Efficiency Measurement

65. During oral evidence Mr Andrew Foster of the NHS Confederation spoke of the adverse effects of the need for trusts to adhere to the efficiency index which requires year on year improvement of 2.5 to 3 per cent in productivity. The consequence of this, he said:

"is a critical, undermining factor to the experience of working in the NHS nowadays."[78]

66. Mr Foster argued that even with no slack in the system annual productivity gains were still expected.[79] We believe that such an attitude hinders rather than assists the efficient use of resources and inhibits effective working. It creates an atmosphere of anxiety and pressure which is unlikely to lead to productive change. We believe that it is important that a watchful eye should be kept on potential efficiency savings. The way to achieve this is to target areas where efficiency gains can legitimately be made.

67. We note the Secretary of State's view that:

"Where two hospitals have broadly speaking the same sort of capital investment, the same sort of population, the same sort of folks working there and one is costing 30 per cent more than the other, there is something wrong and it has to be addressed."[80]

In our view it is extremely difficult to assess the basis of costs between different hospitals on current data. Higher costs may be due to a more complex mix of patients, higher quality of care or the location of the hospital on a capital rich site. They may also be the result of initiatives such as leaving a theatre spare for emergency work or keeping beds available for emergency admission, which we would consider to be good practice.

68. We were encouraged to hear that DoH is targeting demands for efficiency savings.[81] But the annual efficiency index is mechanical and appears to place unrealistic demands on both staff and employers.[82] We recommend that the Government consults with NHS employers and staff representative groups in order to establish a rigorous but fair system of efficiency appraisal.

Data Collection

69. Accurate data is a prerequisite of good planning practices. But, there is widespread criticism in the memoranda of the collection and availability of reliable data.[83] The NHS Confederation stated:

"We need to work towards using the same data/statistical information sources when looking at NHS staffing issues. This causes confusion, for example, in the annual Pay Review Body evidence submissions there can be a number of different sets of data quoted in response to the same issue."[84]

70. Professions Allied to Medicine argued that:

"We believe that a central NHS Workforce Data Collection and Analysis Unit should be established by the NHSE. All social partners should be consulted and involved in its work. This Unit should collect, collate and publish workforce statistics for the whole Service. The data promulgated could inform Review Body, local providers, HIPs and education consortia decisions, amongst others. It should be made a requirement of local employers in all sectors of the Health Service, including primary care, to provide workforce statistics. These should be locally collected by professional heads each year."[85]

71. These criticisms were sustained by a variety of witnesses. Mr Richard Griffin representing PAMs told us:

 "We are in the situation at the moment where the Executive is not even gathering the vacancy information; so if you do not know where you are at the moment it is very hard to predict where you are going in the future."[86]

   72. Miss Louise Silverton, Deputy General Secretary of the RCM explained:

 "the reason that we have to have our own data is that the Department of Health data is actually so poor... NHS statistics are poor at various levels throughout the organisation, not only the central ones, but even at trust level."[87]

 Sir Alexander Macara, Immediate Past Chairman of the BMA said:

 "we would not rely on Department of Health statistics"[88]

73. DoH recognised the concerns.[89] The Director of Human Resources at NHSE told us:

"I think there is an issue about communication and discussion about the information that we have. We are open to talk about it and I would welcome that. If there is a feeling of frustration I would want to talk to the organisations concerned."[90]

   74. A review in 1997[91] recommended in the short-term some streamlining and improvement in the coverage of health professional workforce planning information. In the longer term it recommended that there should be an enhanced role for consortia in data collection, and the development of good practice guidelines. Three pilot studies are currently reviewing workforce information flows. The project aims to report in summer 1999.[92]

75. An example of the confusion which currently exists in the various sets of health service-related data was apparent in the written evidence we received. In its memorandum Professions Allied to Medicine referred to the high level of staff turnover in the NHS, which it believed to approach 20 per cent per annum for PAMs.[93] Pay and Workforce Research (PWR), which is part of the NHS, sent us its recent report on NHS staff turnover. In a covering letter the Director noted that:

 "One of the surprising results of the survey is that contrary to public perception of retention problems in the NHS, turnover is generally quite low compared to most other industrial sectors. This would of course, bring into question the cost effectiveness of attempts to improve retention."[94]

 The turnover rate for all groups was given as 12.5 per cent.[95] PWR claimed that the highest rate of turnover related to medical and dental staff - 19.2 per cent annual equivalent, followed by healthcare assistants - 18.5 per cent annual equivalent. But the figures refer to different processes. Doctors and dentists change trust employers as part of planned training programmes. This is not the case for healthcare assistants. The confusion on data may well contribute to differences in the perception of staff morale in the NHS.

76. We accept that the DoH has to:

"balance the value of the information against the burden placed on the Service in supplying the data."[96]

But there has to be some consensus about the validity of the statistics being used. The alternative, particularly during discussions on workforce requirements or pay negotiations, is akin to an international summit listening to contributions made in a variety of tongues without appropriate interpretation.

77. We have already drawn attention in paragraph 70 to the suggestion from Professions Allied to Medicine that there should be a central NHS workforce data collection and analysis unit. When we put this point to the DoH officials, the Director of Human Resources at the NHSE argued that this was already in place.[97] But this viewpoint was contradicted by the evidence we took during the course of the inquiry.[98] It is our view that data and collation in this area is inconsistent and fragmentary. It manifestly does not inspire confidence so far as NHS employees are concerned.

78. Mr Bob Abberley of UNISON argued for a review of:

"How we get information collected in the NHS which all the social partners are prepared to accept as being accurate information."[99]

He suggested a pooling of data from all concerned parties.[100] Reaching consensus on statistical provision is fraught with difficulties particularly in an increasingly fragmented service. It may well be that the three pilot projects set up to review current practice with regard to the gathering of information for workforce planning and to identify the extent to which workforce planning systems link with the business planning process,[101] which are due to report later this year will yield an appropriate way forward.

79. We asked the Secretary of State for his view on the idea of exit interviews to determine more accurately the reasons for staff leaving the NHS. He said:

"I am certainly in favour of doing anything we can to find out why staff are leaving, and to find out the attitude of people who have left and who might or might not be thinking of coming back."[102]

 It seems to us that the introduction of formal exit interviews would help workforce planning by providing a better sense of the reasons why staff leave the NHS. We also recommend that DoH initiate a formal consultation on standardisation of information as soon as possible. It is our hope and expectation that in the very near future all debate on the NHS should be informed by universally accepted figures.

Recruitment and Retention

80. The Government's framework for managing Human Resources in the NHS entitled Working Together - securing a quality workforce for the NHS was published in September 1998. One of the Government's stated aims was to:

 "recruit and retain a workforce which has the capacity, skills, diversity, and flexibility to meet the demands on the Service."[103]

81. The DoH reinforced its comments in written evidence to us when it asserted that:

"The NHS remains an attractive and secure career and the vast majority of posts attract competition from people wanting to fill them."[104]

But, in stark contradiction to this statement, DoH acknowledged that there were staff shortages in nursing, physiotherapy, occupational therapy, anaesthesia, psychiatry and pharmacy. Its approach to tackling the problems was to increase training, target health professionals to resume their careers, broaden career structures, and improve the working environment.[105]

82. These are admirable intentions. The Government is taking steps to address seriously most of the issues of concern which we have raised. It aims to end the routine use of short-term contracts, except for bona fide reasons such as the provision of cover for maternity leave, and to improve the recruitment of ethnic minorities.

83. Racism in any sphere is intolerable. Miss Christine Hancock of the RCN told us:

"In gender and in race issues the NHS is quite often nothing short of a scandal. And I think that that is not only bad for staff, but it also affects the way patients are treated."[106]

Increasing the recruitment of nurses from ethnic minorities we regard as being of particular importance. Current low levels of recruitment were ascribed by witnesses to previous discrimination against nurses from the ethnic minorities in respect of promotion and working conditions. We welcome the Government's proposals to combat racism in the NHS; we believe that it is essential that steps are taken to overcome negative perceptions of nursing in the NHS on the part of potential recruits from ethnic minorities. Since the NHS will continue to rely on overseas staff for many years to come, it is important that the Service ensures their career opportunities are not being restricted by their immigration status. We recommend that DoH consults with the Home Office and the Department for Education and Employment on these issues.

84. It will take time for the full impact of the plans to be felt. Provided the Government maintains both its commitment and momentum towards reform, we would expect to see marked improvement in the NHS before long, although we do not underestimate the difficulty even with an improvement in career prospects, working conditions and pay of attracting the necessary numbers of staff into the NHS. We would, however, like to draw attention to some of the evidence we received during our investigation.

   85. A press notice from the BMA of 5 November 1998 announced that:

 "One third of doctors would not choose medicine if they were starting their careers now and more than four in ten would not advise school-leavers to choose it as a profession."

 Thanet Healthcare NHS Trust explained that their:

 "ability to recruit and retain nurses is a constant pressure point and shortages of trained nurses and other key skills within the hospital does certainly add to an already stressful environment."[107]

 Thanet Healthcare NHS Trust also described its inability to recruit people in Professions Allied to Medicine which led to the need for additional hours being worked. [108]

Professions Allied to Medicine, Pharmacists and Scientists

86. The memorandum from Professions Allied to Medicine described the most severe recruitment and retention difficulties in their group as relating to occupational therapy, physiotherapy and dietetics.[109] It went on to say:

"In November 1996, the Incomes Data Services (IDS) produced a report into recruitment and retention in the public sector. This found that 'by far the worst recruitment and retention problems in the NHS were concentrated in the PAM professions, particularly physiotherapy. In February 1997, the Audit Commission released its report 'Finders Keepers: The Management of Staff Turnover in NHS Trusts'. This found that turnover was significantly worse in physiotherapy (from 8% - 76%) in comparison to nursing and administrative and clerical posts."[110]

The same memorandum also spoke of the need to stem the flow of PAMs from the NHS or Government proposals "will be extremely difficult if not impossible to realise."[111]

87. In oral evidence Mr Richard Griffin representing PAMs developed this evidence:

"The junior doctors' reduction in hours does mean our members are taking greater responsibility, are taking on more and more work. Also, the demand for PAMs will increase, it will increase because of the Government's priorities in terms of the emphasis on rehabilitation, in terms of the expansion of primary care. PAMs have increased in the NHS by 26 per cent over the last ten years; we would anticipate that rise will continue in terms of the demand, but the real question is, where will those members, where will those staff actually come from?"[112]

88. We have heard evidence of a large number of recruitment problems with scientists and PAMs. During our visit to the Royal Hospitals NHS Trust we were told that there is a shortage of bio-medical scientists and medical laboratory scientific officers who suffered particular difficulties with regard to their salaries and inadequate numbers of staff to allow for proper training. We were told that the starting salary for a graduate in these professions could be as low as £7,500.[113] Mr Roger Kline of MSF said:

"Medical laboratory scientific officers can get jobs in the private sector, so one of the key issues for them is they can get more much more in the private sector, sometimes I do wonder why on earth a medical laboratory scientific officer should go and work in the Health Service."[114]

89. Speech Therapists are a further group with particular retention difficulties. At the Royal London Hospital we were told that downscaling was a problem and that there was an absence of experienced personnel. We heard that in many disciplines shortages of fully trained staff meant that there was even less time available for experienced staff to train others. Such problems occurred, for example, with diagnostic imaging technicians and cytology technicians.

90. The Committee were also told by members of the PAM professions that career pathways had become blocked and needed freeing. There was no way of rewarding a good competent professional other than in management. Ms Jocelyn Prudence representing PAMs told us:

"the career structure that we are operating to was created in 1974 so it does not bear any relationship with the modern NHS."[115]

91. The memorandum from DoH drew attention to the PAMs career development initiative, which it said at national level is:

"Informing initiatives in areas such as HR Strategy, Education and Training Strategy and the National Development Framework".[116]

This is fine so far as it goes, but the Professions Allied to Medicine are experiencing exceptional problems in the NHS, particularly in respect of the limited opportunities they have to develop their careers and the degree of overwork to which they are subjected. Many of this group of staff would find it relatively easy to find alternative employment outside of the Service and increasing numbers are taking up options in the private sector.[117]

92. The recruitment of pharmacists is already suffering as a consequence of the greater attractiveness of work outside the NHS. The Chief Pharmacists Group (West Midlands) told us that pharmacists are increasingly attracted by careers outside hospital work, because:

"differentials between hospital and community pharmacy salaries are now far too wide."[118]

The summer of 2000 will be a 'fallow year' for pharmacists following the extension of the degree course in English schools of pharmacy from three to four years. The Chief Pharmacists Group (West Midlands) added that:

 "If we have not found a solution to the problem of hospital pharmacist recruitment by May/June 1999 when the students whom we hope to recruit for commencement of pre-registration training in August 2000 are considering their options, then hospital pharmacy practice will have to be placed on the critical list."[119]

93. A report on recruitment and vacancies amongst hospital pharmacy staff in Great Britain submitted to us by the Chair, NHS Pharmacy Education and Development Committee, indicated that there are:

"a large number of vacancies, that...are hard to recruit to, and that the position is markedly worse than it was two years ago."[120]

 We therefore urge the Government to collate information from trusts in order to allow them to formulate a specific recruitment and retention strategy for pharmacists, scientists and all of the Professions Allied to Medicine as soon as possible.

UKCC Trends

94. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) regulates those professions throughout the UK. UKCC sent us its statistical analysis covering the year to March 1998. This revealed that: the admission to the register of qualified nurses and midwives were at their lowest level since records began in 1984-85; the shortfall in domestic recruitment was partly offset by the high number of overseas- trained practitioners registering to work in the UK, which was also at a record high; of those practitioners coming from abroad to work in the UK the main source countries were, Australia, New Zealand, South Africa, Finland, and the Republic of Ireland; the number of midwives trained in the UK and registering for the first time was at its highest level for four years; the number of practising midwives was at its lowest level since records began. Almost half of midwives work part-time and there is a sharply rising trend towards part-time working in the profession; for the first time, more than 50 per cent of all those on the register are aged 40 or over. We also note there is a well-established rising age profile on the register.[121]

Foreign Nurses

95. The UKCC commented on the recruitment of large numbers of overseas nurses and is considering undertaking some joint research on the subject with the NHSE which it hoped would help workforce planners. It said:

"There has to date been no research into whether this is a cost- effective or sensible way of filling the recruitment gap."[122]

Such research may, UKCC believed :

"demonstrate that, for example, it would be more cost-effective to provide a creche in a Trust for the children of five returners than recruit staff from overseas."[123]

96. This is a plausible hypothesis. We were concerned at the high cost of recruitment of overseas nurses, mainly paid to agencies. We do not think it acceptable to solve our nursing shortages by this means if we are creating shortages in developing countries. We can imagine scenarios in which a planned partnership between two countries would lead to planning our workforce on the basis of a level of foreign nurse support. We realise trusts have to resort to ad hoc recruitment of foreign nurses, but from comments made by staff we are suspicious that not enough was done in some areas to give extra support and incentives to local nurses before resorting to recruitment from abroad. Where foreign staff come for just six months the time spent in necessary orientation is disproportionately high and is a cause for concern. We would always support some exchange of nurses between countries, but we believe it is essential that the root causes of the shortages that have led to increasing levels of overseas recruitment are tackled.

Family-Friendly Policies

97. The Government has committed itself to the introduction of a whole range of family-friendly policies. Child care facilities, flexible hours and job share opportunities are obvious examples of areas where improvements could be made, particularly with regard to the working lives of parents with childcare responsibilities who are on current patterns predominantly women. Currently over 50 per cent of medical graduates are women.[124] We do not though underestimate the logistical problems of introducing such provisions, but the fact that the NHS operates a comprehensive 24-hour service gives opportunities to do just this. Persistent staff shortages are sometimes cited as an obstacle to the implementation of family-friendly policies; but the absence of such policies is itself a major factor in creating such shortages. A determined effort needs to be made to break into this cycle.

98. A briefing paper provided by the RCN during our visit to the Royal Hospitals NHS Trust said that:

 "Most [staff] feel that not much more than lip service is paid to the development of Family-Friendly policies."[125]

Miss Louise Silverton of the RCM thought that:

 "whilst with rhetoric some management may say they do have family-friendly policies, the number of places in creches is very small...The introduction of 12 hour shifts has made it very difficult for working mothers to combine motherhood and working."[126]

Miss Christine Hancock of the RCN noted that:

 "one-third of all NHS nurses are working internal rotation and that has gone up from 23 per cent in 1994 and two-thirds of those working internal rotation say it is not their preferred pattern of work."[127]

99. We heard evidence from many staff on difficulties resulting from internal rotation. Internal rotation occurs when nurses and midwives are obliged to change their shift patterns across the full 24 hours. The way that the rotation is worked varies from trust to trust. The dissatisfaction occurs when staff, for personal reasons, have elected to work day duty (am and pm) or night duty and are then forced to work on the opposite shift, causing great disruption to their personal and family life. The rapidity of changes in some trusts causes particular problems.

100. The DoH memorandum stated:

"The NHS...needs to become a smart employer by understanding that all staff need to be better able to marry their work and their out of work responsibilities. Six out of 10 nurses have caring responsibilities. The Government will work with NHS employers, trade unions, and others with experience in this area to develop a national approach to support the health service in implementing more supportive, family-friendly employment policies for staff."[128]

101. The key phrase here is 'a national approach'. Whilst we endorse the direction of the Government's policy, and accept the need for a local dimension to be built into the overall strategy, the evidence we have heard during the inquiry has not convinced us of the readiness yet of all individual trusts to introduce the required policies. This will require further firm action.

79   Ibid. Back

80   Q364. Back

81  Q366. Back

82   Qq251 and 252. Back

83   See for example the written evidence submitted by : Royal College of General Practitioners - Appendix 15, Royal College of Nursing - Ev. pp 89-101, Professions Allied to Medicine - Ev. pp73-77, Conference of Clinical Scientists' Organisations - Appendix 16, Council of Science and Technology Institutes - Appendix 63, Institute of Physics and Engineering in Medicine - Appendix 61, UNISON - Ev. pp101-110, National Council for Hospice and Specialist Palliative Care Services - Appendix 19, NHS Confederation - Ev. pp161-165, and Chartered Society of Physiotherapy - Appendix 22.  Back

84   Ev. p161. Back

85   Ev. p74. Back

86   Q118. Back

87   Q119. Back

88   Ibid. Back

89   Ev. pp10 and 23. Back

90   Q31. Back

91   Ev. p23. Back

92   Ibid, para 3. Back

93   Ev. p74. Back

94   Appendix 74. Back

95   Ibid. Back

96   Ev. p9. Back

97   Q31. Back

98   See, for example, memoranda from the Royal College of Nursing - Ev. pp 89-101, PAMs - Ev. pp73-77, Council of Science and Technology Institutes - Appendix 63, UNISON - Ev. pp101-110, National Council for Hospice and Specialist Palliative Care Services - Appendix 19 and The Chartered Society of Physiotherapy - Appendix 22. See also Qq 118 and 119. Back

99   Q122. Back

100   Ibid. Back

101   Ev. p23, Annex F, para 3. Back

102   Q335. Back

103   Para 2.3. Back

104   Ev. p5, para 4.4. Back

105   Ibid. Back

106   Q117. Back

107   Appendix 35. Back

108   Ibid. Back

109   Ev. p73. Back

110   Ev. p74. Back

111   Ev. p77. Back

112   Q112. Back

113   Q200. Back

114   Q141. Back

115   Q174. Back

116   Ev. p15, Annex C, para 6. Back

117   See, for example, Ev. p75. Back

118   Appendix 45. Back

119   Ibid. Back

120   SR83. Back

121   Appendix 69. Back

122   Ibid. Back

123   Ibid. Back

124   Ev. p155. Back

125   SR94. Back

126   Q179. Back

127   Q183. Back

128   Ev. p8, para 4.29. Back