I welcome Professor Macpherson and Malcolm Wright to the committee. I am sorry about the noise from the drilling that is going on—we are trying to get it stopped. Clearly, while it continues, it is a bit of a nuisance for us all.
Yes. The postgraduate medical deans in Scotland are now part of NHS Education for Scotland.
I will kick off with a fairly general question about work force planning. Some weeks ago, we had evidence from the then Minister for Health and Community Care that work force planning in the health service in Scotland was a fairly recent phenomenon. What is your feeling about work force planning and how involved in it have you been? I suspect that you have been fairly involved. Do you agree with the submissions that we have received that argue that work force planning in Scotland appears to be occurring in isolation and is not really taking on board what is happening in the rest of the UK or Europe?
It might be helpful if I outline at the beginning NHS Education for Scotland's role in work force planning. As we see the matter, three important elements need to come together. One is service planning, to which Professor Kerr's national review is important. National service planning is important because a number of specialties need to be planned nationally, then regionally and locally.
When you say nationally, do you mean in Scotland or the UK?
I mean Scotland-wide. A number of clinical specialties are so small and interdependent that a national overview is required for them, although much of the planning must be done regionally—across three or four health boards—and also locally with local populations. Service planning is important and must come first.
Are you saying that proper work force planning in the health service is really only about a year old?
Work force planning has been carried out in different parts of the service but I have been encouraged over the past nine months or so by the fact that it is really coming together cohesively at the national level. We are very much involved in supporting different elements of that planning.
Work force planning in medicine is extremely difficult—I am sure that lots of previous witnesses have told you that. For a number of reasons, it has become much more difficult in recent years. The committee will already have heard about the working time regulations and modernising medical careers. However, I have to say that work force planning in medicine in Scotland is also difficult because of the presence of England. England is big—10 times bigger than us—and it is not very far away. There is free interchange of doctors across the border and recent initiatives in England have had a significant effect on what we are trying to do in Scotland. We have to take that into account.
I want to be clear about something in Mr Wright's contribution. Does your area of influence include people in pharmacy and dentistry who are not employed directly by the NHS but work as contractors?
Yes.
Professor Macpherson spoke about the free interchange with England. You have described a pool for the health service in England. However, we could consider it the other way round: there could be a large pool for the health service in Scotland to draw on. Why is it not happening that way? Why is the cross-border flow predominantly in one direction?
There is cross-border flow in our direction. Scotland has a good name in medicine and we attract people across the border, at undergraduate and postgraduate level and at consultant level. However, it is my impression that the flow is more in the other direction. Now, I could say that that is because we are so good at training high-quality doctors in Scotland, who are then attracted to jobs in England. That is part of the answer, if I am honest, but many factors are involved.
Have we missed an opportunity to have robust discussions with the Department of Health in England on recruitment policies that could impact on the Scottish health service? Should we have had more robust discussions to try to prevent the drain of doctors and nurses?
I cannot speak for nurses but I can speak for doctors. It is up to us in Scotland to put processes in place that allow us to retain the doctors whom we train in Scotland. We have put some processes in place but we must do more—we can always do more. With NES's help, we are embarking on a study to discuss with senior trainees, when they achieve their certificate of completion of training, where they plan to go. I can talk about the situation for various levels but, at that senior level, we need to know why those people are going to England.
Is that what has been happening?
I do such studies as a postgraduate dean but we will now do studies in a co-ordinated way across the whole of Scotland. That will yield information. We need to know whether all those senior trainees are going to England because there is an attraction in private practice, for instance. I am aware that that is true in some specialties but it is not the case in all. We also need to know whether all those senior trainees are going to England because better child care facilities are available in English hospitals; if so, we need to correct the situation in Scotland.
Do global figures for the net flow out of Scotland exist? If so, could you provide us with those figures?
Yes.
It would be useful for us to see them.
Is every health service employee who leaves the service asked to undertake an exit interview or complete an exit questionnaire? If so, how are the figures analysed, monitored and evaluated?
I understand that that is not done centrally. We are talking in particular about doctors at the point at which they complete their training. Certainly, discussions take place between newly graduated doctors and their postgraduate deans that give us some information as to why people might want to go down south. As Professor Macpherson said, some of the reasons relate to facilities offered by the health service in England. Also, given the fact that approximately half the doctors who graduate from Scottish universities originate from south of the border, there is a strong pull on them to return there for family reasons.
Do you have figures on the number of trainees who would have stayed in Scotland had positions been advertised or offered to them?
I do not have such figures for medicine, but that is what we are starting to do with the study. Dr Turner is absolutely right: we need to have that sort of information.
I am aware that financial constraints mean that not all jobs are filled or advertised. Some trainees—possibly just a small proportion—may feel that they were forced into making a decision to leave Scotland to earn money.
We have recognised the need to counsel the specialist registrars a year out of their certificate and communicate much more effectively with the health boards and the regional planning groups. For example, if we know that, right across Scotland, 10 potential consultants in accident and emergency medicine are coming off the specialist training next year, we can ask what vacancies exist. If we do not have 10 vacancies around the country, we can go on to ask what we can do to create posts on a pro-tem or permanent basis. If we were to do that, we could keep some of those doctors in Scotland. I am sure that, with better joined-up working, we could achieve that level of retention.
The witnesses are correct to say that we have heard worrying evidence of this sort in the past. Increasingly, we have to make the job more attractive for diminishing returns. We have reduced the overall working hours in order to be European Union-compliant. We have also reduced the amount of out-of-hours and weekend working and increased general practitioner and consultant salaries. Despite doing all that, you have just told us about an issue that is even more fundamental to the Scottish system. The majority of doctors to whom I have spoken tell me that they are not in favour of private practice. However, you tell us that we need to give doctors that option to tempt them to stay in Scotland. The majority will have to compromise a general principle to please a minority. There are other issues to do with how we organise our hospitals and a further area of conflict arises in relation to increased specialisation and subspecialisation. Some specialties are obvious, such as specialising in cancer, but others, at the other end of the scale, are not always obvious. That conflict is causing services to collapse throughout Scotland.
Both witnesses want to respond to that.
We can and should focus on specialisation and there are several examples throughout Scotland where that is starting to happen.
Perhaps I should talk about private practice. I said that many reasons took people to England. Private practice is a reason in some, but by no means the majority of, cases and I am not advocating private practice in Scotland at all.
I enjoyed that insight into the fact that we are getting doctors with a much narrower range of skills, and that the culture values an elbow expert or specialist more than a generalist. Generalists have been talked down. It is your profession and that is the evidence that we have heard. No one has denied it to date.
What particular area are you thinking of?
Any area other than cancer or heart disease that you can mention where you can prove that we get better quality outcomes. Where is the proof that we get better quality outcomes through specialisation and subspecialisation?
You mentioned the elbow expert—
There is no proof.
I think that you should let Professor Macpherson answer.
Sorry.
I do not have figures with me and I am not here as an expert in orthopaedic surgery. However, Mr McNeil will understand that, if someone does an elbow operation repeatedly and regularly, they are likely to do it better than someone who does it once every three months. We must also acknowledge that, if something went wrong with an operation that a surgeon does only once every three months, the first question that we would ask the surgeon is, "How often do you do this?" If we were told that they did it only once every three months, we would say that that was wrong. We are talking about a change in culture, which we just have to face.
Duncan McNeil wants to get back in. I ask him to be brief, because other members have questions.
I will leave it at that, but I am sure that Professor Macpherson reads more often than I do the British Medical Journal, in which a debate on the issue is taking place. Proof that we can produce quality outcomes through a centralisation process that is driven by specialisation simply does not exist for some of the other specialties. In fact, I would like to know who decides what a specialty is and how, at the end of the day, that is supposed to serve patients. I do not think that the case has been proved; the focus on specialisation is merely fashionable.
I am sure that the witnesses can see the general thrust of Duncan McNeil's questioning.
Absolutely.
If there is information that would help us in some of those areas, it would be useful if you could provide us with it. It would also be helpful if Duncan McNeil could give us the references to the British Medical Journal that he was talking about.
I have a question on specialisms. It is right and proper for people to question the number of times someone has carried out a procedure so that they can inform themselves about that person's qualifications and the outcomes of the operations that they have performed. However, we discovered the other side of the argument when we went to visit the Western Isles as part of our inquiry. We found out about the dire lack of generalists in such places, because of the current trend towards specialisation and subspecialisation. How do we deal with that situation? There will always be areas of Scotland where generalists are needed desperately. How can we encourage more people to follow that route rather than be attracted by the sexier route of specialism and subspecialism?
A range of things are being done now, which can be done better in the future. For example, we are funding a range of remote and rural fellowships in dentistry, primary care and hospital medicine in various parts of the north of Scotland. Those fellowships allow young doctors to spend a specified length of time in a remote or rural area learning the specialism of generalism—I hope that that is not too much of a mouthful.
No. We have heard about that already.
That is one of the elements that will be key to success in sustaining health care in remote and rural communities.
That only thing that I want to add is that I apologise slightly for leading the discussion down the route of specialism. The committee should remember that the majority of doctors in Scotland are generalists—they are general practitioners—and that we are also responsible for training them. My personal view is that, if I was trying to run the most efficient health service in the world—I think that that is what we are all trying to do—I would ensure that the best doctors went into general practice. That must be a priority, because that is where the patient first meets the health service. I think that we might have forgotten about that a little in our discussion.
On the same subject, but specifically on surgery, there are serious concerns throughout rural Scotland about attracting sufficient surgeons and about being able to keep them up to speed with the amount of work that is to be done, their training and the boxes that they must tick for the GMC, the clinical standards people and so on once they have been attracted into surgery. If, for the sake of argument, generalist surgeons are trained, it must be ensured that they have the right work load. Therefore, will they automatically have to go on a longer training period in future, which will delay their introduction to providing a service? Will they have to operate on a centrally run rota and work on a peripatetic basis in order to keep up their skills and provide a service?
We are training surgeons for remote and rural surgeries. As I said, if the Scottish health service decides to continue such services, it is our job to try to train people for them. I think that it was mentioned that last week, a surgeon whom we had trained in the north of Scotland took a consultant's post on one of the islands.
But the rotation of senior staff is a real issue.
It is an issue. It is a problem.
How much of what we are discussing is driven by a tendency nowadays to practise defensively, as a result of the fear of litigation?
I think that there is some of that and that that is inevitable, but I think that it has improved the quality for which people are looking, to be honest. It is possible that, 30 years ago, someone in Stornoway, for example, could have carried out an operation that they should not have carried out, but I do not think that that happens now, which is a good thing for Scotland's patients. The scenario that you mention is not entirely negative. People should do only things that they are competent and able to do well in an environment in which such things can be done well for the patient.
Mike Rumbles has questions on the Calman review.
It is interesting that you comment on general practitioners. The evidence that we received from the Royal College of General Practitioners said that, in its opinion, we will be short of 500 GPs within the next eight years. Calman recommended that there should be an extra 100 doctors, and we have been told that that represents around 15 per cent of the training intake of 700 places.
Calman reported on undergraduate numbers, but the issue is much more elongated. I am happy to see more medical students being trained in Scotland, although I should point out to members a fact that I am sure they already know. Proportionately, many more medical students are trained in Scotland than in the other parts of the United Kingdom, which are desperately trying to catch up with us. However, I am much more interested in whether we can retain those graduates in Scotland. At the moment, we retain the majority of them, but we must work at retaining more. Not many students leave when they graduate. Under the current arrangements, they tend to spend their first year in pre-registration house officer posts in Scotland, but a third of them leave after that. Some come into Scotland at that point, but we lose a third of the graduates that we have produced. As I said, we then lose people at the end of specialist registrar training.
You say that we need to have jobs for the graduates. To give you an example, the general practice in Braemar in the north-east of Scotland is the only practice in Grampian that is not in the out-of-hours system; it has opted out. I keep being told that that will be a problem in the future, because we will not get a replacement GP for the rural and remote practice in Braemar when the current GP leaves, which he will do at some time. Similar situations apply in the western Highlands and other places.
That would be an answer. We discussed the training of remote and rural surgeons and physicians, which we are already doing. In fact, we are also training general practitioners in remote and rural practice. We take GPs who have done their basic training into fellowships in remote and rural practice, as Mr Wright mentioned; that experience is attracting those GPs into permanent positions in general practice in remote and rural Scotland. That bit, therefore, is working but I emphasise the distance between that and Calman. There are lots of steps in between, and we have to address each and every one of them. Just putting more medical students in at the bottom will not solve the problem. We have to work out ways of retaining them in Scotland.
I hear what you are saying, but I am trying to anticipate the Scottish Executive's reaction to the Calman report, with which it has not yet come forward. You say that if the reaction is that we need more GPs and therefore that we need to change the system further down the line, that will be in addition to taking on the original recruits. You are not saying that it is an either/or situation, are you?
No. The medical student who graduates is totipotential, and can become a general practitioner, a surgeon, a physician or whatever you like. If we need more general practitioners, we need to have more training places for them, and we need to ensure that our graduates find their way into them.
First, we have increased the number of GP registrars who are going through the training schemes. We are slightly over-established for those posts at the moment.
No comment has been made about dentists, but since we closed one of the three dental schools 10 years ago there has been a crisis, which has become apparent only in the past few years. As I mentioned, there has been a small increase in the number of dentists. What should we be doing?
Much of that is predicated on the outcome of the new terms and conditions for dental practitioners in Scotland, which will set the scene as to whether dentists will want to stay in the NHS in Scotland. Putting that to one side, there are two points. First, the output from the dental schools is increasing. This year it is 116, and by 2006 it will be up to 134, which is a substantial increase. In the detailed work force modelling that we have done, it is possible to envisage a balanced position within dentistry in Scotland by 2008. That does not take into account the work that is going on to train other professionals in dentistry. For example, 40 people will be going through dental hygiene and dental therapy courses and graduating in 2007. A number of measures have been put in place that have not yet borne fruit but which will bear fruit as the numbers come through.
Will you comment on the changes in the health service that we have been discussing, which involve centralisation, a reduction in the number of beds, a reduction in buildings—which in itself means a reduction in beds—and structure and training for general practitioners?
I would like to change the training that is given for general practice. I do not understand why general practice training is so short. I was a surgeon before I became a postgraduate dean. General practice involves the whole breadth of things, and it seems to me that training to be a GP ought to take longer than learning a specialty. Traditionally, however, general practice training has been very short. That is under review and I sincerely hope that two things will happen. First, I hope that general practice training will lengthen. Secondly, I hope that the component of that training that takes place in general practice will lengthen.
You indicate that simply getting more people in through the door is not the solution. That evidence has been led in the past. It has also been suggested that we have a better chance of retaining in Scotland those who train in Scotland, and that we usually lose those who move down south, as they tend to stay there. Furthermore, we turn away about 100 people a year who have a very high standard of qualification. What could be done to rectify that and to get more Scots, who would be more liable to complete their careers and stay in Scotland, to train in Scotland?
If, by that question, you are addressing the matter of admission to medical school, you should not address it to me. However, I used to be the admissions dean for the University of Glasgow medical school, so I can talk about that. The admissions processes for medical schools across the country need to be fair and even handed. We cannot discriminate, and I am sure that you would support that. We have to apply the same criteria across the board. We cannot discriminate in favour of Scottish applicants.
You have spoken about the length of time between entry into medical school and becoming a doctor and then a consultant. You mention in your written evidence that
For me, there is an issue about flexibility between the different professional groups. The national work force committee is taking forward the issue of developing roles—for example, developments around nurse consultants and those in allied health professions and devising new roles for radiographers. There are significant shortages of consultant radiologists around the country, which will not be sorted out quickly. However, there are opportunities for extending the role of radiographers by giving them accredited training that will allow them to do duties that previously only consultant radiologists have done. We are increasingly considering that kind of flexibility.
As far as medicine is concerned, the more specialised the population that delivers the service, the harder it is for them to change. Therefore, I would like more general practitioners to be involved for part of their time in hospital service, because in their GP role they remain generalists with specialist interests—for example, diabetes. If diabetes disappeared tomorrow, we could retrain GPs quickly to develop a specialist interest in areas in which we are still working. A surgeon, on the other hand, can do only surgery, so it would be difficult to go back to the beginning and retrain them.
We have exhausted our allocated time for both of you. I thank you for the clarity of your evidence, which we have all found useful. The evidence that we are given is not always so straightforward and clear.