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Health Committee - Minutes of EvidenceHC 6-ii
Taken before the Health Committee
on Tuesday 29 November 2011
Mr Stephen Dorrell (Chair)
Dr Daniel Poulter
Dr Sarah Wollaston
Examination of Witnesses
Witnesses: Professor Sir Christopher Edwards, Chairman, Medical Education England, Professor Sir Peter Rubin, Chair, General Medical Council, Professor David Sowden, Chair, Conference of Postgraduate Medical Deans of the United Kingdom, and Sir Alan Langlands, Chief Executive, Higher Education Funding Council for England, gave evidence.
Q116 Chair: Thank you very much for coming, and for coming in earlier than originally planned this morning to accommodate the Chancellor of the Exchequer. Could I ask you to begin by introducing yourselves, the organisations you come from and the role you play in this area of byzantine complexity?
Professor Sir Peter Rubin: Thank you very much, Stephen, and good morning to you all. I am Peter Rubin, Chairman of the General Medical Council. The GMC is the independent regulator of medical education and training in the UK. We determine the content and outcomes of undergraduate medicine and of all the postgraduate medical specialties, we determine the fitness for purpose of the exams that are taken by students and postgraduate doctors and we quality-assure medical education and training. We do all those things throughout the UK.
Professor Sir Christopher Edwards: Good morning. My name is Sir Christopher Edwards. I am the Chairman of Medical Education England. As you know, this was set up following the MTAS disaster and on the recommendation of the Tooke report. Tooke suggested that this should be a medical body and should hold the budget. What happened was that the Government eventually accepted the recommendation but set up a body which represented not only medicine but medicine, dentistry, pharmacy and healthcare sciences. We have now been going for three years. We do not hold a budget but we have been successful in producing a series of reports, which you might want to come to later on. In addition, I am the Chairman at Chelsea and Westminster Foundation Trust and Chairman of the Council of the British Heart Foundation.
Sir Alan Langlands: I am Alan Langlands, Chief Executive of HEFCE, the Higher Education Funding Council for England. We fund higher education and research in universities in England. Included in that is a wide range of healthrelated education and training. In 20092010 we spent £360 million on medical and dental fulltime places. We also fund postregistration nursing, subjects allied to medicine and pharmacy. Of course, in addition, we take a close interest in the work of the SHAs in their contractual relationships with universities on nursing, midwifery and the allied health professions.
Professor Sowden: I am David Sowden, Chair of the Conference of Postgraduate Medical Deans of the United Kingdom. It is a UKwide organisation which represents all the postgraduate deans and deaneries within the UK, including dental deans, general practice deans and directors. Our aims include managing the delivery and outcomes of postgraduate medical and dental education to the highest possible standards, and ensuring that these standards are comparable across the UK. At present, we are responsible for about 54,000 trainees across all the deaneries. It also provides a UKwide forum for postgraduate deans to discuss and share information on important issues with regard to medical training and its interface with other professions, and, in particular, postgraduate medical education and training. I am also Postgraduate Dean and Managing Director of the East Midlands Healthcare Workforce Deanery and have been in post since 2000.
Q117 Chair: Thank you very much. I already used the word "byzantine" for this system. Do you agree with this proposition: one of the problems in this area is that, every time there is a problem, we invent a new organisation to deal with it without properly working through how the new organisation will relate to all the existing organisations, and we are at risk of doing the same thing again?
Professor Sowden: Yes.
Professor Sir Christopher Edwards: There is a risk. At the same time, I would like to think there are enormous possibilities to implement significant change. When I take a few steps back and say, "What are the problems?", first of all, we have a system where, perhaps, we have not had transparency of funding-where a very large budget is not being used in a transparent way and, often, is not being used for the purpose for which it was allocated. If we look across the fence at the establishment of NIHR, that has produced very considerable transparency in relationship to research and development, and I would hope this new structure could do the same thing for education and training. I think there has been a failure to focus on excellence-there has been more of a competence culture-and that we have a very inflexible system. If we can make some of these changes, then we can move things forward.
To give you a simple example, we had a surgical trainee who came to talk at the MEE away day. He said he had trained in two London teaching hospitals-one very good and the other very bad. He said the one that was very good got no benefit from being very good and the one that was very bad got no disbenefit. Was that right? The answer is no. But it is very difficult to change that system because, at the moment, if you make any changes it is immediately thought to produce changes in service. With the 72% increase in consultants in the last 10 years, and with our particular review of how this could be done, we can actually change that for the first time. There is a whole series of very positive things that could be achieved.
Q118 Chair: I hear that as being a description of the role of HEE as the national commissioner of education, at least in England, for all the health education professions. Is that what you are describing?
Professor Sir Christopher Edwards: Yes. It is a partnership. It is between HEE, as a coordinating central body, and the local organisations. There has been relatively little criticism of the concept of HEE. There has been much greater concern about what might be the local structure. I am sure we will come on to debate that.
Q119 Chair: We will come to the local structure later. If HEE is to be seen as the national commissioner of healthcare education, the first question-with the national organisations represented here-is how that relates to the activity of the GMC as a regulator, engaged from that perspective, and, indeed, how it relates to HEFCE, a position, Sir Alan described, that they currently fulfil. How do those three functions relate to each other?
Professor Sir Christopher Edwards: I am sure we all have views on it. If we look at the GMC, for example, of the four specific tasks required of it by the Medical Act, two are entirely distinct from any role of HEE-the whole question of registration and fitness to practise. Those are quite distinct. But there is the potential for overlap in relation to the quality of education and training and the quality, in fact, of the workforce.
Q120 Chair: There is an overlap on initial registration as well, is there not? In order to qualify, you have to pass through a commissioned training programme.
Professor Sir Christopher Edwards: Hopefully, there is a partnership. I will give you a simple example. We are extremely anxious that we should have a mandatory period of shadowing. In other words, when a house officer is going to start on 1 August, they would have a period, in the week before starting work, in which they are shadowing their predecessor. There is a lot of evidence which shows that this makes things much safer for the patient and reduces stress as far as the doctor is concerned. To do that, there has to be GMC registration at an earlier stage. In the three pilots done on this, the GMC have done exactly that. They have registered these people at an earlier stage. So there is a partnership between the two.
Professor Sir Peter Rubin: I wonder if I could add a comment there, Stephen.
Q121 Chair: Yes, rather than this being a dialogue.
Professor Sir Peter Rubin: We have some years’ experience of working through a body such as HEE because we have worked closely with NHS Education for Scotland for some years. At the GMC, we determine the content and outcomes of all medical education and training, and ensure the assessments are fit for purpose. Therefore, we ensure that the training that Dr Poulter is getting in obstetrics is the same wherever he trains; whether it is in Aberdeen or Exeter, the content and the outcomes will be the same.
What NHS Education for Scotland does in Scotland, and what MEE or HEE will do in England, is to fund the education to make sure the education can happen and ensure that the quality of education, at a local level, is at a standard that would be expected. We would anticipate that HEE, through Local Education and Training Boards and postgraduate deans, would troubleshoot and ensure that the quality of medical education locally is of the required standard. If it is not, we are there at a national level. We have extensive statutory powers to move in, if necessary, and ensure, in extreme examples, that trainees are removed from an environment where training is not appropriate and so on and so forth. So we are there at a UKwide level determining content and outcomes. What HEE do, and what NES do in Scotland, is fund the medical education and training.
Q122 Chair: There are two problems I have with that. The first is that the people controlling the funds, as Sir Christopher explained it, also have a responsibility for quality. Take the example of the two hospitals which were delivering two different standards of training. Who owns the problem of addressing the difference of standard of training received in two different locations in the same city?
Professor Sir Peter Rubin: Can I answer that from a GMC perspective and then Chris could answer it from an HEE perspective? Assuming the new world happens as anticipated, we, the GMC, would expect that HEE, through the Local Education and Training Boards, would have identified that Hospital A has a problem with its training; put it on notice that the funding for trainees will be withdrawn from that hospital and moved to where the training is good; that they have six or 12 months, or whatever, to sort out the problem; and, if the problem is not sorted, the funding and the trainees get moved. We would expect them to be doing that. If, for whatever reason, that does not happen, we are there, as the nuclear option, to say that, as a national regulator, we are going to remove approval for these posts at Hospital A and they need to be moved to Hospital B.
Professor Sowden: Can I follow up on that? I have experienced covering this pre-GMC, and now this present situation. The situation that Peter is referring to does work extremely well-much better than it once did. We now have an opportunity for dialogue with the regulator about problems with the delivery and standards of delivery of postgraduate medical education. I can tell you that that is a very potent lever to get the attention of trusts. If, at the same time, HEE is established and makes very clear the standards to which it wishes to see the money put, there will also be another lever which can operate there.
The only important thing is to ensure the people quality-managing delivery of postgraduate medical education, or, indeed, other aspects of healthcare professional education, have sufficient independence because a lot of pressure can be put on you by local education providers and trusts. When you take the money away you take the doctors away, and that has a big impact on service. Their claim is, "However bad we are, we will be worse if we do not have the junior doctors."
Q123 Chair: Sir Alan, you have experienced this argument from many different perspectives.
Sir Alan Langlands: I have, of course, from the perspective of the NHS in England and, indeed, running a university in Scotland, where the NES model is interesting. I want to take a step back to your question and suggest that what we are trying to do is not terribly complicated. What we are trying to do is achieve excellence in education and training and, as a result, better patient care. It seems to me that some of the tensions between different bits of the structure creep in when people start taking a transactional view of this rather than working in partnership, as I think they have to.
The other thing we have an opportunity to do here, which is rarely discussed, is give some coherence to the continuum of education, from undergraduate and basic training right through to postgraduate and postbasic-continuous professional development. We have a very fragmented system in this country still-a very British solution-and the opportunity here is to do something about that to give it more coherence.
I am for a model in which form follows function, where there are clear lines of accountability for HEE and for the LETBs and where there is involvement of all the partners, including higher education, at every level of that process. I must say that HEFCE has very strong relationships with the Department of Health, at the moment, and, indeed, with MEE and the fledgling HEE. We are working together well, but that has got to be translated into local action. I have a real fear that higher education institutions are at risk of being shut out of the game, and that would be a road to disaster.
Professor Sowden: Could I go back to your original question? The other problem we have is when people look at this system, which is complex. If it does not work perfectly, they assume it does not work at all and, therefore, try to completely and revolutionarily change it. We have had massive structural change six times since I started as a postgraduate dean. On each occasion, there has been no clear evaluation of what the problem was that the solution was trying to solve. There is a risk, in this particular regard, that that could happen again. However, I agree with Sir Christopher that there is an opportunity here to get things right and to make progress to the benefit of patients.
Q124 Chair: There are two points, one made by Sir Alan and one by Professor Sowden, which I would like to pick up. First-Sir Alan’s point-your fear that the higher education world is being squeezed out of the process. Could I ask you to enlarge on that? Then I would like Professor Sowden to enlarge on the point about where the pinch points are now and the extent to which we are at risk of creating new ones in the new world.
Sir Alan Langlands: Most higher education institutions formed good relationships with their SHAs, in particular. Following some teething difficulties with the previous structural change, we are on a reasonably even path that allows universities and, hopefully, the health bodies and health providers, to take a medium and longterm view of the development of education and training on their patch.
In the scramble for what I think of as the preLETB period, where people are positioning and where there is organisational turmoil, there are early signs that some of the NHS operators are thinking of this as a contractual transaction rather than a productive partnership with universities, misunderstanding the importance of the medium and longerterm thinking and the links with research, which are hugely important. We are dealing here with the knowledge system at the interface between universities and health bodies-knowledge creation, knowledge dissemination and knowledge application. That requires everyone, with all their different sorts of expertise, round the table thinking and working it through, not being excluded on the basis that there is some perception of conflict of interest. NHS providers have conflicts of interest in relation to this because of their responsibilities for postgraduate education.
My simple plea is that everyone is at the table and works in partnership and that we do not get caught up, especially at a time of financial squeeze, in being obsessed with numbers and transactions. These are means, not ends.
Professor Sir Christopher Edwards: To underline Sir Alan’s point, he talks about potentially going down a road to disaster if universities are squeezed out. We have been down that road before and I am sure you will all remember the very large amount of money which was spent on the establishment of the NHSU. It would be an absolute catastrophe if we shut out the universities. We are already, probably, the only country in the world in which the universities do not play a dominant role in postgraduate medical education. If this was an opportunity to further shut them out of that, it would be an absolute disaster.
Chair: There are some quite strong words being thrown around-"catastrophe" and "being shut out." There are clearly some concerns below the modulated tones that you are using in evidence to the Committee.
Q125 Valerie Vaz: I am struck by some of the things that have been said. I would like to hear, from all of you, how you see this new body working nationally and locally. Professor Rubin, you mentioned something about you being "the nuclear option." Does that imply that HEE are going to be doing some of this monitoring and then you come in later? Are you doing some of this monitoring now and will you be doing that? It seems to me there is a duplication of work.
I am here as the ordinary voice of the patient, not a doctor; clearly, I see it from a slightly different angle. The accountability point is quite important. How is this new body going to be working nationally with everyone on board-this is your chance to tell us and set it out-and how do we do it locally? Also, there is this opportunity, is there not? There is this point about Scotland. There are doctors being trained and moving from different parts of England. How do we keep tabs on all that and make sure we get that quality coming through?
Professor Sir Peter Rubin: I will start at the UKwide level and then move in a leftwards direction, maybe. We are the UKwide regulator. We have very extensive statutory powers in the Medical Act. We do not need new powers in order to hold to account HEE, when it exists, or the Local Education and Training Boards. Those powers exist already because of the way in which the legislation is worded. We have the power to inspect and hold to account an amazingly wide range of organisations. It would be inappropriate for the UKwide regulator to be trying to ensure, in every hospital and every general practice in every part of the UK, that everything was going perfectly. We need to hold to account others who are nearer the front line.
The key thing is holding somebody, not a nebulous committee but a named person-nailing a named person-to account for the quality of postgraduate medical education in their area. That needs to be the postgraduate dean. The postgraduate dean needs to have the levers necessary to produce change when change is needed and those levers will usually be financial levers. Money talks, and the money will flow from HEE.
It is entirely appropriate to have a national body like HEE because they have the national overview-and our experience of working with NES in Scotland is very positive-and they hand the money down to a more local level. It is when we get to the local level that people have the granular information to say, as Christopher was saying earlier, "Hospital B is doing a really good job. Hospital A is not. We are going to sort this." We are there at a national level with extensive powers to use if we need to use them. We will use them-be in no doubt that we will use them if we need to-but if HEE and the LETBs work well, we will not need to use those powers. They would have done it already.
Professor Sir Christopher Edwards: Picking that up, first of all, how will HEE work? It will be a partnership with a series of bodies. The GMC will be a key partner. The Royal Colleges-and we will probably come back to those-are another part of the partnership. There would be an absolute need to have shared data and databases. That is going to be extremely important in terms of people and functions. That is a key point.
We have talked about the question of the need for a UKwide perspective. This is absolutely vital. To give you a practical example, the figures that have come out of Scotland are quite worrying. There are about 8,000 consultants and GPs in Scotland. There are 6,000 people in training, a ratio of 1.3:1. You would normally expect a ratio of 3:1. Why is that? It is partly because there has been a 54% increase in the number of consultant jobs in Scotland but very particularly because 74% of their SpRs have gone to England, so you start to see a tremendous interdependence. As soon as the tap is turned off-and, of course, the tap is turned off now because of finance-there is not going to be that growth. It is extremely important that we have a balanced approach across the UK and that we understand each other’s problems.
Sir Alan Langlands: On the UK point, it is terribly important to recognise that we are now running four separate health systems and four separate higher education systems, at least to the extent that the fee models and the teaching funding models are different across the four countries. There is one huge galvanising force at work in the UK, which is research funding and the way in which research is orchestrated on a UKwide basis, and I do not think there is any great appetite to move away from that. That binds, certainly, the university and strong parts of the health community together through these changes.
The only other point I would make is to draw a distinction between-and I am told I am going to be one-the role of a national regulator and the important work that needs to be done closer to the coal face, I would argue, in the LETBs, or whatever emerges in that area; the important work that needs to be done in tracking quality, effectiveness and safety going forward. That, to me, is the dialogue which needs to take place to inform the development of ideas around workforce and future education and training practice.
Professor Sowden: I have to go back a little-where we started-to one of the problems we are trying to solve. One of the problems is to get the full engagement and responsibility of employers for the future workforce. Whatever has been done over the last 12 years-and I have seen most of them at first hand-nothing has really worked. Whatever changes have happened have made the employers feel they are simply being supplied whatever it is, doctors or nurses, and they have to lump it. I am paraphrasing slightly, and I am sure they could speak more eloquently for themselves, but that is very much the situation. They do not feel they have very much influence.
One of the things which has to be sorted out in the LETBs is getting the employers fully engaged: working out what the services are going to look like in the future, how they might be delivered in terms of skill mix and what that means for education and training. But that has to be subject to checking. You can have people going off on extreme divergent patterns which are either not in their interests or those of the population they serve or which destabilise the wider economy across the whole of the health system in England. That is where HEE has an absolutely critical role.
Also, I think HEE will build on what MEE has achieved, which is considerable. The only other thing I would say is that HEE will have to have a very close relationship with the Commissioning Board. We are already seeing examples of the commissioning of services destabilising the provision of postgraduate medical education to the point where it might not be deliverable in certain areas because of the way in which commissioners are acting. A very important link needs to be made there and I do not see it referred to nearly enough in some of the paperwork coming out at the moment.
Q126 Valerie Vaz: Could you give an example of that?
Professor Sowden: Yes, I can give an example of it. In our area, one of the commissioning groups has changed the requirements for people to have reduced visual acuity for second cataracts. The consequence is that we do not have enough simple cataracts for our ophthalmology trainees to learn the basic techniques. We are having to go into negotiations to see if that can be reversed. The troubling thing was that the commission was changed without thinking about the consequences it might have more widely. I can understand why the decision was made. Equally, I can see why it should not have been made.
Professor Sir Peter Rubin: May I also return to one aspect of your question? All we are saying is predicated on the assumption that the money voted for medical education and training will be used for medical education and training. There are concerns-and I think it is important to state these concerns here this morning-that the LETBs may not, and I emphasise "may not," have the independence needed to ensure that the money voted for medical education and training is used for that purpose. That is, potentially, one way in which we, as the independent regulator of medical education and training, will have a very powerful role.
Q127 Dr Poulter: Picking up on a common theme which has come across, there has been a concern expressed by all of you about the lack of investment by some trusts in their trainees. Professor Sir Christopher Edwards made the point, at the beginning, about the variability between two trusts that were highlighted in the London deanery area.
As you say, the employer has requirements for service provision and those requirements and rotas are much more stretched with the European Working Time Directive coming in. There is also reliance on the willingness of the staff within a particular hospital to train their juniors. When there is that great pressure, how are we going to encourage hospitals to invest across the board in the staff they have to train, particularly when we are dealing with the potential deskilling of registrars in certain hospital specialities?
Professor Sowden: Can I follow up on the point you have made? There is no very close correlation, for example, between the amount of money an institution receives, and, therefore, the support it gets for postgraduate medical education, and its quality. What I have noticed most in my career is that, where there is good quality care, there is usually good quality education, and vice versa. Again, there is not a terribly close correlation there with the amount of money some institutions receive.
While I take your point that there are some resource issues, you often see very high quality postgraduate medical education-and for other professional groups-delivered in organisations which are struggling, in financial terms, but still manage to provide very good care and training. However, the situation is made worse-you referred to rotas-by the extraordinary inequitability, historically, of the distribution of the money that supports postgraduate medical education and training. It goes very disproportionately to certain areas, and it does not bear any relationship to future workforce supply.
Q128 Dr Poulter: Are we talking about big teaching hospitals?
Professor Sowden: We are talking about big teaching hospitals and big geographies. East Midlands receives 13.5% less funding than capitation equity would suggest. That is 500 to 600 junior doctors. Spread across our trusts, that would get rid of all of our EWTR problems at a stroke.
Q129 Chair: When you say "capitation funding would suggest," you are taking a norm based on capitation. What is the capitation? Is it capitation of trainees, capitation of patients-
Professor Sowden: Population.
Q130 Chair: That implies that the training should reflect population. Is that right?
Professor Sowden: Increasingly, there is a lot of evidence that it should. When I was training, doctors were very mobile. Doctors are very, very much less mobile than they were. We have a lot of people now who train in the medical school, train in the local hospitals and end up practising there. Certainly, in terms of specialty training, 70% of people train within 60 miles of where they end up working. That suggests you have a very local system. In general practice, it is 20 to 25 miles.
Professor Sir Peter Rubin: There is a slightly different angle you can take on this as well, and I think it is the direction from which the GMC will be coming. Reducing it to its simplest, where do you want medical education and training to happen? You want it to happen at the place where the patient numbers are right, the patient mix is right, the doctors have the time to learn and the trainers have the time to train. It is as simple as that.
If those four boxes are not ticked, we will expect-initially at a local level, the postgraduate deanery analysis-to say, "Those boxes are not being ticked. What are you going to do about ticking them?" If it is not possible to tick those boxes, then we will say, and we will do this if it is not happening locally, "I am afraid that the doctors in training in this environment need to move to where those boxes can be ticked."
Professor Sir Christopher Edwards: Danny, you asked, particularly, what we are doing and how we are going to solve the problem. When Christine Outram gave evidence to the Committee she talked about MEE’s "Better Training Better Care" programme. We are taking the recommendations in the Temple Report on the impact of the European Working Time Directive on the quality of training and taking the recommendations of the Collins Report on the first two foundation years-and, literally, going out to a series of hospitals to look at it in a practical way.
We are saying, "Can we look at best practice, how to do this?", "How is it that some hospitals manage to do it and others do not?", "Is it, in fact, purely to do with staffing, or is it that there is a different attitude in terms of how they cover the 24 hours?" We are trying to say that it is a soluble problem. Certainly, Sir John Temple thought it was a soluble problem as far as the impact of the European Working Time Directive was concerned, but, obviously, there are certain places where they do not have an optimal structure, for a variety of reasons, and where we have to try and influence those people. There is, through that programme, which Sir Jonathan Michael has kindly agreed to Chair, an opportunity to look at this in a very practical way.
Q131 David Tredinnick: May I take you, Sir Christopher, back to what you were saying about the importance of universities and ask if you think that, at a strategic level, medical education should in fact be university-centred?
Professor Sir Christopher Edwards: I have a very strong belief that the partnership between the NHS and universities is absolutely key. That partnership is a very clear one as far as undergraduate medical education is concerned. It then goes to the first foundation year and, gradually, becomes less clear as you proceed.
Q132 David Tredinnick: Would "disassociation" be a better word to use than "less clear"? Is there a complete split? I got the impression there was a division: we have all these people in the universities doing one thing and everybody else doing something else after that.
Professor Sir Christopher Edwards: Certainly, if you went to America, you would find that your postgraduate training was absolutely the province of the university. That is not the case here.
Professor Sowden: It would be too much to describe it as a disassociation. It is patchy, as well. For example, if you look at Scotland-this is not necessarily the consideration here-the relationships are very strong, partly because of the way that NES has been set up. I would say that some of the disassociations or difficulties we experience in England have been because of the way the Strategic Health Authorities dealt with their business on some of the postgraduate medical education.
But that is not to say, for example, that COPMeD is not now working very closely with the Medical Schools Council. We are meeting again tomorrow to discuss how we can work more cooperatively and collaboratively. Certainly, as to the way that the F1 year is delivered-the first year of postgraduate training-and the last year of medical school, we are working very closely on that because of work done by the GMC. You do not have to create an institutional solution to this because I think people genuinely do want to work together in partnership.
Q133 Chair: Do you agree with that from a university perspective?
Sir Alan Langlands: I do agree with that. In the academic health science centres or health systems, we have a model that would be conducive to that. It would bind the thinking and effort on research, education and patient care in strong and creative ways.
I know that all these reforms are obsessed with the notion of commissioning, but we should not lose the opportunity of the academic health science centres-which I think will grow in number and, therefore, we could conceivably have a reasonable spread across the country-to think of them as a focal point for achieving the coherence we do not always achieve at the moment. That is certainly worth thinking about. That argument will be reinforced if the NHS Chief Executive, in moving forward his work on innovation, begins to draw on the expertise in these centres as hubs for that process. That is something the university community generally could be excited about.
Q134 David Tredinnick: I have one other question. You talked about sharing information. Do your computer systems talk to each other? Can you practically share information from one machine to another, and are you satisfied that the IT systems being used at the moment are satisfactory, please?
Professor Sir Christopher Edwards: The answer is that, at the moment, we are very much based, as a very small organisation-MEE has five staff-within the NHS body, so to speak. Clearly, when one is looking at a new body like HEE and that body is to have a rather distinct profile-if it is set up, in fact, as a special health authority-it is going to have to make those sorts of decisions.
My own feeling is this-and it was asked as a simple question. If, for example, you look at one aspect of IT, namely, the question of your website, "Should HEE have the same approach as NIHR, that is, "hee.ac.uk?", which I perceive very much to be an academic, educational and training institute, it seems to me that is a key thing, whether or not you see it as part of education or very much part of the NHS. At the moment, we have to recognise that, on the educational side, there is a long history of sharing IT systems. The health side has had a considerable series of problems on the IT side. That is quite an interesting divide.
Professor Sowden: We clearly do not have common systems, but a lot of the data we hold in deaneries should not be available to the GMC and so on because it is private data about individual trainees. I would emphasise that we have recently worked very closely with the GMC, and increasingly so, with the full knowledge of MEE, around data collection, management and analysis about postgraduate medical education. That is beginning to identify areas where attention needs to be paid but also giving us information about what is working. That is working extremely well. The plans are for that to be a much more intensive programme of work over the next year or two. The fact we do not have common systems does not prevent us working together effectively around common data sets.
Q135 Dr Wollaston: Going back to what you mentioned, Sir Alan, that Medical Education England had five members of staff, how big will Health Education England be and how happy are you with the lines of accountability between that and Local Education and Training Boards?
Sir Alan Langlands: That is probably a question to Chris. It is not for me to comment, although I would love to do so and I could give you a very good answer.
Professor Sir Christopher Edwards: You might be interested that, relatively recently, we had an extremely helpful seminar to which we invited a series of bodies that had gone through a similar process. We had HEFCE, Monitor, FE people and NIHR people all come to talk to us. One of the things we agreed at that meeting, learning from their experience, is that there is great advantage to having relatively small bodies and that a body of about 100 was probably appropriate. The budget, as you know, is likely to be somewhere in the region of £5 billion. We looked very much at the advantages that HEFCE has had of being small in terms of excellent interpersonal relationships within that body, and a whole variety of things that stem from that. Personally, I would not want to be in a body, as is proposed for the National Commissioning Board, of 3,500 people. That could be a rather difficult organisation.
Professor Sowden: The relationship with LETB, I think, is going to be critical. There is a fundamental impediment to that starting off well by virtue of the fact the LETBs are supposed to be in shadow format by April with HEE, the body to which they are accountable and which is supposed to be signing them off, coming into a shadow format in October. Forgive me, but it is like having the cart before the horse.
Q136 Chair: Does that not rather beg a question: are the LETBs locally accountable or accountable to HEE?
Professor Sowden: They have to be accountable to HEE for the expenditure of the money that HEE passes down to them. Obviously, that will be done through some contractual mechanism, presumably a servicelevel agreement, which will specify the activity and the standards to which it will be done. It does seem rather odd that you are setting people off down a track and they are going to make some assumptions about how they will work. HEE may not have those same assumptions. It is going to be very difficult to pull this back and then have a genuinely coordinated system that works across the whole of England to common standards.
Q137 Chair: Let us explore this a bit further. Would it be fair to say that the relationship between HEE and the LETB is similar to the envisaged relationship between the Commissioning Board and clinical commissioning groups? In other words, you have to authorise them and be satisfied that they are capable of doing their job before they can go ahead and do it.
Professor Sir Christopher Edwards: Yes. What is proposed is an authorisation process. Looking at things that this Select Committee could do, it would be immensely valuable to say, "Could we try and fill this vacuum rapidly?" Unfortunately, the problem we have is that, if we wait until next October to set up HEE in shadow form, and then start to work in April 2013, there will be chaos. What is going to happen-and this is happening at the moment-is that all sorts of organisations, who are setting up, will be saying, "This is what we think a LETB should be." Not surprisingly, we will find that may be very different to the model which is eventually being proposed. What will happen next is that people will say, "No, we cannot change our model because it will produce chaos in terms of staff and training and everything else". As soon as possible, we need to have a blueprint of what this might be.
The model which I find very attractive is one which David Fish has. David Fish, of course, is on the Future Forum. The UCL Partners model is a very interesting model. If you asked David Fish, "Who pays you? Are you paid by UCL?", the answer would be "No." As to, "Where does your pension come from?", it is none of those places. It is independent. They have set up an independent group which closely relates to all these organisations but can make independent decisions. It is going to be extremely important to have that sort of structure so that HEE can then negotiate a contract which can be seen to be fair. Otherwise, there will be some very powerful people sitting round the table who, clearly, will not want to make any changes in training or in their staff.
Sir Alan Langlands: Could I make a point very briefly? It is the shifting sands on SHAs moving to clusters, and the early moves at a local level to set up these bodies in advance of there being clear national leadership, that is creating dissonance and causing concern in universities. When I used the term "shut out," some of these local models that are developing are excluding the higher education institutions that provide training, apparently. We have to deal with that quickly. As I see it, if the HEE has clear authorisation responsibilities, clear responsibilities for allocating and accounting for resources, and indeed the outcomes achieved, there must then be a sense of the LETBs being set up in a way-independent, quasi-independent or otherwise-where they can account to HEE for delivering their part of the deal. I would strongly argue that part of that has to be the clear involvement of universities from the outset.
Q138 David Tredinnick: What you are saying is that the Government needs to review immediately the priorities in the change process. Is that correct?
Sir Alan Langlands: Absolutely.
Professor Sowden: To some extent, the pause we have had has been too long. It is an understandable pause, but the Future Forum came out with a very clear direction of travel for healthcare professional education and training. I am not quite sure what can be added to that, but we have not had the Department of Health’s policy statement on what is to follow. It was due out in the autumn. I will ask you whether this is autumn now because it is getting a bit difficult to believe that. That policy gap prevents anybody, so you get this turmoil, turbulence and dissonance within the system.
Q139 David Tredinnick: You have good people out there trying to make the new system work, but there is lack of direction. Is that it?
Professor Sir Christopher Edwards: We are trying to anticipate how it might work, yes.
Q140 Valerie Vaz: Following up your independent little group, we are talking about public money, so who would they be accountable to? You can have lots of independent groups, but where do you get the national standards from?
Professor Sir Christopher Edwards: David Fish would be most upset if he thought that was the case. What one is saying is that there may be, for example, that type of group within an academic health science centre or partnership, and one can see very much how that would be relevant. But I can see a similar thing being relevant outside the AHSC. For example, supposing you had 15 LETBs, you could have that core at the centre of the LETB and then, in fact, have a whole variety of people who then come round and are clearly round the table. However, when it comes to the allocation of resources and the accountability, there is a very clearly and legally defined core. If you want everyone to be legally defined, the Health Service is going to spend a vast amount of money on all trusts saying, "What is my legal liability of going into this enterprise?" I am not sure you want to do that.
Q141 Valerie Vaz: Some of the independent groups can exclude universities.
Professor Sir Christopher Edwards: No.
Q142 Valerie Vaz: You have to have something that says that certain people have to be round the table.
Professor Sir Christopher Edwards: Yes, and that is what in fact UCL Partners has. You have the Health Service, universities and other key players who are round that core table.
Professor Sowden: That can be done by HEE specifying the kinds of things that must be included within these local arrangements.
Q143 Dr Wollaston: Can I turn, next, to the situation with the deaneries? The Department of Health has said that postgraduate deaneries will continue, but under the umbrella of LETBs, and that they will become truly multiprofessional. How confident are you that will take place and that the deanery structure and the best of the deaneries will be preserved?
Professor Sowden: There is a little bit of me which says they have to be because they fulfil such an essential function at the moment. If they were not there, you would only have to reinvent them. Some countries around the world are in the process of inventing postgraduate deaneries by another name because they have had problems with systems that do not have postgraduate deaneries in them.
The issue about multiprofessional deaneries is interesting. I used to run one, but not any longer. Some of my colleagues run multiprofessional deaneries. The multiprofessional bit is not difficult. It requires a different mindset and approach, but it is perfectly possible to achieve. We need to ensure that we secure the expertise we have within the system at the moment. Within a multiprofessional deanery setting, that will be the existing postgraduate deanery staff together with those people in strategic health authorities who run education commissioning-so they are commissioning for the other healthcare professional groups-and workforce planning and development.
Without those two bits together, you cannot create a multiprofessional deanery. Part of the problem, at the moment, is this huge gap with people thinking, "What are we going to do?" These people are a scarce resource. Other people want them. Some of them are going off into the private sector and elsewhere. It will be almost impossible to get their like again for several years because we have struggled with that skill set over the last decade or two.
Q144 Dr Wollaston: Again, another big problem with having an overly long pause.
Professor Sowden: Indeed, yes.
Professor Sir Christopher Edwards: To pick it up a little more, first of all, David is absolutely right. Obviously, you have to have such a structure. I would hope, however, that we do not create a parallel universe again to the universities. A number of these things can, in fact, be shared with the universities in terms of the infrastructure and it would be sad if we spent a lot of public money on recreating an entirely separate group. We have talked a lot about the link with universities. I ask a simple question: who appraises the postgraduate dean? In some places, you will find it is a joint appraisal between the university and the SHA. In some places you will find it is only the SHA; there are no links with the universities at all. That brings out the problem, as far as I am concerned. We have to provide that link. I have talked about the model where we had a core. I would want the postgraduate dean to be part of that core in the LETB.
Q145 Chair: Can we follow the money for a second? This is not only an enormously complicated set of structures. It is also the conflicting funds flows. Earlier in the conversation, Sir Peter talked about the risk of funds that are voted for training finding their way into other activities, Professor Sowden talked about a mismatch, as he saw it, between funds available in one part of the country and another and there is also a question of whether funds should be related to the delivery of high quality as opposed to being distributed by formula. What confidence do you have that the mechanisms are going to change in a way that creates sufficient flexibility in the system to allow those different challenges to be met?
Professor Sir Christopher Edwards: I hope we would have the kind of courage that the NIHR had in changing the system. What happened, as you probably will know, with the Culyer funding-the research funding for R and D-was that that was totally opaque. No one really knew where it was going or how it was being used. What they did on day one was to take the money away. They took it away, gave it back for a threeyear period and then produced a very clear plan. It is going to take quite a long time to work it out.
If you take Scotland, NES-NHS Education for Scotland, a similar body-were given responsibility for the additional costofteaching (ACT) money. That is equivalent to the service increment for teaching (SIFT) money here, a very large pot of money. They took four years to have a dialogue with people locally as to how the money was being used and how it could better be used, and so on. They have now come up with a really sensible way in which that money is being properly allocated. You cannot change things overnight. You will destabilise not only teaching and training but also the delivery of healthcare. We have to be very careful, but it is possible to do it if you have that sort of approach.
Sir Alan Langlands: It is terrible, but I know these two examples well. In fact, I have lived through the second of them and the first bit of the NIHR story. It is hugely important to recognise that these good changes were made at a time of growth. This change is going to be made at a time of financial retrenchment. We have already had quite significant reductions in HEFCE funding in relation to healthcare disciplines. We know, from our relationships with SHAs for nursing, midwifery and allied health professions, that over the next three years we are going to see a cut of 14%.
Some of the tensions between different players in the system will be heightened by the fact that resources are reducing and that, on both sides of the equation of health and higher education, some quite difficult decisions are being made. One imagines that that is only the beginning of a longer process of change. I do not think we should underestimate the difficulties in putting more sense into this, but I agree that Chris’s examples are very strong.
Q146 Chair: Wearing both a university and a former NHS hat, do you think that the structures envisaged will have sufficient authority to be able to change, in a consultative way, the funds flows? These are multiple systems driven by different drivers, traditionally. I question, in what we have seen so far, whether there is going to be sufficient flexibility to do all the things that you have talked about this morning.
Sir Alan Langlands: If we get the relationships right from the outset, there are strong possibilities-maybe even a high probability-of getting some of this right. Widening Chris’s point about NIHR, the research example, for the first time in my lifetime the funding councils, the research councils, NIHR and the Department of Health, universities and, indeed, some industry funders are working together in a coherent way to achieve real progress in biomedical research. We could replicate that for education. But it demands that there are knowledgeable people of goodwill who can sit down and thrash this out and that there is an even-handed relationship between the NHS and higher education with crossrepresentation on the key groups. We have been working at that on the education front, but this set of changes has rather thrown all that up in the air. We have to be very determined to get that right for the future.
Professor Sowden: There is a genuine view in the system-certainly with the discussions that have happened since the consultation came out from the Government-of a wish to see greater transparency. At the moment, this is opaque and through a glass darkly for almost everyone in the system. You cannot properly explain to anybody exactly how money flows right to the end point, which is the delivery of education and training for the student or trainee. That is not an acceptable position. The aspiration to have a tariffbased system is absolutely right and proper. I agree it will take some time to achieve, but it will be worth the effort.
Q147 Chair: What is a key step? You have given evidence about the relationship between HEE and the LETBs and the need to get that clear. Does that address these funding issues as well or are there other specifics that are urgently required to get that process moving more smoothly?
Professor Sir Christopher Edwards: No. I think it does address the present.
Chair: Good. Are there any other questions?
Q148 Valerie Vaz: Can I ask about continuing professional development? That seems to be quite a key thing. How do you entrench that in the new system? Is that something that will come from you from the centre?
Professor Sir Christopher Edwards: To a certain extent it is part of what has been said. There is an opportunity to do something which produces an educational continuum. That is what I think we should have. We cannot simply say, "You have qualified as a consultant. I touch you on the shoulder and you are now God. You are perfect. Nothing needs to be done."
Q149 Valerie Vaz: They do not do that for lawyers, either.
Professor Sir Christopher Edwards: Everyone needs to have continuing education. It should be part and parcel of the process. If you go to Scotland, NES has a responsibility for CPD. We have to look at this as something which is a challenge across the board.
Q150 Valerie Vaz: My point was that the GMC, obviously, have revalidation, and that is all going to be part of that. But what about the nurses? You will be responsible for everyone after that, will you not?
Professor Sir Christopher Edwards: Absolutely. The same thing applies. We have not talked about SAS doctors. They have to have access to training and continuing education, etcetera. No part of the Health Service should feel that it is isolated from continuing professional development.
Professor Sowden: Following up on that point, everybody talks about the feedin of newlytrained doctors and nurses, but it is a drip into a swimming pool. The bottom line is that the swimming pool is the established staff. If you do not continuously focus on their continuous professional development-and it needs to be continuous inter-professional development, because they work in teams now-you are not going to shape a different NHS. It is just not possible.
One of the problems we currently face is that we train people in a particular way to a particular purpose. The trouble is that, if you drip them into a contaminated swimming pool, they themselves become fast contaminated by the system. You have to do both bits. Unless HEE has some oversight of this, we are not going to be able to effect the kinds of changes the NHS needs to see over the next five years. We really will not.
Q151 Valerie Vaz: I have one more question I am quite keen to ask. Having heard various issues as to there being not enough doctors and midwives, there seems to be money for lots of health visitors. Where do you get that pressure point? Who tells who about where you need more of one or the other? Also, in terms of the length of training, how does that start and how do you come to an end point where you get the midwives or you do not get the health visitors?
Professor Sir Christopher Edwards: This is the great potential advantage of the system that is being proposed. For the first time ever, it is proposed that there is a link between workforce planning and education and training. If you look at how the system should work, my view is very clear. You are going to have key local groups of a sufficient size that they can look round their patch and say, "In relationship to midwives,"-or whatever it is-"we think we are going to need to have, over the next 10 years, this sort of number."
There will be other areas in which it is going to be ultraspecialist and very difficult to do that. If, for example, you take something like paediatric liver transplantation, that cannot be done at a local level. I see that, for these large geographical areas, there will be an opportunity for all the providers, the employers and everyone, to get together and work out what the health needs are and, consequently, what the workforce needs are. That has to go to the Centre for Workforce Intelligence, which we have not discussed, which will act as the national integrator and look at the picture in a national sense. It then comes to HEE who will commission relevant education and training. We can produce a feedback loop which, hopefully, will mean we are not in the situation where we blindly produce people. Northumbria University, for example, had a class of 75 physiotherapists and only one of them got a job. At the end of the day, there has to be some relationship between education and training and getting a job.
Q152 Valerie Vaz: Do you think that will solve the problem of agency staff?
Professor Sir Christopher Edwards: Agency staff is a complicated issue. We have to be extremely careful. Wearing my Chelsea and Westminster hat, a couple of years ago we had problems in midwifery. We looked at it very carefully and found that, over the weekends, we were getting up to 45% agency staff. That was behind the problem. Since then, we have put in a radical change and approach. People often do not realise it can be much more expensive to employ agency staff, because of the rates of pay, and, of course, they do not have the same allegiance, attitudes and local knowledge. One has to be extraordinarily careful about the percentage. You are going to need some, but sometimes it gets too high.
Professor Sowden: In terms of junior doctors, part of the problem at the moment is that the employers are not sufficiently informed about the whole system. They do not fundamentally understand why gaps arise and why they are an inevitable consequence of the system we currently run. If they were part of this process, built in much more fundamentally, while I could not promise you a complete absence of locums in the system, I think the demand would decline. They would look much more closely at the workforce planning and also say, "That has consequences. Therefore, we will not have as many of these junior doctors two or three years from now. We will have to look to an alternative workforce." I am not sure that happens at the moment.
Q153 Dr Poulter: It is obviously a more complex issue on the locum front than that, and there is probably an issue to do with the fact that sometimes, and certainly in my experience, trusts tended to be quite prepared to pay agency locums a lot more than they would be prepared to pay inhouse cover. That is a generic problem. But that is not for now and not for discussion today, perhaps. A desire has been expressed by Medical Education England for better training and a better care plan, to bring back more consultantpresent services to deal with EWTD issues and to make training needs less subservient to service needs. I touched on that earlier, but how feasible is that?
Professor Sir Christopher Edwards: We have found, around the country, that there appear to be some hospitals that manage to achieve what is obviously the gold standard we want, which is excellent training and consultant cover going round the clock. It is possible, but it does mean you have to get very good job planning and changes in attitudes of many consultants. That all takes time. One has to recognise that there is also-David I am sure will emphasise this-a difference in the distribution of numbers of staff around the country. That produces problems as well. The "Better Training Better Care" programme is designed, as you know, to try and focus on these issues and come up with sensible recommendations. Then, hopefully, we can get both those things, where the patient benefits at the same time as the trainee.
Q154 Dr Poulter: Certainly the traditional model has been that the registrar is the workhorse of the team, as it were and, obviously, we want to have competent registrars. I have two questions on this. First, if we focus purely on consultantdelivered care, are we going, per se, to run the risk of deskilling our registrars and taking away a lot of decision making which has historically, particularly by more senior registrars, been made very well? Are we risking deskilling that group?
Professor Sowden: Could I follow that up? A common view-forgive me-that I hear from junior doctors says, "I am not independent enough. I am not allowed to go off and make decisions, so I cannot learn." First of all, I am not sure that patients would be terribly happy at the concept of an inexperienced doctor making decisions. What I was going to say was that good supervision does not mean the consultant doing the job. It means the consultant is there to make sure they pick up a situation which is getting out of hand. With consultants present, you can often stretch juniors far more and far more safely than you can in a system where they are not present.
Q155 Dr Poulter: It is absolutely right that there is always consultant advice and supervision available, be it at the end of a phone, as it may be, or on site, but often the service provision of consultants can be in the form of clinics or in the operating theatre. What I am trying to drive at is whether we need to make sure we have a system-because we obviously have a system that is more stretched with EWTD-that is not deskilling the registrar from being able to step up to become a consultant at the end of their training?
Professor Sowden: No, absolutely. I do not know what Peter would feel about this, but we are aiming to produce people who have completed the curriculum in its entirety. That is part of the responsibility of the education system. Part of that is moving to a point where the person is capable of entering the specialist register and to become a consultant. I do not think we are producing doctors who are as experienced as they were 20 or 30 years ago. That is because they are much younger at the point at which they become consultants than they were then. Is that a bad thing? I do not think it is a bad thing, but it means that you have to understand these people will also need some level of support when they go into consultant posts. At the moment, the system is not terribly good at that.
Q156 Dr Poulter: No. Is it the fact that you perhaps do need a senior registrar level or another grade in there that reflects this to some level?
Professor Sir Peter Rubin: I wonder if I should try and answer that, Dr Poulter, because I think there may be a bit of crosspurposes here. It goes back to the four boxes that I said needed to be ticked-that the trainees have time to learn and the trainers have time to train. You can have a consultantdelivered service while the trainees have time to train and the trainers and the consultants have time to do the training.
Over the many years that I have been involved in education in this country, there has been a significant misunderstanding about the difference between experience and training. The two are completely different. Experience is making the same mistakes but with greater confidence. That is not what this is all about. The key, as Chris has said on a number of occasions, is changing attitudes, culture and organisational structures to ensure that the consultants are there but with the capacity to enable the registrars to grow in their confidence as each year of training goes by.
Remember that in North America-where, in my view, there are some examples of worldclass postgraduate medical education and training-they often produce specialists in four years. That is because there are enough trainers to train. There is enough space in the system for the trainees to learn. We need to aspire to that here. It will come down to ensuring that the environment is right and the four boxes, to which I referred earlier on, are all capable of being ticked. That will not be true everywhere.
Q157 Dr Poulter: The second part of what I was coming on to, the issue we touched on earlier, was the investment of the employer in the employee but also the trainee. Is there a key point in this process that, as doctors move up the training scale, it is becoming an increasingly big jump, as has been said by Professor Sowden, from registrar to consultant but also a big jump and step up from, say, foundation doctors to trainee and, particularly, from more junior trainee to what would be a registrar level trainee?
Is there a case, perhaps, for longerterm placements of some trainees at hospitals to engender that sense of thinking, "At the end of your ST2 year," or whatever it may be, "we want to have an ST3 we can use at this hospital, who would be useful on our rota"? Often, at the moment, there is not necessarily that investment. The trainee may have ticked their competency boxes, but are they going to be able to cope at that more senior level?
Professor Sir Peter Rubin: Could I have a go at that one? This is the kind of thing that postgraduate deans and LETBs, if they are working well, could be very influential in achieving. What you have alluded to is something which I personally feel very strongly about.
It is one thing to produce a doctor who has shown that they have achieved a certain competence; it is quite another to produce a doctor who is capable of doing what the public expects doctors to do, which is synthesising conflicting and incomplete information to reach a diagnosis, dealing with uncertainty and managing risk-all the things that doctors do day in, day out. We have to have training programmes which enable doctors to learn these core skills that go to the heart of being a doctor. That is so much more than ticking a competency box.
Professor Sowden: May I follow that? You make a very valid point. We are expecting an enormous amount from these young people. They are training, and it is very challenging, they are usually going through major life events, at the same time, and they are being employed in a system that many would describe as quite hostile. That is quite a triumvirate.
There is an argument for saying exactly what you are saying, but it would require curricula to be more modularised and also require credentialing-in other words, saying you have reached a certain level which allows you to do a certain range of activities within the system. But this idea of stepping on and off an education and training escalator has a lot to be said for it. I agree with Peter. If the LETBs operate well and work well with HEE, there is a real opportunity to deliver that kind of flexibility. Going back to a point Sir Christopher made right at the beginning, we do have a relatively inflexible system at the moment.
Q158 Chair: I am conscious we are on borrowed time. Sir Alan wants to make a point.
Sir Alan Langlands: Yes, very briefly. I sense we are going to move away from the workforce issue but, before we do, I wanted to run up a flag for the clinical academic workforce. Hugely significant progress has been made in recent years to rebuild the clinical academic workforce-not only in medicine, but increasingly in other areas. In these more difficult times, we have to keep a focus on that as a mainstay-a foundation stone-for some of the other things we have been talking about.
Chair: Thank you.
Q159 David Tredinnick: I want to ask one or two questions about wider participation in the medical profession and multiprofessional education. As a preamble, I would like to ask you about strategy. I was at the launch of the chiropractors’ prospectus for the next two years, what they are hoping to set out. Your predecessor-I think he was your predecessor, Sir Peter-Sir Graeme Catto was there, making a presentation. It was a very interesting presentation, too. My point is that he has now gone off to be the Chair or President at the new College of Medicine.
Do you agree with or have views on their strategy, because it seems that this could be the way forward? This College brings doctors and other health professionals together, renewing traditional values, creating a more holistic patientcentred and preventative approach to healthcare. There needs to be better communication between all those who contribute to good medicine. It is essential, they say. Is that a model that you would subscribe to? Do you see that as a way forward, please?
Professor Sir Peter Rubin: Yes.
Q160 David Tredinnick: That is a major break with tradition, is it not? It means it is more patient-centred and more holistic, so it will be looking, presumably, at going back to some of the older traditions in medicine.
Professor Sowden: For example?
Q161 David Tredinnick: For example, the Health Professions Council is now regulating herbal medicine and traditional Chinese medicine. There are these shops popping up in every high street, and I absolutely welcome this regulation. I am sure you are all in favour of better regulation. I am wondering, looking into the crystal ball before I get on to the core questions, whether you subscribe to this view, as I think Sir Peter says he does.
Professor Sowden: There absolutely has to be an understanding of the wider spectrum of the provision of healthcare for the benefit of patients. There is a limit, though, to the extent to which you wish to go down this path. As somebody who would wish to see the doctors I train practising evidencebased medicine, I would be concerned if they were practising medicine or seeking to practise medicine in areas where there is little or no supporting evidence. With that proviso, then, fine. I think you will find that most general practitioners, for example, have good working relationships with osteopaths and chiropractors, but often with a very narrow window of interface. I am much more concerned about some of the extreme aspects of practice.
Q162 David Tredinnick: I sat on both those Bill Committees in 1989 and 1992, I think, from memory, and statutory regulation has brought those professionals from being alternative right into the mainstream, where they are now taking the pressure off orthopaedic surgeons. Do you agree that, if that is a model, there are others that can come in and help? We must move on to other things, but do you agree with that?
Professor Sowden: You have to be cautious in the sense that you can stoke demand to the detriment of the care of those who have other illnesses.
Q163 David Tredinnick: Fine. I am probably testing the Chair’s patience. The Gateways to the Professions report showed the need to make medicine a more socially diverse profession. What effect do you expect the new student fees regime to have on this problem, please?
Sir Alan Langlands: I was the author of that report and I also have the job of introducing the new fees system for higher education, so you can imagine I have wrestled with this issue a little. The honest answer to your question is that we do not know. We have seen a slight drop in the UCAS October figures of applications to medical programmes, but, given the huge demand, maybe that is not a big issue. The question is: is that drop reflecting a particular part of the population or not? It will be some time-probably December 2012 when we understand what the 2012 intake is actually like-before we know the honest answer to your question, or at least begin to get an answer to your question.
That said, there has been tremendous followup on this issue. My work was followed up very strongly by the work that Alan Milburn did. There are some spectacular examples-my favourite is King’s-of university initiatives in outreach for medicine, but that is replicated around the country. People in medical schools, in particular, but in other health professions too, are working hard on trying to raise aspirations in schools, in trying to give better information, advice and guidance to young people wanting to enter other health professions and in trying to assure best practice in admissions. I would argue that progress has been made, although there is probably a long way to go.
What effect will fees have? I do not know. Generally, for the last five years, we have seen a 32% increase in young people, 18 or 19 yearolds, from disadvantaged communities coming into universities. Will the fee issue put that into reverse? I do not know. I do not think the Government intend that. They have put in place very generous support packages for students and a national scholarship programme that is supposed to mitigate that effect, but we will be watching it very carefully indeed, for no other reason than it is important that the professions reflect the communities they serve.
Professor Sir Christopher Edwards: To pick that up, I am very supportive of the point Alan is making. There was an article in the BMJ by Kieran Seyan, a fifth year medical student. He produced what he called "a standardised admissions ratio" to medicine and the figures were quite alarming. If you think that 1 was what you would expect, an Asian in social class I was 6, and an AfroCaribbean in social class IV was 0.07. No pupils in social class V from an AfroCaribbean background came into medicine over a 5 year period.
We have to recognise that there are some quite serious issues. My concern is that some of those groups are very adversely affected by money. One cannot be surprised. If you are an AfroCaribbean person and you want to do medicine-it is pretty difficult anyway-is this going to make it more difficult? We have to recognise some of these problems.
David Tredinnick: I will move on to another question.
Chair: Can we make it the last one, David?
Q164 David Tredinnick: Yes, indeed. What are the consequences of strategic health authorities "raiding" education and training budgets in the past to get financial balance within their health economies?
Professor Sowden: It has reduced the investment in the education and training infrastructure for all professional groups. In some areas of the country, that has been much more of a problem than others. It has continued in the last couple of years, in some areas, to the detriment of the system. Those systems are likely to have to pay a price for it in due course.
David Tredinnick: Thank you very much.
Chair: On that note, we need to move on. Thank you very much for your evidence. You have given us plenty of food for thought. Thank you very much.
Examination of Witnesses
Witnesses: Dr Anna van der Gaag, Chair, Health Professions Council, Professor Tony Hazell, Chair, Nursing and Midwifery Council, John Rogers, Chief Executive, Skills for Health, and Professor Les Ebdon CBE DL, Chair, million+, gave evidence.
Q165 Chair: Good morning. Thank you for joining us-as I said to the first panel, slightly earlier than we originally planned in order to accommodate the Chancellor of the Exchequer. Our objective is to try to bring this session to a close by 12 o’clock in order that my colleagues can attend the statement downstairs. I would like to begin by asking you, as I did the previous panel, to introduce yourselves and perhaps, as you do so, to tell us, in summary, the role that your organisations play in this very complex world.
Dr van der Gaag: Thank you very much. My name is Anna van der Gaag. I am Chair of the Health Professions Council. We are an independent UKwide, multiprofessional statutory regulator of 15 health professions. Those professions range from what I would describe as the biomedical end of the continuum-clinical scientists, biomedical scientists and radiographers-through to the therapy professions such as paramedics, psychologists and arts therapists. Our very smallest group are prosthetists and orthotists, numbering 850 the last time I looked. We have the large professions like physiotherapy, of which we have 45,000, right through to the very small professions, so a whole range. As you know, the Health and Social Care Bill is proposing, from next year, that we take on the regulation of social workers in England. That is an additional 85,000 people.
We have four standards and four processes. All the professions we regulate are regulated under that system. It is very much an integrated system covering all the professions in the same way. So we set standards and we hold a register.
We obviously run fitness to practise processes and, importantly for this Committee, we set standards for education and training. We approve 630 programmes throughout the UK. We do that through a process of visits and annual monitoring as well as something we call a "major change process" where the provider notifies us of a major change and that then triggers a system of scrutiny of those changes. We determine whether those changes, in fact, mean that the provider continues to meet the standards of education and training or not. We work very closely with professional bodies, employers, commissioners and with user groups. We review the standards on a very regular basis because we recognise that, as the professions change and evolve, those standards need to change and evolve as well. We do that always in a consultative way to reflect what is happening in those fields. I will stop there.
Professor Hazell: Good morning. My name is Tony Hazell. I am Chair of the Nursing and Midwifery Council. In the interests of brevity, all I need to say is that our regulatory body performs very similar functions to the Health Professions Council-but, in our case, of course, for nurses and midwives. Not in any way wanting to make this a numbers competition, we are the largest single health regulator in the world, with approximately 670,000 registrants. That, of course, does present some particular challenges for us as a regulator. I would very much endorse all that my colleague has said, and particularly in relation to the setting of standards for education and training.
Out of interest, before taking over as Chair of the NMC-and I am a lay Chair-I was, for six years, a member of the Health Professions Council as well. I will leave it there.
John Rogers: Good morning. I am John Rogers, Chief Executive of Skills for Health, which is the licensed sector skills council for health. Our basic remit is to champion investment in skills across the health sector workforce. Again, Tony, this is not a numbers game, but we cover the UKwide workforce on a whole workforce basis of 2.1 million. Within that, a lot of our focus has been on the bands 1 to 4 workforce because that is where we feel the greatest need is in terms of investment. Our functional roles are things like developing national occupational standards and apprenticeship frameworks. We run academies across England as well.
Q166 Chair: Do we have any increase on 2.1 million?
Professor Ebdon: I am Les Ebdon, Chair of million+, which is a university thinktank that has 28 subscribing universities, all of whom happen to be post1992 universities. The name of the organisation reflects the large numbers of students studying in those universities. Most of the universities who subscribe to million+ have significant partnerships with the NHS in terms of training nurses, midwives and other professions allied to health. My day job is as Vice Chancellor to the University of Bedfordshire.
Q167 Chair: Thank you. I would like to start on an area of this subject that we did not cover with the previous panel, but is relevant to both panels-the question of the changing skill mix in healthcare. I would be interested in your perception of the effectiveness of the old arrangements, and whether that will change in the new arrangements, of ensuring that the training that we provide reflects, accurately and in an uptodate timely way, the changing needs of healthcare providers in order to ensure that skills are kept up to date.
Dr van der Gaag: Are you specifically interested in the change from the current system to HEE and LETB, or are you interested more generally?
Q168 Chair: The answer to that is both. We are clearly going to be reporting, in particular, on changing institutional arrangements but there is no point in only focusing on those. What we are interested in is solving the problem, not just commenting on the structures.
Dr van der Gaag: From the perspective of the professions we regulate, clearly we are constantly observing and, in a sense, assimilating changes that are required by patients and service users. That is what we should be as a regulator. We need to be responsive to the changes that are going on in health and social care. We do that through a consultative approach. We regularly have to look at changes in curriculum and provision in higher education and then need to, in a sense, make changes that reflect what is going on in the workforce. That is something happening currently.
It is important that, under the new regime, there is a truly multiprofessional input in terms of decision making, be it at the HEE level or the level of LETBs. There is some concern that, when we talk about partnerships, we need to make sure those partnerships include all the professions. That can be very challenging because there are so many of them.
Q169 Chair: Partnership does not mean only between the doctors and the universities.
Dr van der Gaag: Indeed.
Professor Hazell: "Partnerships" is a word that has cropped up on many occasions this morning. That is certainly something we believe is absolutely essential. But, of course, it needs to be more than a word; it has to work in practice. We are conscious that, increasingly, care is delivered, certainly in hospital settings, within multidisciplinary teams and that the skill mix within those teams is constantly changing. Therefore, we very much welcome anything which increases the partnership between a national perspective of that skill mix and what is required with a local understanding of how it might be tweaked to reflect particular needs. We certainly believe that it will be very important for there to be a real working partnership between HEE and the LETBs and we would want to be very significantly involved in that at a very early stage.
One of our concerns is that some of the proposals put forward tend to put the regulators a little further down the line. As you heard this morning, from our colleagues from the GMC, we do have a statutory responsibility for setting standards for education and training and, of course, for assuring the quality of those. I would like to think that the partnership will be meaningful, with everybody working very much together.
John Rogers: I would like to widen the definition of skill mix, in that 60% of our workforce is professionally qualified. We have 40% who are not. If we are going to achieve the £20 billion productivity challenge, we need to better use the whole of our workforce. Within that, currently, we spend about 3% of our training budget on 40% of the workforce. There is a question mark in terms on how you upskill that 40% to improve that skill mix to improve productivity and quality.
Q170 Chair: Could you give us one or two examples to dramatise what that means in practice, where there are opportunities to spend money to improve care for patients that you do not think are being followed up at the moment?
John Rogers: There are examples that we have on our website, and I can give you loads of written evidence following the oral evidence. Essentially, you can have examples of healthcare assistants who have been trained up in assistant practitioner roles. Within breastscreening services, that has been rolled out over the last four years and has been very successful. We have other examples there whereby it has been successful in Trust X but has not been adopted across the country. Within that, the issue is about how we get that widespread adoption, but underpinning it all is how we get the investment in those skills.
Q171 Chair: Your core message, if I am not putting words into your mouth, is that you can deliver care for patients by other means than regulated professions in some circumstances.
John Rogers: Yes. A lot of the discussion I have heard this morning, and in previous weeks, centres on the professions around medicine. That is absolutely right and proper and I do not think anybody would have any kind of challenge to that. Therefore, this is not "either/or". It is "and". It is how we maximise the best outcome, in terms of our whole workforce.
Professor Ebdon: To emphasise, again, Chair, the importance of partnership between various parts of the NHS and universities in encouraging excellence and relevance of training and education, nurses, for example, spend 2,300 practice hours with the NHS. Therefore, universities have to be well schooled in what the needs of the service are. Indeed, universities are responding rapidly to the desire to make nursing, for example, a more graduatebased profession. We can see that around the country.
I sound one note of concern about continuing professional development and the proposition that, in the future, the MPET budget should not fund continuing professional development. That would be a serious mistake because we heard, in the earlier evidence, the importance of continuing professional development in the NHS. In particular, issues arise for all professionals, for example, taking the programmes which have been run in recent years about care for patients with HIV/AIDS-a disease which may not have existed or been present in the United Kingdom when many nurses originally trained-and also the increased need to control hospital infections. Those kinds of CPD programmes are absolutely vital.
Dr van der Gaag: If I may reinforce that point, one of the hopes for the new infrastructure is that there will be more proportionate funding, particularly for postregistration-CPD for professions across the board-and, taking John’s point, the support workers also need investment in training. As the needs of the population change, there is much more investment needed in working with people with longterm conditions. The workforce needs to adapt and be funded in order to achieve that.
Q172 Valerie Vaz: I want to turn to the Local Education and Training Boards and your role in them. You are UKwide organisations, are you not? How do you see where your members fit into this new structure, and in terms of the lines of accountability?
Professor Hazell: We are very fortunate in the education of nurses and midwives in that the involvement of local health providers has been developed extensively over recent years. As Les said, it is a genuine partnership, 50:50, and we take that very seriously. When you look at a local situation of education and training for nurses, you are already going to have, in most instances, a very strong involvement both of the higher education section-it tends to be predominantly HEIs that provide these programmes-and the actual care providers, local trusts and so on.
We would expect and anticipate those true partnerships to be reflected in the LETBs because it would be such a shame if so many of the benefits that we have developed in the current system were lost in the new system. The first question that was posed this morning to the other panel was, "Do we need a new system?" The answer that they gave would be very much the same as I would give. There is a lot of good in what we have been doing so far, but we need to make it better. Let us not throw out the good, but let us ensure that that is integrated effectively and adequately into these new structures.
Professor Ebdon: While we are emphasising the importance of partnership, the partnership with the universities is key, as we have seen. Therefore, it seems to me to be a ludicrous suggestion that all of the HEIs involved in the provision of education and training for that particular LETB should not be represented there and actively engaged in the discussion. The suggestion that there might not be universities at the table is very worrying.
John Rogers: From our perspective, the roles of the LETBs are still emerging in terms of what they will be. We have had very good relationships with the strategic health authorities and, in terms of the LETBs, our focus as an organisation is around employers. My board are all chief executives of NHS or independent sector organisations. Within that there is a role, for example, within the north-west at the moment where we run an academy. We have put through nearly 1,000 new apprenticeships this year.
We would look to work with the LETBs in a similar way. There are roles, on a national basis, in terms of looking at what are the requirements for, and development to, higher level apprenticeships and the frameworks for those. One of the things that we are developing also is a skills passport system and how we link with the LETBs on that. There is quite a range of links, but a lot of those will be, to a degree, part strategic, part operational.
Q173 David Tredinnick: Is not the move to a degreebased nursing profession very discriminatory in terms of socioeconomic classes? Will it not exclude a lot of wonderful people who love and care for people, just because they have not got a degree?
Professor Hazell: Clearly, I must respond to that. The simple answer is no, I do not believe that, but you would expect me to give some justification for it. We need to remember that we have had degreebased education and training for nurses since the 1970s. There have been a lot of provider programmes that are already offered at degree level.
In Wales, for example, since 2004, all the programmes have been degree-based. We heard earlier, from the previous panel, about the expectations that are now put on doctors to have skills and competencies that perhaps go beyond some of their initial training. I would suggest that, increasingly, that is the case with nurses. Degreebased approaches to education and training for nurses does not in any way imply that those individuals do not have the same commitments to providing compassionate, fundamental care based on dignity and respect. Increasingly, they are expected to provide higher levels of skill, analysis and leadership.
We believe that the programme being rolled out now in England, to come in line with the rest of the UK, will enhance the quality of that fundamental care. Wales has done some very, very interesting monitoring over the six or seven years that they have had this. They are now producing some very useful evidence to say that there is nothing to support the idea that these people are in any way less caring.
Q174 Dr Wollaston: Can I follow that up with a question? So much fundamental nursing care is now being provided by healthcare assistants and many of those that I speak to tell me they want to have access to improved training and to become assistant practitioners. As Mr Rogers touched on, if we want to have better training for the 40%, we are going to need a bigger share of the 3% of funding. But then you are up against the issue that the medical profession is very powerful. How confident are you, within these new organisations, that you will be able to wrest a fairer share of that postgraduate or, if you like, continuing professional development cake?
John Rogers: To be absolutely honest, which I am in this Committee, I am not very confident at all. I have been in this arena for about 25 years. Every time you get a downturn, the actual constriction of investment hits the 1 to 4 bands more than it does anywhere else. We have done brilliant work with the 1 to 4 bands over recent years. We had a £100 million joint investment fund between the Learning and Skills Council and the SHAs. Also, the Department put about £10 million into apprenticeships last year and there were 8,000 new apprenticeships. The problem with that, for bands 1 to 4, is that it is all initiative driven. It is a pot of money here and a pot of money there. There is no continuity in terms of people being able to plan. That affects the relationships between trusts and further education, and it affects training departments within trusts. It is all stopstart. Within that, the bottom line, if history repeats itself, is no, I am not that confident.
Q175 Dr Wollaston: What powers would you need to make it better? The public are very concerned, are they not, about improving the standards and the access to training, particularly for healthcare assistants, as they are themselves?
John Rogers: Within that, a lot of the focus for me will be around the LETBs-the Local Education Training Boards. If they are truly employer-driven, the employers see the agenda in terms of the challenge with the productivity agenda, then they recognise that they need to invest in that level of workforce. The LETBs need the flexibility from the new NMET budget, whatever it is called in the future, and flexibilities from HEE in terms of being able to adapt that on a local basis. Then we would work very positively with the LETBs.
Professor Hazell: Can I add a comment? All of us are committed to improving patient care, patient safety, and so on. That is the object of any enhanced training. We also need to ask ourselves whether there are other things we can do to contribute to that. Certainly, we believe there are. From the NMC’s perspective, we are currently doing some very important work on improving the guidance we offer to nurses and midwives regarding the delegation of tasks to healthcare support workers. We recognise that those support workers play a vital part in the overall provision of care, but, most of the time, they are going to be given tasks that have been delegated by nurses and midwives.
We do not feel that our current guidance on that reflects current practice and situations. We have begun-and we are almost at the end of it-a piece of work that will improve the guidance and the support for nurses and midwives so that, when they delegate tasks to other people, they are confident those people are competent to undertake those tasks. That is something we can do in addition to-and I totally agree with John here-further investment. I travel up and down the country and have come across some absolutely firstclass examples of local training initiatives for healthcare support workers, often done collaboratively across a number of education providers. I would cite the north-west as a very good example of that. It is not all bad. There are some very good practices out there.
Q176 Dr Wollaston: Is that because they receive better funding in that part of the world or is it that they are performing within the system of funding?
Professor Hazell: It is probably a combination of both. Clearly, the funding available does influence it. A lot of this is about a genuine belief and a commitment of people that they can work together, improve things and be innovative. Again, sometimes we do not talk enough about the innovative approaches to education and training that take place across the UK. We should celebrate those far more than we do.
Professor Ebdon: One practical proposal to safeguard education and training is to ringfence the education and training budget. It has been, in recent years, a soft target for savings and we have seen damage, particularly at the healthcare assistant, nursing and midwifery end of the spectrum.
Q177 Dr Wollaston: Would you ringfence it so there is more of a bias towards healthcare assistant continuing professional development and you do not have powerful interest groups taking a disproportionate amount?
Professor Ebdon: Absolutely, is the answer.
Chair: We have a budget and then we are ringfencing 3% of it.
Dr Wollaston: No. I am wondering how feasible it is to wrest a greater proportion of it.
Q178 Chair: Is it not about the balance? If there is a training budget which is to be the responsibility of HEE and, through HEE, the LETBs, it is a question of maintaining the argument within that budget, is it not? If you start with 3%, who knows whether 3% is the right level? Discuss.
John Rogers: The important part with that is consistency. If it is 3%, or whatever it is, and people know that that investment is going to be made and that can be done in partnership with the trusts, with the colleges, and so on, then it is about the ability to plan. Yes, we would like more as well, but I realise that there are financial constraints with all of this. Tony was saying the north-west is an absolutely fantastic example. That is where our major academy presence is and we have worked with all 38 trusts, with the 15 colleges in the area and very much with the backing of the SHA who have invested in this area. The results there have been brilliant.
Q179 Valerie Vaz: Following up on that point, where is this good practice going? Is it going to some person in the Department of Health and why is that not being rolled out across the whole country? Could you do that under the new system?
John Rogers: As a Sector Skills Council, one of our funders is BIS, as with all of the Sector Skills Councils. We have recently put in and won a bid to BIS for the years 2012 through to 2014 to set up networks for spreading good practice. That is one of the things we are concentrating on in terms of getting networks of employers together and spreading that good practice.
Q180 Valerie Vaz: Did you feed your good practice in the north-west back up?
John Rogers: Yes. On our board, apart from the chief executives from the trusts, there are the four Department of Health representatives as well. They are fully engaged in terms of what we are doing and are very supportive about that.
Dr van der Gaag: I want to add two quick things in terms of looking for examples of good practice. There was a lot of mention of NES this morning. For all of us, there is a sense that NES in Scotland has done a huge amount because it is very much taking a multidisciplinary approach. In England, the multiprofessional deaneries are also a good example of where there is more integration and more shared understanding of what the workforce as a whole needs in terms of education and training and continuing development. Those are few and far between, at the moment, in England, but it seems to me they are very good models that the new system could build on.
Q181 Chair: Dan Poulter wants to come in, but I observe that the Chairman of the Deaneries, who was here earlier on, was one who used to run a multidisciplinary deanery and moved away from it. Does anybody have any comment on that?
Professor Hazell: I have no idea why that might have been. Perhaps I can give another example of where it works very well and apologise, in a sense, for using a Welsh example. A week or so ago, I was present at the opening of a brand new building on the University of Wales hospital site, the Cochrane building, which is a tripartite partnership between the School of Medicine, the School of Nursing and Midwifery and the School of Health Sciences-various health professionals.
That is going to be a truly multiprofessional activity. This is predominantly for preregistration training, so they have joint library facilities and joint skills laboratory facilities where they are going to be able to develop skills on a multiprofessional basis. That is very much supported by the deanery, which is predominantly concerned with postgraduate education. So, yes, it can work. I have no idea why the east midlands moved away from that. You would have to ask David himself why that is.
Q182 Dr Poulter: I want to pick up on some points. Obviously, healthcare assistants, nurses and all allied health professionals not only work in the NHS-and a lot of focus has been on the NHS so far-but in social care settings as well, in care homes and elsewhere. It is very easy to monitor performance and training in the NHS. In terms of monitoring activities in other care settings, how well do you feel that is done at the moment?
Professor Hazell: We need to recognise that regulation cannot be the responsibility of an individual health regulator. We have talked about partnerships, which are crucial. In that context we have to work very closely-and we do-with the systems regulators, which, of course, is a devolved responsibility. We have four systems regulators. Certainly, they have a much larger role currently to assess the quality of care and standards within the independent sector.
Of course, you have mentioned the social care sector, but it is health and social care. The further you go out into the community and the independent sector, the greater the blurring becomes, as I am sure you are aware. We have to work with systems regulators in the current situation and try to get them to share that responsibility. It is not going to be an easy task. We do not have any real hard data as to how many of these people there are. It is very difficult to know whether we are adequately controlling them. We saw, only a few days ago, reports in the social care sector of providing care in people’s homes. How do you monitor that? That is a difficult challenge, I think.
Chair: This is a training inquiry.
Q183 Dr Poulter: Indeed. What I am trying to drive at is how we make sure that those people who are performing healthcare work-and they may have previously worked for the NHS but are now, perhaps, working in the social care sector-have continuing professional development and that their training and skills are of the standard we would expect in the NHS but putting that across to adult social care. That is what I am driving at.
John Rogers: Basically, we work with our sister body Skills for Care, which is the Sector Skills Council for Care. The national occupational standards, which the care assistants’ qualifications are based on, are the same standards for both social care and health. They are the same standard within the qualifications.
In terms of work that we have recently been asked to do by the Department of Health on code of practice and training curricula, that is a joint piece of work between ourselves and Skills for Care to cover the health and care sectors. That partly answers your questions. It is fine in terms of how far it goes. The question in terms of extended roles within that area is much more tricky to answer.
Professor Ebdon: Can I make a practical suggestion to this problem? Some NHS trusts are broad-minded enough to let their professionals study continuing professional development programmes alongside people from the private sector in the settings that you were talking about. Others are not so broad-minded. It seems to me not a very good idea to separate out your staff from this. If we want the same standards, let us have the same CPD activity and let us train and educate these people together.
Dr van der Gaag: Can I give you an example? I can only speak for the professions that we regulate, but we have had in place, since 2006, mandatory standards on continuing professional development. We audit, on a random basis, those on our register against those standards. Wherever they work-whether they work in people’s homes or in independent care homes or in the NHS-they will all be subject to those same standards on continuing professional development and will be selected for audit regardless.
That is a very important baseline, in a sense, on which we work with the professions to ensure that they continue to keep up to date and are fit to practise. That is for the professions we are currently regulating. Obviously, when social workers come into the Health Professions Council, they will be subject to the same mandatory standards on continuing professional development.
Professor Hazell: Can I add that perhaps a number of our healthcare support worker colleagues, whether in health or social care, might be a little surprised at us focusing on CPD. Many of them would be only too pleased to have some initial training. On that basis, we very much welcome the new initiative that Skills for Health and Skills for Care will be undertaking to introduce basic common training for these people. That is where we need to start. We welcome that initiative and look forward to contributing to that work in a constructive and positive way.
Q184 Dr Poulter: A lot of the issues are concerned with who is responsible for adult social care at the moment. Obviously local authorities have, predominantly, a great deal of responsibility for that. What role would you say they should have in helping to coordinate or develop training at a local level? It is all very well to have a national initiative, but, in my view-and I do not know whether you share this-it is important that the people who are implementing that are able to and are doing it. What role do you see for local authorities in helping to support this? We have the NHS that does it in the hospitals, we have the unions and the other groups that make sure training happens, but how do you make sure it happens on the ground?
Professor Hazell: I am sorry to introduce the word "partnership" again, but it is vital that we acknowledge there are some very good examples of local authorities and health organisations working together, particularly in areas such as public health where the responsibility is very much a shared one.
It is essential that local authorities do contribute, particularly on the social care side but, equally, on the healthcare side. We have to try to identify where there are some good examples and roll those out, talk about them and try to encourage. I am more optimistic than I would have been perhaps 10 or 15 years ago about the collaboration that exists between local authorities and health authorities. Anna’s professions cover the local authorities more than ours do.
Dr van der Gaag: Yes, you are absolutely right to foreground partnership working as being essential. You are also absolutely correct to say that there is a level of concern about the amount of supervision, the supervisory structures that are in place and the amount of readacross that is there at the moment. The development towards national standards with much more of a focus on investment in training for those at support worker level is to be welcomed by all of us.
Q185 Chair: Can I turn to the question of the range of social backgrounds for people joining healthcare education-in particular medical education, but not exclusively that? Professor Ebdon, the view was attributed to you-you may think inaccurately-that schools should be willing to be flexible on their entry standards in order to encourage students from low income, disadvantaged backgrounds. Do you think that is right?
Professor Ebdon: There are things other than Alevel grades which suggest somebody will become a good doctor. I would hope that medical schools would look at the range of capabilities of individuals and not only their academic achievements. We also have to recognise that, now, the academic achievement levels set for entrance to medical schools is so high that it favours a certain type of school, those which are particularly academically focused, but, in particular, as we can see from the statistics, feepaying schools as opposed to state schools.
It is quite clear that we would want a range of people from different social classes, and indeed different ethnic groups, to go to medical school. The evidence that Sir Christopher gave was quite challenging, was it not, in the previous session? I very strongly believe that universities should be looking for potential in candidates as opposed to only past achievement. The potential demonstrated by getting good grades in a school where that is unusual is indicative of somebody with potential as opposed to perhaps getting very good grades in a school where everyone gets very good grades.
Professor Hazell: I said earlier that most of the programmes for preregistration nursing education take place in the higher education sector. But many of those higher education institutions have very good partnerships with a range of FE colleges which are providing-and have done for a number of years-what we could loosely call access programmes, increasingly foundation degrees and so on, and a whole range of innovative approaches. The relationship they build with their higher education provider enables people to have greater access.
I would say that higher education has a good track record in working across the higher and further education sectors in encouraging people from nontraditional backgrounds to come into those professions. That is certainly what we see in nursing. It is not only people from different socioeconomic backgrounds, but people at different age levels and from different walks of life. We should be encouraged by the relationships that already exist and build further on them.
Q186 Chair: That is taking the view of engaging with the place where the student does the Alevel, or whatever prequalification it is, rather than simply trying to guess from an Alevel score.
Professor Hazell: Absolutely.
Q187 Chair: Is that what you meant?
Professor Ebdon: I do not think those universities that use what is known as contextual data are guessing. There is a good deal of research evidence behind that now.
Q188 Chair: I acknowledge the mistake.
Professor Ebdon: It is a clear issue about medical education, as we heard from the last speaker, and it is something we have been able to solve in nursing and midwifery. Engagement with schools, colleges and communities is, of course, an excellent way of ensuring a good supply of a diverse population into professions allied to health. Hopefully, the medical profession will learn from it.
John Rogers: Within that, particularly within nursing, there has been a good tradition, as Tony says, in terms of vocational pathways with people coming through NVQ routes-as was-into nursing. Certainly, everybody would encourage that in terms of how you get the vocational pathways into higher education as well.
Dr van der Gaag: I want to add that we have done quite a lot of work in the area of understanding the needs of people with disabilities who might want to become a physiotherapist or an occupational therapist and so on. We produce guidance on this now, which is another way in which we can, in a sense, target particular individuals who might feel that they were excluded.
In fact, we are saying that we very much welcome applications from people with disabilities. Going back to our earlier conversation about the changing needs of the population-more and more people with longterm conditions requiring services-having people who have a personal experience of disability working as professionals with those individuals, improving their quality of life and so on, is very important. That is another important group that needs to be foregrounded in this. We want more people with disabilities in the professions.
Q189 Dr Wollaston: Can I ask a followup question of Professor Ebdon? Where universities have a good track record of recruiting students from disadvantaged backgrounds, such as King’s that was quoted earlier, do they find, when they look at the data in terms of pass rates at the end of the course, that these students are as likely to pass as those from more advantaged backgrounds? It is quite a long time to commit to a course like medicine. I wonder what the data is on that.
Professor Ebdon: I believe that that is so, that the application of contextual data is based on actual cases of student achievement at universities reflecting on their Alevel grades coming in. The King’s example is an excellent example of reachout to local communities as well as a sensible use of entry routes into the profession. It used to be generally true that research suggested students who joined university through an access route achieved significantly better than those who did not. Part of that is because of the greater pressure on such students to achieve and the fact they have overcome major hurdles. They have sorted themselves out on their access programme and, by the time they arrive for the university course, they have learnt a wide range of study skills which, maybe, some of our 18 yearolds have not yet acquired.
Q190 Dr Poulter: I have a quick question for Professor Ebdon. The Department of Health states that the number of midwives entering training is at record levels. Yet the Royal College of Midwives recently had a survey which showed a third of students are leaving their courses due to fears and concerns about debt and a lack of jobs, even though we know, perhaps, there are the jobs available and there is a need for more midwives. Why do you think this is happening?
Professor Ebdon: There is a desperate need for stability in training the workforce. A few years ago, we had a situation where there were deficits in local trusts in the regions that we serve. Drastic measures were taken to balance those budgets in one year and, as a consequence, no new midwives were taken on. You had a situation where people who had been very successful nurses had decided to study midwifery and, because of the accident of the year they made that decision-the year they came out as fully trained midwives-there were virtually no jobs locally. That has a knockon effect years down the line with people considering training for midwifery. We need to make sure that any reforms to education and training in the NHS do promote stability.
The idea that you can take these education and training programmes and treat us like the people who supply the roller towels is ridiculous. For example, at my own university, the University of Bedfordshire, we have invested in a new campus in Aylesbury because we have the contract to train the nurses and midwives for Buckinghamshire. We have spent about £2 million in a simulation and skills centre at one of our campuses in Luton because we think it is increasingly important to use simulation, where we can, because of issues about hospitalborne infection. These are big investments. If, suddenly, somebody says, "We can get this done cheaper down the road," that would be a severe discouragement to universities to make those kinds of investments in excellence in education and training.
Q191 Dr Poulter: You seem to be saying that the hospital trusts need to take a more longterm view of service provision in midwifery and nursing-in this case, midwifery. You say that, in order to meet shortterm financial squeezes in the past, there has often been a freeze on recruitment in midwifery and that lies at the core of the problem. The decisions at those trusts were not being made in a coordinated manner looking at the longterm need for midwives and not coordinating with yourselves.
Professor Ebdon: Shorttermism is a real enemy of recruitment. Let us be absolutely honest. This country, for example, to meet nursing shortages, has, on occasion, denuded other countries of their nurses and brought large cohorts of them into our hospitals. We need longterm planning for the health workforce in this country.
Q192 Dr Poulter: The key issue here also is the tiein with the local employer, is it not? If trusts are making those shortterm financial decisions to freeze the number of posts when we know there is a need for more midwives, there is a disconnect between the longterm workforce planning, what you are doing in terms of training midwives and nurses and the decisions being made by chief executives and boards of local trusts.
Professor Ebdon: Many nurses and midwives train and work locally. In fact, midwives, traditionally, are more mature in years than nurses and will very often have their own families. Having a family can make them think, yes, midwifery is a valuable profession that they would like to enter. But people’s mobility is very much reduced because of all kinds of social phenomena, such as housing, schools for children and so on, and we understand the importance of stability in the education of our children. So they are very much coming from their local community, training at the local university in partnership with the local NHS trust and expecting and hoping to get a job in the local NHS trust. If the messages come back at some time that that is a mistake, there is the possibility they might then return to nursing and the successful career they had there.
Q193 Dr Poulter: Does anyone want to add to that?
Dr van der Gaag: I have a quick point. It seems to me that, in terms of workforce planning, we tend to rely on descriptive data rather than analysing the social dynamics that are at play. There needs to be far more of that kind of investigation and understanding of the reasons why people leave, why they feel they are not supported and why they do not invest in their own training and development. Thinking about the future, that investigation seems to me to be something that we could do much more of to the greater good than we have done in the past.
Q194 Valerie Vaz: Who has the grip, nationally, of those figures? Who is going to have the accountability to look at the UK and England strategically?
Professor Ebdon: Higher Education England is going to be supported by a workforce planning unit. We have to acknowledge that, as a nation, we have not had a great track record in workforce planning. We also have to take on board the fact that this is very much a localised issue. For example, we find it is very much more difficult to recruit to our programmes in Buckinghamshire than our programmes in Bedfordshire, which suggests that there are many other work opportunities for people in Buckinghamshire compared to Bedfordshire. If you go further north still, then you will find that recruitment gets easier.
Q195 Valerie Vaz: Who do you think should be responsible for that? You can have lots of nurses in Buckinghamshire, but you do not need them there.
Professor Ebdon: I assume the idea of having Local Education and Training Boards is to get that local dimension-
Q196 Valerie Vaz: I am trying to tease out of you a possible pathway up to the Secretary of State.
Professor Ebdon: -into that, which is going to be very important. It is going to be very important to ringfence the budget so that, when there are other issues going on in trusts, they do not say, "That is something we could raid for a year and we will make it up again later." It is also going to be very important that the sometimes competitive situation trusts feel themselves to be in does not spill over into disagreement in the LETBs and that we really do see a true partnership both between the trusts, Health Education England, universities and other educational bodies.
Professor Hazell: Could I add a point to reinforce what Anna said? In the health systems-this is taking a phrase from somebody else-we are quite data rich but not particularly data savvy. We have a lot of figures, a lot of data, but we do not necessarily interrogate those data adequately enough to identify the sorts of issues that Anna has already spoken of. I hope that the workforce intelligence system will begin to do that more sophisticated analysis of the figures and the data we have so that we can inform the debate on the basis of clearer evidence.
Q197 David Tredinnick: I want to ask Anna van der Gaag about workload but, before I do, can I get on to another question? Section 5.53 of the House of Lords Science and Technology Report in 2000 said: "It is our opinion that acupuncture and herbal medicine are the two therapies which are at a stage where it would be of benefit to them and their patients if the practitioners strive for statutory regulation [...] and we recommend that they should do so."
You now have herbal medicine, both phytotherapists-English herbal medicine-and half the Chinese discipline, because you have the herbs but not the acupuncture. Do you think this is important and what is happening on that?
Dr van der Gaag: It is our understanding that the Government wants to establish a system for registering practitioners covered under the EC Directive to ensure patient safety and continued access to unlicensed herbal medicine. That is the current situation. We know the Department of Health are very busy drafting and that we expect a consultation document sometime early next year.
Q198 David Tredinnick: They have given it to you, have they not? You have to do it. They have said, quite clearly, that the HPC will regulate it.
Dr van der Gaag: Indeed. We are working very closely with them on this. We have said, since 2009 when the Portillo report came out recommending statutory regulation and that the Health Professions Council was the regulator of choice, that we fully supported that recommendation and would work with Government to achieve that. That is where we are. We are proceeding on that basis and very much looking forward to the consultation document that is due out early next year. It will give the detail on exactly how that is going to be achieved.
Q199 David Tredinnick: Do you have a view about whether that regulation is important or not, please?
Dr van der Gaag: Absolutely. I would fully support it. As I said, from 2009 the Health Professions Council has fully supported the recommendation and we will work with the Department to that end.
Q200 David Tredinnick: I have one further short question. The Lords also recommended that statutory regulation may also be appropriate eventually for the nonmedical homoeopaths. Do you see a role for yourselves there in the future, possibly?
Dr van der Gaag: It is for the Government to make that decision. We are aware of our colleagues in the Council which currently holds a voluntary register for a number of the alternative and complementary therapies. There was talk about homoeopaths coming under that umbrella some years ago. We are very much waiting for the Government to give us direction on this.
Q201 David Tredinnick: Are you not in danger of becoming completely overwhelmed by your workload? The Health Bill has given you a whole new mandate. There is the herbal medicine, which I have referred to, and you have a whole string of disciplines. We have various appendices here listing them. Are you not up against it?
Dr van der Gaag: I do not believe so. We have a strong and good track record in delivering costeffective and efficient regulation for the 15 professions that we currently regulate. Also, we have very good systems in place which ensure that the professions themselves are involved in decision-making where they are required to be and that lay people are involved in decision-making where they are required to be.
Due to the fact that we are truly multiprofessional and our standards apply across all 15 professions, there is scope for extending that to other professions who are very keen to come into a statutory regulatory regime. Multiprofessional regulation, as delivered by the Health Professions Council, works and can work for additional professions should the Government choose to direct us down that road.
Chair: I gave us the objective of concluding at 12 o’clock at the beginning of this session and it is 11.59. Thank you very much for your evidence. We will reflect on it in the course of our deliberations.