Examination of Witnesses (Questions 80-99)
WEDNESDAY 4 APRIL 2001
SIR JOHN BOURN, KCB, MR GLENN HULL, MR NIGEL CRISP AND SIR BRIAN FENDER
80. Each year looking at the figures for each year.
(Mr Crisp) Each year, the increase between 1994 and 1995, it went from, as you see there, 1994-95
81. I know what it says here.
(Mr Crisp) 1995-96, right, I have the figure here
82. Perhaps while somebody may be helping you with that
(Mr Crisp) I have the figure for the commissions, this is actually a figure for the entrants. I am sorry, the figures I gave you earlier were the number of places that we commissioned rather than the people who were actually filling them, which was more relevant to your financial one. I do not actually have here the head count of people who came in. I can give you that. I have got the commissions for each of the years.
83. On 2.16, table 4, I notice a depressing decrease in clinical psychology practitioners. I can tell you when I visited the pain clinic at Astlie Ainsley Hospital in my constituency with the Minister a fortnight ago on Friday one of the things that was told to us, especially by patients' representatives, was that the pressures on doctors are such on pain management that the waiting times for clinical psychologists are far too long.
(Mr Crisp) Yes.
84. That maintains pressures on doctors who can more easily prescribe pills than secure the services of clinical psychologists. What are you doing to try and recruit more clinical psychologists or to make sure that health trusts do?
(Mr Crisp) Right. I think your question in a sense is slightly in two parts. There is the bit about how we can recruit more clinical psychologists into training and the second bit is how we can secure the trusts employing them. There are the two issues. We have to attack it in two parts. The first bit about attracting people in is where we see we have a shortage then we actually have to go out and do the sorts of things that we have been doing and that I mentioned with midwifery and so on of making these courses more attractive and, as I mentioned on radiotherapy, the example here, there is a bit about attracting them in. Your second point though, which is in a sense a more complex one, is about balance of the service, is it not? It is the service model, it is not just having doctors, it is about having psychologists and nurses within it and what is the template of a good pain clinic, what is the balance of staff within that.
85. To paraphrase the previous President, it is the economy that is stupid, it is understanding finances. Psychology is one of the most popular courses in universities.
(Mr Crisp) Right.
86. Is the problem not that trusts do not see it as a priority to fund clinical psychologists?
(Mr Crisp) That was the point I was making about if you need to decide how you want to deliver the service. The points you make I entirely understand, whether it is through a more medical model or through a more psychological model.
87. What is the Department doing?
(Mr Crisp) The thing that we are specifically about to start doing is a National Service Framework for long term medical conditions which includes precisely the sorts of issues that you are talking about there. What that does is it sets out national standards for how you organise a service in clinical terms, evidence based, not just anecdotal based if I can put it like that. I think it would catch the sort of service that you are talking about. Once you have done as we have already done for coronary heart disease and we have done for diabetes, national standards for how you organise the service and, as I say, importantly evidence based, then you roll that out across the country and make sure the services fit in with that model. If that model shows that we need more psychologists in proportion to the number of doctors we have got, then we have an implementation programme to make that happen. That is exactly what we are doing with coronary heart disease, but I have to say this is a new process. It has only been going for about three years where we are saying this is a National Health Service with national standards and we expect to see those national standards applied across the board.
88. What sort of timescale are you looking at?
(Mr Crisp) What, for the National Service Framework on long term conditions?
89. For the review and then any implementation?
(Mr Crisp) Again, I am going slightly from memory here but it will take something of the order of two years to bring all the people together who need to create the evidence base. That is our experience, that actually to secure consensus from the people who are working in that field, who understand that field, the academics and the clinicians, will take something of that order. We will then have an implementation programme thereafter. It is slightly difficult to predict exactly the pace of that but we are looking at that probably starting in something of the order of two years' time, that will be when the implementation programme starts. That is my estimate sitting here rather than the commitment. The commitment to create the National Service Framework has been made.
90. I do not know, Mr Crisp, whether I misheard you but I think when you were answering some of the questions from Mr Griffiths you said that it was very difficult to predict future workforces. Did you say that?
(Mr Crisp) Yes.
91. I think that is a bit of an incredible statement to be quite honest. If you look at page 18, paragraphs 2.8 and 2.9, it clearly states that your Department requires local health authorities to put into their Health Improvement Programmes, what does it say
(Mr Crisp) Plans.
92. "... backed by comprehensive, realistic and credible workforce plans looking three to five years ahead, and to include details of employers' plans for recruiting and replacing staff...". Now you are saying it is difficult to do, your own Department is saying they should do that.
(Mr Crisp) Yes.
93. When you read further on it says "... 99 health authorities in England ... had produced a Health Improvement Programme ... only two of these programmes fully addressed both workforce planning and education and training issues. Over a quarter did not address these issues at all". On the one hand you are sitting there saying it is difficult but then your own Department is telling them to do it and they are not doing it. What is the explanation for that?
(Mr Crisp) Right. The fact it is difficult does not mean to say you should not do it. You should do it knowing that it is difficult and knowing that when you put together a five year plan and say that in five years' time you will need 2,041 nurses, you need to know that there is a tolerance about how many nurses you will actually need. Therefore, it would be derelict of us not to attempt to get the best fix that we can actually get in terms of the future needs of the workforce. I hope we are improving over time in terms of being able to do that. It is difficult and one of the difficulties is that even in a three to five year period there is a balance of jobs you need to provide a service. The example that was just given from over here was an exact example of why it is difficult to predict the balance between, for example, doctors and nurses.
94. You have not answered the question, have you? What I am saying to you is that your Department is telling local health authorities to include workforce plans in their programmes and they are not doing it. There are only two fully addressing the programme and a quarter have not addressed the issue at all. What do we take as a result?
(Mr Crisp) I was going on to the second part of the question which is that bit. In terms of the second part of the question, yes, this year you will see that we have moved on from that and we have made a much more specific requirement about the workforce planning. Indeed, again as this document makes clear, the new arrangement for putting in place with Confederations will place some real responsibilities on Chief Executives of trusts and health authorities and it will be in their objectives that they need to do this workforce planning but the first example was not adequate.
95. So why did they appear to ignore you when they produced these plans? I would have thought one of the most important issues in the Health Service is the number of people working in it.
(Mr Crisp) Absolutely.
96. If you have not got enough people in the service you cannot deliver that service and yet it seems to me the health authorities themselves see this as a very minor role in their planning.
(Mr Crisp) I think the answer is that they did not adequately do it. I think you will find that most of them had some sort of shot at doing it but it may not have been a satisfactory way of doing it. Clearly that is not good enough and that is why we are saying we want better ones now.
97. Are you getting the message across?
(Mr Crisp)And they are being helped to. I go back to the fact that this is difficult. Many different people will have different views about what numbers you need and you need to do it in a proper and professional way.
98. So you are taking steps to ensure that it is now included in the plans?
(Mr Crisp) Indeed, yes.
99. Fine, let us move on then. Page 19, paragraph 2.15, again when Mr Griffiths was questioning you on this I found your explanations a little weak because, as Mr Griffiths pointed out, you can see here that decisions that were taken in the 1990s were disastrous for the Health Service as it happens and for the future delivery of the health service. If you look at the paragraph itself, 2.15, it says: "For example, entries to pre-registration nursing and midwifery programmes decreased from around 17,000 in 1991-92 to just under 12,000 in 1994-95. However, as is now widely acknowledged by the NHS, these projections proved to be inaccurate." I think the answers that you gave to Mr Griffiths were a little weak and were not addressing the situation. How on earth were such wrong decisions taken at that time? It is no good saying that day surgery had come in and people were in hospital for less time. The fact of the matter is that it is quite clear now that that explanation you have given was wrong. There were not enough nurses and yet they were allowed to reduce. Who made these decisions and why were they so inaccurate? Who did the projections?
(Mr Crisp) My answer is still the same, frankly. People made decisions based on certain assumptions and in retrospect those assumptions turned out to be wrong. The decision-making process that was gone through there involved people from the employers right through the system as the decision-making process does now.