands and East in which we want to involve the private providers-obviously those that do NHS funded care. The management of that LETB is going through Skills for Care to involve the social care side. There is a huge workforce out there that is not involved.
We have started collecting workforce data, which we did until 2006 and then stopped. I have a sample with me of the aggregated data. We have made sure that the organisations that have given us data have given it from individual organisations. It can then be split up for NHS Midlands and East LETB, for instance, because they are not going to want to know the whole of the workforce. They are going to want to know what is in their area from the independent sector. We have also done quite a bit of work on what training opportunities there are as in the booklet we did last year "Careers in Healthcare" from the independent sector. The Guardian picked up on one example of how the independent sector contributed to education. I will leave you an example of that. We have recently completed a review of critical care nurse education and supported the publication to make sure that all the acute healthcare staff are aware of their responsibilities.
I am not confident that all independent sector organisations are aware of LETBs yet, but we have a joint conference with the NHS Partners and Skills for Health on 18 April and we have the LETB agenda on it.
David Worskett: The short answer is that there is no guarantee. There is nothing in the structures that guarantees there will be proper engagement with the independent sector, with the LETBs. It would be a great pity if we replicated what has tended to happen in the past, where the level of involvement between the sector and the deaneries has been patchy. In some parts of the country it has been excellent and in other parts of the country it has been very weak. We need to avoid replicating that patchiness.
Q309 David Tredinnick: How are you going to do that?
David Worskett: It is partly incumbent on us. There is no point in always blaming somebody else. We have to get out there and talk about what we have to offer and why it is worthwhile involving us. We need to take that very seriously, which is one of the reasons we have this joint conference running.
I also think it is important for those on the other side of the fence, as it were, to think carefully about the merits of involving the independent sector in some types of training. There are two very obvious examples. If you want to look at some of the finest standards of endoflife care, you would want to involve, say, a great hospice in your discussions about training. It is almost what I might call a "nobrainer" that you would want to go there for training support for that type of care. If you were looking at innovative care in the home, very often, some of the more innovative clinical services in the home are provided by independent sector providers. The whole issue of how you train for delivering those types of care is quite a big one because it is a new model. Exactly how you train for them needs to be thought through, but not to involve a company which is doing very well at delivering those types of services would clearly be a mistake. It is a twoway challenge. We have to come forward and make what we do known and make clear that it is worthwhile, but we need to look to the other side to be open-minded about it as well.
Q310 David Tredinnick: We have a lot to get through this morning, so I will try and speed up a bit. What about the legal status of the local boards? What do you feel about that?
Dean Royles: The Government have said that these should be part of Health Education England, so Health Education England will be set up as a special health authority-nondepartmental-a public body, and the Local Education and Training Boards will be part of that. The staff would be employed by that special health authority.
Q311 David Tredinnick: Are you happy with that? Is it going to work?
Dean Royles: It is the same point that I was making earlier. We understand that as a direction of travel. As we put the architecture in place, it is very important that we get the responsibility and accountability right. As there is one body, there will be a tendency to centralisation. We do not just want to "lift and shift". We want to fundamentally change the way we engage employers in that, so we have to put the right accountability and governance arrangements in place. That is do-able because you have the right people involved asking, "How can you make sure that they exercise that in an appropriate way?", and they feel that they are taking local information from organisations, from their patients and their clinicians, and saying, "This is where we think the direction of travel is. We have the evidence to support it. Therefore, we want to move forward on that basis."
Q312 David Tredinnick: We were told, certainly, that workforce planning has to be done at a national level. If that is the case, local boards cannot be wholly autonomous from Health Education England. How do you think they are going to function?
Dean Royles: There is workforce planning that needs to happen at national level, at Local Education and Training Board level and at individual organisational level. All those labour markets are very different. At the Local Education and Training Board level, there is a regional labour pool where people are recruiting newlyqualified nurses from a range of different higher education institutions in their patch. They will want to ensure that there is an appropriate supply of those. That is better done in a region like the northwest, South Yorkshire or the northeast where people have those relationships with the higher education institutions.
Q313 David Tredinnick: You talk about "subLETBs" in the Health Service Journal on 26 January this year. That is something you are very much in favour of, unless you have changed your mind.
Dean Royles: The appropriate thing is that, if you set up Local Education and Training Boards, they are given the authority to say how best they can configure themselves to deliver for their local organisations and the patients in those areas. With the idea of a labour market in somewhere like South Yorkshire, for example, or places in the northwest around Greater Manchester, where they share a variety of different higher education institutions, it makes perfect sense that that is where that relationship is carried out. Then the governance is in place that means they have done the job appropriately and they are allowed to make decisions on what they feel is an appropriate amount of new training commission or continuous professional development that should be done in that area.
Q314 David Tredinnick: I have one more question. As employers, do you think there is a danger that the local boards will be dominated by employers who lack academic involvement?
Dean Royles: The criteria, in terms of getting them established, is that they should have active engagement with their higher education institutions and that those are explicit in the way that they work, that higher education institutions are engaged.
Q315 David Tredinnick: Should there be an obligation there? You are wishing it and you say it would be a great idea, but should we go further and say there must be some obligation-a requirement?
Dean Royles: The obligation is there through the accreditation process.
David Tredinnick: I will leave it there. Thank you.
Q316 Valerie Vaz: I want to quickly follow up on something that you said earlier, and I am happy to hear comments from other people. You said the right people should be on the board. Who do you think are the right people? Perhaps that would help.
Dean Royles: Employers are best placed to understand what their patients want, how services are changing and how they can better provide those. There are two ways you can approach those changes. One is to try and understand the different ways in which patients want treatment, how medical advances are changing and where people want services delivered-closer to home, more in the community or in a specialist hospital environment-and to ask professions about how they might want to adapt to that different area. Then you bring those together saying, "When we look at our planning, what are the sorts of skills we need in the future to be able to deliver those?" That may be something new or different. It may be about training existing staff rather than trying to recruit new staff.
Q317 Valerie Vaz: I was talking more about specific personnel. When you said "bring people on board", could you be a bit more specific? Would you have patients, doctors or nurses? Would you have other members of the workforce?
Dean Royles: From an employer’s perspective, it would be people like chief executives, medical directors, nursing directors and some of the allied health professions leads that have an employer view, but those are supported in terms of an understanding of what a broad range of employers want. They have access to information. So it is personal expertise and a range of information that supports that.
Sally Taber: It is very important that whoever is the independent sector person on the LETB has the opportunity to get the rest of the people round the table to understand the independent sector. So many times, when I go to working groups, people do not understand. With medical revalidation we had a model that would fit the NHS. Suddenly, we find the smaller organisations that have resident medical officers that have come in from overseas or whatever, and we have to rethink the agenda now. Before we start, we can work with the Centre for Workforce Intelligence to make sure there is a real knowledge of the independent sector.
Q318 Valerie Vaz: Thank you. Mr Worskett, who would you have?
David Worskett: I agree with that. It is quite difficult to prescribe the exact balance of skills on these boards. To some extent, it may also depend upon the availability of people in a particular area. But, clearly, you need a balance. You need people from an employment perspective, academics and clinicians of a variety of kinds. As it will differ slightly according to the needs of the area, trying to prescribe it absolutely from the top down seems to me to be quite difficult.
Chair: We turn to general workforce planning. Virendra?
Q319 Mr Sharma: The Government plan to require providers to consult, provide data and cooperate for the purposes of workforce planning. How do you respond to concerns that foundation trusts and private providers could duck those duties in pursuit of commercial interests?
David Worskett: I cannot answer for foundation trusts, but those of us who are currently deeply embroiled in the proposed licensing conditions being developed by Monitor are aware that there are going to be some very tight licence conditions about provision of information and data. We have said we understand that, we think it is right and we need to try to get the level right so that it is not disproportionate, particularly for small organisations and third sector providers. From the point of view of those independent sector providers who are working for and in the NHS, we absolutely accept the obligations that will be within those licence conditions to provide the data that is required on the same basis as the rest of the NHS. Therefore, it is a common cause, with NHS providers, to try to get that information properly set out and the balance right.
Sally Taber: I feel very strongly about this. We provide data for the Scottish Government and Welsh Assembly Government. We check the data they want and we give it to them each year. They have Scottish independent sector credentials and Welsh independent sector credentials. What we need here is a mechanism for exactly what data is needed. The data I have here this morning is head counts of nurses, physiotherapists, occupational therapists, radiographers, ODPs, how many doctors who are employed and those who have practising privileges, and the number of healthcare support workers. This is not the entire sector at the moment, but there are for example 19,800 with practising privileges. So there is a fair amount of workforce there. What we need is a questionnaire that suits the LETBs, with exactly what is needed, and then the independent sector will be keen to submit that data.
Dean Royles: I do not think that employers per se have any problem with providing data. This is a good example of where to avoid the lift and shift. Employers have a problem with providing data in a bureaucratic form when they do not know what happens to it. People will be more than willing to provide that information if you say to them, "We want data because we have £500 million to spend in our Local Education and Training Board and we want to spend some of that on continuous professional development. Where do you think it would be best spent for the best impact on patients?" That is the advantage of getting employers engaged locally; "You are providing data to look at how we can invest serious amounts of money in education and training to support you as an organisation in the delivery of care to your patients." It is not a problem with providing data per se. It is giving them the wherewithal and the assurance that, when it is provided, it is going to be used for the good of patient care.
Q320 Mr Sharma: Although you have answered the question partly, I still want to go further and ask about the independent sector database. To what extent do independent sector organisations gather the types of data that would be required for this purpose?
Sally Taber: I think I have told you that we have it here from the main independent sector organisations and the individual ones.
Q321 Mr Sharma: Can you expand on that?
Sally Taber: Where you have a problem with the independent sector is that there are so many tiny organisations. For instance, with medical revalidation we found that 287 in central London did not answer the letter from NHS London. They are tiny, with perhaps three or five people. That is where we need some more communication to them to say, "We have to know who you are." The main providers do not have a problem in providing data, providing, as Dean says, they know where it has gone, what it is for and we are collecting it in the right format. The LETBs need to dictate to us exactly in what format the data is required and then it will be provided.
Q322 Chair: We should have a conference to decide what kind of data. It is difficult in the sense that, if every request for information has to be justified at the level you are suggesting, different people will have different views on that and we will go round and round. Somebody at some point has to say, "This is the information we want; everybody has to do it."
Sally Taber: Yes.
Dean Royles: Yes. That is the role of the Local Education and Training Board at the moment. That is done through a learning and development agreement. In many organisations a learning and development agreement goes to organisations that says: "To access this training and development money, there is a requirement for you to provide some information." You get better quality data if people feel they are providing data that is making a real difference to how they use it on the ground. That is the advantage we have in a system that more actively engages employers and providers.
Q323 Mr Sharma: Thank you. The Government want to reduce the NHS’ dependence on agency and locum staff. How necessary is that, and how easily achievable is it?
Dean Royles: First of all, it is important to say that agency and locum staff play an important part in having a flexible workforce. Therefore, occasionally, we need to bring in staff temporarily for shortterm increases in activity or to cover unexpected or more longterm sickness absence. All those things are a legitimate use of agency and locum spend. What you want to try and establish from an organisation is whether they are doing that in the most strategically appropriate way. Are you doing it as a shortstop measure because you have an initial problem? The Government are trying to say, "In terms of looking at that going forward, is there a more planned way that you could have a more efficient temporary workforce to supply those needs, using staff more associated with the organisation so that they provide better patient care?" I do not think it is about eradicating it completely. It is trying to use it in the most strategically efficient way that you can.
Sally Taber: We have worked, from the acute independent sector, with the Migration Advisory Committee who had cut out theatre staff from the shortage list. The independent sector needs a fair amount of theatre staff and they had said that they should not be on the list any more. We managed to get them to change their minds, giving the sector an opportunity to grow its own theatre staff. Skills for Health have done a lot of work with how we grow our own theatre staff. We realised that we were using a lot of agency theatre staff but we persuaded the Migration Advisory Committee to change its mind. There are other ways of doing it: to think a bit more laterally than simply saying, "No more agencies", and asking, "Why have you got agencies?" That is what we did with theatre staff. We have got agencies because the Migration Advisory Committee said they could not come in any more, that they were not on the shortage list, but they have changed their mind on that until the sector can start growing its own.
Q324 Dr Wollaston: Could I ask the panel to comment, particularly Mr Royles, on whether you feel there is a shortage of generalists within the NHS? There has been a concern expressed that if we have a providerdominated service we might see that organisation naturally tending to want to increase the supply of specialists within the hospital sector rather than develop generalist skills. What are your views on that?
Dean Royles: It comes back to the understanding of how care is changing, what patients want and how we can deliver that more effectively. We then start to ask questions as to what sort of skills we need to be able to deliver that, rather than how we adjust and have more or less of a particular variety that we have at the moment-
The idea in a number of reports now, for example, has been about having a more consultantpresent system, seven days a week or 12, 15 or 24 hours a day. Looking at that, you get to the view that you need more generalist skills to support it and specialist skills alongside. I think you would also come to the view that, if you want to treat people closer to home, it would make sense to have more nurse training, for example, carried out in the community where there is a general range of skills, and specialist training back in the hospital. As I say, that is the advantage of looking at a system. Starting with, "How do we deliver care? What is it that patients want?" and then asking ourselves questions as to how we best provide that has to be a good way of looking at how we do our workforce planning in the future. That would take you down the route of more generalist skills for people who are working longer hours in an acute or hospital setting, and people who are working in community settings, supporting people in their homes-or closer to home than a district general hospital or a teaching hospital, for example.
Q325 Dr Wollaston: You do not think there is going to be an issue with not training enough or encouraging more medical graduates to go into, say, general practice training rather than encouraging them to come into fields for which there may not be a consultant post at the end of it.
Dean Royles: There is a challenge there with communication. The work we are doing, for example, with the NHS Careers service is starting to explore that with people in primary and secondary school now so that they are changing their career expectations about what might be available in the future and how that may be carried out, rather than having someone going into medical school determined to be a surgeon-and that is going to be a lifelong ambition for them-when that will not necessarily be available to them when they come through 10 or 15 years of training. There is an opportunity to engage local communities about how professions are changing, how care is changing and the different roles that are needed rather than repeating what has always gone on before. It is the old story that if we keep on investing the same amounts of money on the same amount of professions we will keep on getting broadly what we have. Some years we will have too many and some too few. If we start looking, fundamentally, at how we do it differently then we get into a cycle of breaking that and understanding the different roles and occupations that might be available for people now thinking about that at primary or secondary school.
Q326 Mr Sharma: The Government also wish to reduce dependence on overseaseducated staff. How necessary, and achievable, is that?
Sally Taber: That is what I described about the Migration Advisory Committee. IHAS are on their advisory group and we share all the information with the independent sector. It is very important to work with them because we know that we should not be taking staff from South Africa or from the African countries. The majority of the acute independent sector has probably moved to recruiting from the European countries, but there you have the language problems and we are pleased that that issue is being addressed. There are other ways of doing it and, as I said to you, of thinking a bit laterally on, perhaps, working with the Migration Advisory Committee, saying, for instance, "Why are we short of cardiac nurses? What can we do about that?" Certainly, having been a director of nursing in the independent sector, I worked together with the local trust. We did a critical care course half in the independent sector hospital that I ran and half in the NHS, and the same with renal care. There are lots of ways of working together and, hopefully, the LETBs will encourage this. As David said, where there is best practice, let us share it and try to address some of these problems together.
Dean Royles: It is worth saying that overseas staff have made a fantastic contribution to the NHS, from those who came over in 1948 on MV Empire Windrush and started working in our hospitals to those who are coming from Europe now, or doctors who have come over and transformed things like general practice or care of the elderly, for example. There has been a fantastic contribution from trained overseas staff. Increasingly, in a number of roles, we are an international labour market, where people want to move around in their careers. We have physiotherapists that may want to go and work in Australia when they come out of university and maybe, at some point, come back. We have to have a look at it and manage migration. We have an ability to bring appropriately trained staff in from overseas, particularly when they can come and get learning, education and training and, in that global labour market, take something back to their countries. It is both recognising that the world is much smaller now in terms of people wanting to do that, and making sure that we have a good supply through our own institutions, and that they are providing a sustainable workforce for the future.
Q327 Dr Poulter: On that issue of overseas workers-before I come to my questioning-it is absolutely right to say that the NHS would not function without the many doctors, nurses and other healthcare practitioners who come and work from overseas. We would not have a functional service. However, because of the European Working Time Directive, there are specific problems sometimes with locum provision and the need to employ more locum doctors at some trusts. We all accept that anyone who works at a hospital should have a basic standard of English, but do you have concerns over the fact that a number of doctors who are on the books of locum agencies, for example, are not necessarily familiar with the British medical system and how things operate in this country?
Dean Royles: Absolutely. We have been talking with the GMC about how we might, together, do some form of international induction for doctors on how the system works here and the different cultural norms that may exist, as well as English language testing for people who come from overseas countries to make sure they are competent in the language in which they are going to be prescribing and speaking to other professionals. I would agree with all of those, while acknowledging, as I say, the contribution that people from other countries have made to the Health Service, the way that we run it now and what some people are able to take back to the benefit of their own country as well in terms of education and training.
Q328 Dr Poulter: For example, would you agree that sitting, say, in medical terms, the PLAB-the conversion-exam in itself is not necessarily good enough to show that somebody is able to work as a competent doctor in the British medical system?
Dean Royles: The difficulty with the plans that people want to put in place is how can you do appropriate English language testing within the rules that does not look as though you are rechecking whether people are educationally qualified? There are a variety of different sorts of pilots and tests being done about how you can get the best sort of model of that that gives people who are coming in assurance. The vast majority of our staff sit through some form of interview and have to go through a range of questions and an application form and accept it. I agree with you that, on locums, there is a different process coming in. But we can develop appropriate practice that says, "How can you be assured, at the time you get a locum in, that there has been appropriate language testing?"
Q329 Dr Poulter: That is right. Particularly with the European Working Time Directive coming in, there has been a problem in a number of specialties-for example, obstetrics and gynaecology, which is my own specialty-where there has been an increasing reliance in the hospital sector and in GP out-of-hours service, as has been well documented, on getting people from within and outside Europe coming to work. They may be perfectly competent doctors in their own country, but their understanding and communicating with them about how things work in this country is a problem. There have been welldocumented cases where that has had tragic consequences. Simply being able to pass a PLAB or a competency exam, for those people who are nonEuropean doctors, or being able to pass an exam in their own country, does not necessarily mean they are able to be an active, effective or even necessarily safe member of the workforce. It is that which I am driving at on locums because of the EWTD. What do you think needs to be put in place to improve and deal with those issues?
Dean Royles: I do not know that it is all necessarily driven by the Working Time Directive in some of this. Some of the contractual arrangements-
Q330 Dr Poulter: We will come on to that in a moment.
Dean Royles: It is another discussion, maybe. The problem has been acknowledged. Now the issue is how we put a system in place that people understand-a system that is transparent and not overly bureaucratic-so that we can bring workers in at relatively short notice knowing that they are appropriately trained and have the right educational standard and appropriate level of English to be able to do their job effectively, and we avoid exactly those tragic consequences you were talking about.
Q331 Dr Poulter: Yes. But what I am trying to get at is how can we deal with locums? It is very easy for a hospital employer to deal with. If we went over the river to St Thomas’ they would be able to make sure that those staff who come and work for them are inducted. Responsible employers will induct those staff. Where they have concerns, they will also make sure that those staff can shadow existing doctors within the organisation. There has undoubtedly been an increasing reliance on locums to run services because of the EWTD, and the fact that people have not been able to work the hours they were able to work. Maybe one of your colleagues could shed more light on it.
Chair: Both would like to.
Dr Poulter: Both would like to, because this is probably quite a real concern, not only to the people in this room but to the public as well, in terms of safety.
David Worskett: I want to pick up, in particular, the outofhours problem where there have been one or two terrible and tragic cases. What is noteworthy about most of those is that they were what I would call quite localised, homegrown arrangements. Interestingly, as time has passed, more of these outofhours arrangements have been grouped together in the hands of rather bigger providers who have the clinical governance arrangements and the support structures in place to make sure that things are going to be all right, not only in terms of language but training and how to deal with what is often quite a complex system. What I see is a move towards using the better equipped, more quality assured-as it were, properly governed-independent sector providers to manage those processes rather than wellintentioned, but ultimately terribly risky, homegrown ventures where not all of this support and validation is available. It is very important that we use the right sort of quality providers to manage these processes.
Sally Taber: I think medical revalidation is going to sort this out. There are pilots going on with local agencies at the moment. Some of the local agencies out there are not going to survive because they will not have the structures in place. Every independent sector hospital has to have a resident medical officer 24 hours a day and we use agencies-they are supply agencies-to get those doctors. They all used to come from South Africa, but now they are coming from Europe. As to how that is going to be managed, three organisations at the moment are being worked up as designated bodies to have a responsible officer to check that those junior doctors coming in have the right governance structure to work within, are appropriately qualified and have the language skills. It is happening as we are talking and, as you know, medical revalidation is planned to start at the end of this year.
Q332 Dr Poulter: It will be happening, yes, but at the end of the year. At the end of the revalidation process, which will take a few years, you are hopeful of that. In the meantime, bad things can still happen. We will leave that there.
Sally Taber: We are working hard.
Q333 Dr Poulter: Going back to the workforce issues, there has been-and it was touched upon earlier-the issue about the drive for consultantled care on the ward, in the emergency department and elsewhere. That is something everyone would like, I am sure-to see a consultant first off. What are the benefits and risks of that in terms of the training of the workforce? Indeed, what about the ability of the registrar-historically, they have been the workhorse of the team-to then step up and become a consultant if their level of responsibility, when they have been working in this way, is having less patient contact and being much more intensively supervised? How do you see the benefits and risks of consultantled care in terms of, effectively, training the next generation?
Dean Royles: It is going to be a fundamental shift for us, I think. There are elements about how we see and perceive the entire medical workforce. We tend to think of junior doctors as untrained doctors and consultants as trained doctors, but we also have a whole range of staff and associate specialists who make a fantastic contribution in the workplace. This idea of an appropriately qualified doctor seeing people over a range of specialisms and different times is appropriate, but it is about how we look at using that entire workforce-not only from junior doctor to consultant but also things like staff and associate specialist doctors-how we deliver care and the extent to which we mean that to happen, in terms of elective care over a longer period of time or emergency care where we have more doctors, consultants and qualified doctors on site. There is a fundamental review about how we look at the medical workforce to deliver that.
It is a point I was making earlier about how we can sometimes look at education and training in isolation from things like employment practice and contractual arrangements. All these things go hand in hand in terms of how we deliver them. It is not just about training more to fill the holes created by new service development but how we deploy those and use the other nonmedical members of the workforce, nurses and allied health professionals in different roles. As I said right at the top, it is also about how we use staff in support roles, those in bands 1 to 4, who have a huge amount of patient contact. They are hugely important to the patient experience and yet they are often forgotten when we look at education and training needs.
David Worskett: Might I take the opportunity to make a directly related point about how different conditions are in the different sectors, because the question that was asked is absolutely relevant to the mainstream NHS? In the independent sector, of course, it is interesting that when people are trying to look at what we do and do not do, they sometimes forget that we do not run A and E departments. We have big hospital groups who run them in other countries in the world, but we do not run them here. In a sense, the issue does not arise there. We cannot train in that sort of work because we do not do it. Only consultants can carry out surgery in independent sector hospitals. Therefore, in a sense, it is already fully consultant-supervised because only they can do it and there is not the opportunity to teach junior doctors on the job. This is not a complaint, but the question prompted me to make the point that the conditions are very different in terms of what one is able to train in, not because of what we do or do not want to do but because of what we are and are not allowed to do. That changes the dynamics of what you can do in terms of training and education.
Q334 Dr Poulter: Specifically on that point, the healthcare reforms are going through and there is going to be an increased ability-it will not necessarily happen but it is likely-for private sector providers who are currently in your sector to come forward and provide services. As you say, at the moment in private sector providers, it is only consultants who provide the service and there may be some voluntary sector involvement as well in providing some services, perhaps in palliative care, with bereavement, for example. How does that impact on training?
David Worskett: I am not sure that it is going to make any significant impact in the acute sector. In a sense, the position will remain unchanged there in terms of surgery, in particular, only being carried out by consultants on the register. The interesting area, and it is an unknown area, is what happens with some of the new community services-I have members like Healthcare at Home who provide care at home-and to what extent we are going to be able to meet the training needs and participate in training for services of that kind. That is an unknown factor. I very much hope that we will be able to participate much more in training in those things. But in the area you are talking about, the acute sector and the hospital sector, I am not sure I see this making a huge amount of difference.
Q335 Dr Poulter: I am sure that private sector providers will be bidding for contracts-as long as that is done in an integrated way and meets all the right criteria-and you have acknowledged that is the case. If the private sector meets all those criteria-integration and everything else-there is then going to be an issue that private sector companies may be awarded that NHS contract. If, as at the moment, your services are consultantled and they are not engaged in training, there may be a legitimate concern that the training in certain areas-where private sector companies then come in to provide NHS services-may potentially suffer.
David Worskett: Effectively, we already have what is an "any qualified provider" regime for elective care. Looking only at the hospital sector, that is why I am not predicting a huge amount of change. The regime which the Bill proposes across a wider range of services, to all intents and purposes, already exists for elective care. You are absolutely right in terms of the wider range of services as private sector companies bid for that work. I think the issues you raise are entirely valid.
Sally Taber: There are models out there that we could look at as best practice examples, particularly in the independent mental health sector. St Andrew’s, for instance, does a lot of training between the NHS and the independent sector. There is a model that we put together-and people might not want to hear about this at the moment-on cosmetic surgery training because there is none in the NHS. Patients were told that it was going to be a registrar coming across with the consultant and the fees would be adjusted accordingly. So there are models that could be taken on board. I talked to the president of the Royal College of Physicians about this model and he was quite impressed. Obviously, the whole situation has changed at the moment in view of PIP implants, but I think we could look at that.
Q336 Dr Wollaston: I would like to move on to nurse education and training. There is a view that clinical placements for student nurses are too often of low quality, that mentors may be overstretched with students not having enough supervision and taking on tasks which they are not confident to carry out. How fair do you think that assessment is?
Dean Royles: It is going to be varied. Something like 18,000 nurses, or thereabouts, get trained each year. They spend about 50% of their time in academia and 50% of their time in a clinical placement. In some places-and probably the vast majority-that is going to be a great experience in both academia and in the clinical placement. When we get into whether there has been poor-quality training, trying to define if that took place within the academic setting or the ward environment is one issue that needs to be resolved. Part of the evidence that we put forward, for example, is what we mean by high-quality training and how we can measure it at the end. It is not only about educational attainment but also about the values that people express and how they go about them. That relationship, as I think we touched on earlier, between the higher education institution and the employer-the local hospital, for example-is very important.
Q337 Dr Wollaston: I am referring specifically to the fear that, when they are doing their clinical placements, staffing levels are overstretched and students are not having adequate supervision and training in the clinical aspect of their work.
Dean Royles: I am sure in some places that will be the experience for some students going through. Whether that is a regular occurrence every time they go on to a placement, I do not know. There are also arrangements in place where people can raise those concerns and say "This was not quite the clinical placement I got." There are ways to intervene for the local employer, in the current system, through the strategic health authority, about looking at the quality of the clinical placement and where it went wrong, how to correct it and what sort of thing needs to be done to put that right in different places.
Q338 Dr Wollaston: How competently do you think the new system will be able to address those failings? It would appear that that is not happening at the moment.
Dean Royles: Understanding the entire training and education that someone has brings the employer closer to the education provider. That is not only in terms of new recruits coming into the NHS. The vast majority of the staff who will be working in the NHS in 10 years’ time are already employed and working in it, so that continuous professional development-in terms of updating of clinical skills, which takes place in a clinical environment and in placements at universities-is also important. When you bring all that together-you bring information together, employers that want to put that right, who want to try innovative ways of doing it and want to have a look at how they can deploy their workforce in different ways-then at least you create an environment to enable people to say, "How can we change and fix it where it has gone wrong?" You have that more active engagement of the right people in the right place to put it right.
Q339 Dr Wollaston: The question was: do you think it is a fair assessment, at the moment, that there are places where student nurses are receiving inadequate supervision in the clinical part of their training?
Dean Royles: It is a fair assessment in the sense that I know some people will write and complain or raise concerns within their local environment that they did not get the quality of placement they were expecting or they did not get the right academic input. In the sense that it happens, it is how widespread it is.
Q340 Dr Wollaston: How widespread do you think that is?
Dean Royles: I have no evidence available that says "in X percentage of cases", but my understanding-from talking to employers and higher education institutions and the work that we have done-is that in the vast majority of cases people are getting a high quality educational input and a good quality clinical placement. That will not be perfect for all the staff all of the time, but it is largely being delivered. There are processes in place to check it out, all the sorts of tests that are in place. I do not have any evidence that says it is wrong in X percentage of cases. I can try and find if any exists, but other people may know.
Sally Taber: Certainly, there is plenty of evidence that with clinical placements in the independent sector the staff do well because we have a different staffing structure and a different layout of the hospitals. We will put in written evidence-and I apologise that we did not-but we have quoted the London Clinic, who have been identified as a good practice example from the Nursing and Midwifery Council. They did 92 student nurse placements last year in oncology and critical care and all were very well evaluated. With the LETBs the opportunity is there to use local independent sector providers for placements, which will be an excellent thing. In the past, when I first started in the independent sector, we identified a model, backed by Lord Hunt, where we paid half for a clinical placement adviser and the Department of Health paid the other half and we then coordinated all the clinical placements around England. That worked very well. The opportunities are there because there is plenty of space in the independent sector and good examples of working practice.
Q341 Dr Wollaston: Has there been any independent evaluation of the sort of feedback that you received from nurses having their placements within the private sector compared with their placements within the NHS?
Sally Taber: There has been quite a lot written in the nursing press, the Nursing Standard and the Nursing Times. If you want evidence of that, we could get some evidence.
Q342 Dr Wollaston: Thank you. Turning to voluntary codes of conduct for training standards for healthcare support workers, it is widely argued that statutory regulation is essential to protect patients. What is your view?
Dean Royles: I do not think the case has been well made that regulation is the right answer in terms of healthcare support staff. From my point of view, there is a variety of other things that you can do in terms of standards, right from how we recruit people, the values they have, the training they are given, the qualifications they have, the supervision they receive on the ground and the ongoing training and development. They are all crucial to the way that they deliver highquality care. If we only looked at regulation as a solution to some of the problems that have come up, we would miss a trick. Making sure we have those right, and appropriate standards, is a good way forward to have a look at that huge workforce that operates in a variety of different settings. One of the other things I would be anxious about in terms of regulation is that it would reduce flexibility. You would have different kinds of healthcare professionals that could do different pieces of work when you want them to be appropriately trained and supervised to be able to do a range of work that exists in the variety of different settings they find themselves in. Often it gets portrayed in the press as an "untrained workforce". That is offensive for them. They are very well trained. They get access to training, education and qualifications-NVQs, apprenticeships and all those things that go with them. We should not look at the fact that they are not regulated as saying they are not appropriately trained. We can do more in terms of looking at the processes for recruitment, supervision and oversight, and so on.
Q343 Dr Wollaston: How would you recommend we reassure the public that people are competent to carry out the tasks that they are carrying out? Who is ultimately taking responsibility and accountability if they are not properly trained?
Dean Royles: First of all, it would be to say to the public that being regulated does not mean people do not occasionally get it wrong and find themselves on the wrong side of that regulation regime. Regulation is not a solution in itself to stopping poor practice. What we can do is make sure that, with great recruitment and selection in place, we are recruiting the right people, they are appropriately trained when they come in, they are supervised and there is good ward leadership. A culture or an environment where people can raise appropriate concerns will deliver high-quality patient care. Having staff engaged and feeling valued in the work that they do is, to me, more akin to delivering highquality care than saying, "If we regulate them, it will solve all of those problems."
Q344 Dr Wollaston: Should those standards be set nationally by Health Education England or should we leave it to LETBs to decide?
Dean Royles: I think, in the current system, we should be getting someone like Skills for Health to have a look at what an appropriate standard may be and how that might work in practice so that people can understand it. Having something national in terms of a standard makes sense, rather than having it locally. That will enable a member of staff to have some sort of transferrable piece of paper to show that they are trained to an appropriate standard and that they have access to the right information when they go into different organisations. Going back to the point about investing in that particular group, making sure they have access to training and development is, of course, key to that.
David Worskett: Can I add to that? It is quite interesting that the public is particularly concerned about some of the failures in compassion and basic care rather than what you might call the higher level of clinical standards. I would very much hope that the LETBs, as they get into their stride, will look at some of the independent sector facilities, because if you look at the Care Quality Commission’s published data, on all of its core measurables-which are a lot to do with dignity, compassion and attention to the patient-the independent sector facilities score very highly. I do not want to get into the field of invidious comparisons-it is in the evidence we gave you anyway-but that is, as Sally Taber was saying earlier, partly because of the different management structures and partly because of the greater time provided to training staff in how to look after patients at that level. There is quite a lot that we have to offer there and which the LETBs should try to take advantage of. The evidence of that training, those management structures and that time paying back in terms of the quality is there in the independent CQC data.
Sally Taber: May I say that IHAS is in four countries, so we work in Scotland and Wales. Both now have employerled and employeeled standards. One of the major independent hospitals in Scotland piloted them.1 Ministers in both Scotland and Wales, when they launched the employerled and the employeeled standards, included the independent sector, as we wanted to mandate ourselves. The standards that are there are excellent. I know Wales took Scotland’s, so I cannot understand why we cannot take them. Until we can get regulations, please let us introduce these. Health Education England could do it straight away. I feel strongly, having been a director of nursing, that any regulation is not going to substitute for somebody like me, the ward manager, going round saying, "You do not feed somebody over the cot sides. This is how you do it." That is all in these standards. I urge people to take this on board fairly quickly.
Q345 Valerie Vaz: I am going to turn now to the thorny issue of money and how we fund future doctors, nurses and health professionals. I was quite interested in your views, to start with, on education and training funding and whether it should be ringfenced. Mr Royles, you specifically said that there should be ringfencing but certain services or parts of the workforce should not be ring-fenced. Could you explain that in your answer, and then could I hear from the other two, please?
Dean Royles: I apologise if I get into lots of acronyms now because this is an area that is full of them. We believe that having the £4.9 billion to £5 billion of education and training money ringfenced at the national level seems to be an appropriate thing to do to make sure that we invest that in our existing workforce in terms of continuous professional development and the future workforce that we are trying to recruit. The idea of having access to some national money, enabling employers to do that, is appropriate. What I do not think is appropriate is the way you start ringfencing parts of that money to certain professional groups. As someone said in reports in the past, once you do that you get into the situation of those that are trainingrich becoming richer and those that are trainingpoor never getting access to it. The idea of using that money more efficiently and effectively across the whole workforce is appropriate.
When you look at the funding breakdown, something like £2,000 million of that is for medical education, £1,500 million is for nurse and allied health professional education and about £500 million is for bursaries. There are huge amounts of money that are spent each year in those areas. But the way that we treat patients has moved on. If we always start by putting it in the pockets of those professional groups, then we do a disservice to the patient-we let the patient down-in that we do not adapt the way we train people to those changing needs. Once you say that you have some money available for investment in education and training and you get an effective Local Education and Training Board set up, it is appropriate to say, "How would you use this money to deliver better patient care? What are the sorts of skills that are going to be needed in the future? What are the training requirements for the existing staff to make sure they adapt to that? How can we help staff in more junior grades be promoted, because they have access to that training and education?" We cannot look at, for example, qualified regulated nurse training in isolation from the support staff. It is very important that we do that all together. Work that some regions have done, for example, on assistant practitioners in terms of creating a labour market of people who have qualified-NVQs and apprenticeships at that level that allow you to recruit them into some of those more advanced support roles-has been crucial to that whole workforce. That would be my view. Ringfence the money, certainly, but recognise that the world moves on, the way that we treat patients moves on and we need to use that money appropriately and effectively to deliver the best for our patients.
Q346 Valerie Vaz: To a certain extent, it takes longer to train a doctor than it does anyone else, does it not, so in some respects they should have the balance of the money, should they not?
Dean Royles: I understand that there is a large amount spent on medical education and training because of the amount of time to get trained and how salaries are paid in terms of junior doctors. I understand there is a big call upon that money, but I do not think we should say that we must always spend exactly the same, year on year, on one particular professional group. It might take a long time to bring people to a qualified point, but most of our staff need training from day one to retirement. They want access to that sort of training. It is a 40year career for people and we want to give them access to appropriate training so that they can do their job better each day.
Q347 Valerie Vaz: Can I hear from the other two about a ringfenced budget?
David Worskett: I have nothing to add to what Dean Royles has said. I am sure that is right.
Sally Taber: From the independent sector point of view, we are pleased that the levy seems to be requiring more work on it. We can provide training opportunities, or placement opportunities, in different areas, particularly, as David mentioned, Healthcare at Home. Bupa Home Healthcare do a lot of work in the community. If we could work with the LETBs to make sure there are training opportunities-so that we pay our way that way-that will be much better.
Q348 Valerie Vaz: I was going to come on to ask you about what your view was on the levy.
Sally Taber: It needs a lot more work on it. Levies take a while to work out. The independent sector pays a levy at the moment for the National Joint Registry and that is all worked out-everybody pays. But there are only certain providers that do joints, so it is easier to work out.
Q349 Valerie Vaz: How would you see it in the future? You have a chance now to say how you see it.
Sally Taber: I do not, actually. I see us being almost mandated or encouraged to provide training opportunities so that we contribute financially that way, in that we provide training in the areas the independent sector works in.
Q350 Valerie Vaz: You do not want a levy then.
Sally Taber: I do not know how it is going to be administered. No, not particularly. I do not.
David Worskett: I have not yet addressed the levy because I suspected there might be a separate question on this. Let me now try and deal with it. From the point of view of the independent sector NHS providers, of course we understand the highlevel thinking which drives the idea of a levy. Indeed, on the face of it, one can see why someone might come up with that idea. It does seem to us that in order to make it work effectively and to avoid it producing another set of distortions of its own, and there are a lot of distortions in the current system-the issue is, if you get a levy system, do you finish up with simply a different set of distortions? I think you probably would-for a start, you would need to have a full understanding of who did what training anyway and what the value was. As I have been trying to explain at various points, there is an awful lot of training that goes on already which is not valued and costed, and you would need to get to the bottom of all that before you could decide exactly how to structure a levy. Our feeling is that you would probably finish up by creating another more complex scheme which would have as many snags in it as the current one. The current one is not working that badly. If I might be forgiven for saying so, we have seen some examples of inventing new approaches which add additional complexity even when they were not meant to. So there is a danger there.
We rather like, as a better approach, what has emerged from the Government when it published its strategy, which is the very sound principle that anybody who is appropriate to do training should be allowed and used to do it, that the money should follow the trainee and that you run a system which works that way. I am sure the people who belong to the Partners Network would want to participate very fully in that and bear their full burden of the training responsibility.
Q351 Chair: Do you think that would address the widelyheld view that the independent sector does not pay its way-that the taxpayer pays for the training of the doctors and health professionals you utilise in your companies and you then make a profit? You are not paying your way or contributing to the training costs of those doctors or health professionals. You are simply utilising their skills, at the end of the day. Do you think that what you have said so far would give reassurance to those people who believe that?
David Worskett: It should give a lot of reassurance, yes, but I also think it is important to look at the way the whole of the health system in this country has been structured for a long time, which has always had health professionals of all categories moving between proportions of work done in their own right. It does not matter whether you are a oneperson consultant business who goes and makes money in your own right or whether you go and work for a large hospital group. This is a pluralist system in which people work sometimes as their own business and sometimes for the NHS. Trying to unscramble all of that is a huge challenge.
Q352 Chair: But, overall, the taxpayer and the patient will be getting the benefit of that, not the private company. You are not unscrambling that for me.
David Worskett: I am not quite sure I understand the question.
Q353 Valerie Vaz: Can I put it? You are benefiting from a very long training of professionals. Do you not feel that you should pay something back towards that, given you have the benefit of that expertise?
David Worskett: Ideally, it would be through doing more of the training ourselves and putting the training in.
Q354 Valerie Vaz: But nothing else-no levy back to the public sector.
Sally Taber: Having worked in the independent sector on the shop floor as a director of nursing for 10 years, I only stayed there because I wanted to dispel the myth that we do not do any education. I have raised it with the Chief Nurse and this is why we did the booklet called "Dispelling the Myth". I think that what you have said is wrong. We do contribute. I have an example of the London Clinic and what they contribute. They do not ask to be paid for that at the moment because that is not the structure. But, as David said, we could let the money follow where the trainee goes, providing the independent sector is prepared to train. There are so many opportunities there. I had student nurses the whole time that I was director of nursing for 10 years and made sure that they received good training. We evaluated what we were doing. I think you are living with a myth that is not true.
Q355 Valerie Vaz: Okay. Let me put a scenario to you. I have spoken to a doctor, a radiologist, who says she is penalised because she is doing 25 scans as opposed to someone else who is doing 30 scans, and that is how they are measured. But, she says, "I take trainees." How do you build that into the system? How do you build someone who is prepared to train the next generation and they do not quite come up with the tick box of having done enough scans?
Sally Taber: The independent sector has always taken trainee radiographers as well. I think it is a myth that needs to be dispelled. Perhaps it is our fault that we have not raised our profile enough to say exactly what we do. I am going to leave you this. Please look through it and we will put in evidence as to how much training the organisations actually do.
David Worskett: Specifically on the radiographer point, both the major independent sector diagnostics companies who belong to the Partners Network have very substantive training programmes for radiographers and put a lot of time and money into it. The other point we need to remember is that if you try, in a sense, to almost unravel this complex plural structure you have to look at other costs. As we can only use a consultant in an independent sector hospital to carry out surgery and we cannot use a registrar or an even more junior doctor, that in itself-a training opportunity which we are not allowed to engage in-also means we have a higher cost because a significant proportion of operations in the major NHS-
Q356 Valerie Vaz: You can charge more.
David Worskett: This is when we are doing NHS work. We do not charge more when we are doing NHS work. We do it at NHS tariff. That is quite important. But the cost to us of doing that, given that we can only use a consultant, is, by definition, going to be higher. If we are going to try and even this out-and I absolutely understand where the question comes from-we will get into a terrible morass of interlinked issues, and the system does not work that badly at the moment.
Q357 Valerie Vaz: We are here to find out your views. That is why we are here. Turning, slightly differently, to what is happening to the budget now in terms of education and training, how do you stop that from being raided by the SHAs before 2013?
Dean Royles: You occasionally come across this, that the education and training budget is being raided in some way. I will often say to people, "Just make sure you provide the evidence locally because it would be a scandal if that was the case." What some people mean is that money that they think was ringfenced to one particular profession is not spent in that profession but is spent somewhere else. With the cycles of the way that the money is spent, an academic year tends to work September to September and the financial year tends to work April to April; therefore, sometimes, at the end of the financial year, you have not spent all the money that you would have spent in an academic year. I do not think there is any attempt to try and raid the education and training money.
On the levy and the funding issue, the principle of the idea that you have money following the training makes sense if you can develop something that is transparent to people and they understand how that works and it is not too bureaucratic. Then you have to look at what the transition period might be because this needs money moving around the system. It is important that we do not destabilise organisations in terms of making rapid changes with regard to what can be large amounts of money.
Q358 Valerie Vaz: Could I, finally, hear your views about what the Future Forum have proposed in terms of a quality premium?
Sally Taber: It is a good idea. We have asked the CQC to consider it for those independent sector organisations that use a quality management system, to note that as a premium. I am not saying to reduce their fees but for it to be noted. I think a quality premium is an excellent way forward.
David Worskett: I agree with that. I would like to see part of it targeted at some of those things that are not looked at as much as they should be, such as the more basic evidence of patient care, compassion and dignity, because we need to build that in a rather harderedged way.
Dean Royles: Again, I agree in principle. The idea of rewarding highquality training, given in both an academic and clinical setting, makes sense if we can get a good definition, working with different partners, about what we mean by "quality"-that there is an agreed measurement for that-and then understanding how that might apply in practice and what is the impact on organisations. In principle, it seems to be a very good idea.
Q359 Dr Wollaston: Can I return to an earlier point? Sally has made a good case for the contribution that the private sector can bring to nurse training. However, I am a little concerned. If the contribution to training surgeons is that you offer a discount to less wealthy cosmetic surgery patients in order to have their surgery carried out by registrars, it is rather worrying. Is there a case for saying, in the case of surgeons, that there should be a levy that goes towards providing further training? I realise, to some extent, that your hands are tied.
Sally Taber: Perhaps you did not understand the model. It is a discount to patients, because they are having a senior registrar come across to be taught and because you cannot charge the full rate. It was really very much a model to contribute to training because there is not cosmetic surgery training in the NHS.
Q360 Dr Wollaston: I am sorry, did you say there is not cosmetic surgery training in the NHS for surgeons?
Sally Taber: No. This has been part of the problem-that surgery has been selftaught. Each of the faculties have been asked to look at how they build a cosmetic element into their training. Certainly Dr Andrew VallanceOwen, who is the chair of our cosmetic surgery group, has written to BAAPS to say, "You have to get on with this." So, as such, if a patient requires a mastectomy and breast implants, that is built into training, but there is not a proper training model that is out in the public domain. One of the things we have written to say is, "Please, let us work together to get on with it." I think you are all aware of the conflict that is happening now between the independent sector and the plastic surgeons. It has to stop because we can only tackle this problem if we work together and make sure that people are adequately trained. I feel very strongly about it.
Q361 Dr Wollaston: Or maybe we should reduce the perverse incentives that exist for people to have cosmetic surgery in the first place. I will not get into that.
Sally Taber: The good providers are not-
Q362 David Tredinnick: I had better not run with that one. I could easily come up with 10 questions on that subject, based on our inquiry on breast implant removal last week, but I will not be drawn, Chair.
I think, Mr Worskett, you said that often, or sometimes, as private providers you are making a contribution over and above the basic NHS costs in terms of training. I think you said, for example, that a consultant might be used for training. That is an example, is it not, of where you are offering something as private suppliers which benefits the NHS?
David Worskett: Yes, absolutely. We were talking in the last few minutes about the consultants and the doctors, but that proposition is true in spades of other types of training of nurses and others.
Q363 David Tredinnick: This is significantly underestimated and underpublicised.
David Worskett: Yes, it is.
Sally Taber: Our problem is that we underpublicise.
Q364 David Tredinnick: Perhaps we will give you a chance to publicise and finish by asking you to tell us what the London Clinic does do. You have a paper there that you almost talked about.
Sally Taber: Yes. The London Clinic has a clinical development nurse managing student nurses-a contract with City University. They offer placements for physiotherapy, radiology and radiotherapy students. As I said, last year they had 92 student nurses for clinical placements. They have done 30 so far this year. They have an award in critical care and oncology from what they have done with City University and they have a key mentor forum which looks at good practice and consistency. This has been recognised by the Nursing and Midwifery Council. That is just central London-
Q365 David Tredinnick: How much of that is a free service in terms of the Health Service there?
Sally Taber: It is free to the NHS.
Q366 David Tredinnick: The NHS is getting this from the private sector for nothing, so that we are absolutely clear.
Sally Taber: Yes.
David Tredinnick: And it is a substantial contribution.
David Worskett: This is slightly anecdotal, but in the last six months I have been round three independent sector hospitals that carry out NHS work. In every single one I have been talking to NHS nurses there on secondment through an arrangement with the local trust, undertaking a degree of training absolutely free of charge.
David Tredinnick: Thank you very much.
Chair: Thank you. Thank you all very much for your attendance today and your very helpful answers.
Examination of Witnesses
Witnesses: Dr Tom Dolphin, Chair, Junior Doctors Committee, British Medical Association, Sara Gorton, Senior National Officer, Health Service Group, UNISON, Dr Peter Carter, OBE, General Secretary, Royal College of Nursing, and Obi Amadi, Lead Professional Officer, Unite/Community Practitioners’ and Health Visitors’ Association, gave evidence.
Q367 Chair: Good morning to our second panel. If I might briefly explain, the Chairman is away at a funeral in his constituency. He sends his apologies and the pale reflection will continue to chair the meeting. As I said to the initial panel, could you briefly tell us about your organisation and also how you would summarise your organisation’s view of the Government’s reform plans in "Developing the Healthcare Workforce" and the update, "From Design to Delivery"? We can wrap those two up into one question because we have a lot of questions to ask you. Thank you. Can we start with Tom?
Dr Dolphin: Good afternoon. I am Tom Dolphin, Chair of the Junior Doctors Committee at the BMA. The BMA, as I am sure you know, is the professional association that represents doctors in the United Kingdom.
In terms of our response to the "From Design to Delivery" report, we are broadly quite happy with the detail in that paper and we are pleased to see, particularly, that the postgraduate deans will continue to have a role in the new system and the deanery functions will carry on within the LETBs-the Local Education and Training Boards. We are glad that those boards will also have an independent chair. That is quite important and we are very glad to see it.
In terms of remaining concerns, we are concerned a little about the proposal to extend the use of the existing training funds to cover more things, the education for bands 1 to 4 in Agenda for Change and continuing professional development, spreading it to cover those as well. We have concerns about the linked "Shape of Training and Shape of the Workforce" project that is going on at the moment as to training pathways in the future.
Lastly, we want to see more detail about how the LETBs’ duties will be delegated to them. There seemed to be a lot of scope for flexibility as to how they run their governance structures and we would like to see more detail on that.
Sara Gorton: I am Sara Gorton, a Senior National Officer at UNISON. We are the trade union that represents about 450,000 members working in the National Health Service. Broadly, 60% of our membership is from the nursing family but we have also been responding on the education and training issues, particularly from the perspective of our staff working in support services-therapy support, support to nursing, ambulance support workers and technicians. From the start, we have been concerned about the oversight and governance of the proposed system and potential conflicts of interest that could arise. We have been raising issues about the inclusion of the wider workforce and the responsibility of recognising the important role of training the bands 1 to 4 staff. We were pleased to see that that has been recognised to some extent in the "From Design to Delivery" document but we still have concerns about the lack of detail as to structures and accountability, particularly with the LETBs and their function. There need to be firmer duties covering the wider workforce.
There is a range of issues about how you achieve buyin and participation from all of the future providers within a postBill system into the education and training plans but also how that translates into active workforce planning and reshaping at the moment. Running through all of them is a general concern about the pace of the changes and the risk this has of creating instability.
Dr Carter: I am Peter Carter from the Royal College of Nursing. The RCN has over 420,000 members. We represent registered nurses, student nurses, healthcare assistants- increasingly so-and a range of other roles such as nursing cadets.
It is worth mentioning that although we have a membership of 420,000, 100,000 of our members do not work in the NHS. Nearly 25% of our members are working elsewhere, in the independent sector, the voluntary sector and so on.
We welcome the Government’s aspirations and, broadly speaking, this is a good way forward. However, similar to what Tom and Sara have said, we have huge concerns about the governance and accountability arrangements. The phrase I would use is that there is a lack of what I would call the hard-wiring. We are not quite sure where the levers are or where the accountability lines are, and we want to ensure that all this ultimately ends up as the responsibility of the Secretary of State, not personally for the daytoday operation of these things, of course. What we want to see is that hard-wiring to ensure you do not end up with a federated system.
We also have issues to do with time scales and the lack of congruence, as we would see it, between the Health and Social Care Bill and the paper on "Developing the Healthcare Workforce". We want to see more of an alignment of those time scales, otherwise it could result in confusion. We also like the idea of an independent chair, which is important, but we do think that far more detail is needed.
Obi Amadi: My name is Obi Amadi. I am the Lead Professional Officer for Unite the Union working in the health sector. In the health sector, Unite the Union represents 100,000 health sector workers, including a large number of community nurses, health visitors, school nurses and mental health nurses as well as other professions, such as pharmacy.
We are very concerned about the Health and Social Care Bill. Potentially, it could be a disaster in terms of education and training for the workforce because of the fragmentation it would cause, the increased cost and the risk of privatisation of the service. We recognise that the current system is not ideal but we are concerned about the new system being put in place and its ability to function effectively for the workforce.
As to the amendments of the House of Lords, yes, we acknowledge that. But we are still concerned that they do not go far enough in terms of where we feel we need to be to guarantee longterm workforce planning and education for that future workforce.
With regard to HEE and LETBs, it needs a lot more definition. We are concerned about governance, the lack of detail and clarity and also the timing in terms of moving those forward.
Chair: Thank you. I will bring David in on new organisational structures.
Q368 David Tredinnick: It seems as yet unclear what legal status Local Education and Training Boards will have, and it is a point you touched on. What do you think it should be and how far should the local boards be autonomous from Health Education England? Who would like to take that? We have quite an agenda to get through-a whole range of things-but we are going to stay on organisational structures for a moment before going to general workforce and planning issues. Perhaps we should go down the line, Chair, with your permission.
Dr Dolphin: The BMA is quite supportive of the LETBs having delegated authority from Health Education England. Rather than necessarily being fully independent and autonomous bodies, they should have their authority delegated to them from HEE. That would ensure that they can continue to be held to account for the quality of the training they provide, commissioning, and workforce planning and that sort of thing.
Sara Gorton: We have a concern about the vagueness of the legal status that LETBs seem to have and we would like to see some tightening on that. In particular, we would like to support the idea that Dean Royles was promoting about strong employer involvement. Maybe looking at hosting the LETBs within existing NHS structures could be a way of doing that. We would also like to see a duty on LETBs to promote collaboration from among provider organisations within a local health economy so that you can get the best possible chance of achieving a kind of whole sector buy-in from across quite a wide range of providers.
Dr Carter: We believe that LETBs should be legally established as NHS organisations. Again, there should be clear accountability. We also believe that it would enable more existing NHS staff to be able to go and work in LETBs if they are part of the NHS for their terms and their conditions, otherwise you could end up losing expertise.
Obi Amadi: We are of the opinion that, in terms of the LETBs, there is still some clarity that we need to have, but accountability for them needs to be very strong. There needs to be robust governance. We think that it should remain within the NHS but, also, there are issues to address in terms of conflict of interest.
Q369 David Tredinnick: May I ask Sara Gorton why UNISON is worried about the possibility of a social enterprise model for the local boards in some areas?
Sara Gorton: It is not so much the social enterprise model per se. It is the distancing of the role that the LETBs will have from provider organisations. Maintaining that function, as other people have contributed, will mean, if those people are all part of the NHS, that you do not see a sudden leaching of skills outside the statutory sector. It will also make collaboration across different parts of health provision much easier. One of the panellists earlier talked about end-of-life care. If you are looking at workforce planning for an area like that, which touches on a range of different types of providers, it is much easier to do if it is within part of an existing NHS organisation having a statutory role.
Q370 David Tredinnick: Dr Dolphin, the BMA memo suggests that a wide range of stakeholders should be represented on the local boards. How do you respond to the argument that this could make them cumbersome and effectively stop them from being employer-led?
Dr Dolphin: In the past, as we heard from Dean Royles and others before, there have been problems with employers not having enough voice and input into workforce planning. There certainly needs to be more opportunity for employers to be involved. One of the concerns we had originally was that the LETBs looked like they were going to be too employer-dominated-too heavy on the employer side. The proposition that is currently on the table is a lot better in the balance that it achieves. We are concerned that we have to have all the relevant stakeholders on board, yes. If that includes the private sector providers providing training, they need to be there as well. You have to have the full range there to make sure that you get a valid workforce plan out of the LETB.
Q371 David Tredinnick: You have also suggested that postgraduate deans could be employed by Health Education England and seconded to the local boards. Why do you think that is a good idea?
Dr Dolphin: That would be better in terms of allowing the deans to remain independent with regard to enforcing the quality of training. They would be able to act without fear or favour when they go to the different employers, without having to worry that their employment status might affect their judgment. It also means that, if they are coming from HEE and being sent out to the different LETBs, there will be consistency in how their role is applied across the different LETBs across the country. So you have consistency of standards across the UK.
Q372 Chair: Thank you. I would like to ask a couple of questions to Sara, Peter and Obi. The Chancellor has asked the NHS Pay Review Body to report in July this year on regional and local pay. Could you say what you think the implications are for national workforce planning? Sara, do you want to start?
Sara Gorton: We have huge concerns about the impact of the introduction of a regional pay model, particularly in winding back the clock to reverse the work that has been done and the investment that has been made in the Agenda for Change pay system. In particular, in relation to the education and training issues, we would see the introduction of regional pay militating against a whole joinedup system-the opportunity to share that approach with each type of provider competing. You could end up seeing certain pockets of staff being in shortage in certain areas, which would have a detrimental impact.
We are hearing from members on the ground that what is more of a concern in the immediate future is the impact of the efficiency savings and the budgets that is preventing a joinedup and wellthoughtthrough planned process to changing the shape of the workforce-that is, a lot of the reprofiling work. There is a strong argument for doing it, to look at new ways that we can respond to patient need and train people for different parts of the care pathways so that we can achieve best system efficiencies. The opportunity to do that in a planned way is being missed because there is not a consistent approach with a common understanding about how that will happen. A lot of the time we are hearing that role substitution is simply taking place, with sometimes registered staff being taken out of the system and replaced by assistant-practitioner level staff without a clear understanding of where the layers of accountability and supervision sit within those structures. We would like to see a consistent approach and a recommendation that we look at this issue from a whole-system perspective.
Dr Carter: This is something we will resist strongly. We are absolutely against it. Sara has already clarified the point. A lot of time, work, energy and money has been spent on Agenda for Change, which we think was a huge step forward for the NHS and, if properly implemented, respects and rewards the skills of the whole of the workforce in the way that it should. If this goes ahead, we see huge problems emerging in the service. First of all, it will lead to dissatisfaction and disaffection. It will also lead to migration of the workforce. With people looking at adjoining areas and being able to move across, we can foresee shortages of staff and then trusts and employers panicking and having to play catchup.
Also, people tend to think of it as a regional issue, of, say, a poor area in the north-east as opposed to London. But even here, in London, we have been talking to a lot of chief executives of trusts who are telling us that this is not what they want. In London there are huge differentials in the cost of living and it would be very easy for a person perhaps living in a poorer area of London to jump on a tube and, 20 minutes away, go into a trust that is paying higher. That, again, will lead to problems. Trusts themselves say to us that the mechanism needed for setting up their own individual pay and conditions will probably cancel out any perceived savings the Chancellor envisages.
We would encourage this Committee to look at the examples from overseas, and I will briefly mention one. They tried this in Sweden some years ago. Sweden is a very good example because it is often held up as an economy that is stable and is, relatively speaking, a wealthy country. But there are significant differences in the cost of living in different parts of Sweden. They tried this and about eight years into it, I think it was, it had resulted in such chaos that they basically dispensed with it and went back to the arrangements broadly similar to what we have in the UK. Our advice would be "Do not go there". It is not worth the candle, so to speak.
Obi Amadi: I agree with my two colleagues in terms of that change. It is something that we think should definitely be avoided. The work that was done on Agenda for Change and the principle of it is something that we still value and still has currency today. We are already hearing examples of tensions that exist where some organisations have merged, finding that staff with the same or similar roles are being remunerated differently. The organisation’s way forward is immediately to put all staff on reduced pay, rather than evaluating what their job roles are and paying them according to that. If this is something that is introduced and there is local pay, we can very clearly see that there will be an issue where local health economies will be destabilised and staff will move to where they find they will be remunerated at a higher rate. Then there will be the whole issue of shortages of particular staff groups, which is plainly avoidable.
Q373 Dr Poulter: I have two practical points on this. First of all, accepting what you have said, we know that there are some hospitals, even within relatively affluent parts of the country, and hospitals in Wales as well, for example-and I know we are dealing with a different healthcare system in Wales, but nevertheless-that have difficulty recruiting. Would you say, notwithstanding you are saying there should be a national pay level, that it is a good idea for some hospitals to financially incentivise people to relocate, to go and work at those hospitals? From a doctor’s point of view, it is difficult for some trusts to recruit juniors and consultants, but also-another view-some nursing and specialist posts are going unfilled. When we talk about workforce redesign, it is difficult to redesign a workforce if people are not going to move to work in a certain location. Would incentivisations to get people to move to those places where there is a problem with recruitment be something you would accept as a good idea potentially?
Sara Gorton: Within the Agenda for Change agreement there exist the facility and flexibility to apply recruitment and retention premiums. There is a set of criteria set out so that there can be agreement at a local level across a health economy that there is a need for an RRP to be applied for particular groups of staff. In some places in the southeast there are particular areas where these have been applied to whole job groups. There are other areas where recruitment and retention premiums have been applied to attract staff to specific types of environment, forensic and mental health environments, for example. We would say the system already does have the flexibility. What is militating against applying that flexibility at the moment is the efficiency savings.
Q374 Dr Poulter: That is a point of opinion, not a point of fact. I can see that you have accepted what I have just said. It is a political point, not a point of fact. I am sure you would like to get it on the record as a point of fact, but it is not. My experience as a doctor, when I was training in London on rotation, was that some of the hospitals I went round had very good-and this was before the Nicholson challenge or any of the current healthcare reforms-records of staff recruitment and others were struggling to recruit across all sectors. This is a long-standing problem and it is wrong for you to simplify it in that way, trying to make cheap point-scoring, to be perfectly frank, on that.
Nevertheless, coming back to the substantive issue as to those incentives that were in Agenda for Change, there is concern that they have not necessarily worked. If organisations went further and offered significant financial incentives for people to go and work in a trust where there is a difficulty-and I can think of trusts in Kent that may benefit, in the relatively affluent south-east-would that be something you would think is acceptable, significant financial relocation incentives, much as the private sector may offer to get people to move in to work in their area, rather than it being only on pay banding and whether you are a band 7 or 8 or that sort of thing, which is largely what happens now?
Sara Gorton: There are several issues there. We would not want to see that happening outside the system. We believe-I accept it is an opinion rather than fact-that the system has the flexibility to be able to cope with that. There was an Audit Commission report a couple of years ago which suggested that there were still major benefits to be extracted from the system, looking at other areas, not only recruiting to particular roles but how the organisations can structure the reshaping of their workforce. It is not looking at recruitment solely in terms of financial incentives but looking at it as a package of what an organisation can offer as a whole.
Q375 Dr Poulter: I have one more question before I come on to questions for Dr Dolphin, if that is all right. Earlier on, Dr Carter and Obi Amadi raised the issue that there is a concern with the current healthcare reforms about the potential fragmentation of training. Those are my words, not yours. At the moment, in terms of the nursing workforce and healthcare assistants, a lot of those people are employed not in the NHS, not in the hospital like the one over the river, but in care homes and the care sector as well. A very real problem we currently have-and it has been flagged up in previous evidence-is that we already have a system that is fragmented and does not deal with the training needs of those people who do not work directly for an NHS employer. This is quite a long-standing problem. I was wondering about what you may flag up as solutions, as to how we can address that.
Dr Carter: Can I take the liberty of contributing to your previous question before that is lost? You mentioned the issue to do with differentials in terms of some employers being able to recruit staff and some not. I do not want to sound glib, but I do not think regional pay will solve that. What you have to do is look at why it is that hospital X retains their staff and can recruit staff and hospital Y cannot. I visit hospitals and healthcare facilities all over the country and you will often find staff who will drive past a hospital for, maybe, several miles, because they are working for an employer who makes them feel very valued and that sort of thing.
In relation to the recruitment and retention premiums-and, again, I completely agree with Sara-if Agenda for Change is properly implemented, there is sufficient facility in there. However, what I would encourage you, at some stage, to give further thought to is the whole issue to do with key-worker housing. Different Governments in different eras have looked at this. There is an issue to do with-and I will use this as an example, as you would expect me to-newly-qualified nurses earning £23,000. Many of them train in London and want to stay there, but it is totally unrealistic. They often move off to other areas, giving up jobs that they really enjoy, because they simply cannot afford to get on the housing market. Some more imaginative thinking on that would be a sensible way forward.
Obi Amadi: I would agree.
Q376 Dr Poulter: Can we get back to my other question? I do not want to be too time-indulgent. I want to get back into the question about fragmented training because that is quite an important issue. A number of the medical workforce nurses and care assistants are in the care sector and that has been a longstanding issue. I hear the concerns you are raising with the healthcare reform, but this is a very long-standing issue. How can we go forward in a better way to make sure that that workforce-the workforce that is not directly employed by an NHS hospital-receives the training and support that they need to do their job and to adapt their working practices to modern challenges, such as the increasing numbers of people with dementia?
Dr Carter: I agree with you. Again, this is something that has been a long-standing problem that has gone on for decades. This is not a new phenomenon, which is why, with the reservations that I expressed, we broadly welcomed this latest initiative. There have been long-standing problems with workforce planning, which I am sure we will get on to later, and-again, I am sure we will come on to it later-variances in the standards and quality of education and training. That is why, broadly, the idea of having a refreshed approach to this seems to us to be the right direction of travel.
Obi Amadi: In terms of being able to reduce this fragmentation and the variation that we have, some work needs to be done to understand very clearly the roles that are required- the competencies and the standards of practice that that workforce have to adhere to. If bringing that under the remit of LETBs and others is the way forward, then that is what we need to look at to bring that into better perspective.
Q377 Dr Poulter: Dr Dolphin, we heard earlier from the private sector providers that they were quite hopeful that the private sector does a good job already and can do a good job in terms of workforce training. What is the experience of BMA members-I speak as one, but I am obviously asking you-of the involvement of the private sector in training junior doctors? Is there any?
Dr Dolphin: There has been some in the past. It is quite limited. Within the independent sector treatment centre contracts that were mentioned before, some of those centres were set up to receive trainees for very short, focused periods of time and there was some training that took place in them, but it was quite limited in scope for the reasons they have said. The concern that we have with it is this. First of all, if you try and draw them into the training economy, as it were, they may be less willing to provide training because it requires quite a lot of investment of infrastructure and so on in order to set those things up. Medical training, in particular, requires quite a lot of infrastructure, set-up and time for teaching and training and so on. Although it may not be the case so much now, it has certainly been the case in the past that the independent sector has treated training as being an externality that they can rely on others providing for them. That may be becoming less so, but it was the case in the past.
The other thing is this. When you have these independent sector providers providing training, because of the way the health economy works, they tend to take cases that are going to be simpler and with a high turnover. That is fine for going there and doing short bursts of getting lots of experience and cases under your belt, but it does not give you exposure to the full breadth of clinical practice and you have quite a limited scope within those training posts. It is quite good for topping up your training but not very good for making sure you have the full coverage of everything you need to be fully accredited for the Royal College.
Q378 Dr Poulter: That is very useful. There is a general discussion about the need for consultantled care or the drive for that. Some of it may be dictated by good practice and some of it by the fact that consultants need to be bodies on the ground with the EWTD. What is your view? Is it a good thing to have 24hour consultantled care, or the drive towards that, or is it a bad thing? What impact will it have upon training?
Dr Dolphin: The model we are proposing is not so much consultant-present as trained-doctor service. A trained doctor, of course, can include not just consultants, GPs and clinical academics but also staff and associate specialist doctors who are trained for the role that they are performing. Although it is limited in scope, they are trained for that and often have many years of experience and provide excellence in that area.
While training occurs through exposure to patients and delivering patient care, our view is that junior doctors ought to be viewed as being employed primarily to train. There will be service provision arising from that, but their primary focus should be training. It is the current arrangement they have for GP trainees and we think that ought to be the same in hospitals. Having a trained-doctor service or a consultant-present service-however you want to describe it-would allow that to be achieved.
You mentioned earlier that you were concerned people might be oversupervised. I would disagree with you there and say that, if you are better supervised, you are going to get better training because you have somebody there explaining what it is that you are seeing and correcting mistakes or misapprehensions you may have and so on. You and I have both experienced the stress of being undersupervised at work and not feeling that you are being supported. I think the days of "do not hesitate to cope" have to come to an end.
Q379 Dr Poulter: The Future Forum has pressed for the Government to support Sir John Tooke’s recommendations on longer GP training, more flexible career pathways and encouraging greater generalisation in training in primary and secondary care. What is the BMA Junior Doctors Committee’s view on that? Does training of junior doctors need to be longer? Do you need there to be more generalism, and, specifically, does GP training need to be bit longer than it is at the moment?
Dr Dolphin: The stated rationale for the need for increased GP training is that the long-anticipated-in fact, forever-anticipated-shift to community care means that GPs will need to have a broader range of exposure, and so on. There needs to be a good educational case made for it. They have almost made it, but not quite yet. The Department of Health are very keen to see that whatever extension there is has to be affordable and sustainable. It is quite right that it does have to be-and it should not only be-about providing more service while you are in your training years, which is a concern that we might have, partly because it will involve increasing the number of hospital posts that those GPs rotate through. Not all GP training happens in general practice; a lot of it happens in hospitals as well. They go through exposure to the different specialties they will be looking after in the community. We are concerned that we do not want to impact too much on the hospital by taking training places away from the specialty training.
If I could mention at this point the "Shape of Training and Shape of the Workforce" work stream, something that the Department of Health are doing at the moment and is related to your question, it is looking at the training pathways and how long the training should be, how it should be structured and where people take breaks in that. We are quite concerned at some of the work that is being done at the moment-some of the suggestions that are coming out-that would introduce more break points in training where people leave training in order to consolidate their experience, i.e. by providing service at a junior level. While that is about flexible career pathways, we are concerned that there will be paths out of training but not clear paths back into training and we will end up with people being stuck on the outside of training, partly trained and unable to get back in to continue.
We saw a similar thing in the mid2000s with SHOs being stuck, unable to get on to the next stage of the ladder. There was a growing cohort every year. More people would come in at the back end trying to get on and nobody was getting on to the next stage. That became a very serious situation and we had large numbers of people that were only dealt with through the MMC issues that arose. We are very keen not to see that happen again and we are worried that what is being proposed at the moment might result in that.
Q380 Dr Poulter: Can I clarify specifically the issues about the current training and GP training system, accepting the previous problems? There is now a progression in training in different specialties. The EWTD has come and reduced exposure and time on the wards and service provision, and has compromised training-we have heard in previous evidence-in some hospitals. Do you feel, in view of that, that junior doctors need to train for longer in general practice-have more general training-before they specialise perhaps?
Dr Dolphin: There are several questions within that. We need to distinguish between having more people who are training to be general practitioners and having more generalism within hospital specialties, which are two things that get a little conflated with some of the questions and in other things-documents-outside. In terms of whether people should be training longer, there is a lot of wasted opportunity for training in hospitals.
We accept that the European Working Time Directive has had a negative impact, particularly on the craft specialties-the surgical specialties. Despite that, we think it is possible to train in a 48hour week. It can be done, but there has to be more focus on training. At the moment, the service still depends on junior doctors for delivery of care. That has to come first, obviously, but that does not leave much time in a 48hour week for providing training. If we shifted, as I say, to a trained-doctor service, where the service is not reliant on the junior doctors, they would have a lot more opportunity to get the training they need and to get all the things they need covered within the 48hour week. In some cases, it may be that the curriculum needs to be extended to cover an extra year, but it is for each individual specialty to make that decision.
Q381 Dr Wollaston: I want to move on to nonmedical education. Can I ask Peter Carter a question, please? You have been quoted as saying that some nursing degrees are too geared to classroom learning rather than hands-on training. How much do you feel the blame for poor-quality courses lies with the universities, and how much do you feel it lies with the Nursing and Midwifery Council?
Dr Carter: Thank you for the question. Can I answer that by saying, at the outset, that although I have been quoted in various newspapers as saying things, I want to set the record straight? The vast majority of Britain’s universities that train nurses train them well-or educate them, I should say. I want to be crystal clear about that. Overall, Britain’s training and education of its nurses is something to be very proud of.
However, I have been concerned-albeit with a small number of universities-that we have come across some significant problems. It is a shared problem between the universities and what I would call the service, rather than just the hospital. As you know, nurses are educated and trained in a variety of settings. We have been concerned that, at times, there is a lack of congruence between what the universities and the service are expecting. There has been more joint working. I do not want to trade off where it is working well, and I have already made that point. I have to be concerned with where there are problems.
Can I also take the opportunity to dispel what I consider to be one of these myths? It has nothing to do with nurses being educated at degree level. People currently are saying, "The problem with nursing is they all have these degrees." In actual fact, that is statistically not true. Most nurses currently do not have degrees, so if you are attributing any current perceived difficulties to them being degree-educated, it is not true. Allgraduate education comes in next year. Over the course of time, that will be the case, but nursing degrees have been around since 1926.
If I could go on, you get some of the problems-and I was sitting in on the previous session-when the placement might be satisfactory but, often, there are too many student nurses in the setting. I will give you a brief example. Back in the autumn I was visiting a very good hospital in the southeast and I was on the paediatric unit. It was everything you could have wished for. I spoke to parents and it was great. I spoke to the ward sister and said, "It all feels too perfect. There must be something that concerns you," and she said, "Yes, it is the student nurses." When I asked what the problem was, she said, "The problem is that at any given time I can have up to 12 student nurses, and I do not have the capacity to be able to give them the education and the training that they need to help them with this placement." That would be an example, we would say, where there is a disconnect between the university and the service. We know that all placements are subject to an annual audit. That is an example where, for whatever reason, it has broken down. That is no good for the individual nurse and, ultimately, no good for the service. What we say is that, in these small numbers of universities where it is clearly not working, you have to get your act together for all the reasons that we would understand. Does that help to clarify it?
Q382 Dr Wollaston: It does, yes. Thank you for clarifying your position on the other matters as well. How far do you think the new system will be able to address some of these difficulties?
Dr Carter: Often organisations, Governments and employers look to systems to solve problems. In my experience, irrespective of the architecture, it is how well you implement it. If you take the example that I gave of what was clearly a very good hospital-and I also know there is a very good university-clearly, in that instance, there was a disconnect with what was going on. Irrespective of the system, the process and the architecture that you put in, it is only as good as the people that are operating them. What I said to both parties in that sense is, "You have to get together and sort this out." I rarely think that reorganising will solve a problem if the problem is poor implementation of the existing arrangements.
Q383 Dr Wollaston: Thank you. Do any of the other panellists want to come in to comment on the existing structures for nursing development? No.
The other issue that I touched on with the previous panel-and you may have been here-was the issue of the shortcomings in the personal professional development for nonregistered staff in general. Perhaps, Sara Gorton, I could ask you to comment for bands 1 to 4. Could you explain the causes and consequences and say what can be done about it?
Sara Gorton: In terms of the causes, when Agenda for Change was put in, there was an assumption that the NHS workforce, as a whole, had a properly embedded culture of appraisal and development. We found, to our cost, in many places that was not the case, particularly for those groups of staff who did not have a framework for continuing professional development set as a result of post-registration training and development. There was no reference for those groups of staff, particularly in bands 1 to 4, who are often providing frontline care and have quite a lot of face-to-face time with patients. Suddenly they were presented with what, in the hands of some organisations, became seen as an overly bureaucratic process.
We have now reached a stage where, in 2010, the staff survey found that 77% of staff have had an appraisal. That sounds very good, but when you dig underneath a little, only 34% of those people found that it was meaningful. That means there is still some way to go in order to correct those issues. Lots of work has been done over the last year to make the KSF-the Knowledge and Skills Framework-a lot more pragmatic, and it has increased takeup. We look forward to the staff survey figures in a month’s time to show whether the proof of the pudding follows through into the eating.
In terms of the consequences of lack of appraisal and lack of buyin, I would return to the issues about the future shape of the workforce. People in the previous session-Dean in particular-were talking about the way of not simply replicating old systems but responding to changing boundaries for provision, and new ways of providing care, particularly as we look to move more care outside of hospitals and into people’s homes. We would miss the opportunity to tap that resource, to buy people into that system and, also, to grow our own. One of the risks that we would see from a more fragmented type of provision-plus moving to an all-graduate nursing profession eventually-is that we would have to put more checks and balances in place to make sure that that workforce still reflects the local community that it serves as well, and that people who start working within the nursing workforce at bands 3 and 4 still have the opportunity to progress through that system via the Skills Escalator.
Q384 Dr Wollaston: So that is providing better inhouse training. What about the idea of having concepts like studio schools, where you are locally training a workforce dedicated to coming into this branch of the profession?
Sara Gorton: One of the responsibilities that we would like to see the LETBs have is the role to collaborate, so that if you are looking at quite niche provision-if you move to a system where you have a number of small providers each with only a very limited pool of staff, so you may only have four or five support workers who specialise in endoflife care, for example-you could pool resources across a health economy and more effectively train people. Further work needs to be done on how those would be funded and would interact and respond to the needs of the provider organisations, but it is a very interesting idea.
Q385 Chair: Before I come to Valerie, could I ask a question of Sara, Peter and Obi? We have heard evidence from the Council of Deans that it is possible to achieve appropriate education, training and supervisory arrangements for healthcare support workers without statutory regulation. What is your opinion of that?
Dr Carter: We fundamentally disagree. The situation that we find ourselves in right across the UK is that, over the last two decades, the number of healthcare assistants and support workers has grown incrementally year on year. The current situation is this. Within the NHS you now have 300,000 healthcare assistants and you have the same number, broadly speaking, in the nonNational Health sector, in care homes and residential homes. I do not want to give you a mixed message, but healthcare assistants are an absolutely integral part of the workforce. We want them, they are valuable and we need them. The issue for us is that, while some employers at one end of the spectrum educate and train them to a very high degree and some do it okay, there are copious examples of employers giving them next to nothing.
What basically happens in some of our healthcare settings is that people are employed, they are given a tunic-they look like a nurse-they are put into wards and other healthcare settings and they have to pick it up as they go along. That is wholly unacceptable. You would not do it in any other walk of life and I am not sure why we think it is acceptable in healthcare. It is particularly so with the elderly. Most of the care in elderly care settings nowadays is provided by healthcare assistants, often under the supervision of a ward which has one registered nurse on it at any given time. Many of these individuals, well motivated as they are, are literally picking it up as they go along. We would say you need mandatory regulation and training.
If I may, Chair, I will give you one brief analogy-and I know you are pushed for time-which I have used in another setting. John Lewis, by way of example, is often held up as an exemplar of a very good employer. Yesterday was Monday. Could you imagine John Lewis taking on a shop assistant, giving him a John Lewis tunic and sending him on to the shop floor and saying, "You basically pick it up as you go along"? Of course they do not. What do they do? They take these people in, put them through a proper training course and bring them up to speed so that when people hit the shop floor they know what they are doing. We do not do that with our healthcare assistants. Frankly, it is one of the reasons-only one of the reasons-why the reputation of healthcare in this country is being besmirched. Far too often you have people, however well-intentioned, doing things that they have not had the proper education and training to do.
Sara Gorton: I very much support that view, that we need mandatory regulation. It is all very well having a code of practice and standards for training and service delivery, but unless that regulation is mandatory it will not be enforceable, it will not have any teeth and the current postcode lottery will continue. I would also add that it needs to happen in a way that is responsive to the different types of environments they are looking at. Maybe the HPC, as a regulator, which currently works well with regulating groups of staff like occupational therapists who work across different types of provision, both in health and social care, could be a good model to look at.
Obi Amadi: In terms of the whole debate, we need to remember that there is a definition of a profession and regulation regarding that profession that we need to be very clear of when we are looking at healthcare support workers. It is a twostage thing. There are issues about competencies and standards in education and training as well as regulation. We need to explore regulation as a first stage voluntary registration but then, over time, there is a need to move it forward and consider what statutory regulation could do. Before we get there, we need to be very clear about looking at the competencies and standards.
David Tredinnick: I want to take Dr Carter to task here. I am having problems with this comparison with John Lewis and being on the shop floor. I have been a salesman in my life and been thrown out, told to "Go and sell", and I have got on with it. I do not think it is a fair comparison to say that on a Monday morning in John Lewis everybody has some training. They may do, but selling on a shop floor is a totally different job from providing medical care. Medical care of all kinds is likely to be more complicated. Or have I completely missed the point?
Chair: My life might depend on it.
David Tredinnick: Did I completely miss the point?
Dr Carter: I think you have completely missed the point.
Q386 David Tredinnick: In which case, I apologise. Maybe I was distracted.
Dr Carter: Let me be clear that that is the very point I am making. John Lewis would not dream of doing it but, in many of our healthcare settings, that is what we do. We take people on and put them into wards and other departments. We do not give them any training and, as I said, they pick it up as they go along. That is wholly unacceptable. It is predominantly with elderly care. There is this kind of myth around that, somehow, when you are nursing the elderly, all you need is a bit of common sense. That is not all you need.
Again, through the Chair-if you could indulge me for a moment-if you look at the clinical presentation of an infant who is ill and the clinical presentation of an elderly person who is ill, they are, by and large, very much the same. They are often highly dependent and usually unable to communicate their problems. However, you will find on most paediatric units that the ratio of nurses to children is 1:4. On most elderly care units, the ratio of registered nurses to patients is 1:10. There is a huge differential, yet the needs are broadly similar. Elderly people are highly dependent and quite often incapable of helping themselves. We say that to nurse and care for the elderly you need a workforce that has had proper education and training in order for them to carry out a complex range of tasks that are required in terms of wound care, skin care, nutrition, hygiene and catheterising people. I could go on.
David Tredinnick: So could I, but I had better not. Thank you.
Q387 Valerie Vaz: I am conscious that everybody is hungry-and that is not just me. I want to turn to money and repeat the questions I asked earlier. Where do you see this budget for education and training? Do you see it ring-fenced? Where do you see it and in which structure would you like to see it? We will go down the line because I have a series of questions.
Dr Carter: Definitely ring-fenced. I have a lot of time for Dean, whom we heard before, but, despite what people say, the sad fact is that when the health economy is in trouble it is the education and training budgets that are one of the first to be raided. We know, because they tell us, that our members cannot get study leave and the whole continuing professional development is compromised. Why we want the governance and the accountability structures and these organisations set up as legal entities is so that the money is ring-fenced, they produce budgets and we know that the money ends up where it is intended-that is, to develop and educate the workforce.
Dr Dolphin: I entirely agree. I would also add that, certainly on the medical side, there is very little fat in the budget to trim. I do not know about nursing, but I am sure it is the same there. There is very little fat that can be trimmed from the budget, so if you start trying to make that money do other things, you end up cutting into quality and training placements.
Sara Gorton: We have not seen the impact of the cut in commissioned nursing places this year. There has been a cut of 20% in nursing places from the commissions, but that will not read through until 2014, I think, when those people are trained. It is important that the money is ring-fenced, particularly while the planning stage goes ahead. In terms of contributions that you had before, we would also flag up the need for all parts of the system to be bought in to the same provision so that we are not needlessly replicating within different parts of the future NHS different types of training models but that everybody can, through the LETBs, participate in both the funding arrangements and also the provision of good quality clinical placements and CPD.
I would flag up one more concern around the "any qualified provider model" and how important it is that some sort of mechanism is found for people who are working for any qualified providers. AQP providers have to operate with surplus capacity and we think that for shortage professions-some of the therapies, some types of specialist nursing, for example-they will do so by retaining existing NHS staff or trained staff on zero-hours contracts. Under that model, how do they provide good CPD to people? How do they make sure that those people have access and, also, how do they contribute to providing it? If all of the niche provision for a certain type of cancer care nursing, for example, in one health economy is provided through AQP, where do people get the experience, where do nurses go to train and how do they provide clinical placements? It is that buy-in of participation that is of concern.
Q388 Valerie Vaz: Do you agree?
Obi Amadi: I say absolutely yes, in terms of ring-fenced budgets. Currently, in terms of the way that money is allocated to training and education, there are professional groups who either manage to have access or do not. You often hear stories about "There is not any money for training" and we would not want this to become more of an issue. Clearly, in terms of the new NHS architecture, there are going to be many more organisations involved in providing and employing staff. We need to ensure that staff very clearly have access, and that the employers-any qualified providers particularly being an area of concern-ensure that staff do have access to the training and education that they need.
In terms of the AQPs, there will be, potentially, shortterm contracts. With that, what is the thing that you can let slip? What is the thing that you do not invest in? It is your workforce. We need that more than ever because there is a corporate responsibility here to provide care for the populations that they are going to serve. That may well be the thing that gets trimmed off.
Dr Dolphin: Dean Royles talked earlier about the importance of allowing flexibility within the MPET budget that is there for training of medical and allied health professions. One of the things that worries us slightly about the plans as they are on the table at the moment is that, with this fixed budget that we have-the £5 billion or so-the money would stay the same but it would have to cover a lot more things. As I have said, there is not much fat in the budgets for any of these sectors, so if you are trying to make it do more, you are going to end up with lower quality in what you are doing already.
Q389 Valerie Vaz: I want to follow up on that. Where you have a pressure now on more health visitors, how does that fit in? Where is the tension between a broadly flat cash MPET budget and adding more health visitors, the request for which has come from above?
Obi Amadi: In terms of the target of increasing the number of health visitors, that needs to be accommodated within the budget. We have looked at workforce over the last 10 or 15 years and it very clearly showed that there was a certain level of investment and increase in other areas of the workforce while this workforce was reduced and constricted. There is now an evidence base that shows very clearly that that needs to be turned around in terms of the effectiveness of that professional group. It should not be done at the expense of the other professions. Very clearly a way needs to be worked through and priorities need to be adjusted and accounted for in terms of the longer-term planning. It is not a shortterm fix and it should not have been put in the situation of being a shortterm fix.
Dr Carter: This is a concern of ours because, again, we welcome the Government’s initiative to recruit 4,500 additional health visitors, which are badly needed, but it is no good if you are not going to fund it. We have been assured that it will be new money coming into the system and that is good news. If you simply raid another pot for it, health visiting will do well but it will be at the expense of something else, which is in no one’s interests.
Q390 Valerie Vaz: The Government are consulting on education and training and a levy for that. How would you see that constructed?
Dr Dolphin: As was discussed before, it ought to be a levy that is imposed on all the secondary and tertiary care providers, all the ones who use the staff that are trained using this money. They ought to be contributing to it. Obviously, some of them will then get their money back in the form of the trainee coming to them with the funding, but it ought to be centrally done and then managed by Health Education England within its MPET budget.
Q391 Valerie Vaz: All the providers should be levied.
Dr Dolphin: Yes, because they are using the staff so it is right that they should contribute.
Dr Carter: I agree with that, but it is complex. I listened very carefully to what Sally Taber said and I completely agree with her. The thing is, though, that not every establishment has trainees. The baseline should be that everyone should pay a levy and then there should be a mechanism for recouping or reimbursing as appropriate. There are also problems with economies of scale. If you get, say, an owner of a small residential home with 10 places who might not carry out any training but have two or three nurses that were trained at the NHS, you might disproportionately penalise them. You would have to get proportionality into it, but I think it is right that anyone who owns or is running a private establishment should make a contribution to the fact that many of the staff trained at the public’s expense.
Q392 Valerie Vaz: If the Government move to a tariffbased system, what are the key features that would make that system work?
Dr Dolphin: We should learn from the tariff for service and make sure that we do not end up with a tariff that simply rewards activity. There has to be an element of it that is linked to the quality. Although it is quite difficult to measure the quality in health training, it can be done. There is work going on to find out how best to measure it and it ought be linked to that. The quality premium is a good move towards that.
Dr Carter: The principle is fine. Again, converting that and operationalising it is where it needs far more work. The tariff, as we see in the NHS at the moment, has really struggled. It is not comprehensive and it has been subject to huge criticism. Again, the principle is right. But let us make sure that we get the operation right.
Q393 Valerie Vaz: What do you see as the key features that could make it work?
Dr Carter: One of the issues is that what you have to get is-a bit like I was saying about the nurse education-the component parts of the service talking to each other to be clear about what is the cost, who should be paying for what and drill down and get into the detail. I think, hitherto, that has been a problem.
Sara Gorton: As to the content, people have articulated the complexity in setting that up in terms of relating it to the needs of the workforce, to the quality outcomes framework that has been produced over the last few years and the relationship between the levy and the tariff. It is a very complex set of relationships. I would flag the pace issue and the fact that the tariffs for some of the care pathways within existing elective care have taken a long time to develop and get right and have that right balance. A similar approach needs to be taken here. Doing it without due care and at a dangerously fast pace, as we would see it, is destabilising.
Dr Dolphin: What we have seen from medical student training is that the SIFT funding-Service Increment for Teaching for medical students-comes in two components. There is the placement rate, where the money follows the student from hospital to hospital, and there is also investment in facilities, where the hospital is given money to invest in education centres, simulation suites, seminar rooms and that kind of thing. There needs to be some element of predictability so that hospitals know they can make an investment in those facilities that will be made use of and that they are not wasting their money building an education centre and then all the trainees move to another hospital. That would be a disincentive to being involved in the system.
Q394 Valerie Vaz: I have a few more questions. Did you want to comment on that?
Obi Amadi: I agree particularly with what Sara has said in terms of the complexity of setting out the tariff. As to some of the work that has been done in the past, there was almost a tendency to look at what was the lowest, cheapest common denominator and charge for that. It is much more complex if you want to have quality in that service.
Q395 Valerie Vaz: Could I stay with you for a minute, Obi? You mentioned in your memorandum that there is an impact on public health. Could you explain that a little?
Obi Amadi: In terms of moving things forward, there is a lack of clarity in some areas regarding different public health services and public health practitioners. More work needs to be done in terms of clarifying that role, where people sit and consider the future role of Public Health England, which has not been, we think, fully explored and clarified.
Q396 Valerie Vaz: Should they be part of the LETBs?
Obi Amadi: Yes, they should.
Q397 Valerie Vaz: I will let you go shortly, but I have a final question to Dr Dolphin. The new higher education funding regime may have an impact on future medical students. Professor Les Ebdon says that some of the doctors coming through do not want to go and work in working-class communities. How do you see the new higher education funding affecting our future doctors?
Dr Dolphin: When the tuition fees were put up from £3,000 to £9,000 there was not much consideration given to how that would affect students on the longer courses, like medicine and dentistry and so on. It was also done before there had been time to assess how the £3,000 tuition fees had affected things because the people had not yet worked their way through the system. So we still do not know what impact it is going to have.
There is no doubt that these huge debts put people off from applying to medical school, particularly people in lower socio-economic groups. The debt aversion there is a big deterrent. The Department of Health did a study three years ago that found-and this is the quote-that there was "consensus in research that debt aversion for nontraditional students is a factor that deters entry into higher education." There is no doubt about it. Obviously, if you have a course like medicine or dentistry where you end up with huge debts-and we are projecting £70,000 for people with the £9,000 fees-they are going to be more averse to entering those courses than they are to the shorter courses. We have seen that already. When you look at the socio-economic groups of the people applying through UCAS, the university system, 14% of them applying for medicine are from the lower socio-economic groups. When you look at all the courses as a whole it is more like 29% or 30%, so almost half the number of people in the lower socio-economic groups are applying for medicine. There is a clear difference there.
Q398 Chair: We are due to finish at 1.00. Thank you, Valerie. I wonder if I can seek the indulgence of my colleagues very quickly, and could wrap up by asking two very short questions, one of Obi? Unite raises questions about the impact on longterm workforce planning of "any qualified provider" and, of course, the diversity that is envisaged. Could you quickly explain what your concerns are and what evidence there is? Also, very quickly, the first panel talked about the private sector scoring very highly in terms of quality and staffing ratios and that their training is something the NHS could well copy. What is your view and are there lessons to be learned from that?
Obi Amadi: In terms of the "any qualified provider" there need to be some very clear legal duties that they have in order to participate fully in terms of the education and training of the workforce. In terms of the AQPs bidding and getting contracts, they are likely to be undercutting others. One of the things that will have an impact and allow them to be able to do that is reducing the money and the commitment for training for the workforce. We have already had some examples come to us of our members working in Social Enterprise where there is training that is available and freely given-freely at the point of contact-for NHS staff. Staff that are working in Social Enterprise now want to access that, but, because they are no longer officially part of the NHS, the requirement from their employers is to buy that service, and they are refusing to. So, already, we are getting indications of where staff will be disadvantaged in not having access to the training that they need, which is a core part of the role that they play and the service that they give.
Q399 Chair: What about the question of quality staffing ratios, and training in the private sector?
Dr Carter: As in any aspect of life, it is rarely uniformly good or bad. There are some terrific examples of high quality, excellent care in the private sector but I also think it is the same in the NHS. Equally, from time to time, we come across things in the private sector that are as shameful as what we have found sometimes in the NHS. The most notorious in recent times has been the private hospital, Winterbourne View, which is hardly an example of best practice. While, as I say, there is a lot that is very good, there are also concerns. I always fall back on the statistic that 92% of patients who currently use the NHS express high degrees of satisfaction. That is a noteworthy statistic.
Q400 Chair: Thank you. Are there any further points?
Sara Gorton: The amount of provision that is in the private sector at the moment and the lack of variety in terms of the whole workforce means that it is very difficult to compare the two. Rather than get distracted by what works within a particular pocket of provision- because we do not have private sector organisations training paramedics, specialist therapists or nurses in the same way as we do across the healthcare system-the best use of the resources that we have are going to come from the LETBs and HEE working with what we know works and the systems that have already drawn success, rather than looking to replicate models that work in completely different environments.
Dr Dolphin: If patients are going to be moving in increasing numbers to the independent sector, you are going to have to move the people who are going to learn from them, to follow them into the private sector-hospitals as well. But if that happens, we are going to have to make sure those hospitals are regulated to the high standards that we have come to expect from the NHS, which is an obvious point.
Chair: Thank you. Can I thank the panel for your answers and my colleagues for their patience?
 BMI Ross Hall