THURSDAY 17 DECEMBER 1998

DR IAN BOGLE, MRS HEATHER BALLARD, MR ROGER KLINE, MS JOCELYN PRUDENCE, MISS LOUISE SILVERTON, MISS CHRISTINE HANCOCK AND MR BOB ABBERLEY

  157. Can I wish you good morning and thank our witnesses for coming once again, particularly Ms Prudence and Dr Bogle, a slight team change from last week. We are very pleased to see you here. Can I once again appeal to my colleagues for short questions and reasonably concise answers from our witnesses so we can cover a number of areas that we need to touch on? Can I begin by asking a general question with regard to the attractiveness or otherwise of careers in the NHS. The Department of Health in its memo to the Committee told us, "The NHS remains an attractive and secure career and the vast majority of posts attract competition from people wanting to fill them." I wonder if you would agree with that and I wonder how your organisations contribute to the career and professional development of members within the NHS?

  (Ms Prudence) For the Professions Allied to Medicine, there is an increasingly growing external market that they are now being attracted to. Particularly this is the case in physiotherapy and occupational therapy but increasingly in professions like dieticians and dietetics as well. The NHS is declining in its attractiveness because the pay levels it is offering are not comparable. Clearly, people can do better elsewhere. Generally, there is less pressure and often clinicians will say, "I can do my job the way I want to do my job. I can treat patients the way I want to. I have time to do it", so there is less stress and workload demand as well. Overall, the attractiveness is becoming an issue, certainly contributing to the problems of recruitment and retention that the PAM staff are experiencing, which are quite severe.

  158. Are you defining the private sector as the private sector as paid for by patients and insurance companies or working independently for the NHS? Is there a difference between those two?
  (Ms Prudence) I would say there is. When I say non-NHS, for PAM staff, for example, that could mean independent hospitals, private practice, working for companies, charities, sports clinics. There is a whole range of employers which are health related.
  (Dr Bogle) We are certainly finding it reported to be far less attractive. Although I accept that there is competition for most jobs, the competition is far less than it was, say, five to ten years ago. In general practice, the Medical Practice Committee's report shows a decline in the number of applicants for practices and we do know of areas where practice vacancies are not being filled. The vocational training schemes in general practice are closing and applicants are far fewer in other ones. There is a shortfall of junior doctor staff to implement the New Deal and the training as outlined by the Cowan Report. We reckon that numbers about 2,000. That rosy assessment by the Department of Health that I have read conflicts with reality. We do not know overall how many medical practitioners are practising medicine. The only study that we have done was in relation to general practice a couple of years ago, where it was assessed that about 7,000 vocation trained doctors are not actually practising medicine. There are a variety of ways you can put that right, which I will go into at a later stage, one of which is pay but there is a raft of other issues, I believe. I would disagree with the departmental statement.
  (Miss Hancock) In terms of facts, training for the professions is still relatively attractive, although it is most attractive for PAM, then for doctors and then for nurses. I think it is 12 to one applications for PAM, three to one for medicine and just under two to one for nursing. In trained nurse posts, we know that for many jobs there are no applicants at all. The shortage is quite serious. Our survey this year for the Pay Review Body showed that about 37 per cent of NHS nurses were saying they would leave if they could. That is up from about a quarter in 1993. What nurses often say to me is, "I love nursing but I hate my job". I think people still get tremendous satisfaction out of caring for patients but they hate the fact that they cannot do it properly. There was a letter in The Guardian a couple of months ago that some of you may have seen from a nurse who said that she was asked by the wife of a patient who was dying to make him more comfortable. She said, "I will come as soon as I can." She was tending to another patient. The wife screamed at her, "You are not fit to be a nurse." The letter said, "She was right, so I left." It is that inability to do the job properly. I do not believe, despite the shortage, that nurses feel secure. The increase in temporary contracts is bizarre, if nothing stronger, at a time when shortage is so bad, because I think security is crucial to enable people to do a very difficult job.

  159. I think we want to touch on that issue of contracts of agency and bank nursing in a moment or two. Mr Abberley?
  (Mr Abberley) The question I would ask is: are people queuing up to join the NHS or queuing up to leave? The evidence is that they are queuing up to leave. We all do surveys. The survey we did covers all the work force except doctors. We have not published a full report yet but we surveyed 4,000 NHS staff and two-thirds of the staff said they would not recommend their own job as a career, with only eight per cent saying they definitely would. That is a pretty poor indictment. I listed last time reasons why people work in the NHS: job security, an interesting job. Still the main reason for people staying is that they are committed to the job, about 58 per cent. It is a complex question but generally speaking it is obvious from all the statistics that staff do not see the NHS as the attractive career they used to, but they are still committed to what they do. It is a good job they are.
  (Miss Silverton) We have an odd situation from our survey. Midwives report that they are extremely highly motivated to what they do but they have very low morale. This demonstrates what has been referred to before about not being able to meet the standards of care that you would like to give. For midwifery, there is a very, very limited market outside the NHS. Therefore, when midwives leave, it is a double loss because they go into other forms of employment. They find employment relatively easily in far less stressful jobs and then you cannot get them back because they have learned about not working round the clock, not having weekends and other civilised things that most people do enjoy. Therefore, the NHS has lost those skills.
  (Mr Kline) I can give you two examples. Medical laboratory scientific officers. We did a very detailed survey of heads of department. The majority of all the specialties were experiencing difficulties in recruitment. If you look at the starting pay for an MLSO, it is £11,608. For a typical equivalent post at Glaxo Welcome, for example, it is £16,000. We are talking about very large differentials. The Department of Health do not take full account of the possibility of moving into the private sector. If you take another example of pharmacists, a major survey of all but one pharmacy in the country, 40 per cent of pharmacists surveyed had withdrawn services or refused new services because of their inability to recruit or retain staff. 26 per cent of adverts, no respondents. 33 per cent of all vacancies, no respondents. There is a problem and it does vary for those professions that do not have direct private sector comparators. Other issues than pay may become important. For those professions—and we represent many of them—where there is a direct, private sector comparison, in all cases, there are substantial pay differentials and these days the NHS is not offering those other things, the security and satisfaction, that used to make up for it.
  (Mrs Ballard) I am really repeating what other people have said. Our members say to me that they love nursing, but that is in spite of all the pressures that are around, the inequities, the short-term contracts, which continue. The particular pressures that occur in the community come out of perhaps the internal market. Data collection is one in particular. We touched on it last week in relation to data about staffing. Certainly, with the internal market, the issue of data collection by community staff has been a huge pressure, a huge workload, on top of clinical workload where face to face contacts are the currency of contracts and they know nothing about what health care has been provided and what the outcome of that health care is, but that has been the currency. The information collected is that clinicians get little or no feedback and certainly none that is helpful to them in planning their care and planning their workload. We are working with the National Case Mix Office to try and redress that but it is a slow business and we do not see the issues changing. The emphasis is on the GP level information, where the potential is that if the GP IT system does not interface with the community trust and the health authority, you could have people having to input data in different places and having to travel 30 miles to input data. Those are the pressures that are there, that detract from providing patient care.

  160. Miss Hancock pointed to the contracting system and I wanted to raise a specific question with some of our witnesses about evidence that we picked up certainly in London. Obviously it applies elsewhere and I would be interested how far afield it applies. I suspect it is fairly widespread on the issue of bank nursing and agency nursing. One witness in a London hospital that we went to, who was as I recall a charge nurse, made the point that he was regularly required to remain in post on his ward after his leaving time. The options that he faced were time off in lieu, which he would never have time to take anyway, moving to the bank system, where his pay rate was reduced for working over—and it struck me as one of the few areas where, if you work overtime, you get less pay rather than more pay—or the most attractive option was to move as an agency nurse to work in another London hospital where he got an enhanced rate of pay. How widespread is this kind of practice? What are the implications, particularly for the quality of care provided?
  (Mr Abberley) I think it has become increasingly widespread. The biggest threat to patient care is the lack of continuity. On one hand we talk about having a named nurse and on the other hand there is an increasing use of agency and bank staff. It obviously has ramifications for people's earnings. We also see increasingly now a number of health workers who have second jobs to enable them to live. Overall, we think, yes, it is on the increase and it has a negative effect on patient care.

  161. What organisational look has been taken at this whole area? I appreciate we are not interviewing managers but presumably you, as professional organisations and tribunals, have looked at what this kind of arrangement means to the best use of resources in the NHS because it struck me as a strange arrangement in terms of best use of scarce resources, particularly whereby it would seem, from talking to one or two people, nurses were switching between hospitals; nurses with similar qualifications and similar experience were passing each other in London. It seems a completely nonsensical arrangement. What representations have been made by your organisations to the managers about this kind of business?
  (Miss Hancock) Nationally, one of the problems is that our terms and conditions do specify that time off in lieu is a payment for extra time worked in advance of overtime. People are within their rights within the current terms and conditions. We have tried very hard and produced a national guidance to support our local belief in challenging the abuse of the bank nursing system. The bank nursing system was to enable people, particularly people returning with family commitments who were not able to make a regular commitment to a number of hours, to work on a casual basis when it suited them. It enabled the Health Service and usually the hospitals to have a pool of people that they could call on in peak times. It was never designed as a way of either using overtime or of running your main staffing. It has been grossly abused. The abuse, I believe, is now leading to the fact that far more nurses are choosing to work with the agency because they believe they recognise that they are being abused by the bank. The example you quoted is quite common. That man was a charge nurse. He had a level of skill. During his extra time, he did not leave that extra skill somewhere else. It may be that all they wanted was a basic grade nurse but they actually had somebody who had skills that were on offer of a very high level and they were not prepared to pay for them. People are voting with their feet on that and they are increasingly joining agencies. There is one particular agency which has broken the consensus that has generally existed amongst the agencies to pay rates that are linked to the NHS with extras added on and certain differences. That agency which is based in Bristol is now serving a wide part of the country and is offering, for instance, a specialist nurse on a Bank Holiday at £35 an hour. It offers to provide continuing education and a variety of other things that nurses want. It is not surprising that it is doing extremely well, particularly in areas such as intensive care.

  162. What about the quality of care? This is an issue that has been raised on many occasions: the concerns that nursing staff have, particularly in specialist areas—intensive care, for example—where the agency nurses come along without the level of knowledge that is required to do that kind of work. Are these issues that you are picking up in your organisations?
  (Miss Hancock) Quality is a really serious issue on continuity. To some extent, continuity is maintained if you use your current staff. The danger there is about tiredness and whether people are able to function at the same level, when you use staff who do not know the hospital at all—and that happens too often—compounded by the fact that people do not have the specialist skills. I spoke recently to a nurse from Northern Ireland who, the moment she qualified, came to London and had regularly been put in charge of wards. She was newly qualified; she had never been in the hospital before. That is seriously worrying. The agencies themselves vary. There are extremely reputable agencies. Some of those work really hard and if they cannot find somebody with a special skill they are very open and honest about it and say, "I can find you a pair of hands but I cannot find anybody who is intensive care trained." There are others who are unfair both to the nurses, because they are not honest about what is expected of them, and to the hospital because they are not honest about what they are going to provide.
  (Dr Bogle) I believe last week that a lot of the discussion centred on the advantages of delivering health care as a clinical team. This particular problem goes totally contrary to that. Certainly from my clinical experience, if you have worked with people over the course of many years, you know their capabilities; you know what you can leave them to do; they know what you can do. This disjointed way of delivering care is greatly to the disadvantage of patient care and is inefficient.

  Chairman: Have any of your organisations done any work on the costs of this system to the Health Service? It seems to me to be a highly wasteful system, apart from the quality issues, to be bringing agency people in from other hospitals when they have skilled and qualified staff within their own hospital. It seems a very strange arrangement.

  163. I put this to a director of human resources at a London Teaching Hospital who said that they spent £4.5 million on agency nurses. The point came back that, if that £4.5 million was spread over all the other nursing staff to uplift them, it still would not be enough to take up the gap. I am interested in the Chairman's question because, let us say a hospital has a ten per cent nursing staff shortage which is made up with agency staff. Those agency staff cannot be as efficient and effective because they are coming on to wards they have never worked on before. If you spread that £4.5 million evenly, even if you only made up five per cent of it, you would probably have more effective health care. That is a question I am posing. I know I posed it rather as a suggestion but I wonder whether you have looked at that.
  (Ms Prudence) Physiotherapists probably would be the PAM staff most affected with agency work. We have not done any work in the way that you are suggesting but there is no doubt the costs are very high and it must be cheaper to the government to invest in retention solutions to just stem the flow of staff from the NHS. It would be much cheaper than paying through agencies. Often agencies are not a great deal for the staff either. Just recently, as a small example, we have heard about agencies which are seeking to pass on the costs of implementing the working time directive to both the employers and the staff themselves, offering to save about eight per cent of their salaries so they can pay for having paid holidays. That needs to be looked at quite closely to try to gain a double advantage to the Health Service.
  (Miss Silverton) We have not done work on this but the effect of the working time directive is going to put up the cost of agency and bank staff with the issues of holiday entitlement and other on costs. Therefore, it may not be as attractive a proposition. Agency staff cannot deliver continuity of care which is a very crucial thing for the maternity services. More importantly, they do seek to disrupt the continuity of care that those employed midwives can give, because it takes them an awful lot longer to make sure that they can assist the agency staff with knowing where things are. In emergency situations with vital seconds of knowing where to find something along all areas of critical care it can actually be almost a matter of life and death if somebody does not know where the appropriate fridge is to go and get what is required. One of the big problems that we have is in the use of time off in lieu. Where the establishment is already inadequate, how do you give somebody time off in lieu in order to give them recompense for their extra time worked? I met a midwife in Northern Ireland who told me that she had been sent home off night duty when it was quiet at three o'clock in the morning for her time off in lieu. How on earth is she supposed to do anything with that when she was in the middle of a run of night duty? It does demonstrate the problems that people in the NHS have with the way that the system is working. It is also worth saying, in relation to bank, that many areas employ midwives on the bank but they employ them at D grade which does not fit with the statutory requirements and role of the midwife. This is a huge under-valuing of skills, as we have heard before about the person you met who was probably still practising at the same level but paid a pittance.
  (Mrs Ballard) I wanted to translate some of those issues into what happens in the community. Obviously it is different out in a community rather than in a hospital environment. We know of a community trust in London where all the bank staff are paid on the middle increment of the grade regardless of what they are on normally, if they are paid on the same grade that their substantive contract is in the first place. I really wanted to look at the issue of quality of patient care and the effect that has on our individual members. We find ourselves representing members in disciplinary hearings where, almost without fail, there is an element of there has been too much work to do and the person who is being disciplined or called before a disciplinary hearing is there because they have not been able to do their job properly because of the pressures. We have to argue against the, "Well, we have offered you bank. You can have as much bank and agency as you like." The issue out in the community is exacerbated because you do not have opportunities for informal monitoring of these people who are sent to you to work for the day, for the week or whatever. You have to trust that the people coming to you are competent to carry out the tasks they say they are competent to carry out. There is nobody coming behind until the next visit is due to ensure that task has been carried out competently. A very practical issue in terms of the community is that you have to have people who are able to find their way around a local community and have suitable transport as well because we do not supply a van in the Health Service for community nurses.

  164. I was going to pick up Robert Walter's point. The scenario that he described also involved a 25 per cent vacancy for nurses at that particular trust. It is quite expensive to use an agency but if you are using your 25 per cent under employment to meet your budget deficit you can afford to put in five per cent's worth of sticking plaster to make up for it. I wonder whether there is any evidence of agency nursing being used by trusts who seem to get their employment policy wrong. It may well be a question that we want to ask of managers as well.
  (Mr Kline) It is not just a problem for nurses. I can give two practical figures. Laboratory scientific officers in central London: our representatives tell us that it is very substantial numbers. In some hospitals as high as 30, 40 and 50 per cent of the cover is being provided by agency staff which must have implications for quality. In terms of the figures, career grade pharmacists who might earn £11.50 in the NHS would earn £16 working for an agency. On top of that, you have the agency costs. There are figures in terms of the cost to the service. There are advantages sometimes to staff to work in this way. I do not think anybody has thought through the impact of the working time directive because, for many staff, the reason they do the excessive hours often as agency staff is because their basic pay is too low.

  165. Given that trusts have the freedom to upgrade people, to create their own terms and conditions of pay, are there examples of trusts who have tackled this, saying, "We want to invest in our own staff rather than agency staff"? If not, what is wrong with the culture that is stopping you looking at it?
  (Mr Abberley) The trouble is the use of temporary staff because you can include agency, bank and temporary contracts. This is being used to solve different problems. You are looking at it as though this is a general problem. In some places where there are huge staffing shortages, agency and bank staff are better than no staff. There is no doubt that some trusts, particularly amongst ancillary staff and the people at that end, are saying, "Well, if you are under pressure financially, it is actually cost effective to only bring people in, even if they are more expensive, at a given time than to have someone on the books all the time." People will use it in that way too. We do our survey every year so we compare one year to the next and the use of temporary staff, including agency and bank, has gone up from 46 per cent to 54 per cent in a year and, amongst nurses, 61 per cent.

  166. That is across all the trusts in which you have membership?
  (Mr Abberley) We do 4,000 people, which is a big survey.

  167. I do not understand. What do you mean by those?
  (Mr Abberley) The question we asked was, "Has the use of agency staff or temporary staff increased in the last 12 months?" We then compared the figure this year to the figure last year. Last year it was 46 per cent. This year it was 54 per cent. The other thing is that people are being asked to do a lot of overtime. People are coming to the point where they do not want to have to spend more time at work. Over all staff, 44 per cent reported they were doing more than three hours overtime a week.

  168. What impact has the advent of trust contracts had on this whole area? If there is a move more back towards nationally negotiated terms and conditions, how will that impact upon this kind of problem, if at all?
  (Mr Abberley) I think probably contracting out has had a bigger impact.

  169. I asked specifically about locally negotiated trust contracts. Where people are moving back to nationally negotiated conditions, will that impact at all upon the current arrangements?
  (Mr Abberley) Given that around 40 per cent of people in the NHS are under local trust contracts, probably eight or ten per cent are on locally negotiated trust contracts, but it varies differently from one trust to another. The problem is not enough staff.

  170. Obviously, we are here to learn. We have all learned from meeting people directly affected. If we have people of the kind I described, the charge nurse I described, who is on local trust conditions in his basic place of employment, his hospital, and can move through an agency onto nationally negotiated terms and conditions in another hospital, will the change, the move, back towards national terms and conditions make a difference to the extent to which this kind of what appears to be nonsense is occurring?
  (Mr Abberley) What will make a difference is when we get the new pay system, a flexible pay system, and people are paid at proper rates of pay. That is the problem.

  171. Obviously it is very important that we do hear from our witnesses about the difficulties you are facing. I am particularly interested in recruitment and retention of staff right across the NHS. We have learned a lot this morning from witnesses about some of the problems and difficulties locally. Because we now have to produce a report, hopefully with some recommendations on what to do about it, I am going to ask a fairly broad question. What changes in the current arrangements would create the type of career structures that would improve status, recognise expertise and skills and encourage recruitment and retention? In other words, we have heard about some of the problems. I now want to know what some of the solutions might be.
  (Dr Bogle) I touched on the 7,000 that we know who are out there with vocational training certificates and not in general practice. We have not got the rest of the figures for the hospital services. We do not know exactly how many doctors are out there not working in medicine but we have done some work on the GP. One factor is pay. You would anticipate my saying that. I make no apologies. I am not going to make a bid for pay here but it is discouraging to find that, even by fax at nine o'clock last night, ministers decided yet again to try and screw down an independent review. The profession gets a bit demoralised and it is certainly not going to help recruitment and retention by disagreeing in this way over the review body. The pay also fits in with a recognition of the need for flexible working. This is not just in primary care. Many specialties also have not lent themselves to flexible working, part time working, making allowances for having young children and creche facilities. There is a whole raft of issues which I believe could bring back certainly the 7,000 I know about and probably many more into the hospital service. To go back to pay, you would need in some cases to incentivise that in a pay system. Do not forget that people who are working part time, working in this flexible way, have overheads and expenses that are going to be exactly the same as the full timers. In other words, for example, they will pay full time medical defence subscription but they will earn half, maybe a third, depending on how much they are putting in. You would need to have a differential pay that encourages these people to come back to flexible working. We need to improve the working conditions of, in my case, the doctors but I am sure it will be reflected across here. One way is the incredible workload. This really has to be dealt with. While we have the current workload, shortcuts are being made, to be quite frank about it. I believe risks are being taken because of the rate of work. On Monday morning at the surgery, I ended up with three minute appointments, fitting people in. That really is not a satisfactory way to work and it is not a very encouraging way to demonstrate to young people coming into practice that that is the rate you have to work at, certainly in a city situation. Out of hours work to some extent, despite the previous government, we have managed to get a handle on and it has improved. There are still some problems. The working conditions for many of the junior doctors, both in their living accommodation and their inability to get food when they are working long hours, are absolutely disgraceful and really have to be coped with because there is no doubt that the junior doctors will tell you that, with pay, is at the top of their list. There are many other issues but we have put those in evidence in writing to you. If you are going to workforce plan on the basis of a consultant expansion and you do not deliver the consultant expansion and you stop just over half way, that screws the whole of the hospital employment system. If you do not have enough consultants to have a consultant led service, you get further blocks from the junior doctors and you now have the working time directive which is going to muck up their working hours. From the hospital point of view, the sooner we obtain that consultant expansion the better. It costs, I know, but it has to be done to have a properly geared hospital service that will deliver. They are delivering excellent patient care, surprisingly, but it cannot go on with the staffing skewed in this way. That is the prime thing in the hospital service.
  (Mrs Ballard) There is an issue of inequity in grading in the community, where current grading structures are set on an historical basis and not really looking at the patient needs and differing levels of responsibility. For example, you might have a trust in one place that has B grade auxiliaries, D grade staff nurses and G grade team leaders, district nurses. The next door trust may well have the B grade and the D grade but would also have E and F staff nurse grades in between. That provides for professional development. There does not seem to be any rhyme or reason to that. There are positive developments in terms of grading and potential for increased earnings with the discretionary incremental points that have just come in and the potential for the nurse consultant, but there is a certain amount of cynicism because of the misuse of the current grading system that we already have. The number of H and I grades, which were supposed to be clinical grades of nursing, has fallen I believe and has not been used to enhance clinical posts.

  172. What do you want us to do as a Committee, to recommend sorting that out?
  (Mrs Ballard) There are practical examples of where these things are used properly. To a certain extent, it comes down to the leadership within an individual trust. We have examples of good practice where one trust on the south coast for example has a system of having fast track hospital referrals for their staff. They have free chiropody, free eyesight tests. They have a full range of grading criteria. They have both individual clinical supervision and group supervision as a fundamental part of their practice and time is set aside to do that. You have a very well motivated workforce there. That is possible. For example, with the joint NHS unions we have developed a job share guide that has been very useful to our members because those sorts of family friendly policies have been talked about such a lot but actually have not happened. Something is stopping them happening within the trusts.

  Dr Stoate: Obviously we have a problem that we need to make recommendations to government that we think will stick, not just locally but be a framework for good practice across the country. What I am looking for is concrete suggestions from all the witnesses as to how we can go forward from here.

  173. I was wondering how much the witnesses feel that there is consistency in grading across the country. A lot of work was put into setting up the nursing and midwifery structure many years ago and that was supposed to provide consistency. We have heard stories of it breaking down. Is the principle there still the right one and something that you would be asking the government to enforce or is it basically broken and we need to start again?
  (Miss Silverton) Grading, from t7777777he point of view of midwives, is a subject where, if you mention it to them, they just groan. The grading structure and the definitions never were appropriate for midwives right back at the beginning. We have been working with something that did not fit and did not work. It has been applied in a way which was cash limited rather than relating to the job that anybody did. I am sure this has been the same across all the nursing and midwifery professions. You get people in one trust doing one job and the same job in the next trust has a different grade. Those H and I grades which we heard about, which were for clinical leadership—which is very important for quality of care and service development—were cut in the M3 cuts because they were seen as management. They were not management.

  174. Should there be a new grading system or would you just leave it to individual trusts?
  (Miss Silverton) I certainly would not leave it to individual trusts. We have an issue of individual trusts deciding they can buck the system so they will pay a bit more and we get a roundabout of midwives bouncing from trust to trust, following the F grades. We have a problem with shortage of accommodation. How do you attract people to come and work, particularly in inner city areas, where the accommodation has been sold off and that which is left you are told you have for three months. It is pretty awful. What do you do about people who want to return to practice? We know that there are 60,000 midwives on the register but not practising. How do you get them back into practice when they have to pay to do a return to practice course? There are 92,000 on the UKCC register of whom 32,000 are currently practising. We can say some of them are from the old days when you needed to be duly qualified to get a ward sister's post in general nursing, but even so there are an awful lot of them still on the register but not practising that we could bring back. They are having to pay for return to practice programmes. They cannot get clinical placements and, more importantly, they cannot get indemnity insurance because the trusts will not insure them to do their clinical practice. We are stuck in this bind. Somebody should say, "Trusts taking midwives on return to practice programmes must give honorary contracts which include indemnity insurance", because we are banging our heads against a brick wall here.
  (Ms Prudence) I agree that the career structure is a fundamental problem across the NHS. Certainly for PAM staff, the career structure that we are operating to was created in 1974 so it does not bear any relationship with the modern NHS. A lot of the grading definitions are based on things like head count of large, acute hospitals, which are increasingly less relevant. The most senior grade you could have would be a district physiotherapist or occupational therapist. Districts do not operate any more in the NHS. If they are still there, it is just an historical application. The problem for PAM staff is that the career structure has become very truncated. For your average clinician, it is very hard to earn much more than 21,000, no matter how specialised you are. That is not a very attractive career. It is a very short career if you come in at 13,500 and you are at the top at 21,000. A rehaul of the career structure I feel is quite a fundamental point. I would echo my other colleagues' sentiments about the need for better family friendly employment practices. I see the key ones as child care assistance, job share, part time posts at senior level, greater flexibility on working hours which is beneficial to the employee, not just to the employer. That is absolutely essential but that whole raft of work is developed very quickly and government rhetoric is turned into some sort of reality. I also think career support in terms of continuing professional development, paid study leave, still a huge problem for many PAM staff. They simply do not get paid study leave. They have to pay for their own courses. Involvement in decision making is another very important area that work has started on. The feeling for many years that staff have been operating in a bureaucracy with a management ethos that they are not necessarily on board with. Now is the opportunity to involve staff in decision making at every level. People feel they have a lot to contribute. Lastly, obviously pay is a gigantic problem. It is not just pay; it is the other conditions of service. Our PAM staff for instance work on call for 12 hours, out of hours, for £4. One of my members said that, by the time you take the tax off, it does not even pay for a pint of beer when you have been on the service all night. These levels need to be looked at as well.
  (Mr Kline) In answer to Dr Stoate's question, I would suggest two things. First of all, we discussed last week the question of culture. There needs to be a vigorous performance management of a complete change of culture that starts by valuing staff, seeing them as an asset, not a cost. I do not want to repeat what I said last week but I cannot stress how important that is. Some of those things do not cost a lot of money but they send real signals. Six years ago, the HR director for Trent region said, "What about renegades, subversives and opposers of what is being attempted? Tolerance of difference is not the same as tolerance of destructiveness." That culture has not disappeared from some parts of the Health Service, so vigorous change in the culture needs to reach all the parts of the Health Service. Secondly, to answer Julia Drown's question, one of the issues that will have to be considered, and which I know the Department is conscious of, is the whole question of equal pay. The fact is that women staff in the Health Service in a variety of professions do relatively worse than they should do because the NHS pay systems in no way are equal pay proved. We as MSF have spent the best part of a million pounds pursuing equal pay claims on behalf of speech and language therapists.

  175. Can you expand on that? Obviously, we have an assumption that there is equal pay legislation.
  (Mr Kline) Unlike the Heineken adverts, equal pay has not reached all parts of the NHS. The Pay Review Body, when I explicitly asked them a year ago to make equal pay part of their remit, said that it was not part of their remit and they had no intention of making it part of their remit. The fact is that it is impossible to explain the huge differences, for example, between speech and language therapists and a whole range of other comparators, other than that either somebody consciously sets out to pay women less or they are simply built into the assumptions. The pay system in the Health Service grew like Topsy. There was no system to it; it grew in all sorts of different ways and it has been changed. Everybody accepts I think, including the Department, that the current pay structures in the NHS would not stand up to serious equal pay claims. As a matter of fact, we are winning on behalf of a whole profession a huge equal pay settlement and we are currently negotiating with the Department hopefully to bring it to a conclusion outside the legal process. It has cost us a lot of money but, in the process, it has opened up a really big can of worms. It seems to me the issues round the NHS are two fold. There is the issue that Julia Drown has raised: is the current system fair? The answer is it is not. It is not fair internally because there is no basis on which the differences have grown up. They simply would not withstand legal challenges. Secondly, the current pay system does not meet the needs of employers, to pick up Dr Bogle's point about more flexibility where you can cross between occupational boundaries. They are very rigidly set out. Third, the pay system as a whole has no means of properly comparing itself with pay outside. We sometimes say why are we paid so much less than the doctors but the reality is that, if you compare what a GP gets with what many city lawyers get, there is no comparison. The one that has to be addressed is the current pay structures. We have spent the money and, in our view, they are not sustainable and we seriously hope that the Department, which has so far failed to bite the bullet, is going to get its head round this one because, if it does not, the Health Service is going to spend many years in the courts, fighting equal pay battles and we do not want that because it has already cost us a lot of money.

  176. Can I ask whether the Pay Review Body has been asked to address the issue of equal pay and, if so, what its response was?
  (Mr Kline) I asked them in our evidence last year and the response we had was that they did not want us to raise that issue again. It had not been part of their remit and they were not proposing to change it.

  177. We have had some indication from witnesses about what family friendly policies might partly consist of. We can explore that further but could I ask are family friendly practices for staff in the NHS becoming more apparent? I do not just want to know what they are. You can certainly add to that and say if any have not been mentioned, but are there more of them?
  (Mr Abberley) I think it is important to say that the government I think, in the whole range of areas—new pay system, new human resource management strategy, looking at staff involvement, looking at family friendly policies—is saying almost all the right things. I think it has to be recognised. It is not going to be easy to move from the good intentions at the centre to implementing in the hospital ward. We have as much responsibility to do that as the employers and the government. Is it becoming more apparent? Yes, it is in trusts. It is current management thinking, team working, flexible working, job satisfaction. We are pointing in the right direction but progress is still fairly small. That is why I think the political will and the drive from the centre is important. There is a large number of people who provide services in the NHS but who are not employed by the NHS. Under PFI, that is going to increase. That is something that has to be addressed. How are you going to have a flexible workforce? How are you going to be able to allow job design when up to 40 per cent of the staff may no longer be in the direct employ of the NHS? We think that is bad for patient care. It is worth remembering that those staff have, in lots of cases, worse terms and conditions. They do not have pensions. A good pension is a very important thing for people working in the NHS. People who are under the employment of non-NHS employers do not have as good a pension.

  178. Dr Bogle, I am very interested in the issues in relation to recruitment of female doctors and the whole question of family friendly policies. Have you any thoughts?
  (Dr Bogle) Yes, I have. Howard Stoate asked us a direct question and one of our direct answers was consultant expansion and living accommodation for juniors. I would expect you to want to make recommendations. I believe it is not only the government's responsibility or problem in relation to medicine. The profession has to work with the government to introduce the family friendly policies and the flexibility. Considering that many employers are independent contractors, it would be very wrong for me to say that there is a government problem; you get on with it and we will come along and take advantage of it. There has not been sufficient recognition that over 50 per cent of the intake of medical schools is female. I do not think we have a handle on the number coming through. We know how many are coming through but we have not, between us, done too much about it. Regarding medicine both in hospital and outside, family friendly facilities and policies are conspicuous by their absence. That is not just a criticism of government; it is a criticism of the profession not having a handle on it. We introduced for discussion with government, for negotiation, a new retainer scheme which is for hospital and general practice. In the end, we got a much improved retainer scheme, but there was another part of that which was called the returner scheme, which we have not entered into serious discussions about, not because we do not want to. It was made clear that they really wanted to stop at the retainer bit. The returner scheme addresses flexibility, what sort of family friendly policies, such as creches, such as child minding facilities, you need to put in to get some of these people back. There is no point in getting them back and then exploiting them, saying, "We have got a pair of hands here that we can use part time." There has to be some training introduced so they can achieve consultant status, so they can achieve the top of the GP tree, whether it is an employed status or a principal in general practice. Where we thought a lot of the discussion stopped was we paid lip service to family friendly policies that could bring people back in but we do need an educational progression that will make sure that they have somewhere to go once we have got them back in. To go back to your direct question, what I would wish you to do is to encourage the government to discuss with the profession what needs to change in medical thinking to make it possible. That would be the third thing I would hope you could do.

  179. The word flexibility has been used in a way which indicates clearly that there is flexibility for employees and there is flexibility for employers and they are two different things. Have you any views on the influence of hours of work and times of shifts because in our travels I certainly picked up problems here? Of course, we do not know whether they are general problems or specific to the areas we have been to, but there was a lot of bitterness about forced change of shift patterns and this seems to me to have a great bearing on family friendliness. Have you any comments on that?
  (Miss Silverton) With the introduction of women centred care, midwives who are wanting to provide continuity to a group of women are finding it particularly difficult to meet child care needs and requirements to be on call. This is a particular problem for women who are single parents because their £4.50 on call allowance does not allow them to have somebody sleeping over just in case they are called out to look after a woman and nothing has been done to look at this. We are also very concerned that whilst with rhetoric some management may say they do have family friendly policies, the number of places in creches is very small. There are waiting lists for them. They are not always open at the right times. The introduction of 12-hour shifts has made it very difficult for working mothers to combine motherhood and working. I think it is also worth saying that those people who do opt to job share or, more commonly, to work part-time to meet their other caring responsibilities often find that they are required to work on a lower grade than they would be if they were actually working full time and given that 48 per cent of midwives work part time, this is a very great worry for us. I think one of the solutions would be to implement the Government's minimum F grade for midwives because that is what they said midwives providing continuity of care and women centred care should be receiving. I think these are all issues which compound dissatisfaction and a lot of cynicism that there is not actually anything behind the statements on family friendly policies.