WEDNESDAY 27 JANUARY 1999

RT HON FRANK DOBSON, MP, MR JOHN DENHAM, MP, AND MR HUGH TAYLOR

  320. Good morning. Welcome to the Committee. I particularly welcome the Minister of State to the Committee as this is his first visit. We are pleased to see you and wish you well in your new job. Secretary of State, would you introduce yourself and your team?

  (Mr Dobson) I am Frank Dobson. I am Secretary of State for Health. John Denham is the Minister of State for Health and responsible in particular for what might be described as pay and rations organisation. Hugh Taylor is the Director of Human Resources. He has appeared before you already on this matter.

  321. I thank you for the departmental written evidence, which has been very helpful to the inquiry and for coming to meet the Committee towards the end of our inquiry. You are probably aware that we have spent a fair amount of time visiting different parts of the health service in various parts of the country. We are grateful for the cooperation of various trusts and health authorities in the areas that we visited and we are grateful to the professional associations and tribunals that were able to bring their members to meet us. The general feeling in the Committee is that we have gained a rather disturbing picture of serious staffing difficulties and very low morale across the board. A particular problem that we picked up was the clear frustration by staff that local managers are often perceived as appearing to be oblivious to the extent of the problems facing the staff at board level in local areas. Firstly, how do you ensure that you are aware of what might be termed the "warts and all" views of the NHS workforce rather than the glossier version that sometimes makes its way up the accountability chain? Secondly, do you ever get the opportunity, as we have done, to sit down, without local managers or civil servants, and have face-to-face discussions with grass-roots staff about where they are on a day to day basis?
  (Mr Dobson) To be fair to the National Health Service Executive and the civil servants, the information that they pass to me, generally speaking, is an honest appraisal of the situation. One of the problems that they and we face is that the devolved system of management of the NHS that we have inherited has meant that quite a lot of data has not been collected for quite a few years now because the previous government, rightly or wrongly, decided that they wanted to devolve responsibility for most activity down to the trusts, and did not want to bother them by asking for statistics. A lot of the data at the centre is quite inadequate to the task. We are trying to change that without placing too much of a bureaucratic burden on the rest of the health service by asking them to supply the figures. I try to get out at least once a week to spend a day going to various parts of the health service. I make it by business to talk not just to the managers but also to the staff, and more importantly to listen to the staff and get their clear views about what is wrong. I have no doubt at all that we face a serious nursing shortage. We have had that nursing shortage for several years, but it is greater and worse now than it has been. In some places we also have a shortage of midwives and therapists, in particular occupational therapists and physiotherapists.

  322. Taking account of the constraints that you have been under in obtaining the facts locally, what do the official figures that you have show in respect of shortages of staff at local levels at the present time?
  (Mr Dobson) Taken nationally, I would conclude, looking at various figures from various sources, that there are probably 9,000 or so nursing vacancies which have been vacancies for three months or more—in other words, serious vacancies and not just turnover. However, it is not standard across the country by any means. It is not even standard within one region or one quite small geographical area. The areas with the biggest problems are London in general, some parts of London in particular, Manchester and Liverpool. Those are probably the areas where there are the largest long-term shortages of staff, both from the figures that we get, which are not satisfactory, from observation and from talking to people and visiting Liverpool and Manchester and various parts of London.

  323. One of the strongest messages that we received in talking to the staff was that they felt that a range of initiatives that the Government are bringing in, initiatives that by and large they appear to welcome overall, have not been thought through in respect of the impact that they are likely to have on staffing issues. One example was given to us by a ward sister, who we met in Birmingham. That concerned the way in which the changes to junior doctors' hours have resulted in a number of the functions at ward level that used to be carried out by junior doctors now being carried out by ward sisters, so adding to the pressures under which they work. In the department is there any evaluation of the impact of initiatives, such as the winter initiative and the waiting list initiative, on grass roots, ward level staff? Bearing in mind the shortages that you have accepted are there already, do you believe that the plans that the Government have to recruit additional staff, of which we are well aware, will meet the problems currently faced in addressing some of the new initiatives that the Government have brought through?
  (Mr Dobson) In relation to the long term commitment some time ago by the previous government, quite rightly, to reduce junior doctors' hours, to be honest, I do not know what assessment was made at that time of the likely impact on nursing. It is quite clear that the boundaries of nursing have extended into areas which previously nursing did not cover. It has become more technical. Practitioners are more skilled than they were in the past; their jobs are more demanding. That is partly as a result of having to move into areas which were areas of activity on the wards that were previously carried out by junior doctors. Whether an assessment was made at the time I simply do not know, but it certainly should have been because it has had an impact. As far as things like winter pressures and the waiting lists are concerned, the extra money for winter pressures and the extra money for coping with waiting lists has been intended, in part, to pay for recruitment of staff to carry out that work. It has certainly worked in some places. In relation to the waiting lists it has worked very well, and overall it has worked fairly well even in relation to the winter pressures this winter. I want to make sure that any initiatives in future bear in mind their likely impact on the workforce in terms of demands on time. One of our biggest problems is that there is a chicken and egg situation. One thing that puts off nurses already working in the health service most is the stress and strain and not having enough colleagues. Even if the management want to introduce flexible working conditions, they are unable to because they feel that they do not have enough staff in order to provide the flexibility. That, in turn, leads to nurses leaving which adds to the shortage and nurses contemplating coming back averting their gaze and deciding not to. If we are to break out of this situation we have to get more nurses. The whole future of improving working conditions, improving care for patients revolves around recruiting more nurses.

  324. You set out specific figures to recruit in terms of nurses and doctors. Having made that comment, do you anticipate that there will be difficulties in recruiting those figures, even though the money is available? As things are at present, will you be able to recruit the numbers that you have mentioned?
  (Mr Dobson) There are several aspects to that. One is to do with pay. This is about the third time that we have appeared before the Select Committee very shortly before some major announcement that affects the topic that we are discussing. The pay settlement is likely to be announced very shortly, and I hope that that will prove to be attractive to staff and affordable and that we shall be able to pay it in full. That is something I have been saying for the whole of the year and I am fairly confident that that will be the case. The pay settlement recommended by the review bodies can only be part of our commitment to deliver a better deal for nurses and midwives. We are determined to improve their working conditions and to modernise the pay and grading system. We think that a modern national health service needs a modern system for rewarding the staff and most particularly rewarding the experienced nurses and the midwives on whom the system depends. The present grading system is outmoded and very rigid and it denies to nurses and midwives the career progression that would be good for them and good for patients and the NHS. There are too many grades, and too many artificial ceilings. I believe that nurses and midwives would like to see that changed to just three grades which might be described as "registered nurse practitioners", "advanced nurse practitioners" and "specialist nurse practitioners". Under that system the staff would be rewarded for the work that they do and the responsibilities that they carry rather than for a designation or a grade. We shall have to negotiate that with the staff, obviously, but I think that that would be a way forward. I believe there is a great deal of common ground between us and the staff. There are others things that we need to do if we are to retain the existing experienced nurses and attract back into nursing the experienced nurses who have left. There are 140,000 qualified nurses who are not presently nursing in the NHS.

  325. We shall come on to pay and related issues a little later. On the issues that you have raised about recruitment and the difficulties currently facing the health service in ensuring that the figures that you have projected will be recruited, do you accept the problems that there are in relation to the current year's pay increase? Do you accept that that has had an impact on morale that has been detrimental? That is the picture that we have gathered from speaking to staff. Is that a view that you share?
  (Mr Dobson) Yes, I am certain that is the case. It has been harmful. As I said to the Royal College of Nursing, I was sorry that we had to come to that conclusion, but due to the state of public finances that we inherited at that time, we felt we had no alternative but to stage the pay, which applied to everybody in the public sector. I am pretty hopeful now that the public finances are in a better state that we shall be able to come up with a settlement which is both affordable and which will be attractive to the staff.

  326. I am glad that the Secretary of State acknowledges that the staging last year caused a few problems and that the settlement will be funded in full, or rather the settlement will be paid in full. He did not say whether or not it would be funded in full, and I would not expect him to say that today. That is an issue as far as the health authorities are concerned: that if there is a reasonable settlement in terms of pay that the money will be compensated from the Government.
  (Mr Dobson) I obviously cannot get into any detail about what the settlement will be, but I will say that it will be affordable nationally and locally, and, therefore, it will be afforded.

  327. Secretary of State, I am pleased that you have acknowledged that there is a real problem with staffing across the NHS. It is a refreshing change to see a Secretary of State who will openly, and on the record, admit that we have problems with staffing across the whole of the NHS. You have also pointed out that you are clearly not happy with the way in which data is collected across the NHS, so that we do not really know what is going on. What plans do you have to improve that data collection so that we get a better picture of what is happening?
  (Mr Dobson) Once we have the present pay increases and such like launched, I shall suggest that the NHS officially, openly and publicly conducts a survey of shortages of staff by the end of this financial year. We shall then put that data to any organisation that is interested, and that has put forward other figures, and we shall sit down, sort out and reconcile the various figures. There may be figures produced by the Royal College of Nursing, or UNISON, or some academics of the National Health Service Confederation, or whoever. We shall get it sorted out and bottomed so that in future we do not have stupid, theological disputes about the levels of shortages, which is what has gone on for too long, but spend our time tackling the shortages.

  328. I agree with that. As you will appreciate, this is an inquiry into the future staffing requirements of the NHS. Therefore, workforce planning is central to our argument. Do you believe that the workforce planning mechanisms as they currently stand are adequate to deal with the future of the NHS?
  (Mr Dobson) No.

  329. That is a good answer. Have you any suggestions as to what you might do to improve the planning mechanisms?
  (Mr Dobson) If we were to produce a list of all the various organisations, committees, sub-committees and advisory bodies that have a hand in workforce planning for the NHS, it would probably run to a dozen pages, even with just the names and a short description of what they do. I would want to set about making it more orderly, understandable and joined-up than it is at present. That is not in any way a criticism. A large number of people, including large numbers of professional people in the health service from the health service professions have done very good jobs on these various committees, but we need to bring matters together in a way that would make it possible for Mr Taylor to have a bit of a hand in things rather than just responding as each advisory body comes up with another bit of advice. This may not be true and it is speculation on my part, but I would speculate, for instance, that when decisions were taken on reducing junior doctors' hours there was not a thorough-going look at the likely impact of that on the workload of other staff and how that would be coped with. We need to look right across the board, particularly—as I think everybody increasingly recognises—as most services delivered in hospitals, and for that matter in the community and in primary care, are delivered by a team with a mix of skills. If you want teams with a mix of skills, you need to bring the assessment and the availability of all those skills together. That is not being done at the moment. Mr Taylor and his colleagues are trying to do that, but under the present system it is extremely difficult.

  330. I appreciate that you have a very good grasp of the many pressures that there are on staffing requirements for the future. Do you envisage any sort of over-arching body that will have overall responsibility to plan workforce requirements across the entire NHS staff workforce?
  (Mr Dobson) That has to be a duty of the National Health Service Executive. They need to do that. We have to bear in mind on all these issues that you can have a grand strategy at the centre and if it does not work in Manchester or Scunthorpe, it might as well not exist. We have to make sure that there is a national, and in some cases regional strategy, but they have to deliver. The strategy has to be something that is done at the centre and also built up from the individual units, be they community services, primary care or the hospital service in each particular part of the country.

  331. How does that square with the apparent message that the Prime Minister was giving yesterday of localising pay?
  (Mr Dobson) There have been some rather strange interpretations of what the Prime Minister said.

  332. My interpretation was not strange. I just read what he said in the paper.
  (Mr Dobson) I would not dare for a moment to suggest that the Chairman of this distinguished Committee had a strange interpretation. We are dependent on reading what people have written. Most people recognise that if we have a system in the NHS which is related to responsibility, there will be local variations. In terms of everything to do with pay and working conditions of staff, we have to have a national structure that allows for local variations, and which does not include daft things like half a per cent being negotiated locally, but looking at people's contribution to the team.

  333. You would recognise the difficulties that have arisen in individual areas, where some people are on one contract and others are on a national contract. That has an impact on morale in local areas.
  (Mr Dobson) Yes.

  334. Presumably, whatever everyone's interpretation of the Prime Minister's comments yesterday, you, as Secretary of State, must recognise the difficulties that have arisen in the NHS through the localised arrangements.
  (Mr Dobson) Yes, I do, but again my understanding is that the representatives of the staff would be likely to find it acceptable to have variations as long as they were fair and properly reflected the situation, say, in a hospital, so that what we do not envisage is some people on a national arrangement and then some people on an advantageous or disadvantageous local arrangement. If it suited everyone in the locality, including the staff, to have one lot of local arrangements then we would be prepared to consider that and indeed encourage it if that were of benefit to the NHS, to the benefit of patients and also to the benefit of the staff. What we have at the moment is a mess. We want to get away from that.

  335. Clearly, there are many reasons why there is a recruitment problem in the NHS. One is that staff are leaving. You mentioned that 140,000 qualified nurses currently are not practising. It is important to know the reasons for that. Do you see any benefit in the introduction of exit interviews to find out why people have been leaving the NHS? Clearly, pay is only one of many matters. Do you have any thoughts on the idea of exit interviews so that we can find out exactly why some staff feel the need to leave the NHS?
  (Mr Dobson) I am certainly in favour of doing anything we can to find out why staff are leaving, and to find out the attitude of people who have left and who might or might not be thinking of coming back. The department has instigated a thorough-going survey of people who might possibly return to nursing. There are some very clear issues there. Pay is an issue but it does not appear to be the major issue. The major issue is having flexible employment policies, which would allow people to do their jobs in the health service and at the same time discharge their family responsibilities. Shift patterns that would allow people to take the children to school in the morning or pick them up from school in the evening, job-sharing and that sort of thing are the absolute, top desires among the people who have left the health service and might come back. Clearly, we have to deliver that.

  336. Therefore, what pressure can you bring on trusts and others to ensure that those flexible working patterns happen in practice?
  (Mr Dobson) We are bringing pressure to bear on them. In fairness, at least to some of them, if your shortage is acute it is difficult to be flexible because you do not have enough staff with which to be flexible. That is why it is absolutely crucial that we get more nurses. Most of what we want to do to try to improve the NHS is dependent on getting more nurses. We are pushing ahead with more family-friendly employment practices. As I have said, it is a chicken and egg situation. We are urging management to introduce flexible working hours. Another thing that will attract former nurses back is giving them the confidence to believe that once they are back there will be sufficient colleagues for them to devote enough time to each patient that their professional standards suggest are needed. They feel that they do not have time to give attention to individual patients under the present stressed system. They are always run off their feet and we have to do something about that.

  337. Secretary of State, going back to financial data within the NHS, you will recall that on the floor of the House on 16 July and before this Committee on 22 July when talking about the comprehensive spending review when you announced some grandiose plan for the next three years, I questioned the NHS deflator. Because of high levels of staff costs and advances in health care it was higher than the GDP deflator. You said in evidence to the Committee that, "it is unusual for NHS inflation itself these days to be higher than the general rate of inflation". I took up that point and wrote to you on 2 August, saying that the data that had come from the Department of Health showed that the NHS deflator was on average about one and a half percentage points higher than the rest of the economy in general. I did not get a reply to that letter and I sent a reminder on 14 September. I then asked the Committee Chairman to write, after the summer recess, to remind you that I had not received a reply. Another reminder was sent in December. On 22 January your Minister of State replied to the Chairman of the Committee agreeing with my point and saying that individual government departments may face difficulties facing the pressures according to the nature of their spending programmes. My point is that, firstly, your department accepted the point that I made and, therefore, that calls into question some of the spending programmes that you have going forward. More particularly, based on that data and based on the fact that it is suggested that we will get a slightly more generous pay review for nurses, the cost of staffing in the NHS is 75 per cent of the budget of the NHS. Does that not drive a coach and horses through your spending programmes going forwards in that it is all falling on the staffing problems?
  (Mr Dobson) My humblest apologies for not replying to your letters. My new colleague has now done so, for which I am very grateful. I do not think that I said that there is no difference, unless my memory is playing tricks on me.

  338. I am quoting what you said: "it is unusual for NHS inflation itself these days to be higher than the general rate of inflation".
  (Mr Dobson) That is what I was advised. Several changes have taken place in recent times. One change is that, over the past decade, there has been a big drive for extra demands on the NHS as there has been a huge increase in the number of people over the age of 85. That number has gone up by 300,000. Over the next decade it will go up, and can only go up, as I understand it, by about 100,000. That pressure on NHS costs will be lower than it has been in the past. It is certainly the case that we are finding for the NHS as a whole, over the next three years, an extra £21 billion. We believe that will mean a year-on-year, average, real terms increase of about 4.7 per cent in the money that goes into the National Health Service in England. That is a substantial increase, and we believe that it will not meet every demand, every need, or what everybody in the country would like to see, or everybody in the health service would like to see, but it is a huge step forward and it will certainly cope with pay increases on the lines envisaged. I know that people—particularly nurses and midwives—resent the suggestion that in some way or other paying them is not the mainstream activity of the NHS. They tend to point out that there is "national health" and then there is the "service" and that is what they provide. We cannot distinguish entirely between what goes on pay and what is provided for the service because if we do not have enough staff, and we are not paying them well enough, the service will actually decline. If you have particular questions on the deflator, my honourable friend, drawing on his exquisite command of the information from the Department of Social Security, is quite willing to deal with your detailed points.

  339. Do you want to respond?
  (Mr Denham) I have nothing to add at the moment.