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

  140. We have talked about various shortages, in various sectors, Mr Kline mentioned 2,000 pharmacists short. I wondered if we could perhaps home in and be a little bit more specific, in terms of particular staff areas where there are shortages, whether those shortages are caused by the lack of availability of sufficiently trained staff, or the lack of management wanting to employ people in those particular categories? And then obviously the nursing one, I think Christine Hancock has given us the figures for training, and I think we know about the time-bomb there, but I think I am concerned about some of the other areas where, particular specialisms, there are shortages?
  (Mr Kline) Let me just give you two or three examples, since you asked for it specifically. Clinical psychologists, this is a group that has been repeatedly flagged up as a workforce that should grow, that should play an important role, they have repeatedly come out at the top, or near the top, of vacancies in advertising. There is no shortage, courses are flooded out with applicants, there are simply not enough people being trained; there are some issues about what kind of training they might get, but there is not a problem in terms of applicants. Similarly, health visitors, the issue there has not been one of people not being willing to be trained, it has been the refusal, particularly under the previous Government, of employers to take them on board. District nurses and health visitors, some ten years ago, in 1988, there were figures published which suggested that the numbers of health visitors and district nurses should radically increase, the figures, for example, for district nurses were that there should be an increase from 9,380 to 13,900, similar increases for health visitors were deemed as being necessary, this was the Integrated Workforce Planning Programme; in actual fact, the figures fell, and you can repeat that picture. So, clinical psychologists, certainly I have mentioned pharmacists, medical laboratory scientific officers; in some parts of central London, I am reliably informed, there are as many temporary and bank staff staffing our labs as there are permanent staff, you can imagine the implication for quality of service and clinical governance.

  141. Why do you think that is; is that what they are paid?
  (Mr Kline) The problem that you have and which we have is, of course, the reasons are different for each profession. Medical laboratory scientific officers can get jobs in the private sector, so one of the key issues for them is that they can get more, much more, in the private sector than in the public sector; sometimes I do wonder why on earth a medical laboratory scientific officer should go and work in the Health Service, it is a serious question. Cytology screeners; why on earth anybody should be a cytology screener, with the stresses involved, when they can definitely get more, earning as a shop assistant in Sainsbury's or Tesco's, as indeed can graduate entry medical laboratory scientific officers. So you have different groups. Pharmacists are another group where there is a direct comparison with what they can get paid; that is an issue the Health Service has to come to grips with. Other groups; it has been that there has been no shortage of people being trained and willing to come into the Health Service, but it has been, if you like, policy decisions, or resources, about whether or not to take those groups on, and you really have to break it down. One of the problems you have is that, even with nursing, there are different groups within nursing, but certainly outside those, for the PAMs, for scientists, and so on, there are sub-groups and they each have specific national labour markets, specific comparisons, and it would be very, very helpful to sort of give that a push and give it a steer, because there are not simple answers and there are different answers for different particular groups.
  (Mr Griffin) I think, in terms of PAMs, we have been looking for a number of years now at what the reasons are for the recruitment and retention problems. And the reason it is not is people applying for the courses, and physiotherapy, for example, is the third highest university course, in terms of applications; so getting people into training is not a problem, pre-qualification. The problem is, firstly, how you then attract those people, once they have qualified, into the National Health Service, and I think there are a number of reasons why people are increasingly choosing not to work in the NHS; firstly, they can go elsewhere and they can earn substantially more. Graduates generally earn 22 per cent more than our members do when they qualify, and so, clearly, with an expanding private sector, in terms of health care, there is a market there that members can choose to go into, and increasingly are going into. Secondly, I think students are very informed about what working in the National Health Service is like at the moment, they know pay is not very good, they know conditions are not very good, they know stress and workloads are rising, and that in itself makes it more unattractive as a career. Even if you manage to get people into the National Health Service, the problem then becomes retention, and we asked people, in a survey this year, whether they thought they would be spending their whole career working in the National Health Service, this is people who have just joined in the last year, and only 4 per cent of the people we surveyed said they saw the National Health Service as where they would spend the whole of their career. And, again, there are issues around pay, and the NHS commissioned a survey, looking at, in terms of case studies, why there were problems with recruitment and retention, and pay came up in that survey, and it was found that people would need something like a 20 per cent pay increase, those people that were thinking of leaving the Health Service, to stay in it. There are problems around career development; by the time you are 30, in most PAM professions, you have reached the top of your career, if you do not choose to go into management, and in terms of your clinical development you are at the top of your career and at the top of your earning potential probably around age 30. There is a whole range of problems around support for training and professional development. Because of a lack of resources, workload has increased, 77 per cent of PAMs felt their workload had increased over the last year; that has to affect stress, it also means members spend less time treating patients, which is what they want to do. So there is a whole range of factors, but I think a very clear picture is building up now about what the problems are, and that, of course, leads to the solutions as well.

  Mr Walter: I wondered whether it would be possible for each of the groups here to perhaps provide us, in written evidence, with their assessment of all the various specialisms, where they see the shortages, the shortages of supply, and also shortages within the Health Service, because those people are not being taken on, for various reasons, whether they are cost reasons or somebody has assessed the fact that you do not need these people or these people, and therefore there is actually an abundance of supply of people looking for jobs. You have indicated, in some areas, that there are plenty of courses and there are people applying to the courses and qualifying but they are not actually getting employed. Now they may not be getting employed because the Service does not want them, or it may be just that the Service is not providing enough financial reward for them. I think that would be quite useful written evidence.

  142. The other area that puzzled me, if I can add to your point, Robert, was, bearing in mind some of the salaries that are on offer, and we said we would look at the pay issue next week, certainly, in terms of the PAMs, and we have taken evidence directly from people who were working in the Service, I wonder, on the comparison that I think you made, Mr Kline, about who would go into the private sector and who went to the NHS, one wondered, when looking at the comparative pay rates, how much of a factor is a commitment to the NHS, a belief in the NHS, a factor in recruitment, and the ethos of the NHS perhaps compared with the private sector?
  (Mr Kline) I think that is a very important question. I think that, if you went back ten years, one of the reasons that pay was less important, I think it is the case, less important, some years ago, was that there was, in a sense, an implied contract, that working in the Health Service was a job worth doing, with security of employment, where you were treated, on the whole, not if you were black and not sometimes if you were a female, but on the whole, you were encouraged to get on with the job, you were encouraged to be innovative, and so on. I think what has happened in recent years is that the workforce has become much more defensive, it has been bullied, it has not felt it has been treated with respect, it therefore becomes perhaps more fixed in its attitudes towards flexibility. And I think it is important that you think through the distinction between being flexible and generic working, I think there is an important distinction there, we would be very comfortable with flexible working, less comfortable with generic working.

  143. We might touch on that in a few moments.
  (Mr Abberley) I think we can supply you with that information; how much use it will be I am not sure. Because there are supply side problems, jobs not being available, there are retention problems, which are the biggest and we are dealing with those now. But there are also, for other groups, which I have to keep dragging this back to, in some trusts they cannot recruit ancillary staff, and they cannot recruit ancillary staff because in the labour market they operate in the rates of pay are not high enough, and because it is unusual for an ancillary to move to one end of the country; these problems are just as important, and it is worth remembering that, health care assistants, other groups. And the NHS is a team if it is anything. You are not going to be able to run a hospital if you aint got any porters, that is a fact, and it is worth remembering that every group of staff is important. And the problem is that, very often, no work is done, none, by pay review body groups, in terms of recruitment and retention. When I went to work in the NHS I was an ancillary worker, and I went in because I wanted to do something for people, it was a secure job, it had a good pension, I knew I was not going to be rich. And I can list what I think is important to people when they want to go into the NHS, and most of these have been undermined: good pay, job satisfaction, being able to deliver quality health care, being valued, involved in decisions, job satisfaction, and that is the public sector ethos, employment security, that has gone. It is ridiculous, is it not, we are in an expanding industry, we have not got enough staff, and staff feel insecure in their jobs; somebody has got something wrong there. A safe working environment, no racism, etc, but also family-friendly working conditions, and a good, secure pension; and on almost all of those now, for some groups of staff we are not delivering. And the other thing, which I think has to change, the Government has to stop seeing putting money into staff as not putting money into patient care; it is the same thing. Putting money into staff is putting money into high quality patient care. And that philosophy has carried over from the previous Government to this one, and it is bad, it is bad.

  Chairman: Let me bring Mr Walter back in, because he supported the previous Government, presumably.

  Mr Walter: I think Miss Hancock wanted to make a contribution.

  144. Sorry, Robert; sorry.
  (Miss Hancock) I was responding to the Chairman's question about commitment to the Health Service, and certainly it is one of the things that our annual survey has tried to measure, and showed a definite decline in that commitment, with 1995 as the low point, although there was a dip again this year. And one of the things I think is quite interesting is the way nurses react at the moment to working in the private hospital sector. Most nurses believe passionately in the Health Service. In my experience, the private sector does not have a labour market of nurses who like private medicine but they drift into it for a variety of reasons, hours, accessibility, a job going, whatever, and when they get there one of the things they always say is that they are able to nurse patients properly, and they had not expected to like working outside the Health Service, but what they can do is they can give the patient care that they trained for and they believed in, and I think that is a real risk that the NHS has. One of the biggest things, and I agree entirely with much of what Bob said, about one's reasons for working in the Health Service, that drives clinical staff out of the NHS, is the feeling that they are not able to care for patients properly and they are not able to do their job properly.

  Chairman: Robert, do you want to pursue the issues, or move on?

  Mr Walter: I want to move on to another area, other than just to sum up my question, in terms of the use it is to us to have those figures, because we can then go back and hit the managers of trusts, or the Department of Health, and say "Well, look, these are the shortages, you tell us that you're training this number of people, but you have a shortage; so, why?", it is being able to close that gap. But I would like to go on, because, obviously, we are talking about future NHS staffing requirements, and look at the impact of Primary Care Trusts and possibly moving up to Primary Care Groups, and I wonder if some of the groups here would like to just indicate, quite briefly, what you see is the impact on the particular specialisms you represent?

  145. Can I bring in Mrs Ballard on this, because obviously you have got a particular interest in this area?
  (Mrs Ballard) Thank you, yes. Certainly, from the community nursing point of view, Primary Care Groups and Primary Care Trusts, as they evolve, are seen as a major, positive development in terms of career progression, in terms of being able to be autonomous again, in terms of being able to feel part of a team, being able to speak out and being able to plan health care services, and plan health care services on a geographical basis, not on a basis of which GP practice an individual patient happens to be registered with. We had real problems with GP fundholding, where contract priorities were taking priority over clinical need, and the beauty of Primary Care Groups, as seen by our members, is that that is balancing out, we still maintain our good teamwork, our primary health care teams, which are very valuable, in terms of providing health care, but also we are able to address the public health agenda on a more geographical basis. There are concerns, and very genuine concerns, about the support that is going to be available, the training that is available, the equity issues of those people who are contributing to the Primary Care Groups, but I think, so far, on the whole, we have had very positive feedback. We had a national branch officials conference, very recently, and the feedback that we got from the process that has been gone through to elect and select nurse members of Primary Care Group boards, albeit there have been one or two hiccups along the way, and some of them have been really big hiccups, but on the whole the view has been that it has been a very positive development and people are really looking forward to really grabbing the opportunities that are there.
  (Miss Hancock) I would reinforce a great deal of that. We have been amazed, at meetings, evening meetings, 150, 200 people, all disciplines, really enthusiastic about getting involved. And, one of your earlier questions, about organisational change, I was trying to come back, in fact, to say that I think there is an excitement about that agenda. I believe the agenda is horrendous, in terms of size of change, and I am not convinced about the resources to manage that happening, and indeed the impact on the hospital sector, I think, is much too little understood, but within the community world it is exciting. And I would also like to go back to something that I think we all ducked, around the Chairman's question about the social and health care divide, because, in my view, that still remains one of the most damaging things in its effect on very vulnerable people. And I think the only difference between social care and health care is whether you pay for it or not, in many places. And what effectively has happened is that many of the most vulnerable people, and I think it is one of the real problems for people with serious and psychotic mental illness, also one of the real problems for elderly people, is they are being denied the skilled assessment and involvement of particularly qualified nurses, not necessarily the total care all the time but the ability to see, in things like incontinence, leg ulcers, psychotic patients who are having trouble with continuing their medication, the sort of change in a chronic person's illness, that a skilled—and it does not have to be a nurse, it can be an OT, it can be a psychiatric social worker, where they still exist, who are skilled and experienced, those people. And I think the Primary Care Groups will recognise that investment in qualified staff into a residential home, for instance, is a much more cost-effective option than that person having, often in the middle of the night, in a great deal of distress, to be admitted inappropriately to an overstretched, chaotic, acute hospital, where they get further complications, and quite often deteriorate dramatically.
  (Ms Silverton) I think the position of midwives, with respect to the forthcoming changes, is quite interesting. Midwives, for the most part, are employed by acute trusts, but we actually deliver most of our care in the community. Midwifery has suffered fairly badly from the cuts that have happened in the acute trusts to shift funds from the community at the same time as we have actually been taking our services out. So perhaps midwives are a little sceptical about what is happening; but I think we welcome very much the ethos behind the reforms. And, looking one stage further, from Primary Care Groups to Primary Care Trusts and the changes that may well happen in the configuration of the hospitals, as acute hospitals become even more specialised, I think it is not unrealistic to think that Primary Care Trusts will become significant providers of care, and, from the midwifery point of view and from the point of view of the users of the Service, it would be nice to think that that would include perhaps provision of maternity beds, at least for delivery, in local poly-clinics or local community hospitals. And that will have a significant impact on the working lives of midwives, if they are delivering care in a different way, particularly since there will be a separation of what is essentially the normal maternity service, for women at low risk of complications, from those services in the acute trusts for those women who have possible complications, who have pre-existing diseases, who need access to foetal medicine services, who have been through some fertility treatment. And I think we will see perhaps a division between the acute, the high tech midwifery support that is required for the obstetric intervention and the normal midwifery provided through the Primary Care Trust. As a College, we believe that the employment of those midwives must be kept together, to enable us not to have a second-grade service for any one group of the users of the Service, but I think this has not been looked through. And what also has not been looked through is the need to have clinical specialist midwives in the labour ward, as clinical leaders, who are actually providing the ongoing labour ward support, to produce the quality agenda and to develop the other staff, the other midwifery staff; and, of course, these people as well train medical students and assist junior medical staff very much.

  Chairman: I am conscious that Peter Brand, who has been extremely quiet today, for some strange reason, has to leave us in a moment or two and wants to raise one or two issues before he departs.

  146. Can I actually flag up some questions perhaps for next week, as much as this week. It would be very useful if you could give us any evidence of grading structures differing substantially in different geographical areas. I am very aware that in Darlington there is no alternative to working for the NHS, whereas in other parts of the world there is, and it strikes me that staff grades are being not consistently applied, and even if you have got a national condition of service we do not have a national Health Service, in that sense. I was fascinated by Mr Kline's comment, on workforce planning, that there was a policy decision not to train people further. I am not aware of a mechanism that would allow a policy decision to be made; do you think it was a policy decision, or do you think it was the absence of having a mechanism to deliver that? It was quite interesting, talking to Sir Colin, a few weeks ago, that they looked at the issue of skill mix but found it too difficult to tackle in relation to medical workforce planning, which really means that we are expending a lot of effort on planning what numbers of doctors without knowing what sorts of doctors, we are spending a lot of time planning the number of nurses without knowing exactly what the role of nurses is going to be. Miss Hancock clearly knows what it should be. The Chief Nursing Officer was saying "Well, of course, we've got to get away from all this ritual activity that nurses do." Well, I found that deeply upsetting. To get to my real question, because I needed to get that off my chest, I feel very strongly about some of these things, can we go to staff flexibility, do you think that is a useful thing, or is it just a way of justifying my first question, actually paying people less for the same sort of work? But, in your answer, could you also indicate whether this fashion for skill mix and staff flexibility does not also run counter to the increased specialisation of treatment within the NHS? We seem to have a tendency towards saying everyone should be able to do everything; on the other hand, more and more professional groups are saying "Well, this is nothing to do with me, I specialise in the left foot, go and see my colleague for the right"?
  (Mr Kline) Do you want the answer next week?

  147. I have got to go in three minutes. But how do we tackle it? I have made some outrageous statements, which I think we all recognise as having a real bearing on this investigation, no-one actually has come up with a solution. Is it something that we can plan nationally, or is it something that we need to see evolve; after all, there are no national guidelines on the number of hairdresser trainees, and on geographers, yet somehow people get their hair-cuts, sometimes?
  (Mrs Ballard) I think what we need to be clear about is that everybody, all staff need to be trained and need to be competent for the task that they are doing, whatever that task is. They also need to be graded at the correct level. There is a difference between skill mix and grade mix. If we are looking at grade mix, that is to do with how much you get paid and your status and your position within a hierarchy, perhaps, whereas when you are looking at skill mix you can have a group of people on the same grading but they bring different skills, so an expertise in wound management, an expertise in another aspect of care. So there are those two things. And there has to be a balance between the generalist and the specialist, and that balance will have to be led by the needs of the patient. If I can relate that to a district nursing caseload, for example; as a district nurse, you might have a caseload of a number of people who are predominantly elderly, who have predominantly conditions that relate to the ageing process, and therefore your general knowledge and your specific knowledge in terms of helping those people to live their lives as independently as possible will be geared to that, and you will be able to provide an excellent service to the majority of your patients; but there will be issues where you have somebody who is outside the ordinary, where you will then need to call on the expertise of somebody who has a deeper expertise. Somebody mentioned continence earlier, the majority of nurses, and the majority of district nurses, certainly, have a very high level in terms of promotion of continence, how to assess the issues around incontinence, but still, at some stage, some people will need to have access to a specialist continence adviser.
  (Ms Silverton) Flexibility is present in a number of areas. Midwives, as a result of the introduction of women-centred care, have demonstrated great flexibility in relation to the ways that they have worked, the hours that they have worked, where they have worked, whether they have been in the hospital or in the community, and there has been a willingness to do this, because midwives, by the very nature of the fact that they are midwives, are there to meet the needs of the women. But, unfortunately, the Service has not supported them in that, it has not supported them necessarily by providing them with appropriate communication links, we have had a lot of trouble trying to get pagers and mobile `phones, and if you think of some of the high risk areas that midwives work in, delivering a 24-hour service, I would not be very keen to be going out in the middle of the night to some of the poorly lit areas that our members go to. So that is one area of flexibility. But if you are talking about flexibility in relation to role, I think you have to be very careful here in relation to the quality service and risk management strategies, because, as accountable professionals, there are only certain areas on the boundaries where there are allowances for flexibility, and I think you have to be very careful on delegating to staff who are not actually directly under your area of responsibility, particularly when it is you, as a professional, who are potentially carrying the can for the work that they are doing.

  148. That was the argument GPs always had about the midwives, but I am very glad you now carry the can.
  (Ms Silverton) No; in fact, we always have carried the responsibilty, but, of course, we have not had the rewards. I think the difficulty here is that we do still have concerns, although most of them have disappeared, about GPs delegating maternity, particularly antenatal care, to practice nurses, but that is a risk management issue that needs to be looked at. I think it is worth mentioning here, of course, that the issue of delegation by GPs is potentially due to the way in which the charging system works, in that they are paid to ensure that antenatal care is given, and not necessarily to give it themselves, and probably the unified budgets, under the Primary Care Groups and Trusts, will knock this on the head, because they will not be prepared to continue any longer to pay twice for a service to be given, once for the GP to ensure it is given and once for the midwife to actually give it.
  (Sir Alexander Macara) Peter has raised some very important questions, which, of course, we must address, but let me just, very briefly, inject a philosophical note, which might help us all, and it is this. There was a time when there were only doctors, so-called, mostly pretty poorly trained, and nurses, there were sort of midwives, that Dickens wrote about, the Sarah Gamps, and so on; look what we have got now. Should not we rejoice in the fact that we have developed a much wider range of professions which make a specialised contribution; so we are not deploring that. Midwifery is a very obvious example; Julia Cumberledge's work was seminal in confirming their independent professional status, working, of course, closely with doctors, and so on. Now there is a natural process which I like to think doctors welcome, not because it takes jobs off our backs but because it enables us, in our turn, to develop our skills and to use new technology, whilst, at the same time, trying to become good communicators, for the first time in history, perhaps. So let us welcome this, but reinforce the point that has been made, what matters is the balance, that, in welcoming specialisation that meets patients' needs, we need at the same time, within professional groups as much as between them, to recognise the role of the generalist; and this is particularly important in general practice, somebody who is the patients' advocate, who can co-ordinate everything that happens for them, and so on. In hospital, as well, we are desperately at risk of losing the general surgeon, the general physician, and so on, and going for specialisation. It is desperately important that we address Peter's question and recognise the need for balance, whilst welcoming increasing specialisation.

  149. I would just like to go back, and it may be something that needs to be developed next week, that Heather Ballard has mentioned, the very crucial, I think, distinction between grade mix and skill mix, and, essentially, I think this is the message that came over to us, particularly in Darlington, and in Birmingham, and in other meetings that we have had, that, effectively, the grade mix is finance driven and the skill mix is patient care driven; that is what has been said to us. In that context, and maybe it is something that needs to be looked at next week, if we look at pay issues, but I would like to flag it up now, within that structuring, the use of discretionary points on the higher grades, which, it has been suggested, pump-primes male nurse earnings and adds to the race inequalities as well, whether that is an issue which we ought to be looking at, and could I flag it up in terms of next week but seek some comment at the same time?
  (Mr Griffin) Can I just mention, in terms of the grade mix, skill mix and flexibility, I think one of the problems, in terms of addressing this whole debate, is exactly what has happened in the past, in that skill mix, essentially, has meant grade mix, which in reality means members taking on more responsibilities for no more pay. For example, within the PAMs professions, we have seen a loss of a substantial number of PAM managers, over the last ten years or so; that work has not gone away, it has been downloaded through the grading structure, so that members have ended up taking on more responsibilities. It may have been called skill mix but, in fact, in reality, it was simply a grade mix exercise, and very cost driven, as you rightly point out. In terms of flexibility, it has been a very one-sided debate, it has not been about positive employee flexibility, it has been generally about employer flexibility. So I think perhaps one of the problems, in terms of addressing this whole important issue, which will need to be addressed, as we move towards more multi-disciplinary, patient-centred care delivery, is the history that we have had with this whole debate, and it may be that some of the reaction you are picking up on the ground is actually about the history of what has actually happened before. I think discretionary points is a very much larger issue.
  (Mr Kline) If I give examples of two recent reviews that we have been involved in, which perhaps address the point that John Austin has made, that I would very much endorse; in pathology services, there was a very serious drive, over many years, to produce sort of a generic pathology scientist, a great drive to increase the number of medical laboratory assistants, and so on, very little concern about what this might be in terms of quality and competence and the delegation of work. The academic leading the drive is someone whose name will be familiar to some people here, he is Professor Roger Dyson, from Keele University, who was seen as Attila the Hun, frankly, by all the unions. Professor Dyson has just recently completed a major pathology survey review in Glasgow, and has obviously also gone on the road to Damascus, because he has decided that actually there is no future for the sort of generic person he was looking for, we should revert to much more specialist work, but in the way that Sandy has done it, with flexibility, and he carefully distinguishes—incidentally, he says the main area to save costs is in the purchasing of supplies, not in trying to drive down staff costs, which also surprised us, we were about to hang him and we decided he was a hero. We can also change. So I think that is one example, in pathology. Secondly, within community nursing, district nurses in particular have suffered very badly from grade mix; the number of G grade district nurses is half, I think, what it was a few years ago, that has not happened in health visiting, we have managed to sort of sort that one out, but the reality is there has been an obsession with tasks, rather than roles and processes. I have two young children, I can weigh them, I am not a health visitor, nor should I be entrusted with the job of taking on part of the job of a health visitor, and you can see that all the way through. Finally, the Crown Review, which has looked at prescribing, is going to encourage more flexibility in the way in which, who can prescribe, and so on, without suggesting there are not specialist roles. And I think that balance between more flexibility, as the world changes, technology changes, jobs change, the needs change, without drifting into grade mix and generic working, that that is actually the way forward, it is one that the more far-sighted trusts are doing, I am afraid not all have quite got the message, and, if it is a message that your Committee could just gently nudge along, I think that most people in the Service will give a very big thank you.
  (Mr Abberley) I think, if we are talking about flexibility of roles, then, obviously, people's jobs are going to have to change, and I think the trouble is we are looking forward by reference to the past; skill mix reviews were cost driven and not in the interests of patients, but I think we should be looking at what are the barriers to change. We need to create a change culture in the NHS, it is constantly changing, and we talk about particular points in time as though there is a beginning and an end in the way we deliver care The NHS it is constantly changing, and we need to create a changed environment in which staff do not feel the victims, and that is very important. And one of the things we are looking at is the idea of flexibility in roles, in return for employment security, because the biggest barrier to change is fear, obviously, and I think that it needs to be recognised, when we talk about discretionary points, it is a red herring. The problem is, we have got a pay system that is out of date, it was designed in 1948, it was modified in 1982, with the pay review bodies were created, and it institutionalises groups of staff ,which does not make sense. And so, in the evidence to the pay review bodies, we are arguing that we need, one of the urgent things, if we are going to deliver the modern NHS, is that we have to modernise the pay structure. The pay system has also proved to be not equal value proof. And a new pay system must be central to your work.

  Chairman: We will expand on these areas next week, obviously. Can I, in a sense, move on from what you have been saying, because you talk about the overall ethos in the culture of the NHS, we would like to look at recruitment and retention before we complete this morning's session, and I know that Ann Keen has some concerns, in the wider sense, of the ethos of management, of the culture in the NHS.

  150. It will be a general question to all of the panel, that I am all very familiar with and I know the work that you do, very hard work that you do, in representing the NHS staff. I was a working nurse in 1983 when the Griffiths style of management came in. To what degree do you think there is a need for a change in management style still today in the NHS, and I am sad to raise it but how prevalent is harassment and bullying; would you say it was widespread? How then has such a culture grown? So, I am saying, is there a bullying tendency, is there a management style in the NHS, how do we think that has grown, and what system would you recommend that we could test to see that this is being improved? I am very familiar on the visits, but I am obviously in touch in many, many areas, through either being a Member of Parliament or from being a nurse, and it is constantly reported to me about a style of management that is, I would say, totally unacceptable?
  (Mrs Ballard) If I can say, just because it follows neatly on from my Motion at the TUC Congress this year, which was about a bullying style of management; and it is a horrific thing that, as I speak to so many of our members around the country, they are frightened, they are absolutely frightened, and sometimes it can be about something that you think "Well, why on earth don't you speak up about that", but they are working in cultures of fear. Now I have to blame the internal market, to a certain extent, for that, to a great extent for that; we had competition, we had a financial emphasis on everything, we had commercial confidentiality, where the gagging clauses came in and you were not supposed to speak to people, and so on, and it has been a horrendous experience for people. Nurses and other health care staff have long memories, and we have got to work very hard to convince them that it has actually changed. I remember, four years ago, when I first started in this job, advising one of our members who was a district nurse, working with GP fundholders, who had had the temerity to discuss the vacancy on her district nurse team with the senior partner, who was commissioning that district nursing service, and she almost ended up being disciplined because she spoke to the GP directly and not via the contract manager. This person did not have any access to what was in the contract that she was supposed to be delivering on a day-to-day basis, it was a horrendous experience. And, unfortunately, it has not changed. We were talking about skill mix reviews, or grade mix reviews, we have had some very damaging experiences, where one of our members was left as an experienced G grade district nurse, she was downgraded to an E grade, through this review; it did not actually save any money, because she was within the years of her retirement, which meant that her salary was protected. So here was somebody with her years of experience who was still being paid at her G grade but was actually downgraded to an E grade; and the humiliation for her, as an individual, the effect on her morale and her colleagues' was tremendous. I gave an example, when I spoke at the TUC, about a particular district nurse who had been working in very difficult circumstances, with shortage of staff, long-term vacancies, working very hard to work in close co-operation with her GPs, with her social services colleagues, providing an excellent district nursing service, and, in fact, her manager did say to her that if she were in need of a district nurse she would really like her to come and provide her district nursing service, but the trust could not afford a Rolls Royce service. There was an issue where the manager became aware that this district nurse, in order to provide the service that she needed to focus on, had not been completing all the paperwork, in this trust they had 21 different forms to be completed per patient, that is not 21 pages, that is 21 forms, and she did not do them all, she did the minimum that she needed to do, but she did not do them all because she was concentrating on providing the care; it is a long story. But this ended up in a disciplinary, she was given an oral warning, and in this particular trust there was no appeal mechanism, and therefore the reasons behind the shortfall were not aired; we protested to the Director of Nursing, we said "This is not the way to treat people who have been working in these circumstances, and we're going to publicise this sort of case, it can't go on." And the Director of Nursing's response was to send a copy of my letter to the lawyers, to see if I had committed any illegal act. So those are the sorts of things we are dealing with. That particular individual has gone off sick, she has now voted with her feet, she is not totally lost to the NHS because she has gone to GP, to work as a practice nurse, she is going to work part-time, she is working on a lower grade; what the long-term effects on her mental health and physical health are I do not know. But that is happening now, and even one example is one too many, but there are many more of them.
  (Ms Silverton) Following on there from Heather, I think the previous management culture was not simply due to the internal market, I think the annual contracting was a major factor in that, because the managers had to deliver very quickly. So this culture of no long-term planning, no long-term development of staff, "What I've got to do is get it now, for this bit of the contract", certainly became all-pervasive, and we have to remember how long the internal market was in there. We have a whole generation of managers who were appointed and brought up within that environment, and, to some extent, if you are being bullied from above, well, for many people, unless you are very strong, the thing to do is then you just pass the bullying on, and that is what has happened; we have more and more bullying and harassment coming to light in midwifery. I think now that it is in the public domain people are more likely to actually mention it, and once you get one brave soul who is prepared to let us know then more and more come forward, and it becomes a group thing. But it is actually very difficult, the climate out there is still that people are not prepared to put their heads above the parapet and say anything, because they are terrified; they are worried if that would mean that when they go for a review of their job they are likely to be downgraded, if there are any opportunities for development they are not going to get them. And it is becoming something that really is now institutionalised within the system, and I think tackling that cultural change is going to be a very major exercise.

  151. Could I press you all further on where this arises from. I was a health authority member when the Griffiths general management changes came in, in an area where they appointed a new general manager who came from the private sector, and we saw a marked cultural change, as a consequence of that. How much of that, the problems that we are describing, the problems pinpointed by Mrs Keen, relate to a change in management culture, or is it the internal market? And how is it going to be possible, coming back to the first group of questions that I raised, for a Government committed to a different philosophy to change it without perhaps losing some, if there were positives, and I am not saying there were or there were not, if there were some positives from the recruitment of people from a private sector culture, in looking at the efficiency of the Service in this sort of area? How is it possible for that to sort of impact upon the kind of environment facing your members?
  (Mr Kline) I think there are three or four practical things that come to mind. The first is to seriously make it clear that this is an open organisation, in which decisions are taken openly, in a way that people can understand. There are still Boards who have pre-meetings before their public meetings, there are still organisations where they have wonderful policies about bullying, but it goes on. One of our health visitor members described it, it is like child abuse, it sort of runs in the family, if it starts at the top, it becomes quite addictive, it carries on, and then the people who are bullied themselves bully; there are lots of organisations where it will be very hard to change that culture. But let us have it out in the open and make it clear that what the Secretary of State has said about openness and whistle-blowing actually applies, because it still does not in many places. That is the first thing. The second thing, linked to that, is to make it clear that there will be zero tolerance for the sort of behaviour that has become the norm; those statements enable us, I cannot speak for colleagues but I am sure it is true, many of us, many trade unions and professional organisations, spend a completely disproportionate amount of time counselling and supporting individuals who think they have spent 20 years of their life working in the Health Service and it has been undermined, wrecked, ruined, and they themselves often become seriously ill or they leave the Health Service, all that money wasted. There is an epidemic, frankly, and I have to say it is an epidemic particularly amongst black people. I think the third thing is that the internal market, particularly the short-term contracts, the pressure to emphasise finance at the expense of quality, which hopefully is something which will gradually change, perhaps in part through the Primary Care Groups, that has created a culture of fear for managers, so that managers themselves have had sort of "I've got to deliver, I've got to bully you into doing it." And I think the final thing is the whole question of workloads and cover. There used to be a rule of thumb, certainly within community trusts, and I do not think it was ever set out formally, that we used to have, on top of the staffing that we needed, about 20 to 22 per cent extra for maternity leave, sickness leave, absenteeism, training; that then dropped to about 15 per cent, with the beginning of GP fundholding, that was then the rule of thumb, round about 1992, that was built into most of the GP fundholder contracts, certainly in the community. My understanding, and you might want to ask the Department of Health whether this is the case, is that figure is now about half, it is about 7 or 8 per cent. If that is the case, what it means is there is no cover for anything that happens, and, if you are going to discuss at some point continuing professional development, one of the questions will be where on earth is the cover going to come from. In that culture of excessive workloads, short-term contracts and a child abuse type situation of bullying, it is not surprising, and I think the most important single thing is a clear message from the Secretary of State, which he has given, and then seriously performance-managing that at a local level, in an open and transparent way. If that is done, we will then have a very positive role to play with the better trust managers in changing the culture. If it is not done in that open way it will be very hard for us, and we will continue to act, frankly, sometimes as trade union social workers.

  152. In relation to short-term contracts, Government has said that that is to end; is there evidence that that is the case?
  (Mr Kline) Let me just give you a very simple example. We represent a lot of chaplains; believe it or not, we have just picked up the news, and we relayed it to the Minister a few weeks ago, that at UCH Middlesex the new contracts for chaplains are going to be three-year contracts. Now I am not quite sure what is supposed to happen at the end of the three years, but if they are putting fixed-term contracts onto some chaplains it gives you an idea that the Minister is saying one thing and at a local level something else is happening. There are still far too many fixed-term contracts around, and in the staffing situation we have talked about it is simply not on.

  153. Would short-term contracts still be the case in all the others?
  (Mr Kline) Oh, yes.
  (Miss Hancock) Yes.
  (Mr Abberley) Yes.

  154. Picking up the point that you have made, Mr Kline, we have not touched on the structures, the role of regions, the actual management line, in respect of delivering the new ethos, or the changed ethos, in the Service. Have you any comments to make on how the management of the Service, the role of the Executive, has impacted or not impacted on the kind of problems that we have just been touching on, picked up by Mrs Keen?
  (Sir Alexander Macara) Could I, I hope briefly, express my concern about the conversion of the regional health authorities into being part of the Civil Service. That makes it much more difficult to achieve the culture change which the best managers agree, with the professionals, that they would like to have. Because the perception, rightly or wrongly, now is that the regions do not belong to the National Health Service, that they are not there to facilitate and oversee and guide what happens at the health authority level, and you know a lot of how this used to work; the health district did not exactly like the regions, but now that they have lost them to the Civil Service they are saying they wish they had them back. And it is not just that they have had their governance changed, it is that they have been, in the jargon, down-sized so far that they are not able to help us to get continuing education, continuing professional development, the monitoring of activity, making sure they get the right kind of information, and you will be discussing IT, I expect, next week, they are not able to discharge these sorts of responsibilities, let alone concern themselves adequately with the distribution of resources and keeping an eye on what managers are doing. Could I just add one other thing, taking you back to your experiences and Ann Keen's experiences with changes in management. If you go back to the time when Keith Joseph was reorganising the Health Service, at the same time as local government was being reconfigured, 1973-74, the managers made a bid then to be the chief executives, and the doctors and the nurses between us stopped it, we developed the idea of consensus management and said "If you're really going to make the most influential professional groups feel involved within management for the quality of care, they have to be there at the working level, working with the managers." Now consensus management was perceived to have failed, but if you look at the history of what happened in the seventies, with the oil price hike, and all the trouble that emerged from that, it was never given a chance, it was perceived to have failed, but the managers swooped in on this and said "Ah, this proves we need Griffiths, we need to have a chief executive." Now if I had a vision of what we ought to do, it would be to recognise what could have been done, when the chief executives were introduced as the bosses, and that would have been to retain the consensus team which linked the doctors and the nurses in to management at the effective operational level, but to have had them elect a chairman, who would have been ultimately accountable, in the way that the chief executive now has to be, for clinical governance. I would like to see us taking a fresh look at the way in which management changes have occurred. I see it not least for this reason, that Roger is so right, when he talks about the culture of fear, within management as well as within the professions, and if you look at the evidence, work done in Sheffield and other places, you will find that the single professional group in the NHS that shows the greatest evidence of stress are the managers. And, of course, they transmit this down the line, and it is the most vulnerable person at the end of the line who gets clobbered, more often nurses than doctors, but we have a lot of unnecessary problems, just because people are running scared. And the chief executive's responsibility ultimately to be accountable for delivering quality of care, under the new arrangements, will perpetuate that climate of fear, unless somehow the new arrangements can be introduced in such a way as supports him and the professionals working with him in a positive and constructive way. I think that is desperately important and Ministers have to understand that.

  Chairman: I am anxious to try to curtail this session in a moment or two, and I want to stress that we will pick up a number of these points next week, because we have reached, I think, some very important areas that do relate to the wider culture and recruitment and pay which we will touch on in some detail. Audrey Wise would like to flag up a couple of points for you to be thinking about and reading up on over the weekend, possibly.

  Audrey Wise: Yes, it leads on from the bullying sort of approach. Bullying, it seems to me, can come from personal, you can have a manager who is a bully, or a supervisor, or a higher grade person, whatever, or there can be what you have indicated, a bullying kind of coming through the system because they are being put under unreasonable pressure. We had some examples in the West Midlands of staff, psychiatric in-patient staff, who were injured by patients and not allowed to go off duty for several hours, after quite nasty injuries, because there was nobody to cover for them. And we had a person who received news via her manager of a bereavement, she lost her father suddenly, and the manager, her immediate manager, was told "But you've got to tell her she can't go for four hours, to her mother"; now he refused to do that. If he had not refused to do it, I do not know whether you would have said "Well, he's a bully" or quite what, but he refused, and then somebody probably got on to him. So these things are both individual attributes, but not only. Now there is one thing which is worrying me; we have heard about less cover and we have heard about, in other sessions, higher bed occupancy, pressures on that, so the intensity increases with less cover. There is a lot of focus now starting on differing costs, as between one trust and another, for the same procedures; now I am keen that there are not unreasonably high costs in place X compared with place Y, but there can be good reasons and there can be bad reasons why costs differ between one place and another. And what I would like you to be prepared to talk about a little bit next week is, to what extent are you able to take any interest or have any knowledge of reasons for differing costs, whether they are coming because somebody is empire-building, because of somebody's bad practice, sheer inefficiency or desire to keep people in longer, or whatever, and to what extent are you following whether it might be because you have higher graded staff being employed, appropriately, or more staff being employed, appropriately? Are you able to keep any tabs on this, and are the staff able to keep any tabs; how much knowledge do you have about the costs being incurred so that you can form a view about whether this is simply wasteful, high expenditure and needs clamping down on, or there are good reasons? You cannot answer that now, but I would just like you to be prepared to answer next week, as much as you can.

  Chairman: Two quick points from John Gunnell and Robert Walter before we conclude: John.

  Mr Gunnell: I would say, having been in the same session in Birmingham, some of the examples we have got, and probably it extends elsewhere where we have been, of thoroughly insensitive management, who are very much out of touch with the people that are employed, were tremendous. There were examples of people who, when arguing about structure of pay, and so on, for themselves or for groups of people, were told that if they did not like it they knew where the door was, and that seemed to be a phrase that was very frequently used in that particular place. And I would also like to say that when we come to looking at PFI we should look at the impacts of PFI on management and on the way that they then direct the whole resources of their trusts towards getting an acceptable bid for a PFI and how that leads to great, I think, insensitivity, both to staff and to patients, and I hope people will think of examining PFI in those sorts of ways.

  Mr Walter: I just wanted to flag up one thing. I sense a certain amount of complacency amongst managers in the NHS about the use of agency staff, and I am concerned about the efficiency of using agency staff, and not just the money involved but the actual effectiveness of patient care of having a succession of people coming onto a ward who actually do not know what it is they are supposed to be doing, and I wonder if that is something you might like to just pick up on next week.

  155. A final point on the bullying is that the BMA said that doctors are seldom in that situation, or it is not as obvious.
  (Sir Alexander Macara) More often than they should be. What I was saying was, not as often as the nurses, they are more likely to be bullied than the doctors.

  156. What I want to go on to say is that, in actual fact, the evidence that we had on our London visit, where the bullying was mainly taking place was in the very low paid ancillary staff and their constantly being told to "Go, if you don't like this change in your terms and conditions", in an area which is very difficult to get other skills. If you have worked in a laundry for 28 years you are skilled in that particular role; and I think we should be looking maybe at evidence coming forward from many of the ancillary staff and how they are being treated.
  (Sir Alexander Macara) I think, certainly, we get a perception that the lower down you are in the hierarchy, in a sense, the likelier you are to be bullied. But, of course, that is the norm, unfortunately, in most organisations; one just would have hoped that it would not be, in the National Health Service, as simple as that.

  Chairman: Colleagues, can I thank you for a very useful session. We are most grateful. You have got a flavour of what we may be touching on next week, and plenty of homework for the weekend, so we look forward to seeing you on Thursday. Thank you very much.