WEDNESDAY 27 JANUARY 1999

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

  380. Experienced registrars have disappeared. They are having to do more and more work. Where will they come from? I am very impressed that he made that speech as he left but where will the consultants come from? Registrars are disappearing. The pressures are increasing all the time. I am glad the crisis in the Health Service exists no longer. That is not what I find. There is a crisis in the Health Service and it has not passed.
  (Mr Dobson) There are more hospital doctors in every category now than in the previous year and the year before that. Next year there will be more in each category. The year after that there will be more in each category.

  381. I would like to move away from the soundbite politics of the last few minutes because they may impress small sections of the media but they do nothing to edify this Committee and I think also some of the so-called facts being bandied about by Members do not bear much relation to reality. I think it would be far better if we question you, Secretary of State, on the realities of the NHS which I think are a very serious matter. I would like to clear up a point on waiting lists before I go any further. My own trust in Dartford has shown a 20 per cent reduction in waiting lists over the last eight months. I wonder whether you think that is a good thing or not?
  (Mr Dobson) I do. From April until the end of November, the number of people on waiting lists has been reduced by 150,000. Most of those folks probably thought it was a good idea that they got an operation. That is what they expect the Health Service to do and I pay tribute to people in every part of the National Health Service who have really got on with doing that. Let me also say that the even more recently retired President of the Royal College of Surgeons has said to me, when we announced the waiting list initiative, that he was glad we were doing that, providing we were going to continue it. We are going to continue it because those waiting lists are too long. Until the previous Government introduced its much vaunted reforms and competition into the National Health Service, there had never been a million people waiting for treatment. Since they introduced those reforms there has never been fewer than a million people awaiting treatment. There are other ways of measuring the performance of the Health Service. I want to look at those ways and get everybody agreed—everybody in the Health Service, the academics and all parties, where humanly possible—nevertheless, the numbers of people on waiting lists are important. It is a huge credit to the Health Service that they have been bringing them down.

  382. I am glad you gave that answer, Mr Dobson, because I was rather confused. I got the impression that somehow it did not matter. My medical experience over the last 20 years is that every person who comes off the waiting list is exactly what the NHS is all about and what it should be doing. Really the question I wanted to ask you was: what, in your view, is the current status of GP recruitment? We have talked a lot about nurses this morning. We have not talked very much about general practitioners. What is your view on the recruitment situation for general practitioners?
  (Mr Dobson) Broadly speaking it seems to be all right. There have been difficulties in certain areas. In those areas, using the powers given to us by the Primary Care Act, introduced by the previous Government, the gaps are being filled by the introduction of salaried GPs. So generally speaking, the situation is fairly reasonable. I think it is fair to say that.

  383. The BMA and others have expressed the view that there is currently a shortage of about 1,000 GPs in the country and in certain areas there are quite significant problems. I wonder if you shared that view.
  (Mr Dobson) There are problems in certain areas, usually inner-city areas, and it is in those inner city areas where the salaried GPs are being introduced. What we do want to see is not just related to the number of GPs but we do want to try to improve the availability and standard of general practice in some of the most deprived areas. So we are making a concerted effort to improve premises and things of that sort in order to serve the patients better but also to make general practice better. If the choice is between working from some very pleasant premises in a fairly prosperous area, or trying to look after the population of people who are poor and ill more often, from a lock-up shop next to a chip shop, you can understand why people opt for the former.

  384. I accept your comments of obviously salaried GPs being an option and it will go a long way towards deprived areas. Nevertheless, it appears that the majority of GPs are not particularly in favour of salaried service and would like to continue with independent contractor status. Even given that, it seems as if there are problems in some areas. Could you throw more light on how we can address that, with particularly what look like increasing problems, the large number of foreign trained GPs who will be retiring in the next ten years, who will need to be replaced. My reading of the situation is that the problem of GPs is set to get worse rather than better unless we do something more about it.
  (Mr Dobson) It certainly is the case that unless we do something about that, supplying enough GPs in every part of the country will become more difficult. That is why our policies are intended to improve the supply and also to get them particularly to go to those areas which are run down, deprived areas, which are the ones that presently have the lowest level of cover. Also they do, of course, coincide with the areas where a large number of the overseas doctors that you referred to, who may be coming up to retirement, are concentrated. Quite frankly, had it not been for them and their really heroic efforts to provide services in some of the most deprived areas, there would not be a GP service in some of them. So we are doing our best to concentrate effort on not only producing good GPs but on getting them to go into those areas. We are not suggesting for a minute that we get away, generally speaking, from the private independent contractor status. If that is what GPs want it is fine with us; but it was the case that after we got in and the powers under the Primary Care Act enabled us to authorise the appointment of salaried GPs, we were actually under pressure from the BMA to get on with it because some of their members saw them as providing relief in the most stressed and pressured areas.

  385. A final point. It does appear, and the evidence shows, that GPs are now retiring younger than they were. I do not know whether they have been coming in earlier. Has that been factored into the future planning requirement for the NHS in terms of the projections, say, in the next ten years?
  (Mr Dobson) I understand it has. It looks as if people are coming down a bit in the age span, but we do not know whether they have stopped coming down in the age span. I suspect that if it came down a lot further, we have not made sufficient allowance for people to start retiring ten years earlier than they have in the past. If we can make being a GP more attractive, it ought not just to be more attractive to people thinking of going into general practice. It also ought to ensure that folks who might have thought of packing in, delay packing in for a year or two longer than they had originally intended. Certainly that is what we want to bring about if we can.

  386. To raise the subject of junior hospital doctors, we had a very interesting session with at least a dozen junior hospital doctors. Quite a lot of concerns were expressed. The first is that the hours they are working is still far too long. There was concern with pay and particularly with the overtime rates they got for working. There was concern that they did not get perhaps as much training—coming back to the shortage of consultants—they did not feel they were getting value whilst they were doing it, and were being given perhaps too much responsibility. Also, a point we fastened onto was that the support for junior hospital doctors in terms of cafeterias, rooms to sit down and have a cup of coffee in, left much to be desired. That trusts have been under pressures. There were not those rooms. When they work at weekends the cafeterias sometimes are shut. Junior hospital doctors, as a result, are not leading the healthiest lifestyle because they are not able to have a decent meal or a place to sit down. Even in one or two cases we heard about sports facilities which had been sold off or reduced. As a general point, Secretary of State, this must be a very key concern of yours to see how we can improve their conditions and keep them in the profession. A lot of them, even as junior doctors, were saying that they were actively considering leaving medicine.
  (Mr Dobson) I will get John to reply in more detail on the junior doctors. Certainly the ones I have talked to now are more likely to raise with me not so much pay and hours, as the diminution in the facilities that are available to them. That does seem to be much more of an issue certainly in terms of what they raise with me. It is something the hospital managements are going to have to look at. It may well be a false economy to take the room away from the junior docs if it puts them off staying. There is one other thing, which we clearly need to address over this, and that is that with the very large increase in the proportion of junior doctors who are women, we have to recognise that if you take the period from when someone becomes a medical student to becoming a consultant, from a point of view of a woman it might, roughly speaking, be described as the usual child-bearing years. So when we talk about a more flexible approach to staffing arrangements and employment arrangements and offering people flexibility and the opportunity to try to deal with their family commitments as well as their work, it has clearly got to apply to junior doctors as well. The idea that they are all going to be on-call at all hours, the traditional approach, it simply will not work. So there has got to be a more flexible approach there if we are to retain the people in whom we have invested, as a country, huge sums of money in their training.

  387. That point came out at the hearing with one junior doctor who was pregnant. Certainly I think there are difficulties with the training programme. They were saying they almost had to make a choice between a career and family. That is really a key issue which has to be addressed.
  (Mr Dobson) I do not want to describe women doctors as a problem, that is the last thing I want to do, but as the proportion of women in the medical workforce increases, then the need to address their problems, their particular requirements, will grow. We are trying to address that because unless we do things will just get far, far worse and a lot of these projections will not make sense. This is because the people who were part of the workforce plan will have decided they are going to have another plan all of their own and it will not involve the Health Service.

  388. May I pick up a point on female staff. It also affects male staff, but particularly female staff. It is slightly away from Robert Syms' point, but bearing in mind the process of increasing the direction of care and support within the community, the Health Service's emphasis is more directly on staff working to support people in their own homes. This means that nursing staff, in particular, spend more time in the community. We have heard, on a number of occasions, the very serious concerns about security issues in the NHS and violence in the NHS. Specific issues relating to women—not solely to women but more particularly to women, in a way—was the number of people we met who were working on-district, (district nurses, midwives, health visitors), who felt very strongly that the Service was way behind where it should be in offering them things like mobile phones; the means of having contact when they were out of the district. I have some sympathy with that. I worked as an on-call social worker, working at night, in Leeds, when the Yorkshire Ripper was on the prowl. As a male that was an alarming time—you know that as much as I do—but I felt very strongly that the Service really does not appear to be taking seriously some of the security issues, particularly for women who are out on-district, often at night and often on their own.
  (Mr Dobson) I do not know where to start really. I suppose ten years ago, maybe a dozen years ago, I felt obliged to go to the funeral of a man who was a ticket collector on the suburban railways somewhere in East London, who had attempted to get a ticket from some yobbos and one of them picked up a reinforcing rod, (because the station was being done up), jammed it in his eyes, and killed him. Ever since then I have had a bit of an obsession about people being assaulted and abused at work. It somehow caused me great personal offence that the man had kissed his wife in the morning, and she reasonably expected him to come home in the evening, but he had been killed just doing his job. So ever since I have had this job I have really put a lot of effort into trying to make sure that the National Health Service takes the problem of assaults and abuse of staff more seriously. It is not long ago that again in the East End, when a member of staff had been assaulted, and the person who had assaulted them was successfully prosecuted, their employers then went on to threaten to dismiss them because of their response to the person who was assaulting them. This seemed to me wrong at the time and I can remember taking part in the protest. When I got in to this job there were managements in the NHS who prided themselves on not prosecuting anybody who assaulted members of staff. That is definitely changing. We have issued two lots of guidance, mainly related to people working in hospitals and buildings. I have been collaborating with the Lord Chancellor and the Law Officers and the Home Secretary to try to make sure that when all else fails and somebody is assaulted, that the justice system takes it very, very seriously. I hope this will have some effect. We have been trying to make sure, say in accident and emergency, one of the reasons for concentrating on that—renewing a quarter of all the accident and emergency departments next year—is to improve the security by changing the lay-out, introducing closed-circuit television and things of that sort. I have been looking, again with the BMA, at how to provide protection for GPs; and looking also at how we provide some element of protection for people who are visiting people in their homes. I certainly think that at the very least we should be providing people with alarms or mobile phones or things of that sort, perhaps with a mobile phone that you press one button and it rings somewhere. Maybe people are more capable of using their mobile phones, but on the odd occasions when I have found myself with one I am sure that if somebody assaulted me I think the last thing I would manage to do is to press the right button and make a call. So I do not think a mobile phone necessarily does the trick. We need something fairly special. However, it does need to be done. I find it terribly disturbing that in our society somebody should assault the people who are trying to deal with people who are sick or wounded or injured.

  389. I wanted to come quickly back to the question about GPs. I was going to attest to the points made by my colleague about junior hospital doctors and their concerns. Part of their concerns is that because of the nature of their training, (and under the system they move on every six months), they are dependent on their current trust for a reference for the next two jobs they take. Therefore, they do not complain as often they might in other jobs. I can certainly point to an example of a junior doctor who worked a 37½-hour shift last week with just two 45-minute breaks in it, because it was my own daughter who is a junior doctor not a short swim from here. On the question of GPs, I was looking at some figures for principals. The increase in part-time working—those who hold less than full-time contracts—those on half-time contracts has increased from something like 1 per cent of principals in 1990 to 6 per cent in 1997. The total on less than full-time contracts is now 15 per cent of the principals. Although there has been a static, maybe small rise in the head count of GPs, in fact the numbers on less than full-time contracts is increasing quite dramatically. I just wonder if that is having an impact on your thinking.
  (Mr Dobson) Two things. On the junior doctors, in this document Working Together, which we produced for the NHS, we specifically talk there of having acceptable standards of food and accommodation for all on-call staff, agreed by the local work force, and getting the things in place. That applies particularly to junior doctors but, of course, there are other staff who are on-call. I hope that will make a start in dealing with the very real problem that you raised. As far as GPs, some of them part-time, there are certain tendencies in our society now which we are just going to have to go along with. More people working part-time is clearly one of the options that people are taking. I guess with some people, if we were to try to press them to work longer than part-time, their option would be not to work at all rather than work part-time. So we have to try to get as much as we can out of the people available. As far as I know, our projections do reflect the change in that direction.

  390. Before we leave the junior doctors issue, for the record could I point out that when we met these junior doctors it was not only the women but the men also saying that the nature of doctors themselves was changing. If you went back 10, 20, 30 years, you would have people coming into the profession who wanted live, breathe, work, eat, everything to do with the hospital and not have a life outside. The men and women there, who are junior doctors today, were saying, "We are different animals. We do have outside interests." They actually thought they were better people for it and were likely to have a better bedside manner. This was because they had a better understanding of the problems of people living because they did do something outside the hospital. This issue about flexibility is not only an issue about women but men and the changing nature of doctors themselves.
  (Mr Dobson) I would agree with that.

  391. However well trained and educated the staff are at the beginning of their careers, it is generally accepted that they need to have continuous professional development. What level of financial responsibility should the individual have to bear?
  (Mr Dobson) That is a big question, as they say. It will vary, I think. We are not starting from a blank sheet. We are in a situation where traditionally some people have made some contribution and other people have not. It has, broadly speaking, all been provided free. A fairer system needs to be introduced. I do not want to say anything which says I am going to authorise everything being free.
  (Mr Denham) To take the wider issue, there is an issue that comes up from time to time with regards to nurses and their study provision. They are required to do five study days every three years and that is not something which is automatically provided for, although it is something we encourage employers in the Health Service to provide. The RCN certainly expressed the view that it is not a major or onerous obligation to make that available. So there are areas like that where there is not a hard and fast right, but it is very clear what we would regard as good practice by employers and we encourage them to do so.

  392. So you would look with favour on things like provision of study leaves, or people do not have to take their holidays to do their continuous development, things like that?
  (Mr Denham) If you take the junior doctors again. It is quite right to say that there is no entitlement as such to study leave. There is a maximum number of days set out in the terms and conditions of service which can be taken. At the same time, there are a number of pressures within the system to try to make sure that suitable support is available where it is needed. It is still the view, at the moment, that trusts are the appropriate organisation to make sure that individual trainees get the opportunities to study when they can. The pressure comes onto the trust there through the Committee of the Postgraduate Deans and other pressures. From the other side, what has been perhaps a fairly unplanned process in the past, is increasingly going to be within the much better manpower personal development planning which we were talking about earlier. So we do hope that by this time next year, April next year, trusts will have in place personal development training plans for the majority of their professional staff. We are encouraging them to look much more coherently at it. We will be producing guidance in the next couple of months on continuing professional development. It is not simply an exhortatory framework within which we say we are quite likely to do this. We will make sure that organisations have the most coherent planning mechanisms to identify the needs of their staff. If I can just mention a couple of things, which have not been raised so far by the Select Committee and which come into this. There is the requirement, which we are going to put on trusts, to survey the views of their staff: so they actually have staff views available at local level, which would not be just on training issues but would be important to the whole discussion this morning about retention and career development. In addition to the user surveys, which are important, we will be receiving sometime, (possibly this month), the report of the Task Force on staff involvement within the National Health Service. Again, this is a first time initiative—actually to involve front-line staff who are involved in delivering the National Health Service—and for them to give their views about how they can be much more effectively involved in the development of the Service. Again it takes us wider than the specific issue of individual training. It sets the context, in a way, which might tackle other issues which you are raising.
  (Mr Dobson) The idea of personal development plans is really part of the whole clinical governance initiative. Sometimes people think clinical governance is intended to catch people out. That is not the idea at all. The idea is to try to make sure by extra training, extra effort, on the part of the management and development of staff, that things do not go wrong in the first place. The whole motivation for our concentration on improving quality of service is that if Mr Hinchliffe goes into hospital, what he wants is top-class treatment. He does not want to feel that if anything goes wrong somebody will be singled out and punished. The object is to have top-class treatment. Part of that effort to establish top-class treatment everywhere is that as part of the machinery of clinical governance people are having personal development plans.

  393. Thank you. I am glad about the absence of exhortation. I am quite allergic to exhortation. I can give you as well a sort of instance which I would like your opinion on. Enrolled nurses. There are still enrolled nurses. Some of them still want to convert to being registered general nurses. I took up the case of such a nurse with great vigour and total unsuccess, which I do not like to have to say publicly. She was having to pay the cost of that conversion. Now it seems to me that somebody who is an enrolled nurse, who is a good enrolled nurse and wants to convert, should be given every assistance. People like enrolled nurses—and there will be others—are amongst the worst paid of the staff. I would like to feel that you were, even at the risk of exhortation, encouraging trusts to take a more enlightened view about situations like that; so that when people want to develop it is made even a joint thing. She could not get a penny towards her fees.
  (Mr Dobson) It will not be just exhortation. It is our intention, backed up with money, that 2,500 extra enrolled nurses should be able to gain RGN conversion over the next three years. We are also saying to people who have left and are seeking qualifications that we will help them get their qualifications. Also, although not the same point, people who have left and want to come back. Being the dedicated professionals they are, they are aware that time has moved on, things have developed, and they want refresher courses. We are providing refresher courses for people who want to come back. At the RCN conference last year I was able to announce that we are putting in £4 million into the return to nursing courses so that they could be free

  394. Thank you. One final short point reverting to junior doctors, which has not been said. One of the things that was put to us reminded me of when I was at school: the idea of how to teach you to dive was to push you in the deep end. I never learnt to dive. Some of the junior doctors seemed to be telling us that some of their training was rather like that. They are nevertheless, unlike me, not learning to dive, thank goodness, but it did strike me a little chillingly, (and I was rather glad I am in splendid health), because they said and they were not blaming anybody—I do not know whether it was the consultant or the supervisor or whoever was responsible—but they were not actually blaming them. They said they worked hard but the system was more geared to they, the doctors, actually getting on with the job rather than being trained. I do not really expect an answer from you now but I would just like to ask you to keep a beady eye on this: to make sure that when you are making sure that they have their proper eating facilities and capacity to live a healthy life and be a role model, that they are also getting the actual proper (might probably be statutory) input into their training.
  (Mr Dobson) There are considerable variations in approach from not just one hospital to another, but from one specialty to another. Certainly some of the more progressive ones, if I may so describe them, a very considerable effort is put in, not just to junior doctors but even new consultants, to make sure that there is an element of help and surveillance and supervision in all that is done, so that people develop their skills but at minimum risk to the patients. It does vary from place to place. Of course, that again will be one of the matters which will come within the ambit of clinical governance. This is because it will be necessary for the management and the board to take a close interest in how anyone who is dealing with the patient has been trained and supervised.

  395. When this survey is conducted into shortages of staff in the National Health Service, I very much hope that our report will be used in conjunction with it, if the Select Committees are to be of any value. I have a final point and if somebody could write to me on it. I had a letter this morning from the National Bureau for Students with Disabilities, who are very concerned that although there are severe staff shortages in the NHS, some able disabled candidates for nursing, midwifery and other NHS professions are being unnecessarily turned down or discouraged from training. Now I am sure she would not mind me saying it, but our newish Director of Social Services in Southend is a disabled person. She is doing a magnificent job under very difficult circumstances, so I hope the Secretary of State and his Ministers will take into consideration the pleas by the National Bureau for Students with Disabilities.
  (Mr Dobson) I thought I had made clear in my evidence to you that this is exactly what we are trying to do.

  396. Before we conclude, may I raise an old chestnut, which is one we have discussed with you at length previously, and this is the issue of PFI and also, to some extent, CCT; and the impact that CCT and PFI have on staff morale. I think it is fair to say that right across the hospitals we visited, where PFI schemes are being proposed, there was a serious concern about the implications of that. I do not want to get into the merits or demerits of PFI. We have had this discussion previously and no doubt we will be having it again. However, there was a concern about the revenue consequences of PFI schemes: their impact upon future staffing levels, the ability to maintain existing staffing levels, and the argument about the number of beds. What was of particular concern, and which came over loud and clear in a number of the areas we looked at, was the way in which PFI divided the NHS staff team into two clear groups. I have a memory of a consultant at a hospital in the East End who was there with a range of staff—cleaning staff, portering staff, ambulance men and women, paramedics, nurses, right the way through the whole range of people employed in the health team—making the very strong point that health care is about team work. He underlined the importance of what might be deemed the most humble member of that team. What came over to us loud and clear were the very serious concerns. That PFI will divide that team into sheep and goats in a way that they did not feel would be helpful to the Service jelling together in the co-operative way the Government would want it to work, and to future recruitment patterns.
  (Mr Dobson) It would be foolish to deny that there clearly will be a division. It seems to me that it will be necessary for the Health Service management and the consortium management to work together to maximise proper productive relations across that boundary. I do not know whether I should say this but displaying one of what I think is one of my observations of this world: while people are within one organisation it is sometimes assumed that communication between the various parts of one organisation will proceed effectively by osmosis without anybody really arranging it; whereas sometimes if you have two separate organisations people actually realise they have to establish proper communications. Sometimes the situation can be better—not always—but from observation I think that is true sometimes.

  397. Some managements of trusts who consult do not take any notice. We certainly got an example of one trust embarking on a PFI scheme which surveyed the staff, as you suggest they should, on their attitude to it. They got a very hostile reception to it but they have kept on. I think they have ignored, as we saw it, everything that was talked about—from incontinence pads for patients to the flexible hours of nurses—in order to make sure that they strengthened their bid for the PFI scheme. It was a very salutary warning to us.
  (Mr Dobson) If you could let me have the details of that particular case I will pursue it, because the object is to get some private capital into providing new buildings, plant and equipment—which will be for the first time ever in the history of the Health Service properly maintained—but it is certainly not to be done at the expense of reductions in staff or, for that matter, reductions in the working conditions of the staff. Certainly not in terms of trying to reduce the number of incontinence pads that are available. That is just barmy. If people need incontinence pads in hospital you have to have a system which delivers them, whether it is PFI or not. There cannot be any question of tolerating different standards of care as a result of the PFI. I recognise there are problems. There is no evidence at all, looking at the various capital schemes of the PFI hospitals, that although a hospital is in a PFI scheme, that it is having a differential impact on the number of staff employed.

  Mr Gunnell: Perhaps the difference in this case was that it was a trust which was hoping it would get a PFI scheme, so it was doing all it could to promote its image in terms of cost-effectiveness.

  398. You will be corresponding with us on that?
  (Mr Dobson) Yes, by all means, yes.

  399. Just a question, Secretary of State, about different people employing the staff. In primary care there are already different employers because the general practitioners themselves are employed. They employ staff directly who are then their employees. Attached to the staff are Health Service employers in terms of district nurses, and quite often Social Services staff, home care managers or social workers. So there are already divisions of employment across primary care which works very well. However, the question I wish to raise is about Pay Review Bodies. There has been speculation that you wish to look at the way Pay Review Bodies work across the different professions. I wonder whether you have any thoughts, at this early stage, about how that might be changed in the future.
  (Mr Dobson) I need to be very careful about saying anything about the long-term view of the Pay Review Bodies this side of hearing their forthcoming announcements. It is no secret that we have been having discussions with representatives of all people who work in the Health Service about trying to have a more modern and up-to-date way of determining pay, which is above all fairer to the staff, than the one we have at present. I think it is fair to say that those who at present have review bodies certainly do not fancy giving them up, which is perfectly understandable. We have not made a great deal of progress with our discussions on this, but we are sounding people out because we feel that a lot of the pay determination and a lot of the rules about people's employment and such like are just amazingly archaic and to the disadvantage of the staff. The exploratory discussions we are having are partly at their behest. I do not know whether we have it here but I saw the document that determines nurses' pay in detail. The index is nearly a dozen pages. I do not think that is the way you should employ dedicated professionals. I do not think you need 88,000 words of detailed rules.

  400. In your opinion, would you like to see Pay Review Bodies merging right across all the professions in the Health Service, or would you like to continue the current system where they are separate?
  (Mr Dobson) To be truthful, I think my giving a view at this moment might not help.

  Chairman: Are there any further questions from other Members? If not, Secretary of State, Mr Taylor, Minister of State, thank you for your attendance today and for your co-operation with this inquiry. Thank you very much.