THURSDAY 10 DECEMBER 1998

SIR ALEXANDER MACARA, MRS HEATHER BALLARD, MR ROGER KLINE, MR RICHARD GRIFFIN, MS LOUISE SILVERTON, MISS CHRISTINE HANCOCK AND MR BOB ABBERLEY

  Chairman: Colleagues, can I welcome you to this session of the Committee, and particularly welcome all our witnesses. We have a number of declarations of interest relevant to this inquiry, before we actually begin. Can I declare my membership of UNISON, which may have some relevance to this session.

  Julia Drown: I am also with UNISON.

  Ann Keen: I am a member of CDNA.

  Mr Austin: I am a member of MSF and Chair of its Parliamentary Committee.

  Dr Brand: I am a member of the BMA, and I think I have still paid my dues.

  Mr Gunnell: I am a member of the GMB.

  108. Can I welcome our witnesses and can I thank you for your very helpful written evidence for this first session. You are aware, of course, that we have agreed, because of the importance of your evidence, to split the oral evidence into two, so we meet again next week. I apologise that you are together in a large group. But we did feel, as a Committee, that it would be more appropriate to explore with you collectively, rather than individually. So we recognise this makes for a rather clumsy session, but perhaps I could at this stage appeal for short questions from my colleagues and short answers from our witnesses, in order that we can make good progress. I also would like to make the point that the Committee feel it would be helpful if we perhaps split the subject areas, to some extent, between now and next week. We are aware of the very contentious arguments in respect of pay and rewards that have been raised with us by yourselves, and in particular by witnesses that we have met in the sessions that we have undertaken in various parts of the country. PFI was another issue, CCT was another issue. Could I suggest that, while it may be appropriate for you to make reference to these points, these areas, this morning, we leave those areas to deal with in substantial detail in the session next Thursday, which gives us chance to explore other areas today then come on to those next week. I can assure you that we will want to ask some very detailed questions about your evidence and about our experiences in respect of those areas; so if we leave PFI and pay, in particular, and the CCT questions until next Thursday. Having said that, could I ask our witnesses to individually introduce themselves to the Committee: Mr Abberley, would you begin?
  (Mr Abberley) Yes. Bob Abberley, Head of Health for UNISON.
  (Miss Hancock) Christine Hancock, General Secretary of the Royal College of Nursing.
  (Ms Silverton) Louise Silverton, Deputy General Secretary, Royal College of Midwives.
  (Mr Griffin) Richard Griffin, Co-Director of Industrial Relations at The Chartered Society of Physiotherapy, and representing the PAMs (PT `A') Staff Side.
  (Mr Kline) Roger Kline, National Secretary for the Health Sector of MSF.
  (Mrs Ballard) I am Heather Ballard, Professional Officer, Community and District Nursing Association.
  (Sir Alexander Macara) Sandy Macara, immediate past Chairman of Council, BMA.

  109. Thank you very much. Could I begin by asking a question that I asked of the witnesses from the Department of Health when they came to the first oral evidence session, which is, what are your views on the steps taken by the National Health Service to ascertain the views of staff, the staff morale issues, the feelings of staff on policy development, what are your views on the procedures and mechanisms that exist, or do not exist, at the present time, to assess the views formally and informally of people who are actually doing the work within the National Health Service? I do not know who wishes to start: Sir Sandy?
  (Sir Alexander Macara) It is very helpful to have the opportunity, Chairman. Could I take as a starting-point the study, with which everybody may not be familiar, which is a study on the health of the NHS workforce, in which a number of us were involved, under the auspices of the Nuffield Trust, and this was the subject of a conference, I think, at the end of May. Now that was very interesting, because there were representatives on it of the NHS Confederation and of the Department of Health, as well as of the professional organisations represented here, and others. And we identified the fact that there were preventable causes of stress in the way in which the system operates. I am not going to be political about this, but it is obvious that there were problems in the last few years, which may, hopefully, be resolved as the result of learning from them.

  110. You are talking about the internal market, presumably?
  (Sir Alexander Macara) Yes, and the financial pressures, and these now I think are being resolved, at least one would like to think they were, but there needs to be more imaginative human relations policies, and I know that Andrew Foster has that very much in mind, on behalf of the Confederation. We do, of course, have a situation bedevilled by the European Directives, on limits of hours, and so on, and that is why our view is that, whatever may be done internally by the personnel management people, we do need more resources in the system, we need more people to relieve the stress that is on people, we need to look at what everybody does, to see how we can share out tasks to make the maximum of the potential that all the work groups have. But we cannot expect that that sort of thing is going to save labour, as it were, because, of course, the better we do things the greater demand as the expectations keep increasing all the time, they have all sorts of evidence which we put in about the increased pressures. So stresses are going to increase in the system, however good management is, and information technology, there is a lot they can do, as a result of that and other studies, but we do need more people in the system to make it work.

  111. I do not necessarily want to work my way right down the table on each question, I am looking to colleagues to catch my eye. Mr Abberley, you wanted to respond to this question?
  (Mr Abberley) Yes. I would welcome the opportunity to say something on this, particularly as I sit on a Government Task Force looking at how we can improve staff involvement in the NHS, and which will report to Ministers early next week. Part of the work was that we did actually go and visit quite a number of NHS sites, a number of focus groups, etc., and what it showed was that there was some extremely good practice and some extremely bad practice, and that, in the areas where there was a high degree of staff involvement, it was obvious that it did lead to better decision-making. And I am talking about staff involvement at all different levels, involvement in the policy issues but also a style of management that involved staff in decisions right at the sharp end, and it was obvious that decisions were better, and also that staff's morale was higher. However, I do not want to go on to other issues. Staff involvement is only one part of the solution to a morale problem in the NHS, but it certainly will help. But central to staff involvement working, is a commitment and a partnership between the employers and the trade unions locally, because good staff involvement will only happen in the context of good industrial relations, the report will say that, that it is central. And also that it means that the employers need to commit resources to the process, because you cannot involve staff if you do not put the resources in to allow them to participate in the processes, and the good employers that we visited had managed to find a way of doing that, because they saw it as part of delivering good quality care, and that is important; so I would say that there are some very good and some very bad. But I think the Government has recognised this as being important, and obviously the Task Force is an example of that.
  (Miss Hancock) I think that, nationally, there is a clear commitment to address these issues, but nationally the Nurses and Midwives Pay Review Body, for instance, last year, commented on the poor state of morale amongst the workforce. I think the commitment, for instance, of the Secretary of State on issues of violence at work has been really important in terms of strong messages, and the English Human Resource Strategy, if, or when, depending on how optimistic you are, implemented, I think will make a fundamental difference to morale. But at the moment those are very national, and they are very remote, and I am not sure that many of them have had much impact on morale locally, and I think that local morale varies and is often, in my view, quite shockingly poor; and that is not just bad for staff, we know, from evidence, that morale of nurses is directly linked to patient outcomes, including patient deaths. Recently, in a trust in the West Country, when they asked for voluntary redundancies, 40 per cent of the qualified nurses offered their names forward. And I suppose the most critical thing, the most helpful thing, that a Committee like this could do is urge that something systematic is done about morale. The Royal College of Nursing, for the last 12 years, has commissioned an independent body to survey nurses every year, as part of our evidence to the Review Body, and morale is very difficult to measure, but has asked the same questions, over a consistent period, one of them being "I would leave nursing if I could": a quarter of nurses agreed strongly with that statement in 1993, and that had gone up to 37 per cent in 1995 and has remained at about that level. So I think a systematic commitment to looking at morale, both locally and nationally, would be important.

  112. Before I bring in some of the other witnesses on this general point, Sir Alexander, in his opening comments, made reference to the workforce implications of NHS changes, in recent years, and also with the new Government. I would be interested in learning what your views are on the workforce implications of the changes that have taken place in recent times, with the new Government, positive and negative, because certainly we have picked up both positive and negative in discussions so far. Issues arising, for example, from the Waiting List Initiative, which has impacted upon the work that people have been expected to do, the issue of winter beds has impacted upon the way people have been under pressure to work, and I am also conscious of the European Directive, the junior doctors' hours question has impacted directly upon other members of staff. We picked up, very strongly, from nursing staff, the way they feel that there have been consequences for their work of the reduction in junior doctors' hours. Ms Silverton?
  (Ms Silverton) I would like to step back a bit to look at an initiative from the previous Government and then come on to your point. The introduction of women-centred care, as a result of the work of this Committee, and the Winterton Report, did produce profound changes in the working lives of many midwives, and for the women receiving the service, very great benefits to the women. However, at no time when those initiatives were being worked through by the various Government health departments were the workforce and human resources issues looked at. This was a national initiative, it was well accepted by the leaders of the profession, but, of course, when it got to local level there were a lot of differences in the ways that it was implemented. Where decisions were made at the top locally and it was just implemented from the top down, there were great problems, as you would anticipate, with morale and in the working lives of the midwives; where it was left to co-operation between the midwives and the management to develop it themselves, there were much better successes, and most schemes for the most part ran very well. But, unfortunately, many of those schemes have now been disbanded because they have been seen to be more expensive than the traditional form of maternity care, predominantly, I believe, because they are more expensive in midwife power than they are in the use of the institution. But these changes with women-centred care and increased use of the extensive skills of the midwife also came at a time when there has been increasing use of technology in the Health Service, and this is not just in the field of childbirth. We are seeing women coming to use the maternity services who previously never would have been able to do so, women with very complicated medical histories, a change in the age of foetal viability, so we have got 24-week foetuses being cared for, multiple pregnancies through the assisted conception programme, and, of course, a raise in Caesarian section rates now, so rates are between 18 and 20 per cent. So there is a huge split in the range of women that midwives are caring for, but an increased pressure on them to deliver care that the women want. And I think this, within the climate, for example, of the reduction in junior doctors' hours in obstetrics, has meant, for example, that junior doctors taking part in antenatal clinics has been very much reduced, antenatal clinics have been removed from hospitals, for the most part, there are some hospital clinics, but they mainly take place in GP surgeries and in health centres now, putting an increased strain on the work of the midwives. The pressure on hospital beds, we do not, obviously, have waiting list issues, because you cannot tell a woman when she is pregnant "You are on a waiting list", but, of course, the pressure on hospital beds has resulted in much shorter post-natal stays, often far shorter than the women themselves would like; and remembering that many of these women tend to have very socially disadvantaged backgrounds, that community midwives are now trying to deliver very good care to women who need an awful lot of social support as well as technical midwifery services. And the whole issue is, in fact, extremely complex, to tease out is it the reduction of junior doctors' hours, is it the Government's initiative, is it the fact that we are trying to develop and deliver a very high quality service, using evidence-based practice, which midwives are, in fact, very much committed to. And at the moment it is an issue thhat you seem to be pushing more and more into a very, very full bag, and at some point it is just going to burst and the strain on the midwives is going to be too much. We have very grave midwifery shortages, and the midwives themselves are saying "We don't want to do this any more, we're fed-up." One of our members last week rang up and said she is going to work on the beauty counter of a London department store, because they are offering her more money than she is getting now, she does not have to do any shifts and she will not have to carry any responsibility, and I think that is indicative of the problem that is building up.
  (Mrs Ballard) Just really to come at it from a community nursing point of view, where we have seen, over the past recent times, a real shift of services and work from hospital care to community care but we have not seen any evidence of a shift of resources. It is only right and proper that more child health care, more cancer care, more palliative care, takes place in the community, and it can be done, given the right resources; unfortunately, staffing levels in the community have been based very much on a historical basis, rather than looking at the need that is there. We describe it, in the CDNA, as the ward without walls; if you have a ward in a hospital that has got 28 beds, when they are full they are full, and there is no argument about it, but when you have got, potentially, a district nurse, for example, being attached to a GP who has a list of 2,000 people, potentially, those 2,000 people could require nursing services, it is unlikely but that is the potential that is there. And, whilst there are policies in place in a handful of trusts for actually saying "Well, the ward is closed", "It's full up", or "We need to set up a waiting list", there is very little evidence that they have actually been used. So the result is that the nurses are working harder and under more pressure and they are working longer, and those longer hours are not accounted for either.
  (Mr Griffin) I think I would like to highlight four issues from PAM's perspective, in terms of the Government's reforms, and, I should say, members generally have very much welcomed the initiatives that the Government have put forward, in terms of changes in the National Health Service. We also, like the RCN, gather data on morale, we have recorded a fall in members' morale over the last ten years, and one of the major reasons for that has been workload and also the change that they have had to face, and it has been a period of continuous change. I think that is the first issue. Though members welcome what is happening, it is a period again of increasing change; it is important that members' morale and their commitment to that is actually addressed. Waiting list initiatives do and have highlighted the major problem there is with shortages of PAMs. An Emergency Action Team report actually highlights a number of areas where waiting list initiatives were not able to go forward because of shortages of PAMs, and at the moment we have a vacancy of eight posts in a hundred being vacant because of the problems with recruitment and retention. So though these initiatives are very much welcomed they are highlighting very clearly the problems that exist around PAM recruitment; and the NHS Confed., in their evidence, the Pay Review Body indicated that 82 per cent of trusts have problems recruiting PAM staff. On other issues, workload is increasing because of these initiatives. 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 increasing independence for people, 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. We have a growing vacancy problem now; unless it is addressed and the issues that are causing those are addressed, there is going to be a real problem in terms of actually delivering a number of the Government's key priorities, and I think that is very, very concerning.
  (Mr Kline) If I can take you back, Chairman, to your original question about the involvement of staff, if I just make three points. I think the first one is that we represent a lot of people in small professions, 3,000, 4,000, 5,000, the biggest are scientists and health visitors. And I think it is very important that in amongst, dare I say it, the Daily Mail, their campaign on one particular group of staff, it is very important to realise that you cannot have a casualty ward that exists without the MLSO`s the scientists, the radiographers, the district nurses, and so on, to make sure that the thing flows, and it is very important that a whole view is taken of staff, and that is the first thing. I think the second thing I would say, which perhaps has not been touched on, is that there are some groups who feel, that we would see, at national level, there is much more consultation with staff, much better listening to where staff are coming from, which is in sharp contrast with what our experience in recent years has been.

  113. Can you say a little bit about why you believe that, could you explain that for us?
  (Mr Kline) I can give you a number of examples. One obvious example would be health visitors; we represent most health visitors. It is quite clear the Government has been listening to what health visitors and others have been saying about the cognitive dissonance, really, between the need for preventative public health policies focused on social exclusion, and the fact that in many organisations health visitors, amongst many other groups, were seen as a soft touch for cuts, and I think that has now clearly changed. Government policy on health visitors, for example, now, we hope that the staffing plans will now reflect what Government policy says they should be, rather than policy going off in one direction, staffing in another. And there are a number of other examples like that. For example, we have been discussing in detail with the Department about pharmacists. There is a huge shortage of pharmacists in this country; the Department has been listening quite carefully and I think shares with us our concern about the shortage of pharmacists. I have to say, I am not sure we have yet agreed on what should be done about it, we will perhaps come back to that later. But, at local level, the level of the local employer, there is, there seems to me, rather as Christine Hancock put it, it is as if some places have not realised there has been a general election and there is not a change of style and they have not all yet been on the road to Damascus and come back, and I could give you lots of examples, if you wanted, but if I give you a single statistic. Health visitors were a group that, four years ago, 24 per cent only said they would recommend a young person to become a health visitor; as a result of the Government changes of policy, it is now 59 per cent will recommend a young person to become a health visitor, but, no doubt a reflection of what is going on at the local level, 22 per cent in a huge survey we did recently said that they expect to leave the Service in the next four years. So almost a quarter of the workforce are going to leave, even though a majority of the workforce now would recommend it to a young person. If I just say one last figure, for you perhaps to think about, one group that in some professions makes the difference between there being a staffing problem and not being a staffing problem are black staff in the Health Service. We drew attention in our evidence to the fact that, if you take `over 55' nurses, 8.7 per cent are of African/Caribbean origin, if you take `under 25' nurses, 0.8 per cent are of African/Caribbean origin. And I sat down last night and did some figures, and they might be a little bit ragged at the edges, because not all the statistics are there, but I think it is a safe statement to make that, if the proportion of nurses who are black amongst the `over 55' workforce were employed at all levels of the nursing workforce, you would have about 17,000 more nurses being employed in this country, which is round about the figure that the Secretary of State says he intends to increase the nursing workforce by. That group are not yet convinced, I have to say, despite the serious efforts of the Secretary of State to move on this issue, they are not yet convinced that their voice is being listened to.

  114. The Department of Health has said it wants 7,000 more doctors, 15,000 more nurses; we have had some discussion with Department witnesses about how to get these figures. But I am not going to ask you at this minute how to get them, or how to keep them, we will come on to that, I want to ask you whether you think that the Department has got its figures right in terms of the necessary increase in staff, never mind whether you can get them, are the figures right, are the objectives right? And do you think that sufficient account has been taken, for example, of the need for extra staff to combat workloads that are too heavy and cause too much stress, and also to supervise students during clinical training? Are there other factors which lead you to question the objectives, or do you think the Department has got its figures broadly right; and do you think there are gaps as well?
  (Sir Alexander Macara) I think it would be true to say that the Department are conservative, with a small c, of course, and naturally they would be, wouldn't they, and we are not, we are radical, because we recognise that, in this country, for example, we have 1.8 doctors, odd sort of doctor, 1.8, but 1.8 doctors per 1,000 population, as against a figure of 2.9 in France and 3.4 in Germany, well, of course, our doctors are very much better than the French and German doctors, which is why it is a great pity that we have to rely on a good many of them coming over to service our A&E Departments in the Midlands, for example. And the same can be said for nursing. Let us try to be honest about this. It is very difficult, is it not, to make a satisfactory estimate of needs five, ten, 15 years ahead, because so much is changing all the time. Now I have given you one estimate on the basis of international comparisons; you can look at estimates locally, in terms of how many more people might be required to relieve immediate stresses, but then that is complicated by mergers of trusts, by the Primary Care Groups, changing the situation in general practice, or I should say in primary care, because it impinges as much on the nurses and PAMs, and so on, as on the GPs. But all we can do is to make best guesses. I am impressed by some of the more independent best guesses, the Campbell Committee, for example, and you have heard Sir Colin's evidence, estimating we need 1,000 more doctors every year. Well now, the BMA said they thought we needed 2,000, and I thought that was commendable, because I was taught, as a young man, you organise for scarcity so that you can plead for higher wages, because otherwise you will not get people; but we thought we honestly needed 2,000 more per annum. Campbell said 1,000, to which our reply was "Well, okay, that will be a lot better than nothing", but then, of course, the Department cavils at that, because of the resource implications. But, to answer your question, all the factors you mentioned demand more people to deal with it, however good the personnel practices, because even where they are very good there are problems. The positive thing is, of course, that morale is bound to improve, it cannot do other than improve, and it will improve as we see that we are able to base what we do on the basis of evidence of real need, as against demand, which is a very poor indicator, and on the basis of the quality of the job we do. And that is why the BMA so strongly welcomes the opportunities that clinical governance gives us, especially if Government is wise enough to give the ownership of this process to the professions, let us drive it, let the doctors and the nurses and the PAMs take responsibility for delivering quality of care, but so long as it is recognised that where there are shortages of personnel, however good the working relationships, the skill mix, and so on. We cannot deliver what is expected without the best guess, that is what I am saying, in terms of different types of workforce.
  (Mr Abberley) I would agree with Sandy's first comment. I think it is a conservative estimate. But it is difficult, because, obviously, we are in a crisis, or on the verge of a crisis, and those of us who have been around a long time can see the patterns, you get problems in a specialty so you encourage people from the general side into the specialty, then you have problems in general side, it is a pattern that is emerging. And the trouble is that we keep going into this crisis, dealing with it, and then in a few years there is another crisis, and I think that is why we need to improve our workforce planning, so that we have some sense of what is the real workforce that we do need in the NHS. And the problem with the Government's current approach, it is also too focused on doctors and nurses, and we know there is a crisis there, but, of course, we need to look at the broader team, there is no doubt that there are shortages everywhere, and that, certainly, the contracting-out process has led to. We did a survey, which was unpublished, which showed, for instance, that the contracting process had led to a definite worsening in cleaning of hospitals, as a result, irrespective of who delivered the services. So it is a question of what is your figure. I think, a move towards quality as the main driver, as opposed to cost containment, also would help, and I think then, hopefully, with some proper workforce planning, employers would be focusing on that. It was almost rewarded for being able to do the job with fewer people, irrespective of what effect it had on the people that were doing it. It is almost universally accepted now, universally accepted, that there is a morale crisis, and that there is a link between high quality health care and valued, well-motivated staff, and something has to be done about it. Because I was on the same group that Sandy made reference to; there is no doubt that staff shortages are leading to health workers paying for that in their health, they have paid for it out of their pockets for years, now they are paying for it out of their pockets and through their health.

  Chairman: Before bringing in other colleagues, can I ask two of my colleagues to ask questions in this general area. David Amess, I think, wants to ask something. Can we make them quick answers, please.

  115. Chairman, I am the one probably who feels that I have not entered the Promised Land, and I know that we are told not to talk down the economy, so I suppose we should not talk down the National Health Service. But I did want to say, Mr Chairman, I thought the three ladies' contributions were very useful, following our visit to Whitechapel Hospital, at the start of the week, and, I know you said directly on this point, I just simply wanted to ask Miss Hancock, given your statement that you feel morale is low, which certainly is our impression so far, then you said you urged that something systematic is done about morale, as we have got to come up with a report, can you give us any help?
  (Miss Hancock) I think what I suggested was that there was a systematic look at morale, because it is a very subjective comment, and I think it needs to be looked at much more systemically, both locally and nationally. But there are loads of things that could be done about morale, just like involving people, asking them, letting them take some control over their own workload, having an input into some of the decision-making. And perhaps if I could come back to the Chairman's earlier comments, which I do not think anybody particularly picked up, about organisational change. Yesterday, the Secretary of State announced the end of care in the community. I saw no reference to the need for significant numbers of qualified mental health nurses; we know that there is something like a 17 per cent vacancy. We see nothing about how actually to give staff time to prepare for change. The Royal London and Barts have been through some of the most traumatic, high profile, forced change, and it is not surprising that people are very vulnerable over that. Now there have been some good things that have come out of that, they have come out almost subsequent to that.

  116. I want to pick up a point that Roger Kline made, and ask some of the other representatives. Roger Kline referred to the fact that the NHS was a multi-ethnic workforce, and made some comment. The Policy Studies Institute has indicated that, certainly at the higher grades in nursing, black nurses seem to be falling behind. But on the question of gender, and particularly a question to Christine Hancock, you represent a predominantly female profession, where, in the senior ranks of the Service, there is a disproportionate number of men. My question really is, I do not want to go into at this stage how that might be redressed, because I think that will come up when we look at working practices, but just a general impression of what effect on morale and staffing would there be if the NHS seriously tackled both race and gender discrimination?
  (Miss Hancock) I think the straight answer is to go and look at places where they have, and one very good example is the hospital at Ealing. And Ealing has done a number of imaginative things, but one of the issues is about addressing the question of equal opportunities, and it has almost no vacancies for staff. West London, in many ways—I may be offending people—does not have a great deal going for it, it is not an obviously attractive area.

  117. Can I say, as a Yorkshireman, I am totally baffled at this stage.
  (Miss Hancock) It is very close to Heathrow, with all of the service industry jobs that nurses are easily attracted into, it is a sort of concrete jungle that was created out of a number of older and more loved local places. And local managers have addressed a number of issues, but one of the most important ones, and it is in an area with a very mixed ethnic community, is that it has addressed very strongly and has a clear commitment to, and everybody knows that it has, equal opportunities. And I think both 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. And when you can still find places that have no understanding of some of the cultural differences of a birth, illness, death, and that that is quite clear, then that leads to people not taking up health care, not feeling comfortable in going and seeking out health care. And I think that there is no doubt that where trust boards, and it has shifted in the last couple of years, both on gender and less, but equally, I think, just as hard a commitment to change in terms of ethnic minority issues, when there is somebody at the highest possible level who does not have to think, like maybe somebody amongst you did, we are an all-white group, looking at an issue which actually involves a large number of people who are not white, that there is somebody who does not have to think this is an all-male meeting, because I always say in my organisation, it is easy for me to think the gender issue, I do not have to try, I have to be conscious to think the ethnic minority issue, and that is why it is important that there are people round the top table that really understand those issues. And, as Mr Austin points out, even in a profession that is 91 per cent women, men have a disproportionate number of the top jobs.

  118. Can I get back to the original question, I tried to ask a narrow question, and then if colleagues go on asking about morale you could not be much wider than that, and then we go off; but, to get back to the question about are the numbers, objectives well founded. It may be that the answer has to be we do not know, we cannot tell, it may be that you have got ideas about how to build up properly a better estimate, or it may be that you think the estimate is fine, but I do think it would be quite useful to get on to that. We have heard about the doctors, but what about the nurses, and what about other professions; have your organisations made any estimates of your own, or how do you think we should go about getting better estimates, if the estimates are not satisfactory?
  (Mrs Ballard) The answer to that is that we do not know, and I think, certainly in the community, as I mentioned before, we have had a big shift of work to the community and we expect, far, far more, with the development of PCGs and PCTs, there is going to be a massive change in the way the Health Service is organised, and that will have a massive impact on the staffing needs. What we have not got at the moment in the community is any consistency in terms of grade and skill mix. For example, in district nursing, around the country, there are huge variations which do not seem to bear any resemblance to local needs; you might have one trust where they have a grading structure which consists of B grade auxiliary nurses, D grade staff nurses and G grade district nurses, and, next door, they may well have B grades, Cs, Ds, Es, Fs, Gs and Hs, and there does not seem to be any rhyme or reason to that. And so there needs to be a lot of work done on clarifying what grades people should be on, what the structure should be, what the levels of responsibility that should be taken at each grade should be, so that we have a proper workforce plan so we know what the needs are going to be.
  (Mr Kline) If I just pick up on Mrs Wise's comments, if I give two examples. Pharmacists: because of a change in the structure of training, there is going to be a fallow year, at just the time when Primary Care Groups and the multi-chains in the private sector are radically increasing the demand for pharmacists. It is all guesswork, but our guess is that about 2,000 extra pharmacists will be needed, and nobody knows where they are going to come from. The other interesting area, and again it is one of the kind of poorer cousins of the NHS, is mental health services; mental health is identified as one of the key areas that the Government wants to develop. There are, and again we do not know the precise numbers, very significant shortages, for example, amongst clinical psychologists, amongst community psychiatric nurses, amongst speech and language therapists. And, I think, from the Committee's point of view, one of the problems is, there are all these different groups, and the ways of working out what is needed will be different for each group, so it is a big job, and our concern is that substantially more work needs to be done to make sure that the numbers being trained, a five-year training cycle for clinical psychologists, matches the changing direction of Health Service provision.
  (Mr Griffin) This is an area we do feel very strongly about, and I think this whole issue highlights the lack of a systematic approach to workforce planning. There are 70,000 PAMs who work in the NHS; as I said earlier, over the last ten years that workforce has grown by 26 per cent. We are not aware that any systematic investigation or forecasts have been undertaken by the Department about what the future needs, in terms of PAMs workforce, are. In fact, we have been in the situation, this year, when we have not even got information about vacancy rates for PAMs, so we do not know if the recruitment and retention crisis is any worse this year than last year; we strongly suspect it is because of the evidence we are getting from our members. 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. We are trying to do this, as a Staff Side, and, as I said in my first contribution, our strong view is there will be a greater need, because of the Government's reforms and its priorities, for PAMs. Where that workforce is going to come from, how we are going to retain more of the workforce that we currently have, how we are going to make the NHS a more attractive career for newly-qualified staff; we found out, through a survey we undertook, that 11 per cent of newly-qualified staff, who qualified in 1995, had last year already left the Health Service, and for 68 per cent of those people the main reason was pay. So we are very concerned that there is no systematic information gathering and forecasting going on at the moment. We think it is absolutely essential you do that, and it will be different for different groups, different needs, different factors to be taken into account; but this has to happen or we will continue to get into the kind of mess that we are in at the moment.

  Chairman: Before our witnesses comment further, can I bring in John Gunnell, because I know he wanted to ask specifically a question about this area.

  119. Yes, I did want to ask a question about data, because you are all using data, the Department of Health use data, though they have talked about their data system and agreed that there are, what shall we say, some areas that were not properly dealt with, and Sir Colin Campbell obviously had independent data, as well as using Department of Health data. Do your organisations each collect their separate data, and to what extent do you rely on Department of Health data, or do you have your own systems for collecting data, because you have all used various statistics this morning, and what are your sources?
  (Ms Silverton) Can I say that, partly in answer to your question and also to Mrs Wise's question, I think the reason that we have to have our own data is that the Department of Health data is actually so poor. In our particular case, we get data for nurses and midwives; in the same way as the Secretary of State, in his welcome statement about the employing and training of more nurses and midwives, did not differentiate between nurses and midwives, and, given that they are trained in different ways, it does not help us at all to know if those numbers go any way to meet the shortages that we think are out there. It is also worth saying that I think NHS statistics are poor at various levels throughout the organisation, not only the central ones but even at trust level; it is often very difficult to find out, for example, the various grades of staff, which staff are full-time, which staff are part-time, how do they add up in relation to whole-time equivalents. Almost 50 per cent of midwives work part-time, but we actually cannot find out how part-time they work, it is almost impossible for us; and, from that point of view, I think that is why we all have to collect our own statistics. Also, at trust level, we find that, whilst most trusts would, on an annual-by-annual basis, review their staffing requirements, the basis against which they do this is very variable, and a lot of this is simply historical; so you can have situations where the staffing from one trust to the next, with adjacent geographical boundaries, is very, very different, not only in the grade mix of the midwives but in the actual numbers of the midwives, and there are no widely accepted norms against which they can measure themselves. We do, in midwifery, have something called Birthrate, which we referred to in our evidence, and that has been used quite well, although it includes psycho-social needs as well as physical needs, it is not as good perhaps at some of the more broad social needs that are needed to meet disadvantage. But I think the situation really is a bit of a mess out there.
  (Sir Alexander Macara) Briefly, we would not rely on Department of Health statistics; that is not a criticism of the civil servants, they have been so reduced in numbers themselves that one has a certain sympathy with them, but not with the political direction, which has failed to acknowledge how important it is to try, at least, to make some estimate of what we need. What we do in the BMA is, of course, to prepare evidence every year for our Review Body, about which you will be hearing more next week, and, I can tell you, they are highly competent, and unless our evidence is well based and impressive we are in trouble when we go to give oral evidence. Now we collect our data through a highly professional Health Policy and Economic Research Unit, which, frankly, does the kind of job that I reckon the Department of Health ought to do, but we are confident of our statistics on the basis of study. Just to take one simple example, we would not have waiting lists for surgery if we had the ratio of surgeons to population that they have in a country like France, or Germany, we only have something like one-third as many specialist surgeons in this country as they have in these competitor countries. That is the kind of information we have, and we validate it, we give it to the Review Body, we are confident about it, so we know where we stand, the best estimates we can make.