§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Allen.]
§ 7 pm
§ Dr. Evan Harris (Oxford, West and Abingdon)
We are heading towards making redundant a number of ready-to-be consultants, which the national health service desperately needs and who have cost the country a fortune to train. I shall set out the figures involved, then describe the demand for consultants and consider some of the problems meeting that demand and some of the potential solutions to both the immediate crisis and long-term work force planning problems.
In a written answer from the Minister of State, Department of Health, the hon. Member for Southampton, Itchen (Mr. Denham), which I received today, I was told that there are 117 specialist registrars in obstetrics and gynaecology who hold national training numbers, NTNs, and are therefore eligible to take up consultant posts and who have obtained their certificate of completion of specialist training, CCST, but for whom there are no consultant posts available. Of those 117, 86 had been in that position for more than six months.
Similarly, it was reported in January that 112 specialist registrars holding NTNs and with CCSTs had no consultant posts to go to, of whom 23 completed their training 18 months earlier. It was envisaged then that 82 more people would be in such a position by March 1999, of whom only a few would be mopped up by newly established consultant posts and the filling of consultant vacancies from retirement and death.
The number of new CCST holders who will complete specialist training in 1999–2000 and 2000–01 has been estimated to be 188 and 122 respectively. Similarly, Department of Health figures for the next three calendar years, are 137, 185 and 100 respectively. Either way, that makes for about 500 trainees with NTNs who are eligible to be consultants and waiting for posts, on whom this country has spent a great deal of money. At the current rate of consultant vacancies and establishment of new posts, such people will mostly have to be made redundant or find other sources of income. That is clearly unsatisfactory.
According to another written answer, it costs £160,000 just to put a medical student through medical school. The cost of training a doctor up to CCST level in obstetrics and gynaecology can be estimated by adding up the element of their salary that is paid for annually through the medical and dental education levy—generally half the basic salary, except in the house officer year, when it is 100 per cent. of the basic salary. Even a quick calculation suggests that an average general and specialist training period of about 10 years costs at least another —150,000—making a grand total of about one third of a million pounds per doctor, for many of whom there will be no consultant post.
It has already been made clear to me by individuals that they will not be hanging around waiting to be sacked when the 18-month stay of execution runs out on those with certificates of completion of specialist training. They will be moving abroad or into other jobs. I have heard of one trainee who plans to become an air hostess because she cannot bear waiting around with no likely career progression. 1187 There is a desperate need for more consultant posts in this country. Let me make clear the current planned rate of expansion. The Department of Health has indicated that about 50 consultant appointments were made in the past year. My understanding is that about half those were vacancies through retirement and other causes and about half were newly established posts. At that rate, about 350 of the 500 trainees with CCSTs who will be eligible to become consultants over the next three years will have no posts to go to. It is a problem of degree of magnitude, not something that can be improved quickly or without the radical action that I will be urging on the Government.
This country is in desperate need of additional consultants, particularly in our obstetric units. The fourth and fifth reports of the confidential enquiry into stillbirths and deaths in infancy have indicated that about 80 per cent. of intra-partum deaths—deaths during labour—that were identified for the study, were criticised for sub-optimal care because alternative management would reasonably have been expected to make a difference to the outcome in about half the cases and might have helped in another quarter.
The confidential inquiry into maternal deaths from 1991 to 1993 raised concerns even then about a possible lack of senior obstetric consultant input into the care of critically ill women. It drew attention to inappropriate standards of care due to inappropriate delegation of responsibility for clinical management to relatively inexperienced junior doctors. The evidence from confidential inquiries shows that we are letting down the women of this country in the quality of service we are providing.
In addition, the confidential inquiry into perioperative deaths, which impacts on gynaecological emergencies as well as operative obstetric emergencies, indicated that direct consultant involvement in emergency surgery, particularly out of hours, may have led to an improved outcome for many patients. That is now accepted wisdom and best practice in the health service.
The Minister will be aware of the cost to the health service of clinical negligence in obstetrics. It dwarfs the cost of clinical negligence and litigation in other specialties. The clinical negligence scheme for trusts has identified the importance of consultant input in the labour ward and suggested that a standard of at least 40 hours of consultant sessions on the labour ward during the working week is desirable. That was backed recently by the joint report of the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives which, for the first time, have come together to endorse clear recommendations for consultant expansion, among a range of other suggestions.
There is a need to expand the number of consultants to improve the quality of care for women and to reduce the enormous costs of litigation as a result of inappropriate care, perhaps because of inappropriate levels of experience among the doctors concerned.
According to figures I have seen, which are not disputed, only 28 new posts were established in 1998, as opposed to vacancies, of which only a similar number were filled. Yet there were 37 appointments of non-consultant career grade doctors in 1998 alone. There is no way that the Government will be able to direct the 1188 consultant expansion we need while there is a free-for-all in medical work force planning. Answers that the Government have given to me show that they accept that it is still a free-for-all for trusts. They say that it is for NHS trusts to decide the number and grades of staff they need. That is a free market in staff. It does not allow the Government easily, if at all, to implement their policies in terms of quality and of reducing litigation costs to trusts which are, for better or worse, concerned with making the books balance in the short term.
We have an immediate problem, and various solutions have been proposed. One solution is for those doctors to continue occupying specialist registrar posts; but that will not do. They would either block slots for new trainees, or impose an extra cost on the national health service as their slots were filled by newer trainees. Therefore, additional money should not be spent on prolonging their tenure in those posts, and any available money should be invested in ensuring quality and in solving the problem once and for all. Regardless, keeping those doctors on in those posts for much longer would continue to deprive future consultants of those training opportunities.
Another proposal is to do nothing or to fiddle about with pilot schemes, which—judging by a letter of 28 April from Mr. Hugh Taylor, the NHS director of personnel—the Department of Health currently seems to favour. The letter quite accurately describes the current stark situation, and makes no bones about the crisis engulfing medical work force planning. It is not satisfactory to wait. Staff will leave, and quality and care will not improve without direct investment in consultant posts. Regardless, it simply will not be possible to remove junior doctors, as envisaged in the letter.
The letter proposes that temporary non-consultant posts should be created for a further 12 months. Therefore, by definition, the posts—unless they are a continuation of training posts, in which case one wonders from where the funding will come—will be non-consultant career grade. It would not be possible for the health service to remove doctor posts, at either senior house officer or specialist level, by entirely eliminating slots or by not filling specialist registrar slots with visiting trainees, who are critically necessary to cover out-of-hours work rotas. Without them, the junior doctors hours initiative—which, this week, has featured so prominently in the media—will be under further pressure.
Perhaps the Government intend that the proposed 12-month extensions for doctors—who are ready to be consultants—should involve on-call duties with junior doctors filling the posts they are seeking to leave. I have heard a rumour, from the Trent region, that a doctor was promised a post in which he would receive 50 per cent. pay—the standard on-call overtime rate—but would not be paid for daytime work. Doctors would therefore be allowed to use NHS research facilities, but would not be able to make their mortgage payments.
The Government's proposals that I have seen would not be effective. Perhaps the Government are seriously considering trying to tempt trainees into some type of non-consultant career grade post—such as the 12-month temporary extension—but such a post would clearly be a blight on a trainee's curriculum vitae. They would not be a popular option. It is also not clear how the posts would be paid for. If no extra money is provided, and training slots are left as they are, the new posts will impose an extra cost. It would also not be satisfactory to seek to 1189 remove medical and dental education levy funding to pay for posts in other specialties. However, if extensions are required but there is no additional Government funding, that funding will have to be used.
None of those solutions is a real option. The only solution is a centrally funded expansion of consultant posts. It would cater, in waiting list initiative cases, for improved training, supervision and service; for increased cover on obstetrics wards; for decreased litigation and litigation costs; and, by investing in adequate senior medical cover, for insuring against problems in recruiting senior nurses and midwives. That is the solution, and it would be true modernisation of the health service. If the Government would only use some of their funds to fund those posts, it would solve all the problems that I have described. Moreover, it is the action that has been called for by the British Medical Association and the Royal College of Obstetricians and Gynaecologists.
The joint report which I referred to earlier called for 24-hour consultant cover on big obstetric units and 40-hour a week consultant cover with no other clinical duties on obstetric wards during the working day. That implies an increase of around 300 in the number of consultants. That is the number needed to deal with the problem in the short term.
However, there are also longer-term issues. We must try to prevent the problem from arising again and secure the consultant expansion that the health service needs to provide a consultant-based service. The solution is clearly to restore manpower controls and end the free-for-all. There should be a limit to staff grade appointments back to 10 per cent. of the consultant work force, which would give incentives for trusts to expand their numbers of consultants rather than the non-consultant career grades. Associate specialists should once again become personal appointments, not advertised as additional non-consultant career grade posts. We should create paths back to training for those in non-consultant career grades who have been lured into those posts for lack of consultant opportunities.
We should ban the creation of illegal SHOs with no staffing or training approval. It is outrageous that doctors are led into applying for those posts when they hold no training or staffing approval because there is inadequate training in the posts. We should ban the use of non-standardised posts, which lead to poor-quality care and confuse patients. If a patient sees the word "specialist", they assume that the person is a consultant. That is the European term and the term that the Government use. Instead, trusts have created trust specialists and trust grade doctors willy-nilly as a short-term, cheap, expedient way of getting through service work of a lower quality than that which consultants offer.
I accept that planning is difficult. Having too many junior doctors causes this sort of problem, while having too few can hold back the consultant expansion that could develop the specialty. The answer is clearly to have more central control of manpower resources. I speak from experience, having served on the central manpower committee, which is a joint committee of the profession, and having worked in the area for three years.
The final aspect of my solution is to give 100 per cent. of the basic salary of trainees to deans to use within the medical and dental education levy. That would be a 1190 powerful tool for ensuring that trusts were rewarded for consultant expansion by attracting new specialist registrar slots and would give some protection of training for juniors against the exigencies of the service. I sincerely ask the Minister to take action to solve the acute immediate problem and to take on responsibility for the long-term solution. We have a duty to women and we must not scrimp in quality care. We have a duty to trainees and we must not waste doctors.
§ The Minister for Public Health (Ms Tessa Jowell)
I have listened with great interest to the points raised by the hon. Member for Oxford, West and Abingdon (Dr. Harris). He is right to say that there is a serious mismatch between the number of fully trained specialists in obstetrics and gynaecology and the number of consultant jobs available. We are rightly concerned about that.
I should like to set out the background. By the end of April, there were 117 doctors who had completed their specialist training in obstetrics and gynaecology but had not found suitable posts. We expect that, over the next three years, the number of specialists completing their training will be 137, 185 and 100 respectively. Between 1992 and 1997, consultant expansion in the specialty grew by around 4.5 per cent. a year. To absorb all those doctors completing their training into consultant posts over the next three years the consultant expansion will have to increase to approximately 10 per cent. a year.
This difficult and complex situation needs to be handled sensitively and carefully. There has clearly been a failure to appreciate fully the supply and demand position for the specialty and in particular the pace of change in relation to consultant expansion.
We have already acknowledged the need to look more closely at work force planning processes—locally, regionally and nationally—so as to ensure a better match in the future between those trained and the jobs available in all specialties and professions. We will be undertaking work over the next few months with that in mind.
In the short term, we accept the need to deal with the immediate problem of career prospects for those currently training in obstetrics and gynaecology, including the current surplus of fully trained higher specialists. For that reason, we set up a small working group last autumn including representatives from the Royal College of Obstetricians and Gynaecologists, the Royal College of Midwives, the joint consultants committee, the junior doctors committee and NHS management. The group reviewed the position and proposed a way forward.
The working group recognised that there were strong arguments on quality grounds—to which the hon. Gentleman referred—for balancing an increased emphasis on midwifery-led services with access to the best-quality medical advice and expertise to deal with emergencies and difficulties. It noted that, in practice, the ratio of consultants to juniors was lower in obstetrics than in most other specialties. It also expressed concern about the numbers of appointments that were continuing to be made to non-consultant career grade posts.
The working group noted the joint report from the RCOG and RCM, "Setting Standards for improving Women's Health; Safer Childbirth", which dealt specifically with staffing and organisational issues. The 1191 report recommended greater consultant cover on labour wards in all but the smallest obstetric units. The RCOG has sent a copy to all NHS chief executives. The group also considered another report from the joint consultants committee which discussed issues about consultants' job plans in obstetrics and gynaecology. The JCC proposed changes to consultants' working patterns in future to provide for a consultant-based service.
The working group agreed that a combination of short, medium and long-term action was needed to address the situation. In the short term, it was agreed that it was imperative to engage the NHS in discussions about staffing and grade mix in obstetrics and gynaecology.
My officials have taken action to ensure that that happens quickly. A series of workshops is about to be arranged by each regional office to address that specific issue. They will not only look at the urgent and immediate problems of current surplus specialists without appointments, but address issues connected with those currently in specialist training and their career prospects. It is important not only to look at our current problems, but to consider the numbers in training.
We want two main outcomes from the workshops: first, to discover ways to find employment quickly for current surplus holders of the certificate of completion of specialist training, and in so doing improve the quality of current obstetric services, and secondly, to secure agreement from a number of trusts to act as pilot sites to evaluate different ways of working and staffing profiles which have less reliance on juniors and more input from qualified staff—midwives and fully qualified specialists.
My officials met representatives of each regional office at the end of April, and workshops are now being set up. We expect the first one to take place in July, probably in the west midlands. In the workshops, we will be working jointly with the profession, as was agreed by the working group.
§ Dr. Harris
The Minister is hinting at consultant-only units with no junior doctors; something that has been suggested in other specialties, including by researchers in my area in Oxford. However, that will cost money, as it will take a lot of consultants to give that on-call cover. Will there be new funding as part of the short-term and long-term solution?
§ Ms Jowell
I am setting out the stages by which we intend to address the problem. The first stage is to engage in joint discussions with the colleges, the working group and the NHS to address the short-term problem in the context of the need for clarity about the long-term position.
In the meantime, there will be continuing local action aimed at discussion with the postgraduate medical deans, who are continuing to extend the training period of all newly qualified specialists for as long as 18 months to give them time to secure a post. They will also continue to offer advice and help to all specialist trainees in obstetrics and gynaecology, and give particular support to CCST holders experiencing difficulties in securing a post.
Postgraduate deans will also explore ideas and opportunities aimed at improving the career prospects of all specialist trainees in obstetrics and gynaecology, including the feasibility of switching to another specialty where career prospects are better. I understand that the 1192 RCOG is having discussions with the Royal College of Surgeons to consider the feasibility of whether specialist trainees could, at an early stage of training, switch to a surgical specialty. Similar discussions with the Royal College of General Practitioners will also be held. We are fully supportive of the RCOG in its efforts to find solutions in this way. We want to work with the college and support it.
We are encouraging regional directors—through local workshops, and action by deans, consortiums or local medical work force advisory groups—to persuade trusts to offer temporary appointments of 12 months to CCST holders on fixed-term contracts. Such posts would be distinct from career-grade posts, and would be open to competition. Essentially, these would be developmental posts, with particular emphasis on new ways of working; possibly in the context of the pilot studies that I have already mentioned.
As I have said, the problem of surplus specialists in this specialty is multi-factorial and complex. Equally, solutions likely to improve the career prospects of those currently engaged in specialist training, or those who have recently completed training, are likely to vary. Such solutions will be thoroughly explored with local NHS management, by the profession and by my officials, as appropriate.
We have already taken steps this year to reduce higher specialist training opportunities in this specialty to ease the situation. In the light of advice from the specialist work force advisory group, which considers future investment in training across all medical specialties, we have reduced training opportunities by 76 places during this year. This will have the effect of restricting entry to the specialty to 65 places nationally. This decision was taken to avoid the detrimental effect of closing entry to the specialty altogether, given the knock-on effect that that would have on senior house officers and their career intentions.
§ Dr. Harris
Before she finishes, can the Minister guarantee that none of these doctors—who have cost us at least £300,000 to train—will be made redundant this year? Will she address the question of bringing back manpower controls?
§ Ms Jowell
Every possible effort will be made to ensure that those 117 people are found jobs. That cannot be a guarantee, but I have set out the steps that the Department intends to take to address a completely unacceptable situation. The remedy lies in immediate action—which we are taking—and a sustained, long-term assessment of the need for consultant posts and the deployment of consultant posts in the specialty.
The issues throw into sharp relief the difficulties associated with work force planning. In some respects, there have been improvements in recent years—for example, in addressing shortages in specialities such as anaesthetics and accident and emergency—but minimising shortages or over-supply remains a difficult balancing act. We must look carefully at our approach to planning—
§ The motion having been made at Seven o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at half-past Seven o'clock.