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

  120. Are we necessarily comparing like with like, when you refer to European statistics? As a Committee we have looked occasionally at the different specialisms, different professional roles, and see marked differences. So are you satisfied, in making the point about European comparisons, that we are actually comparing the same issues?
  (Sir Alexander Macara) That is a very, very fair question. Of course, we are not. Our management in the NHS is infinitely more effective and efficient than the systems in an insurance-based country, like Germany or France, so that our management costs are very much lower, and they are more efficient, so we are not comparing like with like there. We are not a `for profit' organisation, in the NHS. Our staff are paid significantly less, it is part of the implied contract, job satisfaction, providing for people in relation to need rather than in relation to our own wallets or purses. So it is not like for like. But even if you take that into account questions are raised by such enormous differentials, both in the proportions of public expenditure devoted to health, with which you are very familiar, and in terms of the personnel, across the board, to deliver.

  121. It clearly is very difficult for us. If everybody is working to their own data, and the Department of Health similarly, and to some extent people may select that data that is most favourable to the case which they are putting forward, now, in those circumstances, how do we make a judgement as to whose data represents an accurate picture and not a picture which is slanted towards their own point of view?
  (Sir Alexander Macara) Let me say this about the Campbell Committee. They were immensely impressive. We had to persuade them every inch of the way about the validity of our arguments. It was particularly interesting when they heard from our medical students about their career aspirations and what they thought they could contribute, when they realised, for example, and this is not a sexist point, please do not misunderstand me, but now that we have over 50 per cent of our graduates who are women, and we welcome that, for all the right reasons, the qualities they bring, and so on, the total number of hours which they inevitably will be able to contribute in their professional lives will be less than that of their predecessors. Now you may say, well, of course, men should share, and, of course, they should, and we hope to God they will, but if they share then the number of hours they will be able to contribute will be reduced. So this is one of the problems of balances; as you improve something, you remove gender discrimination, you allow women to make their contribution, so that there is a knock-on effect there, in terms of the total work that can be done. But we know about this, we can make these estimates. Now the Campbell Committee is a good model. Now I reckon if we had more exercises of that kind, and especially across the board, because we, in the BMA, are anxious, we realise that we cannot estimate how many nurses are required, Christine has to do that, an across-the-board estimate, of the kind the Department ought to be doing but does not itself have the resources to do, would be invaluable. And you could say that, and that would help.

  122. I want to bring in Julia Drown in a moment or two, on a slight shift of emphasis, but I know one or two of our witnesses want to make a point. Can you make those points briefly, if possible, please?
  (Mr Abberley) I think you are on a hiding to nothing, because all of us use statistics like a drunk uses a lamp-post, and that is more for support than illumination. We have moved away from the collection of data at the centre, and still for some groups there is no data collected, and even if there is data it tends to be on how much the pay bill is, rather than on the numbers that are involved. And I think what you ought to be looking at is how we get information collected in the NHS which all the social partners are prepared to accept as being accurate information. And one of the things that UNISON is arguing for is that we should have, we call it, a Unit of Good Practice, at national level, which is owned by the Executive, the employers and the unions, in which we do pool our information, and that we agree on what information can be used. Because our style of industrial relations is bizarre, because we all produce information which supports our case,also we ignore it, each side, and then we negotiate around something that is common ground. The Unions do not even share information amongst ourselves, all this information is being collected, it should be pooled with information from the employers and the Executive so that we do all work together, establishing what is the right workforce, because it is as much our responsibility as it is the Government's. So, in a sense, pursuing the line, you are not going to get an answer, because there is no common information that we all support, I do not think; and that is what we need.

  123. Is the vehicle for getting that Colin Campbell's Committee; he obviously has the Department of Health statistics, but he does have the means of independent research?
  (Mr Abberley) The important thing about information is that, when it is used, all the people that are going to use it should believe that it is information that is accurate, and that is the importance of having some kind of body in which all the social partners putting in their information are happy to draw that information from it; that is central. It is no good having information which only comes from one group.
  (Miss Hancock) I am more optimistic than Bob. I think the straight answer to Mrs Wise, have they got the figures right, must be no, because I do not think they know where they come from, and workforce information, workforce planning, as everybody has said, is incredibly poor in the Health Service. But even if people had had, over the last 15 years, a very simple chart, with a crayon line on it, they would not have made the mistakes that they have made. The fact that in the mid eighties something like 38,000 nurses qualified in one year, and last year it was 9,000, if somebody looked at a chart, they would have said "Are we right to cut back this fast", they may not have got it absolutely right but they would not have continued the line going down. The number of nursing students has been cut back from 70,000 to 40,000 over a ten-year period. Now in our evidence to the Review Body, and I think a lot of our information is in the public domain, it may need unravelling; for instance, one of the reasons why there has been such a crisis in nursing is because what limited planning did go on never took account of the explosion in nursing homes and the explosion in practice nurses. Why practice nurses are not in the NHS statistics is bizarre, and I could not begin to understand, but that information was there, because Alan Milburn, in a previous life, elicited it on the basis of a PQ, so it clearly existed; we were surprised, we did not know it was there, but it was there, and now it is much more available regularly. We have got very detailed statistics in our evidence this year, for instance, about the number of new registrants that would be needed just to replace the ageing workforce, and I could read them out, Chairman, or I could give them to you on a piece of paper, in the interests of time.

  124. That would be helpful, thank you.
  (Miss Hancock) But I think the other issue is that there is a political dimension to the issue of numbers, and, of course, it links to pay; if there is a shortage you have a clear case for more pay and if there is a surplus you do not, and that, I think, is behind some of the legacy. But what is needed now is to recognise that the situation is one of crisis. From a nursing and midwifery and health visiting point of view, there is excellent data, it is the data of our registration; and the Government could take that data and they could systematically try to find out how many of those people are practising, where they are practising, where they are working, if they have left what they are now doing, what might entice them back, if they are 110 it will be quite easy to work out, and fewer of those are on our register than there used to be, but all that issue could be done. And if there was a commitment to address knowing what the problem is and beginning to address the problem, then I think there is enough good data there to make it much better than it is at the moment.
  (Mr Abberley) But for now, that is the problem.

  125. Can I bring in Mrs Ballard now, and can I just throw in an area that is directly relevant to your work, picking up the point that Miss Hancock has made. In looking at what is happening in the community and the number of district nurses, do we also need to assess the extent to which the district nursing role has actually spread out into social care and is being taken on board by social care professionals, as opposed to people based in the NHS? I am sure you are aware we are actually looking at this issue at the present time and we will be reporting in January on that?
  (Mrs Ballard) Yes. A couple of points, first, if I may. First of all, I think, in terms of data collection, it is really important to be bottom up, I know it is a bit of jargon really, but I have certainly sat in on a disciplinary hearing where my member has been saying that "We've had a shortage of staff and we've only had this number of staff" and statistics have been given from the personnel department that says a different story, and my member of staff is there, in that team, working, and knows how many people are actually there on duty. And I do think, as well as those people who are on the workforce, consideration needs to be taken of sick leave, maternity leave and other absences and the changes that happen. So there is a very poor quality at that very local level. Certainly, we are looking forward to the outcome of the Audit Commission work that has been done on a study of district nursing, which is due out in February, and I think they have asked quite a lot of questions around about skill mix and grade mix, and some of those questions have been quite difficult to answer, for some trusts. But, in terms of the shift of health care to social care, as you say, we have already addressed those issues, I think, in a previous inquiry, and what has happened is that, although a certain amount of work has shifted across to social services, I think there is widespread agreement that a lot of that should not have gone, in the first place, and needs to come back. And the shift that I have already talked about, about work that has come out of hospital that maybe did not need to be in hospital in the first place, has very quickly taken its place; so there is no slack in the system and there has not been a "We've got rid of one lot of work, where's the next lot coming from?", it is coming through the door before the other lot has gone.
  (Mr Griffin) Just a few points. I think, clearly, the information we all gather is a reflection of the paucity of the information that the Department of Health gathers. Just one example, this year, we gathered information about why our members were leaving the NHS to be employed outside it, so we have a list of reasons; as far as we are aware, that kind of information has not been being gathered by the Department. I think the issue of the structural reforms that have been introduced, that you have touched on, also indicates the importance of getting this right, things like Health Improvement Programmes do set three-year and longer plans, which do talk about looking at workforce issues locally; without the information to actually facilitate that, I cannot see how that process can work as efficiently as it should do. And, also, in terms of the actual accuracy of this process, I think we need to remember, in the private sector, and elsewhere in the public sector, although people recognise this is not an exact science, it does happen and it happens quite well. In the first job I had in the private sector, workforce planning for a large, multinational organisation, workforce planning was a central part of that private sector organisation's role, because it wanted to make sure it had the right amount of staff to do the work that it needed to do. It can be done, it can be done well, and we would certainly support the view that Bob has put forward, there needs to be some central independent unit, that all the partners have a part in being involved in, so we can produce information that everybody can use nationally, Health Improvement Programmes, the education consortia, there is a wide audience for this information and it should be gathered centrally for all groups.
  (Mr Kline) Two sentences, Chairman. Cytology screeners are a group that we represent, and I think one of the problems we have is that, whereas at national level there is a serious attempt to be open and honest and involve staff in the way things are done, this is a very good example of a group where the first response to our suggestion there was a serious staffing problem was one of denial, it was probably what is called a clinical cycle, first of all denial, then "Well, maybe there's a problem but it's only a small, localised one." Now we are in a joint working party with the Department, looking at why this is happening, why it is so serious, why it is a public embarrassment and why something has to be done. I suppose the final stage of the cycle will be to see what happens, and that maybe strays onto issues you may want to discuss next week. I think that, centrally, to be fair to the civil servants, there are those now who are making a serious attempt to avoid some of the traps of the past, where I think statistics have been a very political issue, and certainly Sandy and Christine and myself and others have been in situations where you clearly have had figures thrown at you that bear no relationship to what you know is happening. We do not know the answer to your question, what we do know is that it is possible to identify some common ground, pharmacists is another area, and to move from that, but it needs an openness and involvement and not going through this sort of denial cycle, so that by the time you accept there is a problem it is too late.

  126. I just want to pick up a point that Christine Hancock made, in terms of trying to find solutions to these problems, and one of the things you were saying was how people need to be involved in the decisions around them. It has been very clear from our evidence that staff feel very remote from their trust boards. One suggestion we had, from the NHS staff, was that there should actually be a staff side representative on a trust board, and I wondered if any of our witnesses had any quick comments on that suggestion?
  (Mr Abberley) I think, when staff talk about staff involvement, they mean about decisions in the ward, really, and although you need to have involvement at all levels, when you talk about having someone on a trust board I think that it is much more to do with the industrial relations side, and I do not necessarily think that, if you had someone on the board but you did not have staff involvement in the ward, it would change anything. And I think that, obviously I would say this, wouldn't I, but I do think that the task force is addressing a lot of these issues, actually, and I think the report, when it comes out, is going to be very valuable and will make a major contribution, if it is implemented, on improving morale. But I just wanted to say we need to not focus just on doctors and nurses when we talk about information statistics, there are not statistics for a lot of the people who deliver hands-on care, health care assistants, etc., and I think it is important to remember that, because you would expect there to be, the register is an example. But in the future a lot of the hands-on care is going to be delivered by people like health care assistants, and I think, when you start looking at the work of the consortia and the regional Educational Development Groups, they should be looking at what are the sort of training needs, not just for the NHS but for social services, the voluntary sector and the `not for profit'. Because, whether we like it or not, and we probably do not, that is how health and social care is delivered now, and we need to make sure that we are training the right people, and I am talking at health assistant level, NVQ level, as well as registered staff.

  127. Can I press you further on this, because this is the point, in a sense, I was making to Mrs Ballard, that the nature of the work is changing so profoundly between the different professional roles; we have referred already to the move of certain junior doctors' functions particularly to ward sisters, that we have picked up. The evidence that we have seen, quite clearly, within the community, indicates that substantial parts of what was a district nurse's role is now being handled by social services, and, by the way, means-tested, as a consequence, so how do we actually take account of—if we are trying to work out comparisons, we are actually comparing shifting ground, rapidly shifting ground, and that is the difficulty?
  (Mr Abberley) That is why the workforce planning needs to be across the workforce as a whole, and involving all organisations delivering care. The problem is, the NHS is compartmentalised, and so when Christine talks she talks for qualified nurses, and it is worth remembering that. There is an issue of whether we have got the right skill balance, which is about workforce planning, and we need to have mechanisms to allow that debate to take place, and I do not think we have that. Bob Fryer, you know Bob Fryer, described the British Health Service as the British class system writ large, and it is, in a sense.

  128. Let me press you further on this issue of compartmentalisation, because you, in a sense, are in a unique position to answer this point, and you know my concerns about what happens within UNISON, because you actually have Health Service workers and you have social services workers. I have not seen any great evidence that the fact that you have all come together in one organisation has reduced the compartmentalisation that you have referred to; are you working on that?
  (Mr Abberley) If you go to Northern Ireland, there is no evidence that having health and social services under the same—

  129. We might differ on that at some point.
  (Mr Abberley) We are talking about groups of workers that have barriers around them, and it is a problem we have to face, and we probably have different views about that. But if we are going to deliver health care effectively then these barriers have to be brought down, and people's skills are going to change, and we have to have a training and qualifications system which allows people to move up through from virtually the cleaner to the doctor.

  130. The other area I wanted to ask you about was health care assistants. You say, in your written evidence, thet the numbers of health care assistants recorded by the Department of Health was very different from what you believe it is, I think you were saying three times as many as the Department of Health think .Is there a reason for this? You also said that there are impending shortages of health care assistants from the sort of people who traditionally become into being health care assistants. Do you think there should be just one point of entry for many more professions in the Health Service; and what is the solution to ensuring that we do have adequate health care assistants and they are properly trained?
  (Mr Abberley) Certainly, we think NVQs should be widely available and should be the basis, certainly, for people who are not currently on the register, and I think that is important. But what I was trying to say was, and we represent, half our membership are nurses, but we have tended to focus on, in terms of training, in terms of statistics, and everything, on doctors and nurses, and the reason why there are no statistics on health care assistants is because they are regarded as people who work in a local labour market. But that is not true, and it is not going to be the pattern of care, because we do need—I am repeating myself—the system where we know what are the best skills to deliver the service. And the other thing, finally, which does impede breaking down the barriers, is the current pay system we have, and that is why we are saying we need to have a new pay system which allows, as part of it, job design. Because what we have at the moment is labels on people's heads, and the argument is about which label you have, and you have got groups of people who are fighting to become professionals, because if you are a professional you are valued, and if you are not you are not valued, and we have to change that. So I think the pay system reinforces the barriers, actually.

  131. Following on from that, we are tending to see that the qualified nurse is becoming too qualified, too academic, lots of criticism about the entry level for nursing and that we could solve the nursing problem if we actually reduced the educational level that is presently required, and that really nursing is about caring, and you automatically know that, you are born as this caring person, and particularly if you are a woman. But, going on from what you said, about this entry gate being wider and NVQs being used, do you, one, think that nursing is too academic, are their qualifications becoming so much that they are forcing there to be a problem in nurse recruitment because of that, or could we look at NVQs differently and could we look at the entry gate being widened? Maybe Christine might want to answer that first?
  (Miss Hancock) I entirely agree with Bob, that an ideal would be a vocational qualification system that enabled you to move from being the cleaner to being the doctor; we are a long, long way from that. And I think the vocational qualification model ought to enable a much easier move between professions; for instance, at the moment, you could be a really experienced community mental health nurse, with a Master's Degree in psychiatric nursing, and if, for some reason, you wanted to be a consultant psychiatrist, you would have to go right back to square one. Now I do not think that is the scenario that happens very often, but it is an illogical one that it should happen. And, indeed, the reverse is true; there are a very small number of doctors who have decided to be nurses, and they have also had to go back to square one. And that is clearly illogical. And there is no evidence that nursing's gateway is too narrow. The gateway to nursing is an NVQ level 3, or, indeed, a special access course for older people; the problem is that individual institutions set different levels. And, for instance, I heard just recently that, in Northern Ireland, Queen's University, which is the sole provider of nursing education in Ireland, or, at least, a young person told me that their entry requirements are two As and a B; so I challenged that, and they said "No, no, that's not true, but we get so many applicants that the only way we can devise a short list is to look at the higher...", so, effectively, it is two As and a B, and, of course, they are able to set that. When nursing's entry requirements have grown, over the years, and, in fact, they are not particularly high now, recruitment has actually increased, recruitment into undergraduate programmes is much higher now than recruitment into the traditional programmes. So, in my view, there is not any evidence that nursing is too academic.

  132. Can I say that this is something which would be challenged by a number of the people that we have met over the last couple of weeks.
  (Miss Hancock) Yes, indeed.

  133. Is it not challenged by Mr Kline's figures which he gave, actually, they are your figures, are they not, on the number of black people and people from disadvantaged backgrounds, under 25, in the nursing profession; they have obviously been balked at the gate? Either the gate is too narrow, or it is of the wrong shape?
  (Miss Hancock) It is a bit like medicine, is it not; individual people choose, at different times, to set their own entry gates.

  134. Either people can be encouraged or they can be put off?
  (Miss Hancock) And, I think, picking up, and I think Roger would agree with me, the evidence we have, and I think he would share it, is that black people have been put off by racism in the Health Service, and there is no evidence, and, in fact, many places are running, particularly in areas with high ethnic populations, like East London, where you were recently, they have, for over a decade, been running access courses to encourage and facilitate and help people from ethnic minority programmes to enter nursing. But I think we need to ask two things. It is very easy for people of my age to feel very threatened by people who are having a different training. I do not have a Degree in nursing. When I left school, it was unusual for girls leaving school to go to university. Fifteen years ago, at the Middlesex Hospital, nurses doing a traditional training programme had higher A-levels than the medical students, by a long way, and that was true throughout London, and those young people were exploited, they were put through a training programme that gave them nothing at the end, it gave them no currency, it gave them a ticket to do a job, and that was it; and large numbers left. The reason the nursing education programme was changed was not to make it more academic, or to give nursing greater professional status, it was because 30 per cent of the people who trained when Ann and I and Louise trained never survived, and another 20 per cent never worked as qualified nurses. We had what was like a world war one manpower plan, you put lots and lots of young people, untrained, ill-prepared, into horrendous situations, and some of us, and I do not know what our characteristics are, survived at the end of that, but large numbers did not, and they were bruised and they were damaged. And that is the reason that the current programme gives you more time in college, more support, less time; at the end of a training programme, nobody else in the world thinks they are skilled to do a job, when you have finished your basic training, that is when you start practising, even if you are an accountant let alone when you are dealing with critically ill people. I can remember, the whole of my training, I never did a shift on night duty with a qualified nurse, ever, and that was looking after sick people; the people now are much, much sicker. And I believe the evidence, and there is clear evidence, that, at the end of three years, these nurses do not have the experience of doing the same thing lots of times that we had in our training. But, within six months, qualified nurses are saying, they are brighter, they are better, they are more questioning. And if this country wants, alone almost in the world, and not just the industrial world but the developing world, to see nurses as the only health care profession that is denied university education, at a time when the Government and employers believe that 35 to 45 per cent of young people should have access to higher education, then you will continue to keep nursing as downtrodden, demoralised and, most importantly of all, not to have the skills and the knowledge to argue the case for their patients, and to see their patients get what is really the best possible clinical care that is available for them.
  (Ms Silverton) Can I support everything that Christine said. We, as a College, have a viewpoint that we would like to move towards a graduate profession in midwifery, but that is not at the point of entry, because we believe that you can develop the theory to go with your skills once you have qualified, you can take your theory further. And we are looking for multiple points of entry into the profession through the post-nursing route, through the three-year route and the four-year Degree route, and then that people should be facilitated to develop further, if they wish to, in their career. But I would say that we are very concerned at what has happened, now that education has moved from the NHS into university, in relation to entry, to training. We heard from Roger about the reductions in ethnic minority people in the NHS. In midwifery, in the school that I ran, very near here, we had between a third and a half non-white entry to the programmes; the successor to that programme had one non-white student in all three years, and this is because the universities are not looking at what those people can offer but simply what they have got on pieces of paper. Access courses were set up with local colleges, which worked very well; and that, together with, I think, something that Roger did not allude to, which is that the parents of these people from ethnic minority communities have said "Don't do what I did, don't put yourself through what I did, I had expectations, I kept being knocked back, the institutional racism is still there, don't do it." And I think you have got to address those issues, because we are actually not recruiting people who would make wonderful health care professionals.

  135. Can I, before I bring in John Austin, John Austin wants to explore the workforce planning question, I was interested in Miss Hancock's concept of some kind of common areas of training and the porter being the consultant, or the consultant being the porter. Sir Sandy, you have got some spare time now, I do not know whether you will be going back to portering, but what would the BMA's views be on that concept, about common areas of training, which surely do make sense, and the ability of people to cross these great boundaries?
  (Sir Alexander Macara) We would obviously welcome it. The problem is that there are logistical problems. I tried as long ago as 20 years ago to provide an element of shared undergraduate experience for doctors, nurses, well there were not then graduate nurses but the equivalent of those who are now in graduate entry to nursing, and social workers, and so on, and it was a tremendous experience, it was deeply enriching, we banished the stereotypes, these youngsters wanted to learn from each other, they were keener to learn their own trade because they recognised where it related to their colleagues. But it just is very difficult to organise. So, in principle, yes, absolutely, a common basis, so far as one can get it; in practice, it is difficult to organise.

  136. A number of people have mentioned the question of the way in which the NHS is changing, and even the Director of Human Resources at the NHS Executive said to us that the changes that are happening in the Service are moving ahead of the formal workforce planning mechanisms that we have, and the Chair has also talked about changes in the way that training may be delivered. I would like to ask, the planning bodies that we have, whether you feel they are representative of all the staff within the NHS, perhaps develop the question which the Chair has put, about the possibility of joint training, and whether the current workforce planning mechanisms, such as the Medical Workforce Standing Advisory Committee and the local education consortia, are well designed and efficient and whether they need to be reformed; and, again, in terms of the consortia, whether staff are adequately represented on those?
  (Mr Abberley) I think that it is too early to say, really, but, to your question directly, no, is the answer, and I think the key to delivering high quality care in almost everything is that we do have to build and institutionalise this concept of partnership, and I think that is very important. And I do not think that the staff, or even the staff side, are adequately represented in these bodies. I think, the idea of common training makes sense, Sandy may be right, but it seems daft not to have common training around communications, around public health, all these kinds of issues. For instance, I do not know whether it is true or not but it is widely believed that nurses are good communicators and doctors are not; now is it something to do with the training, I do not know. If we had a common training they would either be all good or all bad, but there are plenty of reasons why we should have common training. I am focusing on the other end, really, because at the other end you have got a lot of people who could go into the professions. NVQs need to be the standard for everyone who works in the NHS. If you have an NVQ, that should then be the route into the professions, which should be more competency based and underpinned by academic knowledge. Because, I think, although Christine may be right in theory, it is a big leap from being a level 3 health care assistant to being a Project 2000 nurse.

  137. Can I just intervene at this point, because I am interested, coming back to the point I made to you earlier on, about UNISON's ability to bring people together, and it has struck the Committee, very strongly, in the sessions that we have done in various parts of the country, the way in which the witnesses have had a very collective view of the teamwork, this has come across from porters, right the way through, you could say up or down, depending on your point of view, to consultants, this has come across very, very strongly to all of us. What I want to put to you, not just to you, Mr Abberley, but to your colleagues, or witnesses, as well, what are you doing about bringing this about; have you, collectively, put forward some ideas, because you are in a unique position to perhaps bring pressure to bear, along the lines of the suggestions that Christine Hancock made? This is not just addressed to you but to the others as well.
  (Mr Abberley) I think we are, if you think of the kind of agreement that there is amongst the Trades Unions here, when probably people thought there would have been a lot more disagreement. But you are dealing with institutional problems, and unions reflect society and we reflect the people that we represent, but, I do agree, we have a role to try to break down those barriers. But I just wanted to mention one thing that has not been mentioned, and that is the issue of enrolled nurses, because we think that there was a gap created, and certainly a lot of black people were enrolled nurses, their experience post-Project 2000 has been pretty bad, and therefore they have tended to, and we are all saying the same thing, say "I wouldn't go into nursing if I were you." The other thing, about racism is that we have a responsibility to deal with that too, because it is some of our members who are practising racism but it is also having employers that are prepared to say to users that say they do not want to receive care from a black that racism is unacceptable: a nurse, is a nurse, is a nurse. So, I think, combatting racism in the NHS is a responsibility for the employers and the trade unions. But we do think that there is definitely a gap for what used to be known as the enrolled nurse, and probably some kind of NVQ level is important to adress that.

  138. Could I just explore with Miss Hancock the point you made, very strongly, about Project 2000, about your views in relation to the academic requirements, which were different from what we picked up, including some of your own members, by the way; how does that tie in with the issue of racism and the recruitment of black nurses, which came over very strongly in what Mr Kline had to say?
  (Miss Hancock) Again, we come back to the fact that we do not have good information, there are a lot of subjective views. And if you take, for instance, enrolled nurses, if you had applied to the hospital across the water there in the so-called good old days, and you had six O-levels but they wanted two A-levels for SRN training, they would have trained you as an enrolled nurse, and there was a phenomenal exploitation of enrolled nurses, many of them black, who had quite clearly the entry requirements to do first level registration, and were told locally, when they often knew no better, either because they were young or because they were recent immigrants and did not know, and thought that they had done very well to get a training place in this grand hospital, and did not really discover, until the end of their training, that that ended their career. And I think the big mistake with Project 2000 is with the approach to the enrolled nurse. The Briggs Committee that recommended, in the early seventies, the original changes, saw there being a route through, and it was not a dead-end, and I believe that aspects of project 2000 was and remains a big mistake. I think it has then been compounded by the horrendous use of phrases like "conversion courses", which makes it sound like you are in need of either a religious revolution or electric convulsive therapy to become an ordinary human being. So I think that is a really big issue. The same is still true for nurses from black and ethnic minority groups. If you look in our Institute and our library, you will find close to, I would guess, 40 per cent of our students are from black and ethnic minorities; their desire to gain extra qualifications, for which they are frequently, usually, paying for themselves, and rarely rewarded, the downgrading, the significant—I was talking recently to a group of black nurses, and the jobs they were doing should have merited completely different grading, they had trust-wide responsibility, on a D or an E grade position, for something like incontinence care. That would never have happened, I think, in many other trusts, for other nurses, so I think their position has been grossly exploited. And, in fact, much of the evidence of school-leavers in this country at the moment is that many people from black and ethnic minority communities are actually achieving more than the indigenous white population. And, therefore, I think, the issue is not necessarily about access courses, it is about making sure there is no racism at entry; but there are also all sorts of things. And if you are really culturally aware you think through when you come to short lists. And the reason we changed our Institute was rather like my earlier story about Queen's, we were so flooded with applicants that, in a very unthinking way, people were using things like science A-levels as a way of drawing up a short list, and science A-levels were likely to discriminate against people from black and ethnic minorities, and we got rid of those sorts of criteria. And it is that sort of issue, often, that people are unthinking about, I think, and unless they have faced and indeed had training about racism they are not aware that they putting up racist barriers.

  139. To reinforce the West London impact, not only due to the quality of the representation of the Members of Parliament but I think the educational institutes in the area made a conscious effort to recruit locally, because of the population it was serving, the community it was serving, and so there was, without question, a deliberate approach to do that; are there ways that organisations, like yourselves, could encourage that to happen with educational institutions, are there ways that you could positively work?
  (Mr Kline) I think the first thing, Chairman, would be that the same requirements that are now being made by the Secretary of State of the NHS, in terms of starting to be aware and not tolerating racism, ought to be placed upon those organisations that train staff for the NHS, and there is plenty of evidence around, some of it public, some of it not, that these institutions are significantly worse even than the NHS in terms of their approach to these issues. I think, if you are looking to widen the base, it seems to me that would be something that would be extremely useful for this Committee to think through in its recommendations.
  (Mrs Ballard) Following on from that, our members of the CDNA are predominantly women, predominantly older women, who have family commitments, and therefore find access to further education very difficult. And we do have in this country a system of CATS (Credit Accumulation Transfer Scheme), where credits can be awarded at Diploma level and Degree level, and in theory passed between university to university. Certainly, the experience of our members has been that that is not an easy task, that there are many hurdles put in the way there; that needs to be applied much more flexibly, so that people can, we are talking about moving between branches and developing, and so on, and people need to be helped to do that in a flexible way. For example, CDNA, we have developed, with partners, a series of stand-alone distance learning modules, so that people can work through a module that can be awarded a certain number of credits at Diploma level or at Degree level, and they can do that in their own time and fit it around their other commitments, and they do not have to go physically to the college at a certain time on a certain day, and they do not, necessarily, physically, have to have access to a library.
  (Ms Silverton) I would like to follow on what Roger said about the NHS being firmer with the people with whom it contracts. It gives an awful lot of money to higher education institutions for the provision of education for health care professionals. I think it should not just look at the recruitment of students and ethnic minority issues, but it also needs to look at teachers, because, before the move from the NHS into higher education, midwifery education had a significant proportion of non-white midwife teachers, and in many cases those were the people who were selected for redundancy. And this is an absolute scandal, I am afraid. And, also, on the issue of teachers, if you are increasing the numbers of students, would you please think about who is going to teach them, because in England last year there were only four midwife teachers who had their new qualifications recorded on the register.