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Baroness Sharp of Guildford: I thank the Minister for her reassurance on this issue. In the light of her answer, I beg leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 6 agreed to.

Clause 7 [Directions]:

Lord McColl of Dulwich moved Amendment No. 62:


Page 7, leave out lines 3 to 28.

The noble Lord said: I wish to speak to Amendments Nos. 62 and 64 which concern medical workforce planning. I should declare an interest. I have been closely associated with training junior hospital doctors for the past 40 years and I actually ran a training programme which attempted to solve some of these problems and on which the Calman training scheme was based. I should also declare an interest in that 20 of my relatives have been closely associated with the NHS over some years.

The purpose of these amendments is to try to move some way to restore the morale of junior hospital staff whose future in some specialties is becoming bleaker week by week. There is a desperate need for suitable and effective overall planning for the workforce in the National Health Service. Several groups have looked into the problems and needs of the medical workforce and they have made recommendations, but there is no process to ensure that those recommendations are approved and implemented.

National Health Service trusts must employ sufficient medical consultants in each of the relevant specialties to provide such services to meet the quality requirement in Clause 13 of the Bill. It is notoriously difficult to estimate accurately the workforce requirements for consultants in various specialties but there is a committee called the Specialty Workforce Advisory Group, known as SWAG, which does the best it can in estimating the requirements for new consultant posts. Unfortunately, it often operates in a vacuum in recommending the number of trainees because the evidence and the figures which it receives are often invalid.

With all the difficulties of the Specialty Workforce Advisory Group, it does its best to make sensible recommendations, but no mechanism is in place to ensure that the recommendations on the number of consultants that are required are acted upon. The colleges and the BMA have pointed out to me that the classic example of this at the moment can be seen in the obstetric and gynaecological scene where, this year, there will be 200 fully trained obstetricians and gynaecologists but only 50 consultant posts will be available. In the following year, that figure will go up to 250, and in the year after that, to 350. What an appalling waste. These people are being told that when they come to the end of their training this year they will

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not have a job. There is nowhere for them to go and they will be unemployed. Several have already been laid off. Each of the trainees has been in training for 20 years. Noble Lords will understand how demoralising that can be. The National Health Service is a monopoly employer: there is nowhere else for them to go. It is not possible to set up in private practice in obstetrics and gynaecology just like that; and emigration is increasingly difficult.

When recommendations were made about the numbers to be trained in obstetrics and gynaecology it was agreed, and assumed, that the increase in new consultant posts created every year would continue. It was increasing. However, during the past year it has decreased by 33 per cent. The situation is desperate. This is not a party-political matter.

The situation is desperate, also, because the quality of service in the obstetrics and gynaecological world is now deteriorating; 65 per cent. of all medical litigation cases are to be found in that specialty. Many trusts are faced with scores, if not hundreds, of outstanding legal cases which will cost the NHS many millions of pounds. That money has to come out of funds that should go towards patient care. The situation will inevitably result in fewer patients being treated.

There is a tremendous wish to reduce the number of people on the waiting list. We on this side of the committee have always said that the number is totally irrelevant. It is how long people wait that matters. If we did what we should do--namely increase the number of consultants by the extra 4,000 that are needed immediately--it would increase the number of people on the waiting list but the length of time they waited would be greatly reduced.

I am aware that there is no waiting list for obstetric cases--apart from the nine-month waiting list--so there is not quite the same demand to reduce the number of people waiting, unless one is in the business of population control. But we need 4,000 more hospital consultants. That figure is agreed by the BMA, the Colleges and the Department of Health.

The need for an expansion in the consultant grade is agreed. However, a different kind of job is being created which falls outside the approved training structure. Increasing numbers of sub-consultant grade doctors are being appointed. The NHS is wasting valuable resources by employing non-consultant career grade doctors who, unfortunately, are not able to provide the comprehensive service that patients deserve.

It is clear that the Secretary of State must have the power to act promptly. He could use some of the extra £21 billion, about which we keep hearing, that is to be given to the NHS for the next three years to create, this year at least, 200 consultant posts across the board. That emergency measure would tide the NHS over the present crisis. But the amendment that we propose, to give power to the Secretary of State to act in this field, is designed to help solve the problems of medical workforce planning in the long term. I beg to move.

Lord Clement-Jones: I support the amendment. The noble Lord, Lord McColl, has raised a novel concept--

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not a declaration of interest but a declaration of relatives! I suppose I should declare that I have a nephew who is a registrar in obstetrics. In the recent debate that we held on the National Health Service the noble Lord was as cogent in his remarks on the shortage of consultants in the obstetrics area as he was today. As he explained, it does not stop there, it exists in other areas. The current situation is that trainees coming through will find at the end of their training that they cannot get consultants jobs. I know that the noble Lord, Lord Winston, raised the issue in his own areas of expertise. The problem exists right across the board.

One issue that concerns me is the speed at which the Government are assessing the issues arising out of the Calman training reforms and the New Deal. The Calman training reforms impose certain requirements in terms of accreditation and requirements on the consultants themselves. Also, the New Deal means that the training junior doctors are undertaking is more difficult because they spend fewer hours being trained. Then there arise issues such as whether, even at the end of accreditation, they will be trained to the same standard as those who are now consultants. There is a whole slew of issues which relate strongly to the question of consultant posts.

The answer that the Minister gave me a couple of months ago was that the assessment was taking place over a three-year period and there would be no interim report. That struck me as being a slow-boat-to-China type of approach to an important issue.

One of the key concerns throughout is that over a period of time the duties of consultants have changed dramatically. They are now the key pivotal persons throughout the care process, whereas before it was different. For example, when my late wife trained a whole hierarchy of people were in the hospital, such as junior housemen. They were obviously madly exploited, they worked one in two, but there was a continuous system of healthcare, through the junior housemen, senior housemen, registrars and so on. Now, effectively, the consultant is the only person who is really responsible for providing that round-the-clock care.

The issue of how many consultants there are and how they are trained in the health service is of great importance. That is why I have considerable sympathy with the concept of workforce planning, which needs to be grasped. I ask the Minister whether there is some way in which the evaluation of the Calman reforms, their impact on consultant posts and so on should be accelerated. It is getting to crisis proportions, as those who are consultants will say. I beg to move.

Lord Skelmersdale: On a different point, I have been struggling with the juxtaposition of the new Section 17 of the 1977 Act, as described in Clause 7, with Schedule 5A to the same Act, which is Schedule 1 to the Bill. The new Section 17 (1) states:


    "The Secretary of State may give directions to any of the bodies mentioned in subsection (2) below".
That includes primary care trusts. A little further we discover that he cannot give any directions which may

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be given under paragraph 9 of Schedule 5A (Schedule 1 to this Bill). Paragraph 9 states:


    "the Secretary of State may direct a Primary Care Trust ... to make the services of any of its officers available to another Primary Care Trust, or to employ any person who is or was employed by another Primary Care Trust and is specified in the direction".
It seems to me that the two overlap to a horrendous degree. One wonders, taking these two together, what adjustment is being proposed. At some stage, probably not tonight because I suspect the answer is complicated, perhaps the noble Baroness would write to me on it.

Baroness Hayman: I am immensely grateful to the noble Lord for those final comments. The issue is extremely complicated. No Members of the Committee spoke to Amendment No.62, before the noble Lord rose. That amendment deals with those issues and interrelationships. I would have had to warn the Committee that, as it stands, taking out Section 16C, while repealing Section 13 in subsection (4) would wreck not only our proposals for primary care trusts, but basically the whole existing legislative structure of the NHS. No one who has spoken in support of the amendment today could have had that intention because it would be dramatic. There are complicated interrelationships here as the noble Lord, Lord Skelmersdale pointed out. Perhaps the best way to clarify the matter is to set it out in a letter to him. However, I urge the Committee not to accept Amendment No.62 as currently drafted because it would have far greater repercussions than first envisaged.

As to Amendment No. 64, we have heard some very eloquently expressed and strongly felt concerns, which I well understand, about workforce planning issues within the NHS, in particular the training of consultants and the effects of the Calman reforms. Some of the problems that arise, whatever workforce planning regime is adopted in the NHS, are related perhaps to the period during which decisions must be made because of the length of time required to train someone to reach consultant status and the changes that take place in terms of the service required. I do not minimise the effects that unsuccessful and flawed workforce planning can have on both trainees who look for appointment and the service as a whole--I have had experience of this--when there is a shortage of trained personnel to provide much-needed services. We all agree that there is a need to improve workforce planning arrangements, and the Government are taking a number of steps to that end. There are complex variables involved in the process. We must ensure that we are more successful than we have been sometimes in the past.

As the noble Lord, Lord McColl, points out, there is a particular issue related to specialist registrars in obstetrics and gynaecology and the flawed planning that has occurred in that specialty. In the past the noble Lord has argued very cogently--I have some sympathy with him--that there is a need for a more consultant-led service with the benefits that can bring not only in quality of service but in a reduction in litigation in obstetrics and gynaecology. Currently, a working group comprising NHS management and members of the medical and midwifery professions is considering the

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difficulties experienced by specialist registrars and issues related to the provision of quality service. That group will be reporting to Ministers shortly. There is perhaps hope of making some progress although it is a difficult area that involves a large number of people. The noble Lord, Lord McColl, made reference to emergency measures that sorted things out in the short term. I know only too well that because of the tenure of consultants the commitment to employ them within the NHS becomes a very long-term and expensive one. I do not minimise the very real problems that exist in that area.

I turn to the specific amendment that has given rise to the debate on workforce planning. I believe that it would be inappropriate for the Committee to accept it and allow directions to be made in matters of medical workforce planning. In any case, it is not something that should be set out on the face of an NHS trust establishment order. It is not a core function of that trust. We are working with NHS trusts and other NHS bodies to develop local workforce planning linked to service plans across sectors and professions.

We believe that the approach of co-operation, not diktat from the Secretary State, is the way forward. It could be interpreted that the amendment is intended to have the effect of requiring NHS trusts to employ as consultants all the trained doctors supplied through national medical workforce planning processes. I think that that is the wrong way to take the issue. Quality of service to patients must drive local planning, including workforce planning. The noble Lord is right to suggest that the quality of service is related to the availability of trained consultant staff. But I do not think that as a matter of principle any employer should be required to employ every person who has the appropriate qualifications, whether or not the needs of the service dictate that.

For those reasons I hope that the noble Lord will not press the amendment.


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