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

  200. Obviously pay is a huge subject. I would like to start off with something we got from the Department of Health where they are saying that "the pay of health professionals over the last few years has grown ahead of average earnings", and I would be interested if our witnesses accept that, and I think perhaps one particular point around that is that the Government refer to actual earnings and not basic pay, and whether that is a particular issue which causes controversy.
  (Mr Kline) I have got some figures which came in this week. Looking at this year, for example, and this is from IRS, increases in starting pay, public sector 2.3 per cent, private sector 5.3 per cent, and private sector services and private sector manufacturing 4.4 per cent. I think you can toss these figures around. The fact is that if you look at what people actually earn, the differences between what they earn either compared with direct comparators, pharmacists in the public sector, third year after registration, £20,000, whereas in the private sector £30,000, and when you look at what cytology screeners get, £7,000 to £8,000, training MLSOs with an honours degree starting at £7,500, when you look at what they get compared to what they could get outside, I said it last week and I will say it again, it is quite surprising that they come to work in the Health Service at all. Now, the Health Service got round that problem in the past because it had other attractions; it was a vocation, it was fulfilling, there was a career structure, there was job security, but there was a trade-off, and the trade-off has disappeared. I am not sure that the Department quite understand the degree to which the trade-off has disappeared. To be fair, they are trying through the human resources strategy to remedy that, but I am afraid it is no longer the case that they cannot address the pay issue, and it is not just the levels of pay, but it is the question of equal pay, it is the question of whether there should be a national pay system. For your information, I have four times written to the Department asking for the evidence that demonstrates that you need local pay schemes to improve local flexibility and asking whether there is any academic research being done for this, and the reply has come back that there is none, there is no research which has been done, so if we are into evidence-based research in the rest of the Health Service, I think it is time for some evidence-based research around pay. If we do have that, then we have to accept that the differentials are enormous for many of the professions either where there is a direct comparison or an equivalent profession, doctor and lawyer and so on, and, secondly, that they have to tackle the equal pay issue if the Health Service is not to spend vast amounts of time in the courts, thirdly, we have to recognise that terms and conditions in law are part of the equal pay package, and I am not sure that is always understood, and, fourthly, that there is no merit whatsoever in local pay schemes. There are now a number of trusts, and the most recent one is Norwich Community Trust, who have abandoned all local pay arrangements because it deters people from applying, so if there is evidence, it is in favour of a return to a national structure, a much more flexible one based on equal pay and it has to be one which every level of the NHS looks at carefully, and we are not silly, we know there is not an unlimited pot, but something has to be done about the differentials that have emerged, otherwise, the staffing shortages are undoubtedly going to get worse. The smallest thing, the impact, for example, of the Working Time Directive on laboratory staff, could make the difference in some places between the Service working properly and it seriously not working properly. Many of them work silly hours because they have to. When that comes to an end, and it may well do, then there is going to be a problem; they will go and work somewhere else.
  (Ms Prudence) I would certainly endorse everything that Roger Kline has said and I am not sure that getting hung up on one particular set of statistics is very useful because I think it is about looking at it in a general context and certainly for PAMs, the starting salary is 22 per cent below average graduate starting salaries in the economy. If you look at overall PAMs' earnings, they are about £19,500 compared to overall police earnings at police officer level of £24-25,000, a teacher of £24,500, the list is endless and I think there is a bit about it in our evidence, so overall I would say that the case for an earning differential between the sectors is very established.

  201. In relation to pay, the pay review bodies in, I think it was, 1994/95 awarded doctors, dentists and nurses the same and then over the last few years there has been a marked increase in the differential between the doctors, dentists, nurses and midwives and the last was where it was 5.8 to 3.8 to the nurses. What effect would you say that has had on morale and is this a male-dominated profession, predominantly male-dominated as opposed to a more female-dominated profession?
  (Miss Silverton) This has had a very bad effect on morale. It has not helped team-working. I think it has broadly come about because the doctors and dentists' review body have felt themselves more able to resist Treasury pressures, but, be that as it may, it opens up the whole issue of equal pay for work of equal value and particularly for midwives, if you are looking at midwives of three years qualified, earning £16,300 compared with SHOs whom they are actually teaching and supporting in the labour ward, it looks really ridiculous that not only are they being paid less, but they are also deemed to be less worthy of the cost of living increase. What of course you then get are widening differentials and it has just been very, very poor for morale.
  (Miss Hancock) For the last four years we have received below inflation pay rises. Two years, 1995 and 1996, the attack on local pay probably dominated nurses and midwives and their staff organisations. We now have a situation where almost a third of NHS nurses have a second job and that 80 per cent of them say that their second job is primarily to provide an additional link-up.

  202. Do you have any information, going back to the point we talked about previously, about agency nursing and bank nursing and how many of those jobs are within the NHS and how many are outside the NHS?
  (Miss Hancock) I think we do and I think we could provide it.

  203. Could you provide us with some information?
  (Miss Hancock) Yes.

  204. I wonder, Chairman, if I could say on that perhaps we could distinguish between pay levels and the pay bill because if you are employing more agency staff, then the pay bill for the NHS will go up, even though the pay levels remain at the lower level.
  (Miss Hancock) Although quite often they are actually accounted for separately and indeed sometimes that is one of the reasons why some of the information is so difficult to get hold of in a clear way.

  205. I appreciate that.
  (Miss Hancock) But the agency bill is often seen as the cost of buying from a supplier and indeed VAT is charged on it and so on. The pay bill is seen as something different within the hospital accounting system, but Julia is 7probably more expert than I am on that.

  206. It is too boring!
  (Mrs Ballard) I suppose really the main point to make is that pay is one of the issues that is creating the crisis that we have in staff recruitment and the fact of the matter is that individual members of staff can only do eight hours' work in eight hours and if there are not enough staff around, you end up with those people who are in post working harder and more subject to stresses, more subject to making mistakes and so on, and you have those people in post working longer hours and often those hours are not accounted for and not costed. I think really in terms of delivering a modern, dependable NHS, we cannot do it if we have not got the staff to do it.
  (Dr Bogle) I am going to comment little on variations between different awards; I just think everybody else this side of the table would tell you that the Health Service do not pay well right across the board. I wanted to address the figures that the Department of Health produces which is where we start with this. It depends where you pick your time to pick your figures from and if you are wise in presenting figures, you pick them from when the last big pay rise was and you present that as being one magnificent achievement. Of course the art on my side is to pick a time when it was absolutely diabolical and produce figures, so we have got figures which are diametrically opposed to what you said, so it does depend on timing and it depends on whom you compare it with. It is really just the comparators I want to go into because most of the other arguments are known through the review body evidence. To compare only those in the public sector, which is what has been done for all of them, is to compare people who have probably got depressed pay awards because of public policy with others who are seeking pay awards who are going to have depressed awards and it is a circular argument that depresses everybody pay award if you only compare in the public sector, which is in fact what has been suggested in the evidence from the Department and is what in fact has been done over the recent years.

  207. We listen very carefully because of course this might have a bearing on our circumstances.
  (Dr Bogle) Yes, although my understanding is that in your case the comparisons outside have been rather more liberally allowed than in the case of the medical profession where—

  208. That is not my understanding of it, but anyway.
  (Dr Bogle) Well, I will get back to what I know something about. It has certainly been made clear to me in discussions that private sector comparisons are not something that either the Government or maybe even our review body would want to take into account. I think that misses the point, but certainly for my colleagues the NHS is virtually a monopoly employer. I know that some consultants have some private practice, but it is the minority and certainly in GPs' case, that does not exist. To take advantage of that and not make comparisons with other professions is wrong, it is unjustified, and I think that if you were of a mind to make such a recommendation, well, it was written into our review body terms of reference in 1971 and, as the Minister tells me, "27 years is a long time and we do not recognise 1971", but I would like that reconsidered.
  (Mr Abberley) I think there are a number of things around pay. One is that we do have to break this idea that investing in staff is not investing in patient care. The pay of staff has a direct bearing on the quality of the patient care which is delivered, so that is one. I think we do need to grow up actually, all of us, because we talked last time about information and if you are a negotiator, you love all this, but all the different statistics mean nothing when you get into negotiations because at the end of the day there is an amount of money available and that is where you start talking and I think again we need a central unit of information where we can take information on what is really happening. Privately everyone, whether it is senior people in the Government, civil servants, we all know we have got pay problems in the NHS and that is why we need to address it, I think, because the evidence is really not disputed, the evidence we give about the effect of pay. When we had the question about what was the effect of different awards, well, the problem we have is that we have got not one pay system, but we have got lots of pay systems and that is why we support the idea of a major review of the payment system to make it more fair. The pay review bodies do not have to think at all about what the other pay review body is doing, they do not have to, but they just work on what they are doing themselves, so it is not surprising that you get different awards. The fact that the PAMs and the nurses actually have the same people may help that because they know what is going on and it is only since we had what was called the framework agreement that it has meant that the None review body groups have had the review body award rolled up. Prior to that, the review body groups took a slice of the cake and the None review body groups of course got what was left, so I think that the system itself is fundamentally flawed and will lead to that kind of unfairness.

  209. Is that point shared, this point about looking completely at a new arrangement for pay and conditions for staff which will bring together some of the anomalies and differences that you have highlighted? Is the view that you have just expressed supported by other colleagues who are here today?
  (Mr Abberley) I think the view that we do need a new pay system is supported by all of us. What exactly it is may differ, and that is for negotiation, but I think most of us agree and in fact it was in the Review Body evidence, I think, that we need a new pay system. I just want to quote three statistics from our survey and in a sense this is what is most important, not arguing about if we have done well or not done well, and again I remind you that we do it every year, so you compare it with the previous year, nearly eight in ten of the staff surveyed believe they are not well paid for the jobs they do and that is an increase since last year of three points. Of those who have considered leaving, 57 per cent gave pay as a reason, which is three points higher than last year, and, which is not good news for the Government, but providing they do something, over a third give the hope that pay will improve and that was one of their reasons for staying. I think for me I have every reason to believe those figures are fairly accurate, pay is a problem, but the staff are giving the Government the benefit of the doubt to do something about it and if they do not, then I think the flood will turn into a torrent or whatever.
  (Miss Hancock) I was just going to back up, firstly, the new pay system idea because I think Bob is absolutely right, I think everybody agrees in principle, but it is not only what it might produce, it is the reality of how you change a pay system across an organisation as large as the NHS and I do not know a way of doing that unless you have got significant sums of money around and I think that is one of the anxieties that I would have, that there is a lot of talk about the need for a new pay system, but, in my experience, any new pay system costs significant sums of money. If I could also come back to something that Dr Stoate said some while ago about what should this Committee do, no doubt pay is absolutely crucial, and pay is the factor mentioned by over a third of nurses that you talk to, but there is also the HR strategy and I do think that the Government's HR strategy is very good news for the NHS and covers a lot of the things that we have been talking about, but it needs to be implemented and there needs to be not just good intention, but also a way of managing what trusts do because, coming back to something Julia said, I have been amazed that trusts have not managed their staff better, have not used some of the flexibilities they could have and some of the opportunities, and they have not. In the vast majority of cases, where there is an opportunity to do something with the staff, it has not been taken, so pay and the HR strategy. The third is careers and again, coming back to clinical grading, as mentioned earlier, clinical grading has almost disappeared. Nurses who qualified in 1989, five years on 80 per cent of them were off the bottom grade, and nurses this year who qualified five years ago, 45 per cent of them are still five years on on the bottom grade, on the D grade salary scale. There is a big difference across the country and, not surprisingly, the south of England has fewer people on the bottom grade than the north of England. The third thing that is needed, therefore, is a proper career structure and I think that does link to looking at pay. Fourthly, there is a need, and again we have all touched on it, people need management of the workload and there is very good evidence that when midwives or nurses actually get up and run the services, one of the things that makes them so positive about it is not somehow about being in control of something, but it is actually about being able to manage the workload so that they are able to look after patients properly. So the four things I think that we need to look at would be pay, the HR strategy, career and management, how people are managing workloads in the Health Service.
  (Dr Bogle) I would just like to make two points. One is with reference to the pay review body. The BMA would wish to have an independent review body for doctors' pay and I have spent most of the autumn trying to make sure it was still there, to be honest with you. When you look back in the history of why it was formed, it seems the only sensible way that we see forward to stop the yearly row and all that follows from a row between the Government and the profession. I am less than happy, as you will realise, with what I think have been attempts to nobble an independent review body, but I have said that in other places and this is not the place to pursue that, even to the extent of a letter that was faxed to me last night, but, nevertheless, I still think it is the best way to protect the public from an annual disagreement, that it is independent. I would like to make just one general point and this is to do with all Health Service workers, that there is nothing more galling than to have a very happy day for the Health Service with the announcement that there will be £21 billion invested in it over the course of three years followed by, "but not in staffing". That is paraphrasing what followed it, but, nevertheless, it is not for staffing. That does not do morale an awful lot of good and when you consider that when any of you, and we are all patients at times, when you actually go to see somebody, a doctor, nurse or whoever, it is the person that counts actually. When you are ill, it is the person that counts, you can get away with other things, so that was one of the most galling things of the year. As I said then, it should have been a very happy day as I have not seen an investment like that in the time I have been in a national position in London, but it was very unfortunate to be followed by "but not for you".

  Ann Keen: If I could come back on that, could you say why you feel an independent review system for pay structure for doctors is still paramount, especially when the panel, and I believe yourself, stated the importance of team-working and how it is all one service?

  210. Can I add to that question as well because last week obviously you were not here, but we did develop some kind of collective view among the witnesses of the need to look at common training elements, common staffing points and the ability to move from one career structure into another and I think there was a broad consensus, including your colleague, Sir Alexander Macara, on this and it does seem, as Ann obviously implies, to be somewhat at odds with what you have just said about the arrangements for doctors.
  (Dr Bogle) Well, how do I put this delicately? I am the current Chairman of the British Medical Association—let's put it like that—and the policy that I have given you is the current policy of the BMA and as evidenced by the debate we have had this autumn when the review body, in our view, was under threat. I would commend to the others on this side of the table the idea of an independent arbiter of pay and certainly if there is a way that we can get some common thinking from that arbiter, I have no objection to doing that at all, but I am here to put the profession's point of view and, as it stands at the moment, the profession is solidly behind what we have got, the reason being just to avoid the confrontation. It has not been all that successful this year, but, nevertheless, the theory is that you do not confront until someone independent makes an assessment. Now, I have no objection to the assessment being made for others, not at all, but I think we have got a better way than the other ways I have heard suggested.

  211. It is probably unfair of me to pursue this because obviously you did not hear the discussion last week, but there was a general consensus about the need to look at common training modules and it strikes me that there is a parallel here in some ways when you talk about the review of the salary structure with a review of the training structure as well alongside it.
  (Dr Bogle) Can I just come back on that? I have no problem with that. Team work in the health field is absolutely essential, and I said that earlier on in reference to another question, but if I think that the structure we have got for deciding pay is the best one, having heard the alternatives, all I would do is commend to my colleagues our sort of model and we resume team work under the same sort of model.

  212. Just for clarification, when you used the word "independent", I thought you meant independent of government?
  (Dr Bogle) I did.

  213. Obviously colleagues think you mean independent of the other professions.
  (Dr Bogle) No, no. Sorry, can I just clarify that and say that the term "independent" mean that they make a judgment that is independent of the profession and independent of government. I was not referring to independence in that it is just us. At the moment it is just us and the dentists, but no, the independence referred to is of government and the profession.

  214. I am interested again in evidence from the Department of Health to the review body for nurses, midwives, health visitors and PAMs where they said that there is "a case for an enhanced increase in starting salary for newly qualified nurses", and certainly, as we have gone around the country, there is support for that, but the difficulty of course is the squeeze on differentials. Do you believe there is a way of implementing that in a way that would be acceptable by nurses and midwives generally and PAMs?
  (Miss Silverton) The Royal College of Midwives would have a lot of concern with that because the entry grade for midwives is set at E, but obviously the Government's own advice in EL95-77 is that the grade for midwives giving continuity of care for all maternity care provision is actually F. Now, we find ourselves very much squeezed in the middle here. If something is done to reward people at the bottom, which I think needs to be done and needs to be considered, and I would not speak against that at all, our members who have worked, some of them, for 30 years on the equivalent of an E grade are going to feel even more disadvantaged and left out of it all because they cannot get up to F which is where they should be and in the last PRB report, we were given extra increments, which were not funded, which did not have agreed processes by which people could achieve them, but those were only for F grades and above and about 50 per cent of our members are stuck on E grades and may be there in perpetuity. I think this demonstrates the way that the grading structure is not flexible, it does not work, and, whilst not speaking against any of the other professional groups, I think you would have a revolt on your hands from the midwives of this country if that is the way that the PRB decides to go this year.
  (Mr Kline) It seems to me, Chairman, that there are two or three issues that need to come together here. The first is that, as Mr Abberley pointed out, there are several pay systems and one of the biggest groups are those who are employed within the NHS, but are not covered by pay review bodies, and certainly one of the things that needs to be looked at is whether they ought to be when the system comes in because many of the pay differentials that have grown up, 34 per cent differentials have grown up since 1984 as a result of bigger increases for pay review body groups compared to the non-pay review body groups. I think that the Department of Health evidence appears to have two strands to it. One is that pay is not such a big issue as we all think because there are all sorts of other things that attract people and keep people in the Health Service, and, to be fair, this Government is not the cause of many of the problems, but it has inherited many of them and they are seriously trying to do something about them, but I think that unless they can get their heads around pay, and, in my view, that means a new pay system, it may include a pay review arrangement, but it needs to be a new pay system that stands up to equal value, unless they can get their heads around that, there will inevitably be a question mark about what happens to the rest of the HR strategy unless you can do something about pay because whilst pay is not the only issue, it is a central one, and I would endorse everything that Bob Abberley has said about a new pay system. Finally, that which is thrown at everybody from doctors through to ancillaries is the question of affordability. There is plenty of evidence, and I would be happy to supply it in writing, that if you do not, for example, employ pharmacists, if you do not employ skilled cytology screeners in the right numbers and with the right training, it actually costs the Health Service lots and lots of money. For example, cytology screeners, just think of how much money has been spent on the various inquiries into problems in the cytology screening service which might have been better spent on salaries for staff who work there, and the examples go on, so there needs to be some joined-up thinking. There is not necessarily a contradiction between having a pay review body system of some sort and a new pay structure, but what seems obvious to me, and I think there is a great consensus, is that the current arrangements are not sustainable as a system and are not sustainable in terms of the levels of pay, and the Department has to get its head around it. The Department has not caused the problem, but it is now their job to do something about it and if they do not, then I am afraid that there is a risk of many other consequences from not getting their heads around it.
  (Ms Prudence) I certainly welcome the fact that the Department of Health actually put forward to the review body fairly positive evidence insomuch as they did not say "a tiny increase" which is what they usually say and they have asked the review body to look at specific problems. The PAMs are probably a little bit different from nursing staff, so we have highlighted slightly different issues to the review body when we met them, but I think that the approach is very welcome. I think there is, however, a big danger of the review body continuing to take an ad hoc approach to trying to resolve these long-standing differences. If we do not have discussions on the new pay system fairly soon, and I can understand totally why they have not attempted to try and address solutions by doing things like a discretionary point system, for example, where we have agreement now that it is not very popular with staff, it is not getting implemented properly and we do not think it is going to resolve the problem, but I certainly welcome their attempts to move these problems forward. I would also like to endorse what Roger Kline said about the new pay system. I think that is of paramount importance and certainly the PAM organisations are fairly relaxed about it being a review body system, it could be one review body, it could be a number of review bodies, but I think what we will be primarily interested in is having a review body system that shows greater independence and perhaps a more broad make-up than the review bodies have had for quite a few years.
  (Miss Hancock) I think I read the Government's evidence with less optimism than Jocelyn did. I read everything the Government is saying as, "Don't give a big general uplift at the moment", and I think that that is serious because I think that that is the only way really to tackle quickly the current recruitment and retention issue. I think one should always look with caution when governments appear to be being generous and the removing of the bottom two increments was a very welcome measure, but my impression, and I do not know what the Committee have found, going around the country is that rarely now is anybody even attempting to recruit on the initial increment of D grade because it is so low that they know they cannot recruit and most D grade jobs are being advertised or offered at higher than the bottom level anyway, but the cost to the Government of that important measure, because I think it will immediately up the starting salary, so it will spend something, but I think generally the straight answer to Julia's question is that I suspect that we need to look at removing entirely the D grade level because it is too low and the entry point to nursing on the current salary scale should be £14,700 at the bottom of the E grade and that is the way to address the real recruitment and retention, but particularly the recruitment, problem.

  215. Just getting back to the midwives' point, if grade E is uplifted substantially, then there will be no negotiation about that pay level within any trust, and an advantage of that differential then being squeezed would be actually that the negotiation which needs to go on to move somebody from E to F is actually smaller and thus it becomes much more achievable.
  (Miss Silverton) Potentially. Our experience of the negotiation of getting an individual from top E on to F is actually extremely difficult. The only things that encourage this are either by taking group grading appeals and grievances, which we have done with some success, or where there are issues of problems of recruitment and we see this in London and we see, as I a7lluded to earlier, the issue of west London where the midwives hop around from one trust to the other chasing the grades. Coming back to Christine's point, without a decent career progression, all you get is people running around causing a lot of expense to the trusts and a lot of dislocation in the service in order to get themselves on to the next grade up and at the moment there does not appear to be the willingness from the management to address these issues in a widespread way.

  216. Do you believe that when staff working in the NHS and fully trained by the NHS transfer to the private sector, there should be a levy paid towards the cost of their training?
  (Dr Bogle) I think it is the one question I would want to duck. I think an instant response would be most unwise, so if you really want that answer, I shall answer it in writing.

  217. Give it some consideration and drop us a line.
  (Dr Bogle) I know when I need to think about a question and I surely need to think about that one.
  (Mr Abberley) It seems attractive to say there should, but does that mean that if you train a Rolls Royce engineer and they move to British Aerospace, it is the same? I quite like the idea of people being trained in the NHS and I would not want them to be trained in the private sector. I wanted to raise something else actually about the minimum wage because no one has asked about that.

  218. Can we come back to that?
  (Mr Abberley) Well, I am looking at the time, that is all.

  219. Well, we will come back to that. Miss Hancock?
  (Miss Hancock) That was tested in Barbara Castle's day, if I remember rightly, and the private sector at the time demonstrated that they took very few people from the NHS and they quite often recruited people that were not working or people from overseas. There would of course at the moment be a challenge to the NHS as to whom it paid for the very large number of overseas nurses it was importing, particularly those that it is importing from countries whose healthcare actually needs them to stay there, and South Africa in particular.

  220. I did ask that when we met officials.
  (Miss Hancock) But there is some interest from the private sector in actually contributing, so I think in a way there is a climate of change and many of the large groups would actually recognise that and, in our experience of talking to them, the interest is in being involved and, in my personal view, coming back to something we talked about last week, unless some of the nursing homes particularly begin to offer good quality placements for training, then the finding of placements for training of nursing students particularly in some of the simple areas of care will become increasingly difficult, so I think there may well be some changing of some of those views over time. I am not sure that it will produce large sums of money in the very short run though.

  221. Mr Abberley, do you want to come back on the minimum wage?
  (Mr Abberley) Yes, I just wanted to make a reference to the effect of the minimum wage or the lack of effect of the minimum wage because very few people will be directly affected, virtually none, though there might be some cadets and that is it, as the lowest currently ancillary rate is £3.74. However, the IDS survey has indicated that a considerable number of trusts are getting worried about their ability to be able to compete in the labour market once the minimum wage is brought in, so we may find that we get a recruitment and retention crisis at the bottom end because obviously we are going to see employers lifting up their pay levels and certainly with some contractors, all the trusts worry about the effect on contracting out, though, from our point of view, that would probably be a good effect. Certainly that needs to be looked at because I do not think people at the bottom end of the NHS are going to continue doing the jobs they do, and they are quite complex jobs actually, it should not be underestimated, for what is a few pence more which they could get in a job elsewhere which is far less stressful. I think that kind of message may get forgotten and it is something that we have to address before the problem comes rather than after and I just wanted to make sure that point was made.

  222. Are there any other very quick points from any of our witnesses on issues which have not been touched on this week or last week that you feel ought to have been?
  (Mr Kline) Continuing professional development, Chairman. We are going to in the next few weeks have a major document on clinical governance and a major document on life-long learning. I do not think it is clear to any of us that the Department have taken into consideration how staff are going to get the cover that will enable them to do something that they will either be required to do on a statutory basis, and certainly be required to do in terms of the duty of care and the standards that the NHS expect, and I think it would be quite helpful to perhaps enquire of the Department how they think staff are going to be able to do their continuing professional development with cover when it is quite clear at the moment in some departments that there is no possibility of that happening.
  (Miss Hancock) Just following Roger and agreeing entirely with what he says, from nurses' point of view, whilst pay is the most important, continuing professional development is second and family friendly policies third in terms of the importance to them in their work.

  Chairman: Well, if there are no further points, can I thank you all for your very helpful evidence this week and last week and your written submissions. You have indicated that you will follow up on a number of points by way of further written evidence. We are most grateful to you and can I at this stage wish you all the compliments of the season.