I ask the first panel of witnesses for our work force planning inquiry to come forward. The panel comprises Professor Tony Wildsmith, who is a Royal College of Anaesthetists council member; Dr Mairi Scott, who is the chair of the Royal College of General Practitioners Scotland; and Professor Graham Teasdale, who is the president of the Royal College of Physicians and Surgeons of Glasgow. We will move on to questions and Jean Turner wants to go first.
This might not be an easy question to answer, but what are the witnesses' impressions of the work force planning process in Scotland?
Do we have a proper work force planning process in Scotland?
In the past, such a process has been lacking. However, during the past two years there have been many developments and improvements and the foundations of planning for the future look much more secure.
Work force planning for general practice is complex, because we are independent practitioners. That has had an impact on the number of general practitioners who are in the work force and the issue is of concern to us. As Graham Teasdale said, we are beginning to see a way forward, but much remains to be done and we have some catching up to do on GP work force planning.
We are having a bit of a problem with the sound, which is not projecting well. Could people speak up a little until we establish what is wrong? At this end of the table we are having difficulty hearing what is being said.
I know that I am the deafest person in the room; that is why I am wearing headphones.
I and many others have always regarded general practice as bearing the burden of changes in the national health service, such as centralisation and the reduction in the number of hospitals. Is Dr Scott worried about how we will fund the numbers of GPs that will be needed to cope with the new contracts and the new work loads that will come the way of GPs?
Yes, we are worried. There is capacity and capability within general practice and primary care to deal with many of the issues that will arise from service redesign. However, adequate resourcing will be needed, some of which will be about increasing training opportunities in the current and the new programmes. Resourcing considerations will need to take account not just of the number of opportunities for people to take part in the training programme, but of the support that the established GP principals, practitioners and trainers can give and of the structures in NHS Education for Scotland and the colleges for delivering that training. There are opportunities for us to deal with the issues, but we will need considerable resourcing to deliver on them.
Are you worried about the number of staff that might be available in hospitals as you increase the teaching of young doctors who come along? Are there enough consultants or senior registrar-equivalents in hospitals?
An important thrust of the new training for general practice is that more training should take place in the general practice setting. I can say confidently that we will have the capacity, particularly if we grow the work force over a couple of years, to deliver that training. However, the emphasis on the hospital component of training continues to concern the Royal College of General Practitioners Scotland, not least because we consider the proportion to be inappropriate. Some training posts deliver excellent generalist training to future GPs, but some do not.
I address this question to all the witnesses, but it might be interesting to hear from the consultants' perspective. Do you have concerns about the new contracts? I am thinking about the differences between the contracts in Scotland and England. It seemed from the submission that you were worried about the United Kingdom initiatives as opposed to the possible implications of our approach to work force planning being slightly different.
I think that you want me to respond to that, Dr Turner. There are a number of aspects to the new contracts. The first is that how they have been introduced at trust health board level has created tension between the time that people spend providing clinical service and the time that they have for education. Quite naturally, trusts and doctors have tended to give priority to clinical service, but the feedback that we receive is that that is at the expense of commitment to education. We surveyed our members and about a third of them felt that the new contract arrangements were impeding their involvement in training.
That is an obvious concern because we already have a staffing problem and more people might go south.
I agree absolutely with that.
Does Mike Rumbles wish to ask a question?
I wanted to ask a specific question about the submission.
The second paragraph in Professor Teasdale's submission makes the general point about the need to recruit more people to allow training to take place. How significant is what you say in that paragraph, for example the remarks about off-the-job training and training that takes people off the job? It is my observation that a lot of training takes place on the job. From our point of view, there are many opportunities for that: clinics and peripheral hospitals allow such training to take place. New ways of training, such as through software packages, are not mentioned in your submission. Are we in a box? Is it that we know where we are at present but not where we would like to be? Although your submission identifies the problem, it is a bit short on proposed treatment.
We are not in a box; we are on a very fast-moving runway. The situation is changing more rapidly than anyone in the profession or the Executive expected.
I accept that. I speak to consultants in hospitals and I know that as well as junior doctors not being available when they are wanted, consultants are sometimes left with a major clinic while the junior doctor opts to be somewhere else in the hospital. Is it time to examine the new junior doctors' deal, given its impact on patients and services, at least in the short term?
The legislation that has made the biggest impact has been the European working time directive, which came into effect in August and with which I am sure members are familiar. It limits the time that a person can work in 24 hours—a person must have 11 hours rest in 24 hours. One problem was that the original legislation dealt with only two states—working and resting. That created a difficulty because if a doctor is in hospital providing cover and gets a full night's sleep, is that work or rest? Two court judgments have defined that situation as work, which has given rise to many of the intense pressures. Whether the judgments are right or appropriate is a topic that the committee might debate with other colleagues, such as the representatives of the British Medical Association. The issue is being considered. The European Commission has issued a consultation to consider the definitions in the light of the judgments.
It may be more appropriate to ask the BMA about that.
I will focus on Dr Scott's written submission, which I found genuinely fascinating, especially the table on the number of GP training posts. I analysed the figures and found that the Royal College of General Practitioners Scotland is saying that in the past 10 years we produced on average 270 doctors a year, while in the 10 years before that we produced on average 318 a year. We produce fewer doctors now than we did 10 years ago and we produced fewer then than we produced 20 years ago.
I will answer the second question first. We have been talking about the issue for the past few years. Work force planning for general practitioners is a complicated issue. We did not compile the figures alone, but with NHS Education for Scotland and the Scottish general practitioners committee of the BMA. Because GPs are independent practitioners, it is difficult to count up the number of hours that any one doctor gives to the service. Some GPs will be on a list and may contribute only one session a week as a locum, whereas others are full-time practitioners in a practice who deliver 10 sessions a week. The numbers game is complicated.
How appropriate is the Calman recommendation that 100 more doctors should be trained every year? If the Scottish Executive funds the recommended number of 100 a year, will that solve the problem in the long term?
No, that would not solve the problem in the long term, because those extra 100 doctors would not all be general practitioners. That number would be the increase in the number of graduates from medical school, some of whom would go for alternative career pathways.
I wish to pursue this. The committee feels that it is important that we find out what the blockage is in training GPs to meet the needs of Scotland. We are told that there are four applications to become a doctor for each place that is available, so the demand is there in our schools. People want to become doctors. Who is the gatekeeper? Who is not allowing those people through? Is it that the Scottish Executive is not giving the funding? Is it that the universities are not providing the places? Is it that the royal colleges are not pushing the doors open? What is it?
The simple answer, which is really complicated, is that it is all those things. The journey from becoming a medical student to becoming a GP is a long one. Naturally, during that journey there are opportunities to make career preference choices, which is why I say that increasing the number of graduates by 100 does not mean that 100 more GPs come out the other end.
I want to focus on what you said. You want more doctors to be trained. Is that right?
Yes.
So where, from your perspective, is the blockage? I know that you said it is all the things that were mentioned—from which I take it that you as a royal college are taking some responsibility, along with the Executive and the universities—but if you had to put your finger on it, where is the blockage that we are attempting to unblock?
The current blockage is the number of GP registrar posts. That is a clear block. We have a number, and it is the number we can train. We cannot train any more because of that.
Who changes that?
The Scottish Executive.
Quite a few members want to come in. I will try to get as many in as possible.
My question was on training.
Perhaps we will stay on the current topic for the moment.
I want to go back to something that Professor Teasdale said about the pressures in balancing the time for service delivery with that for training and education. I seek clarification, because in your submission, under urgent actions that are needed, you ask for a
That is a wish for a wand to be waved and, of course, there is none. I was reflecting the comment that when the new contract was introduced, most doctors identified that they were working 56 hours a week whereas the maximum funding is for 48 hours a week. In deciding what to include in the job plan, service delivery was given priority at trust level. That was understandable because the trusts are charged with service delivery. The inclusion in the job plan time for an individual's own continuing education and training meant that their contribution to education and training others was squeezed. We are going to need more of that because, as you heard from Dr Scott, new training is going to demand more time. From the new plans that are being introduced, all countries expect that doctors will be trained over a smaller number of years from start to finish and over a shorter period of time during the day. It has been calculated that people will have had a third of the experience that they get now, so the time that they are actually in hospital has to be maximised and has to be proper training time, not just time during which they provide a routine service. That training time has to come from somewhere. There has to be time to train doctors and to develop programmes. I can quote quite a number of my colleagues who say that their contributions to education have been threatened by the new arrangements.
I appreciate what you are saying but the business of health is service delivery. From where the patients are sitting, their priority is to have the services delivered locally. The difficulty that you highlight is that there is no magic wand.
First, I will pick up on two of your earlier points. The Executive attempted to encourage a balance between work and training but implementation fell to the trusts—there was an attempt to wave a wand, but it was not a magic wand.
But is not there a responsibility on consultants, in recognising that, to be more flexible in the light of the new contract, particularly in relation to out-of-hours work? The matter seems to come down yet again to finance. Your submission states:
The BMA might want to take up the issue of hours and rates. Consultants put patient care as their priority but if they are working nights and weekends they could be taken out of work time during the week.
I agree in general with Professor Teasdale. There are different specialty views, which is why there might be some differences between what he has written and what I have written. However, the use of non-consultant or consultant career-grade staff for out-of-hours cover, to which I refer, should be seen in the context of trying to provide an interim solution that keeps a service going until there is a more rational solution that does not necessarily involve so many acute sites being open out of hours. Putting a consultant on a rota out of hours is a relatively expensive and inefficient use of that consultant's time unless the hospital is dealing with acute emergencies out of hours. My submission talks about an interim solution.
I want to pursue Mike Rumbles's line of questioning a little further. I heard the answers, but I am not sure that I was satisfied that the panel answered his questions in full. We understand that there is a point at which people withdraw from the pool to go down the specialism route, but Mike Rumbles made the point that, at the very beginning of the university medical school teaching process, there is a massive pool. We heard about that at our previous meeting. I think that Mike Rumbles said that around five people chase every university place. We have not heard from anyone why the number of places is being limited when there is such a dire shortage throughout Scotland. Why are we not capturing every person in Scotland who wants to train as a clinician?
There is a limit to how many doctors we can train. In the past 20 years, there has been a huge expansion in the number of medical students in Scotland, but we have reached the stage at which patients occasionally complain about the number of students who queue up to examine them. That is why every medical school is exploring different ways of training people, for example by opening clinical skills units. We cannot expand infinitely to train all the potential recruits, and not all applicants are necessarily suitable. I do not know whether they are all suitable, and they might not be.
Does that not contradict what Dr Scott said? She said that there is the capacity to do the training, but the issue is to do with getting people into the medical schools. Let us say that 2,000 people are chasing 284 places. Why can we not get those 2,000 people into universities and teach them rather than limit the number of places to 284?
That is because it is necessary to treat training as a continuum. I cannot answer for general practice, but I think that Dr Scott was saying that, from the medical school output, there are applicants for training in general practice but there is not a sufficient number of posts for that postgraduate training.
Does that not come across as a restrictive practice? We, as politicians, and the man on the street are asking whether this is about consultants wanting to ensure that, rather than have a sufficient number of consultants available to fill all the posts, there is such a shortage of consultants that they get paid over the odds. The man on the street wonders whether this is about consultants protecting a very lucrative market for themselves.
I have been volunteered to respond—it was ever thus.
I will pick up on the general practice aspect of training. We are clear that there is capacity to increase training and teaching in general practice. As both my colleagues have said, we are examining ways of allowing medical schools' clinical teaching to take place more often in community settings. The number of occasions on which GPs come on to campus to teach clinical skills and vocational studies, among other things, is increasing all the time. However, we currently deliver 12 per cent of the teaching for 5 per cent of the funding budget. Again, the issue is the need to shift resources in order to increase capacity. I am clear that that can be done.
We are back to the boxes again—this is the way in which we have had to deal with the evidence. Each panel looks at their particular interest and sometimes that can be presented as self-interest. Do we genuinely need all those graduates to be trained to consultant level? Do we need all those GPs, given all the talk of teamwork and the increased use of allied health professionals, nurses and so on? Why do we need all those doctors and all those consultants if not to pursue specialisms and subspecialisms, which the panel members have not mentioned today? That matter is of at least equivalent importance to the European working time directive and the hours worked by junior doctors, and it certainly has an impact on which services can be delivered locally in many of our communities. That is all part of the package that we are being presented with.
On the generalist aspect, what you are talking about is skill mix. GPs clearly work extensively in teams and without the primary care team primary care itself would not function at all. However, there are training issues about developing skill mix—you would expect me to say that—and we should put aside the issue of whether there is adequate personnel in other branches of the profession, such as AHPs and nursing, because there are recruitment problems in those areas as well.
You made the point that you get too little of the training budget. Should we allocate that training budget to other health professionals besides doctors? Is not that a fundamental question?
I return to my answer that it is about team working, sharing responsibilities and ensuring that skill mixes are appropriate. You simply could not train off one branch of professionals and say, "There, now you've got the skills," and expect that to make the service manageable and the patient journey safe.
So it can be done only through the GPs.
No—it can be done only through the set-up that I am talking about, with the general practice and primary care skill mix. GPs have to be integrally involved in that.
Do you control it?
No. We are involved in it.
I believe that Mike Rumbles wanted to comment. Has your question been dealt with in the interim?
I will come back in later with a question for another panel of witnesses.
I refer to paragraph 4 in the submission from the Royal College of Anaesthetists, which concerns the shortage of anaesthetists and discussions that have taken place in the past and in some other EU countries about the use of nurses in that role. The submission states:
British anaesthesia as a whole has long supported the principle that anaesthesia should be delivered by properly trained, medically qualified specialists. There is certainly a view that one can, under certain circumstances, use one physician anaesthetist to supervise two other non-medical individuals—from a nursing or some other background—who would do the mechanics of the anaesthesia while the physician stays a little bit in the background. That requires a different way of working in hospitals and operating theatres to the one that we are used to in the UK, and the impact would probably be as great on my surgical colleagues as it would be on anaesthetists, and perhaps even greater, because operating room schedules would have to be arranged very differently. We also feel that our standards are higher, but I cannot quote you any evidence to prove that.
Are you are saying that the reason why there is not a great deal of enthusiasm for the extension of the role of nurses into this area is the impact on nurses and the specialisms in which they work rather than a lack of enthusiasm from your profession?
It is both. For some of the reasons that Professor Teasdale talked about, the pressures are a lot greater south of the border. A number of my colleagues in the south are prepared to review the issue and there are some pilot studies of the training of either nurses or operating department practitioners up to the equivalent roles that are used in Europe. I am on one of our college committees—to some extent as one of the unbelievers—and I recognise that we have to look at the matter, but we must do so cautiously because we might create a problem somewhere else.
What does the evidence show from the other EU countries where this has been tried? Has it been successful there?
Most of them would like to move to our situation, in which anaesthesia is delivered only by physicians.
So they are doing it because the need is so great.
Their needs may be greater, but it is more traditional in those countries—it is just the way in which they have worked in the past.
We are running into a slight difficulty with time. I have been trying to have a conversation about how to proceed for the rest of the afternoon. It is evident to me that we could keep on questioning the panel for the same amount of time that we have used already and we would probably still not exhaust our questions. However, we have two other panels. I wonder what the committee's view is: should we continue with this panel for a little longer in the expectation of making up some time later this afternoon or should we consider asking the panel to agree to come back? Of course, the difficulty with my second suggestion is that it would involve consideration of our forward work programme and when we plan to finish the inquiry. I do not want us to spend only 45 minutes with the witnesses when we could clearly spend considerably longer with them. Do members have any views?
My questions have been asked to some extent—perhaps not in detail, but the generalities have been covered.
The problem is that there are still a lot of other questions; I do not think that everybody else will feel as Helen Eadie does. I am guessing about that, but I have scribbled down a number of questions that I would like to ask and I wonder whether others are in the same boat.
Given that the panels have made the effort to come here today, I wonder whether you would care to have a short suspension and discuss with all the panel members whether they are prepared to extend the afternoon to save making a second journey to come back to the committee.
Does anyone else have any feelings on the matter?
One way forward, although it is not ideal, is for us to put in writing the questions that have not been asked and pursue any burning issues orally for an extra 10 minutes. It would be difficult to extend the afternoon significantly at this stage.
I was thinking about the possibility of inviting the panel back for a second session on another day, if members think that that would be appropriate. The only thing is that that will give us some difficulties with our forward work programme; the clerks are probably cursing me as we speak. It seems to me that we run the risk of not drawing out from the panel the full extent of their information. If we invite the panel back, people can hold their horses in respect of questions.
I agree with that.
I am just concerned that we are only halfway through the panel. I know that Fergus Ewing is probably attending the meeting in relation to the Belford hospital action group. Fergus, do you have any specific questions for this panel that could be dealt with before we move on? [Interruption.] I see that Carolyn Leckie wants to get in, but the point is that I am going to ask the witnesses to come back.
If I may, I have three specific questions about work force planning in rural areas.
Well, that is precisely the route that I do not want us to go down. I appreciate that everyone wants to ask such questions, but it will take up another 45 minutes. I apologise to Fergus Ewing, but I think that I should ask whether the witnesses are prepared to come back to the committee at a future date. There is a lot more that needs to be explored.
I am very keen to come back and help the committee as much as I can.
I am happy to come back before the committee, but I am equally happy to answer most of its questions in writing.
It might be helpful to combine the two approaches.
I really wanted to ask this panel three brief specific questions. Indeed, I could put them into one question, if that would help.
I will allow it if your question is genuinely very brief and if we can get relatively brief answers from the witnesses. If the witnesses feel they cannot give a brief answer to any part of your question, they can offer a response in writing.
I am extremely grateful, convener.
I said that you could ask a short question, Fergus. It is already very long.
First, have the panel members some sympathy with the recommendation from the group, which is made up of 15 clinicians, that there should be a new category of hospital, namely a rural general hospital?
Come on, Fergus. I gave you the leeway to ask a single question and you are putting your three or four anyway.
Finally, accepting the convener's admonition, I wonder whether the witnesses recognise that NHS Quality Improvement Scotland presents particular difficulties for work force planning for a sustainable future for such hospitals.
I will not invite the panel to answer those questions, because each of them would require a fairly long answer. If you can provide a written response to Fergus Ewing that could be copied to the rest of us, please do so. We will also notify him of your next attendance at a committee meeting.
I would have pursued this point with the first panel of witnesses, but I will do so with this panel, because it relates to a fundamental issue. I address my question particularly to the witness from the BMA. The submission from the Royal College of General Practitioners Scotland says:
Professor Rubin is probably better placed to answer that, because the GMC has responsibility for undergraduate education.
That is a good answer.
I am happy to answer the question, not least because I have the facts in front of me. The facts are in the public domain and can be obtained from the Universities and Colleges Admissions Service, through which all students apply to medical school. For the autumn 2003 intake, there were just fewer than 900 applicants for just fewer than 700 places at Scottish medical schools. I hope that I can correct the misapprehension that thousands of highly qualified young people have the door slammed in their faces. That is not the case; there are around 1.2 or 1.3 applicants per place in Scotland.
If there are 900 applicants for 700 places, 200 people do not get a place. To the best of your knowledge, are we rejecting 200 people who qualify for a place under the current requirements? Are there people out there whom we could train?
I do not think that all 200 applicants would qualify, but a proportion of those applicants would meet the academic and other criteria for getting into medical school.
I am pushing my luck by pursuing the point. If the Scottish Executive were to accept the recommendations in the Calman report that we fund 100 extra places in Scotland, would there be a problem finding qualified people to take up those places?
There would not be a problem for two reasons: first, because of the numbers that I outlined; but secondly, because if for example some or all of the Scottish medical schools were to go down the route of graduate entry—members might know that the English medical schools have done so to a large extent and that there are 14 graduate-entry medical schools in England—there would be a new pool of applicants who would be interested in changing career and entering medicine in their 20s, 30s or 40s. There would be no risk that the new places would remain unfilled.
The demand is there.
Yes.
I add one point to that, with reference again to Professor Calman's report. There is an issue around Scotland-domiciled students versus students from other parts of the UK or the rest of the world. Scottish students are disadvantaged in gaining entry to medical schools because although they are required to achieve five highers at one sitting, many schools in Scotland do not allow students to take five highers at one sitting. That is the fundamental point in Professor Calman's report that is worth bearing in mind.
Shall I ask my questions now? That might be the easiest way.
Yes, you can continue on the Calman report now that it has been mentioned.
The first question concerns the lack of capacity in the university sector, for which the Executive has been blamed. The second question is about postgraduate training. Over weeks of evidence, rather than just today and at our previous meeting, we have heard that there is not enough time for people to give training within the hospital system and to deliver patient care. Have you any comments on that situation, or any solutions for addressing it? Even if we get graduates into medical schools, where do they go after that? How do they get trained and how do we retain them?
There is a fundamental issue about numbers. Scotland has always been a net exporter of doctors, so there is an issue about trying to retain the graduates whom we train. There are specific problems in academic medicine across the UK and in Scotland. There are concerns that, as a result of the introduction of top-up fees in England, we could lose medical academics to other parts of the UK. Undergraduate and postgraduate training is not entirely within the remit of medical academics, but they have a key role to play in it.
Are you suggesting that we need a new breed of medical school staff who would be teachers rather than researchers?
The only significant new breed of medical academic staff needed is specifically in medical education. Again, that is in Professor Calman's report.
The breed of people who teach medical students is not, by and large, the academics but the clinical staff who work in hospital wards. The problem in postgraduate education is part of a much bigger problem. When a consultant is appointed to a post, that can make it seem that services have been expanded. However, a consultant can be appointed without their having, for example, an operating theatre, an office, a secretary or clinic space. Such services add hugely to the cost of an appointment and they are often neglected because there is no funding for them.
So if the Executive funds medical schools to take more students, a bottleneck will still occur in NHS clinical training.
Yes.
The figures from the BMA and some colleges tell us that we are likely to be 1,000 medics down in the next few years, on current requirements—although techniques may change. How do you envisage such a bottleneck being removed? Is that down to the consultant contract? Or do we need to employ more consultants and equip them with the services that you have just described?
The association that I represent hopes that the consultant contract will contribute to tackling the problem. Consultants in most fields do not spend all their time working fixed sessions. For example, surgeons are not always in an operating theatre. The majority of surgeons will have three operating sessions a week, in either the morning or the afternoon, and they may also have a couple of clinic sessions; that leaves other time during the day that is not necessarily used for clinical work. That other time may be used for administration; it may be used for seeing relatives; it may be used for teaching. It has been apparent to many of us for a long time that a lot of that time is not spent profitably in teaching. We hope that the consultant contract will nail down that time and ensure that consultants, rather than being elsewhere, are present and teaching, and that they are not leaving the teaching to junior staff.
Is there a magic cure?
Hospital general managers now have a tool to tackle the situation, in the form of the contract.
Mike, do you want to come back in on Calman?
No.
I have a quick question for Dr O'Neill. In your submission, the first paragraph under "Medical students" refers to
I would be happy to write a 500-word essay and submit it.
Perhaps you could be a bit more succinct.
Clearly, we have a problem in retaining graduates in Scotland. We must examine that, and provide consultant opportunities or places in general practice at the end of their training.
On the working time directive, David Currie's submission refers to the
At the moment, the elephant in the room for medicine in Scotland is the European working time directive. We can talk about solutions of all sorts for our existing manpower problems, but the big problem that is standing in the way and creating the most staggering anomalies is the European working time directive. For example, we have an across-the-board standard for working hours, irrespective of whether one happens to be the dermatologist working in Inverness or the orthopaedic surgeon working in Glasgow, with a hugely different intensity of work. We are not considering the intensity of work; we are applying standard working hours across the board.
Are you aware of differential application of the European working time directive within the European Union? Is it not the case that, in some countries outside the EU, similar processes are being introduced anyway, even though they might not be referred to as coming under the European Union working time directive? Is what is happening here wholly anomalous or not?
I do not have evidence on that, but the committee might find it very useful to seek such evidence. The word on the street is that a lot of European countries ignore the legislation.
Do you have any evidence at all for that?
No.
You, personally, have no evidence of that.
No. We are, however, aware of efforts being made in this country to get round the legislation. The current deal in Lochaber represents one such effort. There is not going to be an increase in the number of consultants, but a deal has been worked out. With a little bit of creativity and co-operation between different units, we can go some way towards meeting the requirements of the working time directive. However, we will not satisfy it altogether without either an amalgamation of services and a stripping of services out of the rest of Scotland or a big expansion in the number of consultants, which I do not believe we can achieve.
Does the same situation confront non-EU countries, as far as you are aware?
I am afraid that I do not know that.
Does anybody on the panel have any information, experience or evidence about what is happening elsewhere?
The one concrete piece of evidence is the number of doctors per 100,000 population. In the United Kingdom, we have disproportionately fewer doctors than in other European countries. There are approximately 250 doctors per 100,000 population in the UK, although the figure is slightly higher in Scotland compared with England and Wales; in most European countries, there are around 330 to 350 doctors per 100,000. In some countries, there are in excess of 400.
How many of those doctors are unemployed in Europe?
Some countries have some unemployed doctors, but—
What is the point of that?
We heard some conflicting evidence earlier this afternoon about the situation in Germany, which suggests that the issue is not straightforward.
I was struck by how honest David Currie's submission was in its analysis of who benefits from the health service and whether the health service is designed around the needs of doctors rather than patients. It is refreshing to hear that view being expressed in such an up-front way.
Could you ask a question, please?
It is a question. Would it be possible to achieve an increase in the number of consultants with a broader skill base? If so, how could we implement that solution within a reasonable time?
I will take your last point first. We are making moves to train people specifically for medicine and surgery in remote and rural areas. The first such consultant—a Scottish graduate, trained in Scotland to be a Scottish surgeon on one of our islands—has just started work in Shetland. We should be greatly strengthening and encouraging such initiatives for posts that have mostly been filled by people from abroad and which have very rarely been filled from among our own graduates.
I would like to pursue that, because I think that it is an important issue. If I heard you correctly, I think that you said that the people whom you were talking about were trained outwith Scotland.
No, they were trained in Scotland.
Where were they trained and how did the royal colleges respond to that? We get the feeling that there is a dislike of that model, because we hear that it is safer to have more specialisation because of the number of people involved. However, someone somewhere has clearly turned that around and has faced the other way. Who did it? Where were the people trained?
The royal colleges have accepted that as a legitimate specialty and the first graduate has been appointed as a consultant with accreditation in remote and rural surgery. The training was provided in a multi-centre fashion, principally in Glasgow but also in Aberdeen, and it involved visiting the different specialties that that surgeon will be required to know something about.
Are more people coming behind that surgeon?
There are more people coming behind, and I think that you will have the opportunity to speak to Professor Needham, who is the postgraduate dean for the north of Scotland and who has a specific interest in the subject. I believe that she will be speaking to the committee next week.
That is interesting.
I want to develop the question of alternatives to the orthodoxy of centralisation. I am always reminded that one of the main drivers for setting up the NHS in the first place was to avoid the sucking in of specialisms into teaching hospitals and the lack of access that resulted from that. The aim was to spread out the specialties and to address inequalities. I sometimes wonder whether we have come full circle, as we are having to make the same arguments again about the balance between centralisation and generalism.
Carolyn, come on.
Sorry. What co-operation is there to support nurses into medical training and would you support such a move? That is it.
This witness panel has only 10 more minutes. If issues have been raised to which you think it would be better to respond in writing, please do so. If there are issues that you think we can deal with relatively quickly this afternoon, you can do so too.
I will deal briefly with the midwifery issue. As an undergraduate I was terrified of midwives, rather than taught with them. I am sure that Carolyn Leckie will remember those days.
Does any other panel member wish to respond on any of Carolyn Leckie's points?
I agree that general practice specialisation has a great deal to offer us. A lot of what has traditionally been kept jealously as hospital specialty work is now being done—increasingly in the form of clinical networks—by general practitioners and hospital colleagues. Nurse practitioners are an important brick in the construction of some kind of out-of-hours service in hospitals, given the reduction in junior staff hours and the coming reduction in the number of consultants. Nurse practitioners are coming in in a patchy fashion, but they have a huge amount to offer in keeping specialties where they are.
Why does an expert on the elbow have higher status than a generalist who can deliver the services that a community would want? Why are people being given a choice between excellent service and no service at all in their locality?
I will have a go at that question. One factor that encourages medical students to follow a certain path is the role models that they have. I will give a parochial anecdote. My medical school at the University of Nottingham was established in the late 1960s primarily to improve the woeful quality of primary care in the east midlands. A major approach to doing that was to ensure that primary care was a big part of the undergraduate curriculum and that from an early stage—week 1 of year 1—medical students were exposed to enthusiasts in primary care.
I will follow up Duncan McNeil's point. Does England provide lessons to learn from foundation training? England does not seem to have the same difficulties in converting undergraduates and graduates into GPs.
I am not entirely sure whether I understand the question. Are you talking about the new foundation programmes and modernising medical careers?
Yes.
They come into effect next year. The committee will take evidence from NHS Education for Scotland next week or the week after, so perhaps the question would be best put to it. We are considering systems to ensure that people have access to most sectors of medicine during the foundation programme, which will last for two years immediately post graduation—that is expanded from the current one year. I am not sure whether I have answered the question.
I asked the question because I wanted to know what the groups that the witnesses represent think of foundation training and because the answers that you have given suggest that the resources are not available to provide the programme in Scotland. Is that the case?
Significant progress has been made on examining the details of the two-year foundation programme. Recently, a commitment was made to include the opportunity for teaching in general practice in the programme. Modernising medical careers goes beyond the two-year foundation programme to specialist training and offers great opportunities. Significant challenges will be presented and much detail must be worked out, but the solutions to many difficulties that we now face across the NHS rest with modernising medical careers. I have seen nothing that suggests that Scotland is worse off than other parts of the United Kingdom.
Do your colleagues agree?
I agree.
Do you agree in the light of the evidence from the Royal College of Physicians and Surgeons of Glasgow? It has stated categorically:
I do not disagree that challenges will arise, but we can overcome them. The will and commitment are present to sort out the difficulties that will arise from the changes throughout the range of postgraduate training.
You would not have used the terms that I quoted.
I would have used different phrasing.
Nobody else wants to comment on the harm that the Glasgow royal college says is likely to be created.
Meeting suspended.
On resuming—
I welcome the third panel of witnesses: Dr Holdsworth from the Chartered Society of Physiotherapy Scotland and Stephen Moore from the Society of Chiropodists and Podiatrists, both representing the Allied Health Professions Forum Scotland; and Marc Seale, the chief executive and registrar of the Health Professions Council.
We share the view of the previous Minister for Health and Community Care. Although I speak on behalf of the physiotherapy profession, I know that many of our concerns are shared by the numerous disciplines that make up the Allied Health Professions Forum. The advent of work force planning for our professions has been very recent. I am aware that an advertisement has been placed for a work force planning officer in the Scottish Executive to lead on that agenda; we believe that that measure is long overdue.
I echo that and add that, as soon as the work force planning officer is in post, we will need to put in place systems that provide robust information for the health service to make judgments on work force planning. That information has not been available in the past, so we need to look critically at what information will be helpful and how we will get it, so that we can have it as quickly as possible.
I have no knowledge of what has been happening, but the Health Professions Council has an enormous amount of information about health professionals, for example on geographical breakdown and age, for anybody who is undertaking work force planning.
Members want to ask a number of questions so I will try to ensure that we get through as much as possible in the short time that we have.
My first question is for Mr Seale. The Health Professions Council website claims that it is a
We approve about 350 programmes throughout the UK, predominantly at universities, although training for paramedics is not undertaken within the university system, for example. We influence the quality of the individuals who complete courses in several ways. One is by setting what are called the standards of proficiency, which lay out what we expect a new registrant to be able to undertake in their profession. Secondly, we publish standards of education and training, which, in essence, are the standards that universities must reach to ensure that the individuals who complete courses meet our standards of proficiency. Thirdly, we run tribunals on fitness to practise. If a registrant does not meet the appropriate standards, we can act either to remove them from the register or to have them retrained.
Do you have as much influence and control over nursing courses as the GMC has over medical training?
It is difficult for me to comment on other regulators. There are nine regulators of health professionals in the UK, each of which works under substantially different legislation. While I have a reasonable understanding of what the HPC does, I cannot comment on other regulators' work on educational standards.
Do you have influence over recruitment and retention for the various professions?
We do not have a direct influence, but because health care is an international market, one of our roles is to ensure that international applicants who come to the UK meet our standards of proficiency. For example, if a Scottish hospital recruited a Spanish radiographer, we would ensure that that individual met the required standards.
I am sure that the panel knows that we have a particular interest in education and training. What collaboration takes place between your organisations, the higher education institutions and NHS Scotland on education and training for your professions?
Stephen Moore and I would struggle to give a comprehensive answer to that question because we are not from the education sector—we are NHS employees. You might get a better answer from another source. There is a view in the service that education is extremely disjointed, which leads to problems, such as the matching of supply and demand, particularly because, we feel, we are different from doctors and nurses. We have different professionals within our organisation, but what we have in common is the fact that we are usefully placed to meet many of today's challenges and many of the challenges that will hit quickly—in five or 10 years—as a result of demographic changes. Whether we do so will be determined by how much we increase capacity and the number of allied health professionals out there. We are unique in that we qualify as first-point-of-contact practitioners, unlike members of many of the other professions. Technically, we can go straight out the door from training and start dealing with patients in all sorts of settings.
I appreciate that you are not involved specifically in education, but are you saying that, although we have a shortage of physiotherapists, for example, there is no strategic thinking or vision in the NHS and the education sector about how many people we need to train in the next 10, 15 or 20 years?
I am not aware of any forum where that is formally debated. That comes back to the issue that very little work has been done on establishing what the demand is. Modelling and projections for the future need to be done.
It is about developing the skills to predict what the future demand on the service will be. Over recent years, there has been a knee-jerk response to various professional developments in the health service. We must be more scientific and establish more evidence about what is required. The relationship with NHS Education for Scotland is a fairly new one, so to an extent it is necessary to watch this space.
Might not it be in the remit of the Allied Health Professions Forum Scotland to do projections to establish what the future need will be?
I would certainly hope that, along with other agencies, we would be far more involved in that process.
As a regulator, we have an influence on what happens, although we do not have direct control. That relates to the concept of standards of proficiency. Within the UK, what a particular professional can do is not defined and is not written down. We control registrants through use of the title, so if a physiotherapist wants to practise in the UK, they have to be on our register.
Among the submissions that we have received is one from the Chartered Society of Physiotherapy Scotland. The submission questions the ambition of the Scottish Executive to increase the number of allied health professionals by 1,500. The Scottish Executive currently has control, or some influence, over the number of places in medicine. What is your view on the Scottish Executive having more control over the number of places on undergraduate courses in the allied health professions?
I think that you are referring to the fact that, although we very much welcomed the statement in the Scottish Executive partnership agreement that there would be 1,500 more AHPs, it is not clear whether there will be 50 more physiotherapists and 1,000 more of something else—what is the split? There are nine different professions, and one could argue that the demand on some of the professions is greater than that on others. There does not seem to have been any dialogue with the professions about what the split will look like or how the provision of 1,500 places will impact on our ability to provide services. That is the query in our submission. There does not seem to have been any discussion about developing the roles and about how the 1,500 places will be provided. I do not know whether Stephen Moore wants to add anything.
Dr Holdsworth has covered the matter well. We support the Scottish Executive having more input on funding and on the total number of places, but that must happen in partnership with health boards, professional bodies and the universities.
The question that flashes across my mind is whether work has been done to compare historical provision with future needs or whether planning has been ad hoc and random. Perhaps the witnesses cannot answer that today, but it would be helpful if they could write to the committee with additional material.
We will be happy to do so, if that is possible. However, I think that you have got the gist of the issue: there is no historical basis and no evidence base for the determination of the numbers. We acknowledge that we need a significant piece of work that can model into the future to enable us to plan ahead. We cannot plan just on the basis of historical data because, as we all recognise, health services are changing and everybody's career is being modernised. We can pick up some of the key roles that are associated with those changes, but we need to model into the future.
If I heard him correctly, Mr Seale said that the Health Professions Council regulates entry to a profession for someone using a restricted title, but does not interfere if that person takes on other activities. What happens to public safety and accreditation in such situations? Who is ultimately responsible for the employment of someone who takes on a role that the council has apparently not registered them to take on?
The principle is professional self-regulation. Every professional, when they decide to treat a patient, in effect asks themselves, "Am I competent to carry out this treatment or should I refer the patient to an individual who is competent to do so?" Before a professional takes on a new task and extends their scope of practice, they must decide what training and experience are required to enable them to take on the extended role. We set the threshold requirements for the individual to come on to the register, but if someone wants to develop into a particular area of practice, it is for them to ensure that, before they do so, they are competent because they have been trained or have built up the relevant experience.
When you responded to my earlier questions, you talked about the council's influence on training courses. Why do you give up at that point, given that you already do part of the job?
It is not a question of giving up. Health professionals undertake a range of tasks and we do not know what tasks might develop in five, 10 or 15 years' time. Also, one professional might go down one route and another professional might go down another. The HPC's role, which is driven by legislation, is to set threshold standards for individuals to come on to the register. Beyond that, it is for the professional to decide which direction to take, on the principle of self-regulation.
Do the other two panel members have views from their professional perspectives?
Physiotherapy is possibly one of the AHPs that has extended its role the most. That has tended to be driven by the people who are keenest in their specialty, and has happened predominantly in orthopaedics and in musculo-skeletal clinical areas. Individuals have been very much at the cutting edge and have tended to form their own networks and specialist interest groups, in a way to legitimise their roles under the auspices of the Chartered Society of Physiotherapy. There is an opportunity for people working with extended scope in all clinical areas to work with their professional body to establish a framework that is perhaps not regulated formally.
Does your organisation want that to go to formal accreditation?
I cannot talk on behalf of my professional body because I am not allowed to do so.
We broadly support the approach taken by the regulator that it is down to the individual clinical profession to demonstrate its competency and to prove that in a recognised format, so that the public and the regulator can be confident that a person has the appropriate skills or experience. Taking that approach will also mean, I hope, greater collaboration between the professions, because people are not being put into fixed silos to work.
Am I allowed to make a couple of extra comments?
Yes, of course you are.
It is also important to mention that we expect that, as a profession develops, a new profession will start to emerge. At that point, there would have to be new standards of proficiency and individuals would have to be educated differently. It is like an amoeba; the developing profession would split off at the point when it becomes a new profession and we would regulate it separately.
When a doctor is delivering services and is trying to cover the work load because the work force is not there, they have to think about public confidence and competence, which is sometimes difficult. People can be given many jobs to do and doctors might wonder how confident they can be that people out there have the competence to know when they should pass something on to someone else.
Question, Jean.
I am trying to explain that we are trying to get the organisations to focus on the work force. I am not getting information from them that gives me confidence that there are competent people ready to replace the people that go into specialist posts. There are not enough podiatrists or chiropodists out there, for example.
I would love to have the complete answers. I agree with you on many of the issues that you have raised.
Should the Executive be addressing the issue by providing more money?
There is obviously a capacity issue within the higher education community. I presume that the number of people who can be trained is not unlimited, but I know for a fact that two Scottish universities that do not currently provide physiotherapy education are desperate to run programmes. Having done a lot of work on the viability of such a proposal, they feel that it is certainly feasible. People like me who are based in the NHS are perplexed by why such issues are allowed to drag on for years instead of being solved. It takes 10 years to get a good physiotherapist, podiatrist or other AHP, yet the current situation seems to continue every year.
I have one more question. Let us assume that there are suitably qualified people out there. Do you think that posts are advertised quickly enough when they become vacant?
No; we have a problem. At the moment, 5 per cent of posts are frozen.
There is an anomaly in that delays are built into the system for replacing staff. The fact that they are not replaced in the short term places further burdens and pressures on the system. It takes a minimum of three months to replace staff, but often it takes longer than that. Periodically, health boards freeze posts to make short-term financial gains to adjust their financial position. Although that may be understandable and acceptable, such deliberate freezing of posts is a bit at odds with the Executive's view that more AHPs should work in the service to improve patient care. Unfortunately, there are examples of posts being lost within the various allied health professions both in Scotland and across the United Kingdom. I do not have hard evidence for this, but my perception is that that is due to short-term financial management rather than the strategic thinking that the committee is looking for.
It is important to say that there is no guarantee that allied health professionals will remain in Scotland just because they are produced in Scotland. There is an international market. Individuals can move within the four home countries, within Europe and internationally. Demand will not necessarily be met simply by considering the supply of health care professionals.
Another element is the use of assistants and staff to support the allied health professions. We have discussed the role of allied health professions to support medicine in delivering better services. There are many good examples of that, but there are also examples of using assistants to support the allied health professions. We must invest in and develop that area. Regulators should ensure that there is confidence that people who are in assistant posts have the skills and abilities to undertake the tasks that they are asked to undertake.
Do you agree that it would have saved money if we had looked into the matter earlier in order to keep people mobile and able to walk about? There might not then have been as many people in hospital beds as a result of a lack of foresight.
There is an overall public health issue, which extends beyond health into the responsibilities of local authorities and so on. The public health message is owned by many people in the public sector.
I declare an interest. My wife is in practice in Aberdeenshire and is a member of the Society of Chiropodists and Podiatrists.
At the risk of upsetting my colleagues in the allied health professions, we would like all 1,500 to be podiatrists.
Your submission contains the following throwaway line:
If that information is available, we would all appreciate it if you could submit it in writing. I think that Shona Robison wanted to ask about the more general aspects of the matter.
My question is on the same issue, but focuses on how we provide allied health professionals in rural areas where, after all, there are particular challenges. For example, we heard earlier about centralisation. Can you suggest any solutions that would ensure an equal provision of allied health professionals across Scotland?
I quite agree with the thrust of that question. With the increase of AHPs in some primary care and community settings, we are beginning to address some of those issues in certain areas, although perhaps not yet in very remote or rural areas.
Given that my day job is head of podiatry for NHS Western Isles, I already work in a remote, rural location.
Two helpful comments have been made, but I wanted to ask a question on the Executive's 2002 document "Building on Success - Future Directions for the Allied Health Professions in Scotland". Has that strategy been the trigger for your 2005 start point for your accredited CPD? Have the promises or commitments that were made in that document been delivered?
The decision to bring in the CPD in July 2005 was driven by the extensive consultation process that we undertook when we were in shadow form. In essence, there were so many views and concerns about CPD that we decided to leave it for a year after our register opened. That is the reason—it was driven by the HPC legislation. Beyond that, I cannot comment.
Can the other witnesses comment on that?
The "Building on Success" strategy was developed by Scottish AHPs for Scottish AHPs. I am not sure that it would have had a major influence on the decision because we are registered with our UK bodies and with the HPC, which is the UK regulatory body. However, the decision would have been informed by the strategy.
It would be helpful if we could have a written answer on the roll-out of the Scottish Executive document.
Okay, if the witnesses are happy about that.