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Lord Winston: My Lords, the hour is late and I do not want to detain the House but I am absolutely obliged to speak briefly to the amendment because it concerns another area about which I feel passionately. I will tell my noble friend the Minister a brief story about one of the people on my own unit to highlight the seriousness of the problem. She has completed her training. She got an excellent degree at Cambridge and has three higher degrees, including a doctorate and a distinction. In September, she will be redundant. She is one of the most deft surgeons we have trained and she is excellent with patients.

It seems extraordinary that such people can be on the scrap heap of their speciality. That applies to obstetrics at the moment but, as the noble Lords, Lord McColl and Lord Patel, said, it will apply to other specialities. I agree that this may not be precisely the right amendment but it is a critical issue for the health service. Given that there is growing public expectation of a consultant-led service and growing risks of litigation, particularly in obstetrics and gynaecology--

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with the need for consultants to be on the labour ward--I beg the Government to examine the issue closely and with a degree of urgency.

Lord Skelmersdale: My Lords, this bullet must clearly be bitten by the Government and I hope the Minister will say that it is being bitten. Whether the type of biting will be acceptable to your Lordships remains to be seen.

The nub of the new amendment is in new subsection (5). As I read the Bill, subsection (4) is not necessary. Under Clause 7(1) and (2), the Secretary of State may give directions to health authorities and NHS trusts on virtually anything. In my book, the nub of all this and arguably the solution--I should like to hear what the Minister has to say--is new subsection (5) of the amendment, rather than the two together.

Lord Hunt of Kings Heath: My Lords, the noble Lord, Lord McColl, has returned to the very important issue of consultant and medical workforce planning. I do not believe that there is any doubt that anyone who has lived and worked within the NHS for many years would acknowledge that this is a matter that we have struggled with to get right. We still have difficulty in meeting some of the points raised tonight by noble Lords. To get the right balance between national strategy and the issues that face those who run the health service locally is very difficult. I am not convinced that to take a directional approach from the centre is the right way forward.

Clearly, we must ensure that medical and other workforce planning reflects forecast service needs and available resources. It is in the interests of both the NHS and those in training that we get this right. But the amendment goes on to specify a power to require that local posts be created to match a central forecast or recommendation. That surely goes too far. The noble Lord, Lord McColl, himself acknowledged this evening that no one suggested for a moment that all those trained in a specialty should be guaranteed jobs. As my noble friend the Minister said when the noble Lord raised similar matters in relation to Clause 8 during Committee stage, the Government reject as a matter of principle that direction should play a part in medical workforce planning. We prefer to work in co-operation with NHS trusts.

The whole experience of the NHS shows that unless one balances out national medical workforce planning and the needs of local NHS services one will never be able to deal with the problem successfully. NHS trusts are themselves in the best position to judge the staffing and grade mix required to deliver high quality patient services within the framework of their local health improvement programme and service agreements with local health authorities and primary care groups and trusts. In making those judgments they will also be guided by the requirements of clinical governance.

The noble Lord, Lord Patel, spoke about responsibility; and the noble Earl, Lord Howe, spoke about a circle of responsibility. Noble Lords will be aware that in terms of the relationship between the number of junior doctors in training and the number of

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consultants the Speciality Workforce Advisory Group and its associated processes already exist to provide a central assessment both of likely future service needs for consultants and the number of staff in training needed to supply them. Both NHS management and the main professional interests are directly represented on this group. That is of crucial importance because, almost for the first time, it has brought together those people concerned with workforce planning at national level and those concerned with managing services at local level.

Every year this group agrees its recommendation to Ministers about the number of higher specialist training places needed to fill consultant posts in the future on the basis of input from the colleges, NHS management, educationists and other interested bodies. We believe that these arrangements ensure that national workforce planning is properly informed by the local NHS perspective. This should mean in turn that NHS trusts' local workforce decisions are informed by the national planning to which they have contributed. But to go beyond this and pre-empt individual local decisions would go far too far. For that reason I cannot therefore support the amendments.

I stress that while the Government do not believe that these amendments are the right way forward, they nonetheless recognise the real issues to be addressed. Matching forecast demand with planned supply is a complex issue, especially for a multi-disciplinary service like the NHS, with a long period involved in completing full medical training.

Lord Clement-Jones: My Lords, perhaps I may put one point to the Minister. The tone of his response is variable, which I find interesting. He said that he did not believe that a directional approach was the right one. When I read these amendments I cannot see such an approach. It is a matter of establishing the appropriate mechanisms at the centre rather than a directional approach.

In the Minister's response, I did not hear him say that the current system is not working well. Clearly there is a crisis. SWAG may have brought people together but, having brought them together, is it effective? We may be living on past rather than current methods of planning.

I am sorry to ask the Minister a rather long question. However, from the tone of his response it does not sound as though there is a great sense that the current system is inadequate.

Lord Hunt of Kings Heath: My Lords, I did not mean to give the impression that I am complacent about the issues which noble Lords have raised. Indeed, my experience in the NHS is that medical workforce planning and the tying of it into service needs has been one of the most difficult issues faced by the NHS. Simply taking directional powers to specify the number of consultants posts centrally is not necessarily the most appropriate and practical way forward.

One of the problems that we have had over many years is that the needs of the service have not been matched sufficiently with medical workforce planning

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decisions made at the centre. That is why it is so important that in this SWAG group, almost for the first time, people managing the service in the field are working and meeting face to face with the people concerned with the number of doctors and specialists who are to be trained in the future. I believe that is a significant advance.

But we are talking about long lead times. I do not think that one will ever get the situation exactly right. Of course it takes time for improvements to come through. I believe that I made that clear in my remarks. I believe that one can point to some improvements in addressing shortages in specialties such as anaesthetics and accident and emergency. Nevertheless, I believe that minimizing shortages or oversupply remains a difficult balancing act.

I accept, as the noble Lord, Lord Patel, suggested, that many issues remain to be sorted out. Improving the way in which national and local planning mesh together is important. Our intention is that the health improvement programme process will ensure better local links between service planning and identification of the workforce consequences both for medical posts and other professional groups. At the same time we are looking at ways of improving the linkages between local planning and the way in which the picture is drawn together at regional and national level. We recognise and are committed to the need to strengthen those arrangements.

We have discussed the particular concerns over obstetrics and gynaecology. I do not think that I can add a great deal to what my noble friend said in Committee on those issues. We recognise the concerns about job prospects for those completing higher specialist training in that specialty. That is why arrangements were made for postgraduate deans to give one-off extensions to specialist registrar contracts for 18 months to allow more time for those involved to seek posts. Postgraduate deans will be keeping closely in touch with those concerned as the period comes to an end for the first group, to offer advice about job and other opportunities. In parallel we have already reduced the number of higher specialist trainees in obstetrics and gynaecology so as to try to bring supply and demand back into balance.

I listened again to the prescription of the noble Lord, Lord McColl, that no new trainees should be taken on until all who have completed training have consultant posts. But that would have a negative effect. It would effectively close down the specialty for at least two years, making it difficult to generate recruitment after that time.

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