We now move on to our work force planning inquiry. We have two panels of witnesses. The first panel comprises Tom Kelly, chief executive of the Association of Scottish Colleges, Riona Bell, director of funding for the Scottish Funding Councils for Further and Higher Education, and Professor Jim McKillop, head of the undergraduate medical school in the University of Glasgow.
I want to focus on dentistry, which is a major problem in Scotland. For instance, this morning, Grampian NHS Board announced that it is looking for 10 new dentists to work in the national health service. Scotland faces a crisis because of the lack of NHS dentists—use of the word "crisis" does not over-egg the pudding. The written evidence from the Scottish Funding Councils for Further and Higher Education and from Universities Scotland both focused on dentistry.
Our figures are taken from our main grant letter for 2004-05. In calculating the funded places, we start with an output target and include assumptions about survival rates between input and output in order to take account of students who drop out of the course. If we base our calculations on the average history of survival rates, we can work back to intake and arrive at figures for each year of the five-year course, which are added up to make the funded places. Our statistics therefore refer to the numbers of people who are currently in training.
I cannot explain the figures directly either, but I agree with Riona Bell and I think that the figure that Mike Rumbles mentioned refers to graduate production in a particular year. It would be interesting to identify whether the figure is a one-off, because there are different drop-out rates in different years. I suspect that that might be an issue. However, I am not directly involved in dentistry.
If we accept that the number reflects drop-out figures, is the Scottish Executive providing the right information and are the institutions responding in the right way? You might know that there used to be three dental schools in Scotland. There are now two dental schools and an outreach centre is being established in Aberdeen. How many graduates were we producing 10 years ago? According to the figures in the submission of the Scottish Funding Councils for Further and Higher Education, we are producing 134 graduates—only 14 more than previously. Are we responding effectively to the crisis?
I do not know what production was 10 years ago, but there was certainly a period when it was thought that fewer dentists would be required because of fluoridation, for example. We now realise that that is not the case.
Basically, are you saying that you do what you are told by the Scottish Executive?
Not entirely. I cannot speak directly for dentistry, but I can speak about medical student numbers; we are firmly involved in the debate about what the appropriate numbers of them might be. However, at the end of the debate, the Executive takes the decision.
What do you think the appropriate numbers are?
Do you mean in relation to dentistry? I do not know, because I am not involved in dentistry.
Does Riona Bell have any idea?
No.
I would like a written response on the matter, if that is possible.
I recall that we might hear from witnesses who can speak specifically about dentistry later in our inquiry—I am not sure about that, but we can dig out the information for Mike Rumbles.
Given the questions that have been asked, it would be useful if Riona Bell could explain briefly the role of the Scottish Funding Councils for Further and Higher Education in the process, in relation not just to numbers in dentistry but to the health-professional work force as a whole.
We control the number of students who are taught in higher education institutions, but that number is given to us by the Scottish Executive Health Department. We take part in discussions with the department each year to determine the intake for the year and our funding methodology reflects the figure that is determined. We give a number of funded places to the institutions that have medical and dental schools and we then control those numbers by means of funding, which is the only positive control lever that we have. We give funding and we attach conditions to funding.
That is helpful, but it also surprising that places can be oversubscribed when we have a shortage of doctors and dentists. You are talking about how doctors and dentists are allocated places. What about other health professionals? Do the rules, limits, checks and balances apply throughout the health professions?
No. The other health professions are not controlled subject areas.
Is that why we have more of them but are short of doctors and dentists?
The next witnesses will be able to tell you how the numbers are determined for other health professions. That is done between the institutions and the health service.
May I come in on the role of the institutions? Some of you will be aware that Sir Kenneth Calman recently carried out a review of basic medical education in Scotland to examine what would be appropriate numbers of medical students, and therefore graduates who would subsequently join the Scottish health service. The various medical schools were intimately involved in the discussions on what was possible in terms of accommodating increased numbers. One of the great problems that we have in clinical specialties is that a large part of undergraduate training involves a student's being on clinical placement, for which there are limited resources, so any increase in numbers has to be controlled and funded appropriately.
An additional 100 medical places have been requested. Is that realistic? Will we meet that target and will it meet demand?
If the 100 places were appropriately funded, the medical schools could cope and the NHS could cope with the clinical component of their training. Whether they would meet the long-term targets would depend upon the model that was being used. A variety of numbers have been quoted for the number of doctors and other health professionals that will be required by 2020—those numbers depend on the model of the health service that is used. To be honest, 100 medics would probably not meet any of the targets; that number is probably an underestimate.
We will probably come on to some of those other issues.
How can you add more value to NHS Scotland's planning strategy?
Value can be added in a variety of ways. One important thing is to ensure that, within the schools, we respond to changes that will happen in professional roles. The doctors and nurses of the future will not do the same things that doctors and nurses currently do. We can add value by ensuring that we prepare people for the life of change that they will enter.
The answer lies beyond pure funding and the control of funded numbers. We encourage institutions to have dialogue with the health service and to be responsive to its needs, and we have regular tripartite meetings with the institutions and the health service. That is as effective as, or more effective than, blunt funding instruments.
I will focus on doctor numbers, which Professor McKillop mentioned in a throwaway line to the effect that he did not think that any of the Scottish Executive targets would be met. The European average for the number of doctors per head of population is 40 per cent higher than the figure for Scotland. The Universities Scotland submission says that we produce 1,000 doctors in Scotland per year and the Calman review says that we should produce another 100, which is another 10 per cent, so if we wanted to get up to the European average, we would need 400 more doctors per year, not 100. Is that why you say we will not meet the targets?
It is not the only reason; there are different patterns of health care in Europe and different patterns of what different professions do. In the NHS, we have appropriately considered extending the role of a variety of health care workers so that they can do things that might be done by doctors in other countries, so it is not only a matter of the European average. I say that because the Temple report is producing projections of medical numbers and if we examine the projections to 2020—I do not have the precise figures in front of me—they are substantially greater than 100 extra students per year. That may be one of the reasons why Ken Calman suggested in his report that those 100 students should be a first phase and that, further on, there may be a need for additional numbers.
Are you surprised that the number of student places has remained the same for the past four years? Did you expect that the increase would have happened by now? Why has there been no increase?
I cannot say why there has been no increase in the numbers. There has been an impression for two or three years that we need increased numbers if we are to meet the work force projections. There is a view in Scotland that our already having more medical students per head of population than south of the border—even with the increased number of places there—may be inhibiting an increase in Scottish numbers at the moment. However, if we examine the numbers that will be required, it is clear that we need not more medical students but more doctors to be produced at the end of medical degree courses.
Have you been asked about that or did you give any opinion about it over the past three or four years?
The Calman review was set up because the medical schools and the Health Department had indicated that there was a problem and that the approach to it needed to be planned. One of the other issues that we hit is that the demographics in Scotland are such that, if we recruit from the places from which doctors traditionally come, we cannot fulfil the quotas. Therefore, widening of access and participation is important and was focused on in the Calman review. However, if we are to widen access and participation, we need to consider non-traditional ways of training individuals and of getting them into medical school to start with. That has taken time to achieve.
How does the set-up in Scotland—you receive a funding allocation and administer the numbers that the Executive tells you to administer—compare to the funding of places and the direction that is given in other European countries?
The situation is the same in all the United Kingdom countries, but I do not know about other European countries.
The matter really comes back to a point that Professor McKillop made earlier. The issue is not just about having undergraduates in health care courses; it is about the production of qualified persons in health care regardless of the profession. What influence do the royal colleges have on the thinking of the three bodies that you represent?
By and large, the medical royal colleges have a positive influence because they ensure that training is developed, assessed and enforced locally within national standards. There are some new issues that they will have to face, such as the generic training that doctors will undergo and how it is assessed. The royal colleges are working closely with the Postgraduate Medical Education and Training Board, which is established in England but will have a UK-wide basis, and the General Medical Council. By and large, the royal colleges are responding positively.
What about their influence on your university's role as a university in Scotland that is providing those courses?
The royal colleges influence my role as the head of an undergraduate school because I produce individuals who will feed into that system and we need to ensure that we are joined up. A number of initiatives either exist already or are on the way—especially under the banner of NHS Education for Scotland—to ensure that that joining up happens.
I would like to bring in Mr Kelly. If we are not careful, we will spend all our time talking about doctors and dentists.
I addressed the question to all three organisations.
For the non-degree professionals and workers who are our main concern, institutions that set professional standards are absolutely vital. The individual student and, indeed, the employer is entitled to expect that the standard qualification will meet the current requirement for licence to practice. The mechanisms for modernising that and getting it to work differ by specialism. In our area, we are trying to take a broad approach to the work force that recognises the connections not just between NHS employment and specialised health care occupations, but between those and the wider range of occupations in personal and social care because they have many elements in common.
What are the funding implications if the Government decides on a number out of the blue for a specific course? Could you provide the number of places anyway?
Generally speaking, the college courses are one or two-year courses, so we are much better able to adjust if there is a change in demand. To be honest, the burden of getting it right often falls on the student, because colleges are essentially driven by student demand. We do not have quotas in specific areas set by the department or the funding council. The assumption is that the colleges will make a responsible adjustment between what the students would like to do and what the employers say they will require.
Are there sectors of the work force that you deal with in which, at the moment, recruitment is falling short? If so, how could that be dealt with?
No. The constraints are more on the supply of places. There is very strong demand for the courses.
Are all the courses oversubscribed?
Across the country as a whole, there may be instances of a departure from that, but the national pattern is that there is increasing demand—demand that is in excess of the number of places that we can offer.
So, the block is really on the number of places that are funded rather than on the number of students who wish to enrol.
No, the block is on the overall funding for the individual college. The college itself decides how many places of what sort it should offer. You must remember that, especially in a modern college of further education, a lot of the provision is part time. People will choose to study for a supplementary qualification or start to learn for a new field in the evenings, or whenever.
You must also remember that a number of the courses require work practice or the equivalent of clinical placements. It is essential that, when students are taken on, the institution that is teaching them is able to give them work placements.
Do you get a set amount of money for the college, which decides which courses to spend it on?
Yes. You are right to make that distinction. The funding council does not have a lever that allows it to put another 100 or whatever technicians in a particular area.
So at that point it is entirely up to the college administration to make any adjustments that it deems necessary.
But the same holds true across a wider range of employment. On the whole, the system works well, because employers are not slow to say when they need more employees and students are not slow to react to new employment opportunities.
After visiting some establishments, I got the impression that even if there were more funding and more students universities would still not have the capacity to deal with them. They can deal with only X number of students in the university buildings and in the outreach clinics in hospitals, dental surgeries and so on. Am I right to suggest that that is quite a major constraint on the numbers that are going through the system?
It is certainly a constraint. Numbers could be increased if there were additional resources and facilities; however, existing establishments find it difficult to ensure that all students have appropriate training and experience. Moreover, in the NHS, placing doctors, nurses and so on in training slows up the clinical service. If someone is trained as they provide the clinical service—which has to be done if they are to be good clinical practitioners—that will inevitably slow things up. Arrangements have to be made to fund that area. I know that additional cost of training—or ACT—funding is available in medicine, but I do not think that the other professions have provisions that take account of the demand that the increased numbers place on the service.
Do you have anything to do with financing hospital doctors who train medical students?
Yes. ACT funding is an estimate of how much it costs the health service to have medical students in hospitals and practices and in other community placements. That money flows to the health boards and what used to be the trusts in proportion to the amount of training and teaching that they carry out. That said, there is an issue of transparency around how that money is used. For example, it is often difficult to trace whether it has been used for educational purposes rather than for underpinning a clinical service.
So we need to pay particular attention to that matter.
Yes. NHS Education for Scotland, which has taken over responsibility for that area, thinks that transparency is a very important issue.
When the convener asked whether levels in some areas of recruitment were falling short, I was surprised to hear Tom Kelly say that all the courses were oversubscribed. Does that mean that there is a high drop-out rate? If so, do you lose more students in certain areas than in others?
I must apologise as we have not carried out any research into that matter. However, we can do more analysis of the numbers if that would be helpful.
I am just surprised to find that, although the courses are oversubscribed, there are shortages in certain areas. I would be interested to see a breakdown of those figures.
We will try to provide that.
If someone who undertook a further education or access course moves on to higher education, would that be recorded twice?
It should not be.
So those people would not be recorded as being in further education. They would be recorded as a higher education statistic.
Yes; if they do a higher national course, they will be treated as a first entrant to higher education at college, but they would be treated as a continuing student if they went on to do a degree course, as well they might.
We need to move on. I am conscious of some of the evidence that we have had that suggested that the issue is often not so much about the number of students but about the numbers of those who get to the end of their course and then go on to work in the NHS in Scotland. The British Medical Association tells us that something in the region of half of all medical students in Scotland do not go on to work in Scotland, which will also have a big impact. I know that several members of the committee want to raise questions about that.
As has been said, the Calman review recommended that one way of increasing the size of the medical work force in Scotland was to do more to encourage Scottish students to enter Scottish medical schools. I believe that students from the University of St Andrews did their placements in Manchester—certainly it was somewhere in the south. I know that that arrangement was being examined but I am not sure whether it continues. Do you have evidence that such situations encourage students to pursue work south of the border when they become registered?
The figures in the Calman report show that the retention in Scotland of medical graduates is lowest for St Andrews students. It is difficult to disentangle whether the fact that the students go to Manchester is the issue, because many of those students will not have been domiciled in Scotland when they entered the course. There is also evidence in the Calman report that the students who are most likely to stay in Scotland are those who were domiciled in Scotland when they started the course. As I said, the St Andrews figures are quite difficult to disentangle but I suspect that the Manchester placement—the students spend the final three years of their course in Manchester—is a significant factor, and that the situation will continue at least for a spell.
Is the arrangement still in place?
Yes.
Are discussions under way to change the arrangement?
The Executive has still to announce its response to the Calman report. However, the medical schools and associated individuals have begun to work on how we can deal with the situation. There are plans that would allow the 50 St Andrews students who are referred to in the Calman report to complete their training in Scotland. Whether that will increase the likelihood of their staying in Scotland is another issue.
If the St Andrews students were to stay in Scotland to do their clinical training, additional clinical places would be required in the Scottish university to which they then moved on.
Is that likely to pose a problem?
It is being considered as part of the Executive's response to Calman.
Not just places but additional funding will have to be considered. At the moment, the clinical funding for those students is covered by the English funding council.
The other general point that applies to what we do in colleges is that the number of years that people spend on their career is reducing, which is a problem. I do not know what the correct figures are for medicine but if, for example, the length of a career in medicine is coming down from 40 years to 30 years, the argument that people can start their careers later becomes all the stronger. We have to consider whether we have the right mechanisms in place to allow later starters to study towards entry to the profession. Colleges would definitely have a role in that.
Does anyone want to come in on the subject of recruitment and retention?
I have a point that has been mentioned to me previously. Professor McKillop confirmed that if we continue to try and recruit in the usual areas we still will not be able to meet our quotas, even if we attracted all the young people who are qualified to go into medicine. That is a big issue and we need to look beyond the usual suspects. What about the high standards that are required for entry into medicine? Do they have to be considered?
I would not like to pretend that the current entry requirements are absolutely necessary to practise medicine, but I do not know by how much one could drop them. The problem is that they are the objective criteria against which one can judge applications. One could use other ways to conduct an extremely extensive assessment, but that would be expensive.
Do the tough standards apply equally across all the medical schools?
They vary slightly, but only very slightly. The standards tend to depend on the number of applications that the school receives.
How do we compare with other countries that do things differently?
Again, it is hard to make direct comparisons because other countries work to different standards—for example, they may use the international baccalaureate and so forth. However, by and large, medicine tends to have fairly high entry criteria in other countries.
I asked the question because we are constantly being told that health care throughout Europe is better than it is here.
My question goes back to the subject of capacity. As we have said, people may qualify in a subject but if there is no job for them in the city or in the rural or remote place in which they live they have to look elsewhere. Have you done any work on how the new trend towards centralisation and a reduction in the number of sites and buildings might affect people such as medical students and paramedics getting placements?
The Calman report addressed the situation of medical students and recommended greater collaboration among medical schools and the setting up of a board for medical education. The present talks have identified that such a board would need to liaise with NHS Education for Scotland and the existing work force planning arrangements to get a more coherent view of the needs of the sector. NES looks after the postgraduate part of students' education. The member raised the issue of the need to have places for the young doctors to go to once they have graduated, which is being addressed in the sector's response to the Calman report.
Perhaps our move towards centralisation means that we are working towards fewer places.
We may be working towards fewer places in hospitals. Increasingly, however, in undergraduate and postgraduate medical training, importance is placed on the community aspect of the training. The criticism that was quite rightly levelled at medical schools in the past was that we concentrated our training on hospitals. Because of that, our students did not see the reality of illness in the community. Increasingly, our training will have to look at community placements of various sorts, whether in general practice, community psychiatric care or whatever.
That is less of a problem for the colleges. Personal and social care tends to be needed in every community in Scotland, which means that opportunities for placements and jobs are more likely to be close at hand.
I will pursue the point that Professor McKillop raised in response to Duncan McNeil, as I want to get it right. I am a lay person, and everyone tells me that there is a shortage of GPs and consultants—a shortage of doctors—throughout Scotland. You have just told us about the huge demand for places at your school. I cannot remember the figure that you quoted—
We get about 2,000 applications for 240 places, but that is just the picture at one university. It is likely that the individuals involved will also have applied to three other medical schools. A significant proportion of those 2,000 applicants will not meet the academic criteria. Those applicants might not meet the requirements even if they were lowered.
I am trying to probe that point. I understand that your figures relate to a particular university, but the general impression is that it is difficult to get into medical school because academic standards are high. However, students undergo many years of training and people mature at different rates. We are told that there is a shortage of doctors, but you tell us that there are huge numbers of people who want to be doctors and you can offer only so many places. Do you see what I am getting at?
Yes. I touched on the matter when I said that I do not think that the current academic requirements are absolutely necessary for someone to become a successful medical student and doctor. However, they are the objective criteria that we have, given that we have a limited number of places. If additional places were available, a variety of individuals could be brought into medicine.
Are you saying that it is not the case that there is no demand for places at medical school; there is a real demand and people want to train to become doctors?
Yes.
How can we effectively train people who might not meet your current standards at the point of application? Surely everything in life tells us—the education system tells us—that people mature at different rates.
Absolutely. The idea that more mature or graduate entrants might be brought in from elsewhere is important. However, postgraduate training, particularly in medicine, is quite long. Someone who wants to become an NHS consultant might train for up to 10 years after graduation. If people start training when they are substantially older, their working life of service to the NHS might be significantly shorter, so we run up against a problem at the other end of people's careers. We perhaps cannot extend mature entrance indefinitely, although many mature entrants can certainly enter medicine.
The number of funded undergraduate places would have to be increased to allow you to recruit more students.
Yes.
The demand is there.
Professor McKillop said that 900 to 1,000 applicants to the medical school at the University of Glasgow meet the requirements—
I said that that number of applicants is likely to meet the requirements.
How many of those 900 to 1,000 applicants do not get a place in undergraduate training in Scotland?
I do not have precise figures. However, across the UK, if someone meets the entry requirements for medical schools they are, by and large, likely to be able to secure a place.
It would be useful to know how many applicants who originate from Scotland do not secure an undergraduate place in Scotland, given that people who train in Scotland are more likely to stay in Scotland. Could you obtain those figures for the committee?
I am sure that we can find those figures. However, we must accept that some people from Scotland choose to attend an English medical school; they do not go to England just because they cannot—
I am talking about people whose first choice is a place in Scotland.
Students apply to four medical schools, but we do not know which is their first choice. That is one of the problems with applications.
Can you give an indication of the relationship between the universities and the royal colleges in relation to the setting of postgraduate standards for medical specialisms and the identification of training places?
The relationship was not always easy in the past and there was a bit of a turf battle. However, that has not been a major issue during the past 10 or 15 years. There is much more talk about the role of the undergraduate schools and what undergraduate study leads into. That is partly because we are now under the influence of the General Medical Council, which published a document about 10 years ago entitled, "Tomorrow's doctors: Recommendations on undergraduate medical education". The document stated that by the end of their undergraduate training, the student should be a generic practitioner with a wide range of clinical and other skills, who will subsequently undertake an appropriate period of training in a postgraduate sphere that allows them to specialise in a discipline. That approach appropriately and helpfully separated the roles of the undergraduate schools, the medical royal colleges and the postgraduate deans. We are now clearer about where our boundaries are and where we can join up without duplicating activity.
Can you comment on that issue in relation to postgraduate courses for allied health professions?
Not directly, I am afraid.
Can anyone on the panel comment on that?
Not at postgraduate level.
That question is for the subsequent panel.
I have a comment that probably applies at the lower levels. It is important that professional institutions that are not Scottish based are willing to accept and recognise our Scottish qualifications framework as providing levels and credit, otherwise we will not have flexibility in professions in which an institution controls licence to practise. We are working on that matter. At present, we generally work case by case through the Scottish Qualifications Authority for our provision, but we need to have that flexibility.
I have a general question for any of the witnesses. On the issues on which you have been questioned, are you aware of the analogous situation in other countries? For example, are there figures on recruitment and retention in other countries? What is the equivalent figure in other countries for those who graduate and then leave the profession? We would appreciate receiving such information.
There is evidence from the United States that most of what are called there the first responder professions—
What does that mean?
It means firemen, policemen and medical workers. Most of them have qualifications from a two-year associate degree. About 60 per cent of all new nurses in the United States have associate degrees. Those two-year college-based qualifications apply to a much wider range of public services than, for example, the higher national diploma in Scotland does. That is an example of a degree that is offered at local colleges rather than state universities and which is deliberately pitched at a wide range of professions.
In the other countries in the UK, the number of individuals who leave medicine for other jobs is similar. The figures for countries in the European Union are varied, which may be related to the ease of obtaining employment. In some EU countries, there are more doctors than work, so people do other things, whereas in other countries where there is a shortage of doctors, there tends to be a high rate of employment.
Are you saying that in certain EU countries there are more doctors than can find employment?
Yes. For example, Italy has large numbers of medical graduates who are either unable to obtain employment or who can obtain only part-time employment.
That is interesting.
I have a quick final question. There seems to be a correlation between the number of postgraduate opportunities and the number of undergraduate places. We have heard in evidence that the undergraduate positions are under the influence of the funding council and the Scottish Executive. What is the connection with postgraduate places? Professor McKillop mentioned the health boards and money not necessarily being where it ought to be.
That was at undergraduate level.
What about the postgraduate level? There is a connection.
The number of available postgraduate training posts is controlled centrally by the postgraduate deaneries and the body that is now called NHS Education for Scotland. In a sense, that number is constrained by the likely number of graduates that will come through. There is a link: for example, the number of pre-registration house officer posts—for the first year after graduation—is dictated largely by the number of graduates. People need those posts to get full registration with the GMC and to proceed to the next step of training. The two are strongly, although not absolutely, linked.
That is why the funding council cannot change the number of undergraduate places unilaterally. We must ensure that the number is joined up with the number of postgraduate training places, which is why we have a tripartite planning arrangement. We will work through that issue in our response to the Calman review.
In the past 45 minutes, the witnesses have indicated that they could provide further information to the committee—we would appreciate that. I thank the witnesses for their evidence.
Meeting suspended.
On resuming—
I welcome the second panel of witnesses and thank them all for attending. They are James Kennedy, director of the Royal College of Nursing Scotland; Bridget Hunter, lead officer for nursing, Unison Scotland; Christina McKenzie, head of midwifery, the Nursing and Midwifery Council; and Professor Jack Rae, dean of the school of health, nursing and midwifery at the University of Paisley. We have received written submissions from the RCN, and the Universities Scotland submission also applies to the panel.
The Scottish Executive partnership agreement commits the Executive to training, recruiting and retaining an additional 12,000 nurses and midwives by 2007. What are your views on those targets?
The targets are quite challenging for the providers, but they are probably achievable. The main constraint on most of us is clinical practice placements, for which we agree numbers with our clinical colleagues.
From our point of view, the words in the partnership agreement are particularly interesting. Having discussed the matter with the then Minister for Health and Community Care and his officials, I know that the figure of 12,000 is, in essence, a recruitment target. The Executive needs to do very little to achieve that target, whereas some of the other targets in the partnership agreement are about growth. The partnership agreement does not build up any specific growth in the nursing work force at a time when we know that, for example, changes in out-of-hours provision, the consultant contract, the development of school nursing and some increased annual leave that is associated with agenda for change, will lead to an increased need for more nurses in Scotland.
Professor Rae mentioned HNC entry, which Unison considers to have been a great success. There has to be some out-of-the-box thinking about how we bring people into the profession, because the academic qualifications have perhaps restricted recruitment. Unfortunately, we have accelerated that in some ways. I would hope that the opportunities that have been gained from support staff coming into nursing through the HNC route would assist. The numbers would increase if we were to think of other ways of bringing people in.
That is an interesting point; I was going to ask the panel what else we could do to encourage people to consider nursing as a profession in the first place.
Yes, indeed. As you know, the former Minister for Health and Community Care, Malcolm Chisholm, chaired an important partnership—the facing the future group—of which colleagues are all part. That group has very much taken up the mantle of considering the recruitment and retention of nurses in Scotland. One of the issues that we have considered is the situation with health care assistants, who are clearly attracted to care and some of whom are keen to enter nursing. Work is going on to support health care assistants in moving into pre-registration nursing courses, and development work is going on in Glasgow, particularly in primary care, in relation to that. We very much support those alternative paths.
Perhaps I could say something about salaried places, which the committee has spoken about. I agree with much of what James Kennedy said.
The RCN submission suggests that 11.9 per cent of nurses who qualify in Scotland do not register. Has any work been done on that? Is there an opportunity to do something about that issue?
Mr Davidson highlights an important point. As a minimum, we need consistent gathering of data across the United Kingdom to enable us to compare like with like so that we can better determine what happens to nurses who train in Scotland but who then choose to go elsewhere. We are working closely with the NMC in considering how a common database might be established. We recommend to the committee that the four health departments ensure that they can compare like with like. The fact that student attrition rates are calculated in different ways across the UK provides an opportunity for fudge rather than for meaningful debate or solutions. From our point of view, that is an important issue.
I agree with Janis Hughes's suggestion that we must continue the debate on whether people can enter the profession on a salaried basis. Without doubt, student attrition rates are linked to the fact that there is real poverty out there. Some nursing students have to work in two or three different jobs to maintain themselves, but they might also be single parents who have other pressures. If we are to be realistic about finding a solution, we need to take that on board.
The Nursing and Midwifery Council is reviewing the standards for continuing professional development. The requirement for 35 hours of CPD over three years is seen as a minimum, but that is likely to become more robust in the near future.
On the figures for the growth in the work force, the RCN's submission states:
There are a couple of fundamental differences. Until the facing the future working group was established, England was very much ahead of us in recruitment and retention strategies. Some things that England has done in overseas recruitment have, rightly, been criticised, because they have perhaps not been done ethically enough. However, the major emphasis has been on growing the core establishment of nursing. There has been real growth in investment in England, whereas the partnership agreement proposals are primarily about the status quo and involve very modest growth. That is why there is such a significant difference.
Are you saying that England has been more ambitious with targets for the core establishment of nursing?
That is correct. One key element that we have highlighted in our submission is a piece of work on the work load of nurses that was led by facing the future. Each health board is making proposals that will begin to address the increased work load of nurses. We believe that that work will provide us with a much better-informed basis for determining how many more nurses we need. We hope that it will put us in a position to grow even more than we are growing at the moment. In the meantime, the major emphasis must be on retention. However, the Department of Health in England has invested much more significantly in growth, as opposed to maintaining a steady state. That is related to service changes.
We would appreciate it if you would send us some back-up material.
I want to pursue this point. In his answer to Janis Hughes's first question, Professor Rae referred to the partnership agreement target of an additional 12,000 nurses and midwives as "challenging", but James Kennedy takes the opposite view—he referred to the "status quo". I am interested in that contrast. I do not have the words of the partnership agreement in front of me, but I recall that it says that the 12,000 nurses and midwives are additional. Is that not the case?
I understand that the figure of 12,000 is an intake target and is about supply to the pool. That is challenging but achievable. At the end of my answer, I said that the target does not indicate what happens to the work force. James Kennedy picked up that point. The question is whether 12,000 is enough, and I suspect that it may not be. Something even more radical is needed.
Does Mike Rumbles want to follow up on his question to Professor Rae? James Kennedy would also like to comment.
I would like to ask a further question before James Kennedy responds. You are saying that the focus is limited to retention. Are you saying that there is nothing wrong with the 12,000 target?
I am saying that 12,000 is an achievable target. It does not relate solely to training, as it includes nurses and midwives who are returning to practice. The question is, is it the correct target?
I return to the partnership agreement. The use of the word "additional" is interesting. If the target related solely to recruitment, the agreement would say, "We will recruit 12,000 more nurses." However, I am sure that it says that there will be an additional 12,000 nurses and midwives.
I have a copy of the partnership agreement with me. In relation to nursing, it states:
I will pursue that, because I was involved in writing it.
It is a fascinating and powerful use of words.
We have to be very careful about how words are used and how they could be construed later.
We must examine entry into the professions, but what concerns me most when I go around and speak to nurses is the existing work force. We are losing nurses because they are tired and worn out. They feel that they are not listened to and that they do not have enough people working on wards. Their clinical position is compromised. I have spoken to one or two people in recent days who would rather go and work in Asda. What are you doing to retain your qualified work force? If we cannot keep that work force because people want to get out of the profession, you will have great difficulty in getting people into it. What are you doing to improve that situation?
I commend the work that has been done by facing the future. We are on that group, but we are not patting ourselves on the back. Some good, innovative ideas have come forward about how to retain staff and remove some of the workload stress. Some thought has been put in on how to do that, but it will not happen tomorrow. A massive amount of work needs to be done throughout the NHS—and it should not concentrate only on nursing. Everyone tends to look at nursing, but we must consider all the professions that contribute to the NHS, not just medics and nurses. Many of the contributions from the professions allied to medicine have assisted with staff retention. There has been some development, but clearly there must be more. There must be opportunities for the professions to grow, and more multistrata working must be developed. There are pilot schemes on that. I understand that there is one in Dundee to examine how allied health professionals can be brought in as helpers and be developed and integrated into the work force to assist with tasks. The Open University is involved in that work, as well as some of the local universities. It is not just about delegation from doctors, but about how we can share tasks better among the work force. Where there are positive gains, there must be support from the likes of the Scottish Parliament. Unison is also looking to support anything that comes from that.
I have read the transcripts of your visits throughout Scotland, Dr Turner, and sadly, many of the messages you heard resonate with me as someone who also meets a lot of front-line nurses. I agree with your assessment that many nurses are exhausted and wonder whether it is worth their while to continue. Other options seem more attractive; they can go and work somewhere, albeit for a lower rate of pay, where they can go in, work and leave. That is one of the reasons why NHS 24 has been successful in recruiting nurses throughout Scotland; that should have been a wake-up call to NHS employers.
Clinical conditions are particularly important to people who are in training. Throughout Scotland there are areas where there is tremendous pressure on clinical practice and students receive less supervision, so the learning environment in practice, which constitutes half of nursing training, is not sufficiently good. That is a significant factor in wastage before people qualify and means that when students qualify they look for employment elsewhere. There are good areas in Scotland and we can identify boards whose budgets are in balance and whose staffing levels are at a particular level. To echo what Jim Kennedy said, such boards are in a position to invest in continuing professional development. It is important that although medical and dental additional costs of teaching—ACT—funding is in place for medical and dental staff development, there is no equivalent funding for nurses or allied health professionals, most of whom pay for their own continuing professional development.
The RCN submission says that there is a
There are a few key issues. A consistent approach to work force planning is needed throughout Scotland. There are benefits in a regional model, but such a model would have to be built up from local need. Nurse managers in the NHS, who are the main providers of information to the Executive about the number of new nurses that will be required over the next four or five years, tell us that there is often no support infrastructure to enable them to make well informed decisions, rather than guesstimates. In the United States, for example, there are more sophisticated ways of identifying longer-term health care staffing requirements. During the next 10 years, the US will need a million additional nurses. That figure is primarily based on well researched work that shows increasing evidence of a connection between the number of registered nurses and the quality of patient care. There is more and more evidence of that. We are pleased that there are now nurse directors in each NHS board in Scotland, who have a key lead role in that work.
I wanted to put a supplementary question to Christina McKenzie. What negotiations has the Nursing and Midwifery Council had with health departments around the UK, including the Scottish Executive Health Department, about the impact of stepping up CPD requirements, not just on cost, but on the capacity of the system? Will the new approach deter some nurses from sticking in nursing?
There are two issues. First, the NMC is examining the matter, but has as yet made no decisions. As part of the council's usual process, there is open dialogue with all the stakeholders in the country concerned as work develops. In this case, all four countries of the UK are involved. The Scottish Executive Health Department will be fully consulted and involved in discussions as they proceed, so that the council can understand the implications for Scotland.
Are you referring to a lack of support from Government?
There is a lack of support from employers and departments.
I am not sure whether this is particularly helpful or whether it relates directly to the current situation, but when a form of preparation called P2000—the 1992 scheme—was introduced there was a debate about the costs of the scheme and of CPD. Essentially, it was said that both were expensive and that we could have one or the other, but not both. Undoubtedly, it is extremely costly to give a large number of staff supported time for CPD, and nurses are the largest single group of staff. I understand that cost was one of the major factors in the debate about P2000 and CPD. One of the points made was that if a nurse wanted to evolve and develop and a midwife wanted to stay on a register that was their responsibility; they had to do the work in their own time and at their own cost. If the issue is readdressed and some allowance is made, people will be supported and CPD will become less onerous.
Would some of the panellists like to provide us with a little more information on the issue?
We are always grateful for additional information.
I will answer the second question first. We can and do provide information on a four-country basis. For example, the number of nurses and midwives on the register in Scotland for 2004 is approximately 64,000. We can give that information.
The figure does not relate to non-registration, which is the issue.
That is correct. We do not have that information, because the number of places for students beginning courses is commissioned by the health departments and through the universities. The Nursing and Midwifery Council does not have a mandate for work force planning. Our mandate is to protect the public, through setting the standards for inclusion on the register. We have no control over the number of student places commissioned, and therefore cannot comment on that.
So you can provide no breakdown of comparative non-registration in the four countries.
No.
I ask James Kennedy briefly to comment on that, which the RCN raises in its written evidence.
I am reassured that the NMC will continue to provide some data on a four-country basis, because that is critical. Our submission has identified a gap between the data that are collected by health departments and what happens at the point of completion of a programme. That is why we say that further research on our students, using a common data set, must be done on a four-country basis, right through to the point of registration or non-registration. If such research were done, we would be able to compare like with like. That is critical, because we have anecdotal evidence that a number of Scottish nurses are moving south of the border when they qualify.
So we are not following any of it to find out exactly what the problem is between whoever might be ultimately responsible. We cannot follow the non-registered down to find out what is going on.
That is correct.
The Nursing and Midwifery Council basically sets education standards for nursing and midwifery. Can Christina McKenzie explain what setting standards means in practice? Does the NMC have the same powers as the GMC does over undergraduate medical training or is there a difference in how the two organisations operate?
The Nursing and Midwifery Council is responsible for setting standards for entry to education and for the requirements for outcomes from education to enable someone to become a nurse or a midwife—to join the register. Those standards must comply with European legislation; we have to work to directives that cover both nursing and midwifery. We are also responsible for setting standards for some of the specialist practitioner level, which is post registration.
My question is how you go about setting those standards. On what basis do you decide what the standard will be?
That is done through consultation. The standards have not been reviewed since 2000, when they were reviewed by the previous body, the United Kingdom Central Council for Nursing, Midwifery and Health Visiting.
Does the NMC look at international comparators when it sets standards?
Yes.
What countries do you consider? How widely would you look for such information?
We would obviously look at the European standards and requirements. Outwith that, we look fairly regularly at what is happening in the wider world, for example in America, Australia, New Zealand and other countries where nursing and midwifery has a long history and is regulated—not all countries have regulation of or standards for those professions.
When the NMC sets standards, does it take into account the knock-on effect that changes in standards might have on how the professions operate? A number of committee members are concerned that some of the standards that are being set across a variety of professions mean that in rural areas it is becoming harder and harder to justify continuing with certain levels of health service provision. Does any of that form part of the NMC's calculations when it sets standards?
The council members would certainly take that into consideration as part of their discussions and deliberations. Their ultimate role is to protect the public; that is why the Nursing and Midwifery Council is there. The overriding factor would be what best protects the public.
Does anybody else on the panel want to come in on those matters?
One of the issues is that standards often take quite a while to respond, but something has to be done fairly quickly at the coalface. After the consultation, it takes quite a long time before you get the standards that allow you to be more comfortable with how people are working. However, there is a provision that any practitioner can take on whatever responsibility they believe is appropriate, if they are content that they are sufficiently well trained. The previous standards came out in 2000; I do not know when the next lot are due. We therefore have to move along, using the original standards from 2000 as a base, and expand what is done in an appropriate way until the next lot of standards come out.
I will focus on recruitment problems in rural areas. Does Christina McKenzie recognise that there is a difference in the skill set that may be required for a nurse who is working in a large teaching hospital in a large conurbation, compared with that required for a nurse working in a remote and rural area? Does the NMC's standard-setting take account of those differences?
The standards that are set for nurses are minimum standards. For example, there are minimum standards for a nurse to be able to nurse adults. If a nurse requires additional skills and competencies because of the environment in which they work, that is covered by scope of practice documents, which are guidance documents that the Nursing and Midwifery Council produces. As Jack Rae said, nurses can have further training and development. As long as nurses feel that they have had sufficient training and are competent to undertake different roles and specialist tasks, there is nothing to prevent that.
Is there a specific training package for nurses who want to work in remote and rural areas? Is back-up provided to encourage nurses to work in such areas?
The Nursing and Midwifery Council does not develop such packages; local service providers would negotiate with higher education institutions to develop suitable packages for local need. We do not get involved in those negotiations.
When a nurse or midwife qualifies, they have reached the benchmark that is set for the United Kingdom. We do not know at the beginning of the training, or even at the end, where the nurse will be employed—it could be in an acute ward, a surgical area, a highly intensive care ward, or in the community in a remote and rural area. A great many institutions work closely with services in remote and rural areas to develop programmes to meet requirements.
What work is being done on the advanced roles that nurses may take on in remote areas?
A variety of initiatives arose from the remote and rural areas resource initiative, which no longer exists but which is being continued by NES. Up and down Scotland, from Inverness and the far north to Argyll, a variety of initiatives exist, each of which addresses a part of the whole, but they do not consider the whole picture in a coherent way.
Does not the whole picture need to be considered? We need a national strategy to address the issue, but there is not one.
As far as I am aware, there is no strategy to consider the additional preparation that people who intend to work in remote and rural areas will need.
That is a clear gap.
I want to give an example of good practice, which we sometimes need to consider. Professor Rae is being a bit modest. A little while ago, I spent a few days in the hospital in Campbeltown and met nurses who are developing through distance-learning work that the University of Paisley has developed. There are good examples, but Professor Rae is right that the work must be joined up and more effective.
The lack of GPs in rural areas means that there are initiatives, particularly in community nursing. One of them is the family health nurse initiative, which the committee may have heard about. That initiative considers innovative ways of bringing in, integrating and using skills that are pertinent to nursing rather than medicine. The scheme provides a broader range of skills—such as those that district nurses or district midwives have—that are more about coping within the rural setting. The initiative is being considered as a model for urban areas such as Glasgow to find out whether it can be adapted to make it suitable for those areas.
The witnesses mentioned the knock-on effects of co-ordination, or the lack of it. In today's evidence session, and in the previous one, most people who have given evidence have said that work force planning is not their responsibility.
That is a fair comment.
We have heard that from the RCN, the midwives, the medical schools and Paisley University and so on, but we have also had the warm words—which we get at a local level as well—that "This is all a teamwork game" and "We are all interrelated" and so on. Where is the evidence that medical schools are working with universities and that the colleges are working with one another? I can understand the perspective. You are serving a specific group of people who have a particular aspiration in their career, but where is the evidence that work is being co-ordinated? If it is not, what needs to happen? I presume that all health professionals are in these boxes. When do they get the opportunity to be educated and trained together, so that when they go into the health service they are more able to work with one another and afford respect and dignity to one another? Patients would benefit from that.
I go back to my earlier point that there needs to be an examination of what the patients or clients—whatever you want to call them—need and what is the best work force to meet that. We then need to begin to prepare that work force. There are 136,000 people in the health service in Scotland, and they tend to be pigeonholed into particular areas of operation. A lot of work is being done. I am aware that most of the medical schools—and the postgraduate medicine courses—work closely with their local client group. However, that is mainly medicine. The schools of health, nursing and midwifery, and the allied health professionals, work closely within their own groups, but there is no clear overarching bringing together of all of that.
Mr McNeil paints quite a depressing picture, which is no doubt why he is considering that issue. My experience, from visiting a number of clinical environments throughout Scotland, is that, while the professions may well train separately to some extent, they have a shared focus on patients and on delivering high-quality patient care. That is the area in which we would want to consider the issues. On your question about solutions at a strategic level, that must involve considering the nature of the service at a national level, what the nature of the work force is, and then how we will supply that.
One example in our evidence gathering described nurses who were dealing with pain management for terminally ill patients working their way around a reluctant GP. That is not good working.
I completely agree.
We are talking about capable nurses, providing a dedicated service to terminally ill people, having to take into account the sensitivities of a general practitioner who may be offended and may stop that practice. That is only one example—I am sure that there are others, but I do not want to be negative. I know that there are also great examples—I had better watch what I am saying because there are two nurses in my family.
I sense demarcation disputes here.
That is exactly what this boils down to. All the professions in the NHS have territories of which they are very protective. They have to be—it is historic. I do not know how we will change that, other than perhaps, as I said earlier, thinking about a multistrata work force. There is some core training together—there has to be—but such a work force would involve the professions that are allied to medicine working across professions. Each would get a chance to see what the others do, so that they are not so protective about their issues, and so that they can understand other professions. That does not just apply to health. One of the starkest reminders of that is what happens between the health professionals and social work. The joint future agenda is trying to overcome that, and to make things better for the patients that we serve. However, such demarcation lines exist even within the health service.
Finally, the committee has received petitions about the withdrawal of consultant-led maternity services, which has become a controversial issue throughout Scotland. What measurable effects has the withdrawal of such services had? Does the panel have information on that that could be given to the committee?
I will take the issue away and make a written submission to the committee.
I, too, will come back to the committee on that.
There is evidence that midwives are taking on, and are prepared to take on, considerably more responsibility, but there is a tremendous public aversion to change. In some areas I know that the local press has signalled that this is the end, as if the lives of pregnant women would no longer be safe when they are looked after by a midwife rather than by a doctor. A big presentation is needed to change that. Midwifery and nursing-led systems should ensure that people are as safe as they are now.
I support that. There is a misconception that midwifery-led care is a downgrading of service. However, evidence from various units across the UK suggests that midwifery-led services can provide better outcomes. There is an issue about the management of the information.
Any further written information that the panel can provide on that will be very useful. I thank the panel for coming along—
I have been sitting here for an hour.
I am sorry, but the panel has already had to sit for 15 minutes longer than was advised, so I will close the meeting.
I did notify you.
I must close the meeting. I thank the panel members for coming along. We look forward to receiving the information that they indicated that they would provide.
Meeting closed at 15:59.
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