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Lord McColl of Dulwich moved Amendment No. 21:

Page 7, line 28, at end insert--
("(4) The Secretary of State may direct NHS Trusts to establish that number of consultant posts recommended centrally in order to deliver a consultant-based service.
(5) In pursuance of subsection (4) the Secretary of State shall establish the appropriate mechanism to ensure that agreement is reached centrally on the relationship between the number of junior staff in training and the number of consultants required.").

The noble Lord said: My Lords, as usual I declare my interest. I have a score of relatives who have been involved in the health service in this country, some of whom are still in training. In addition, I have trained hundreds of members of junior staff in hospitals, many of whom face a fairly bleak future as they seek consultant posts under the current chaotic system. The amendment is designed to help solve what must be one of the most serious manpower crises in the NHS.

First, I wish again to draw attention to the fact that there are fewer consultants per head of population in this country than any other western country with the exception of Portugal. Everyone who knows anything about this subject agrees that we desperately need more consultants in order to have a consultant-based service. That is the only way to improve the quality of care, especially as there has recently been such a large reduction in the number of hours worked by the junior staff. Secondly, there are far too many junior staff being trained for the consultant vacancies currently available. Thirdly, what makes this even more unacceptable is that at the end of their training, which takes a total of 20 years, doctors are now being sacked without, of course, redundancy payments. The NHS is a monopoly employer and there is nowhere else for them to go. When one considers the millions of pounds that have been spent on training them and the demoralisation experienced by these sacked trainees, noble Lords will realise that we have a major crisis on our hands.

If that scenario is not bad enough, noble Lords will find it difficult to believe that the NHS continues to recruit new, and therefore less experienced, trainees to fill the posts vacated by those who have just been made unemployed. Specific instructions have been given by the Department of Health to the postgraduate deans who are in charge of the employment of these trainees not to renew their contracts but instead to go on recruiting more trainees. I am not complaining; I am offering solutions. One immediate solution to the problem is to stop recruiting more trainees until this totally unacceptable situation has been sorted out.

Some senior people in the NHS maintain that we must go on recruiting junior staff to ensure that we have continuing recruitment into each specialty. We have been here before. At the end of the war and at the inception of the NHS, the number of junior staff was doubled in order to provide an opportunity for those returning from the war to specialise in hospital

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medicine. At the same time, with the inception of the NHS, the retirement age for consultants was raised from 60 to 65. So there was a great increase in junior staff and virtually no vacancies for five years. That created enormous problems. However, the problems were eased by keeping the trainees employed. They were not sacked when they came to the end of their allotted training period, and we never had any problems of recruitment.

As the noble Lord, Lord Winston, pointed out, the problems in obstetrics are probably worse at present than in any of the other specialties. Last year, there was a 33 per cent. cut in the number of consultant posts advertised. It has been estimated that at the end of this year there will be 150 fully trained obstetricians without a job and that within two years that figure will double.

In an earlier debate I drew attention to the fact that 65 per cent. of all the medical legal cases involve obstetrics and gynaecology. The British Medical Association has pointed out that the confidential inquiry into stillbirths and deaths in infancy and the confidential inquiry into maternal deaths have raised questions about the lack of consultant input into these problem cases. The BMA also points out that both the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives have recommended that a consultant should be on the labour ward throughout the normal working week to supervise care. Several hundred new posts will be needed to reach that standard. But, as I have mentioned, last year there was a 33 per cent. cut in the number of consultant posts advertised. Doctor Ian Bogle, chairman of the BMA Council, said recently:

    "This is a human tragedy for trained experienced doctors who are being put on the scrap heap in their thirties and for the women and children who are dying because of lack of care".

When one attempts to find out who is responsible for this state of affairs, everyone points an accusing finger at someone else. The postgraduate deans say that it is the NHS Executive; the NHS Executive says that it is up to the NHS trusts; and so it goes on. It must be written on the face of the Bill who is responsible and who should correct this state of affairs. These amendments go some way towards doing that by providing on the face of the Bill that it is the Secretary of State who is responsible.

I should emphasise that we are not asking that everyone recruited into training should be given a consultant post. No one has ever suggested that. But clearly, if there are only 50 consultant vacancies a year in a particular specialty, it would be unreasonable to recruit 10 times that number of junior staff every year. There must be a sensible relationship between the number who are trained and the number who are needed. As the president of one of the Royal Colleges said today, the number of trainees should be more closely matched to the number of potential consultant appointments. I beg to move.

Lord Clement-Jones: My Lords, I strongly support the spirit of the amendment. The noble Lord, Lord McColl, has cogently described the unsatisfactory situation with regard to workforce planning. We had considerable debate on this issue in Committee. Since

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then we have had the report from the Health Select Committee, which highlighted the situation in technicolour. I had not realised before I saw that report just what kind of alphabet soup we had in terms of the bodies responsible for workforce planning. We have the MWSAC, the SWAG, the MPC, LMWAGs and REDGs. We have a host of bodies, none of which, on their records so far, seem to be very effective in getting things right in terms of the number of consultants we need or the number of trainees who can go through the pipeline to become consultants.

The Health Select Committee said:

    "In the longer term we recommend a major review of current planning procedures which should pay particular regard to their rationalisation and eventual replacement by an integrated planning system".
What better integrated planning system could there be than placing the responsibility where it belongs, with the Secretary of State? The amendment has considerable merits in doing just that. The result of the current planning system is headlines such as the following in The Times:

    "No jobs for 400 doctors trained at a cost of £40m".

I thought that that was pretty hair-raising. Obviously the BMA is highlighting this as a campaign. Two relatives of mine are obstetricians. They are registrars and hope to become consultants in due course. The situation is worse in the area of obstetrics than in many others. However, the BMA highlights the fact that, before long, ear, nose and throat specialists, as well as cardiothoracic and renal surgeons, will face a similar problem. The situation is not satisfactory. Someone must take responsibility for making sure that we have the right numbers coming in for training and the right numbers of jobs available when training is finished.

There are other considerations which can be added to the mix. There is the EU Working Time Directive, the impact of Calman, training reforms and the New Deal. In addition, more doctors wish to work part-time. There are also considerations of how doctors wish to balance their family lives and their work lives. If our planning system cannot get it right, then we shall have a lot of extremely unhappy trainees and a lot of overworked consultants. I suggest that the department should look at its planning system and take on board the spirit of this amendment.

Lord Patel: My Lords, I am unaccustomed to speaking in your Lordships' House and noble Lords will therefore forgive me if I am a little slow. Certain facts need to be clarified. It is correct that a major problem has developed in the specialty of obstetrics. I declare my interest here: I am an obstetrician and until the end of September 1998 I was president of the Royal College of Obstetrics and Gynaecology. To that extent, I presided over the problem that has arisen.

There are several factors which led to the problem, and they apply to all specialties. I am currently chairman of the Specialists' Training Authority and therefore sign every certificate in every specialty when a trainee completes the specialist training, and I know how many

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certificates I have signed. There are more than we originally thought there would be. The problem will occur in other specialties.

The problem has come about because some four-and-a-half years ago we changed our way of training in post-graduate medicine and made it more structured than it was before. The noble Lord, Lord McColl of Dulwich, referred to that. It meant that when a trainee completed the training he or she was issued with a certificate of completion of specialist training, which identified that trainee and enabled him or her to apply for a consultant post in the NHS. The numbers of trainees entering the programme are controlled by a complicated formula worked out by the Specialist Workforce Advisory Group every year for every specialty.

Four-and-a-half years ago, when so-called Calman training was introduced, the contention was that the NHS would move towards a more consultant-based service. What is a consultant-based service as opposed to a consultant-led service? It is a service whereby most if not all treatment is provided by fully trained specialists. We are moving more and more towards a service provided by non-consultants. That is the third problem. Trusts are appointing more non-consultant career grades on short-term contracts rather than longer-term consultant contracts. There are many issues to be teased out.

After the reforms in training, the question arises of how we want to man the medical workforce in the NHS. The public want treatment by fully trained people and those who are not trained or who are in training to be supervised. If that is the intention, many issues must be addressed.

The amendments highlight the problem but I am not sure that they go far enough. A complete review is needed of medical workforce planning. Another problem is that in general practice recruitment is poor, while in specialist services overall, it is good.

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