Response to the Health Select Committee Inquiry into Deficits.
1.1 The Royal College of Nursing (RCN) represents over 380,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets in the UK. This makes the RCN the largest professional union of nursing staff in the world. The RCN promotes patient and nursing interests on a wide range of issues by working closely with government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.
2.0 Summary and recommendations
2.1 The RCN has been monitoring the impact of Trust deficits for a year and has raised concerns publicly and privately on a number of occasions in order for measures to be taken to minimise the effects for both patients and staff.
2.2 Currently the RCN estimates that 15,000 posts are at risk of being lost to the NHS and there are clear examples on where this is having a detrimental effect on patient services. Band 5 posts, into which newly qualified nurses would expect to be appointed, and specialist nursing posts are being targeted. Services for older people and those with mental health needs appear particularly vulnerable.
2.3 The NHS cannot afford to lose nursing posts. These posts were created because of patient demands and at a time when patient dependency, throughput and occupancy have risen. In addition nurse staffing establishments are not full and nurse staffing levels in NHS wards in 2005 are virtually the same as in 2001.
2.4 There is a significant and growing body of evidence that clearly links higher numbers of registered nurses in the workforce with reductions in patient mortality, infections, falls, pressure sores and medication errors. Similarly there is evidence that demonstrates a relationship between improved patient satisfaction and nurse staffing levels.
2.5 The causes of deficits are complex and are associated with a significant number of new policies. However there has been a lack of piloting, fully costed implementation and roll out plans for these policies.
2.6 The RCN supports the principle of providing care closer to home however is concerned there has been a decline in the number of district nurses in recent years and that community nurses have an older age profile than acute sector nurses. If there is a genuine fall in the demand for registered nurses in the acute sector these nurses should be supported through transition arrangements to gain the additional skills required to work in the community.
2.7 Financial pressures rather than planned service change are the key driver behind proposals in many acute and community Trusts to reorganise or reconfigure services and staff. Whilst the overwhelming majority of Trusts do fulfil their requirements to consult in respect of staffing changes which includes potential redundancies, the duty placed on all health providers to consult over proposed changes to health services as contained in s.11 of the Health and Social Care Act 2001 is frequently neglected.
Recommendations
2.8 The relative invisibility of the nursing contribution to quality patient care should be made much more visible and explicit. Mechanisms to achieve this include;
- Establishing national benchmark data sets on both the numbers of nursing staff and the grade mix for different specialisms.
- Determining what the nursing contribution is for each Healthcare Resource Group which would then assist in costing the nursing contribution for the new tariff system.
- Building on the existing evidence base, commission research to consider the optimum nursing skill mix in relation to patient outcomes.
2.9 A reliable national dataset in relation to student nurses should be established and pooling arrangements agreed to ensure newly qualified nurses are offered appropriate employment.
2.10 Commitments to jointly fund specialist nursing posts with other organisations should be honoured.
2.11 Transition programmes that enable nurses working in the acute sector to gain the additional skills to work in the community sector should be made more widely available. Funding should be identified to support the development and roll-out of such initiatives.
2.12 In-patient bed occupancy should be a maximum of 85%. Proposals to further reduce bed numbers must include an impact assessment on occupancy rates.
2.13 All new policies should be accompanied by a fully costed plan for both implementation and roll out.
2.14 Because of the complexity of the reform agenda and the risk of unintended consequences, controlled pilot schemes, supported nationally and comprehensively evaluated, should be undertaken before initiatives that have the potential to significantly destabilise health delivery systems are implemented across the Country.
2.15 The principle of local engagement in the development of health services should be strengthened and penalties created for individual Trusts who avoid carrying out such consultation. This would create a system of incentives for Trusts to ensure that local discussion takes place about the impact on patient care of any cut or variation in services, so that a full risk assessment can be carried out. This would assist in ensuring that the priorities of consultation and fiscal stability become equally important and compatible.
3.0 The size of the deficits and the saving which each trust has to make in 2006-200
3.1 Deficits History
In the Spring of 2005 the RCN first began to receive reports from nurses in England that some hospitals were restricting the use of Bank and Agency staff because of financial pressures. During the summer of 2005 the RCN began to closely monitor the situation through our extensive network of branches and activists supported by staff based in regional offices.
3.2 During the autumn of 2005 we started to receive reports that in addition to preventing the use of bank and agency staff some Trusts had begun freezing job vacancies and were considering deleting posts. On 11 October the RCN issued its first public statement warning that 3000 posts could be lost. Beverly Malone, RCN General Secretary said, “We are putting a spotlight on this issue now before it is too late” and Barbara Tassa, Chair for the RCN Public Policy Committee said “This is a reality check for the government”. This was a central message and lobbying issue that the RCN took to all three party political conferences last autumn.
3.3 During late 2005 RCN networks began reporting that they were starting to see examples of deficits impacting on patient services such as operations and out patient appointments being delayed or postponed. On 19 January 2006 the RCN issued another statement warning of this new development, and that “nearly four thousand NHS posts could be lost”. This was based on declarations that NHS Trusts in Leeds, along the South Coast and East Anglia had made to their local staff side organisations about the number of posts that could be lost. At that time Barbara Tassa said that, “The Government has repeatedly said that actions taken by Trusts to balance their books would not affect patient services. This is now clearly not the case”. She went on, “We have real concerns about the stability of NHS finances, especially in view of the roll-out of reforms such as Patient Choice and Payment by Results”.
3.4 Also on the 19 January 2006 the Health Service Journal issued the results of a survey of mangers it had undertaken. It was reported that 75% of Chief Executives of acute and primary care trusts said that they believed patient care would be affected by financial problems, 63% of acute Trusts had been forced to close wards, 24% had made staff redundant and 75% had brought in recruitment freezes.
3.5 At the time the Government dismissed the RCNs concerns; however shortly after announced that turn around teams were to be appointed.
3.6 The RCN continued to monitor the developing situation and were concerned that nursing posts to be lost were being targeted in broadly two areas. These were Band 5 posts, which are the entry point for new graduates and would therefore have an impact for student nurses, and specialist nursing posts.
3.7 At the end of March 2006 the RCN issued a statement highlighting the targeting of specialist nursing posts in areas such as diabetes, multiple sclerosis and epilepsy. Other organisations such as the MS Society, Parkinson’s Disease Society and British Society for Rheumatology also expressed concern as these posts had proven highly valuable in supporting patients with long term and chronic diseases to manage their conditions in order to achieve maximum stability thereby improving the quality of their lives and preventing frequent admission to hospital.
3.8 In February 2006 the RCN commissioned an ICM poll of a thousand nurses. Almost 70% of respondents reported that bank usage had been stopped, 66% said posts had been frozen, 38% reported ward closures, 33% that posts had been deleted and 27% knew of treatment delays. These findings corresponded with the information the RCN had been receiving through its regional networks.
3.9 At the beginning of the RCN annual Congress in April 2006 the RCN issued a statment which contained the results of an independently commissioned survey of 920 clinical nurse managers which included ward sisters/charge nurses and modern matrons. 45% reported that their had been a reduction in the number of posts where they work in the last 12 months and that 60% said they did not have enough staff to give patients the standards of care they would like.
3.10 At the same time the RCN issued its update on the number of posts that had been identified to be lost from the service totalling 13,000. A breakdown of these posts by Trust was made publicly available with the press release.
3.11 Furthermore two thirds of mangers from the survey of nurse managers said they were under too much pressure in their job, 80% said they were working unpaid overtime several times a week, with 30% saying they did this every shift and 70% said they do not have time to mentor, educate and support junior staff. Beverley Malone said “These are the people who put health policy into practice at the patients bedside on wards and in the community. They (the Government) are dangerously close to losing the goodwill of this key group of nurses”.
3.12 At the RCN Congress the RCN issued a warning that services for older people and mental health and learning disability patients were also being affected by deficits. In addition to the RCN regional networks the RCN set up a deficits mailbox for nurses to report deficit related concerns to the RCN. An analysis of these responses and information from regional activists and staff provided examples of cuts to community hospitals, rehabilitation and intermediate care services, the rationalisation of mental health services and the continued targeting of specialist nursing posts.
4.0 The reasons for the deficits
Whether the causes are systemic or local (eg, the role of poor local management and poor central management, the effect of pay awards and government policy decisions)
4.1 The causes of deficits are complex but can broadly be broken down into the following areas:
4.2 National Policy Priorities
The ‘NHS plan’ is significant in understanding the national policy drivers for expenditure and reform. The March 2000 Budget settlement detailed a growth in NHS funds by “one half in cash terms and by one third in real terms in just five years.”
4.3 The plan gave broad commitments to overhaul regulation, inspection, performance management, training and development, working practices and clinical care. It also stated that the NHS would deliver 7,000 extra beds, the modernisation of over 3,000 GP premises, better hospital food and a modern IT system across the NHS.
4.4 Critically, this massive investment was intended to deliver increases in quality and activity. For example, ending long waits in accident and emergency departments, reducing the maximum waiting time for an outpatient appointment and for inpatient care; implementing national standards for cancer care etc. The delivery of this additional activity and quality requires substantial investment in staff, specifically, a co-ordinated training and development programme and large increases in the numbers of Doctors and Nurses (this specific matter is dealt with in more detail below).
4.5 Individual system reforms
At the same time as attempting to deliver much of the above, a series of other initiatives tackled other system reforms such as funding flows, IT and staff pay.
4.6 The complexity of implementing these system reforms has clearly been underestimated not just in terms of the delivery of project objectives, but also in terms of the unintended consequences each policy has had on the success of the other.
4.7 For example whilst Payment by Results may not in the short term be causing deficits, it has none the less shown significant cost variations between Trusts – it would not be correct in our view to attribute these variations solely to local inefficiency or outdated practices. In effect, some Trusts now face a loss of income against activity (compounded in many cases by poor demand management and historical patterns of referral outside of their control) as a result of the introduction of PbR.
4.8 This is not to say that there should not be reform of NHS finances. It is simply to point out that system reform has impacts beyond implementation costs which appear not to have been appreciated or costed.
4.9 Historic challenges
Across the UK it is inevitable that there will be variation in NHS infrastructure, capacity and capability. Historical decisions about the location and function of services have an impact on the extent to which some Trusts were able to deliver on national policy priorities or spend money within plan.
4.10 PFI unitary charges and uniquely high living costs are examples of pressures which may have been in place before current financial planning cycles or changes in national spending priorities. Some otherwise effectively managed and efficiently operating Trusts will therefore incur persistently large deficits because they are effectively honouring past obligations, planning decisions or demographic trends.
4.11 Management & staff capacity
There are 2 main challenges. One lies with the existing capacity of an organisation to absorb the increased levels of activity required by the various waiting time initiatives or policy reforms. This does not solely refer to the clinical staff required to deliver the care but should also include the Trusts capacity in terms of ‘backroom’ staff to monitor activity, report performance, and manage personnel and finance functions.
4.12 The other issue is the skills inherent in the local management to effectively interpret national policy directives. Various Trust and SHA performance reports and Audit Commission Public Interest Reports (PIR) have hinted at the latter point in reporting on local deficits.
4.13 Target culture
Whilst targets have brought about improvements for some aspects of patient care, it would seem that some organisations, in response to deficits, are decommissioning ‘non-statutory’/non-contractual services or areas of activity which do not work towards meeting national targets.
5.0 The consequence of the deficits
The number of job losses/the effect on care
5.1.1 Latest Information
During Congress 2006, the RCN published a table of Trusts who had reported either publicly or through our activist network the total number of posts they intended to delete to help address their deficit position. In total we reported that 13,000 posts were at risk of being lost to the NHS as a result of these plans.
5.1.2 We were careful to refer to posts that could be lost from establishments and did not say that these losses would all be through redundancy.
5.1.3 The loss of nursing posts has caused great concern to RCN members because they were originally included in nursing establishments in order to ensure high quality patient care was delivered. Nurses do not believe that patient needs or demands have diminished, in fact occupancy, throughput and patient episode indicators suggest the contrary, therefore nurses question the clinical evidence that exists to support a reduction in nurse staffing levels.
5.1.4 Indeed nurses have been working excess hours, the overwhelming majority of which are unpaid, in order to cover the gaps that exist in nursing establishments as a result of unfilled posts.
5.1.5 There is a paucity of national nursing workforce data, however the RCN believes that last year approximately two thirds of SHAs had fewer qualified nurses than planned. It would therefore be wrong to assume that the loss of posts was being made from nursing establishments that were full. Add to this normal assumptions about covering annual, sick and study leave for staff and it is clear why the loss of posts is a critical issue for nurses.
5.1.6 Since RCN Congress there have been further significant announcements of posts to be lost, for example in, Nottingham, the Pennines and Oxford. At Appendix 1 the RCN attaches its most up to date list of posts to be lost which currently totals over 15,000. We are aware that some Trusts have revised previous figures both upwards and downwards and have been careful to adjust our figures accordingly.
5.1.7 An NHS Employers briefing dated 16 May 2006 gave nine examples of Trusts that were losing posts and were “able to confirm their plans and willing to be named”. There are 50+ Trusts named in the latest RCN update.
5.1.8 Through the monitoring of posts to be lost, the RCN has identified that Band 5 and specialist nursing posts are being targeted.
5.2.1 Band 5 and Student Issues
Up until very recently, the key feature of the NHS nursing workforce has been growth, reflecting an increase in admissions to pre-registration nurse education supported by increased government funding. There has been a sustained increase in pre-registration diploma and degree students. However, in the latter part of 2005 and early 2006, the RCN began to receive reports of newly qualified nurses (NQNs) having difficulty finding jobs, mostly in England. Difficulties related to local labour market issues or financial shortfalls in the main, leading to staffing freezes or planned redundancies in the NHS. The 2005 NHS Employers survey highlighted that 39 percent of those surveyed reported ‘oversubscription’ of vacant posts. However, redundancies are also an issue for the independent sector with the Nuffield group announcing 460 redundancies at the end of 2005.
5.2.2 Reliable data on nursing students’ job destinations is scant reflecting a wider problem with workforce planning information. However, the Council of Deans of Schools of Nursing has recently agreed to try and determine what labour market information is available in terms of graduating students and available posts and also to talk to Universities UK about statistics Higher Education Institutions hold on first destination employment.
5.2.3 Widening access to higher education opportunities has helped increase the potential for nursing to become a more diverse workforce. Reductions in employment opportunities may impede this welcome trend. The RCN has concerns about the impact of recent decisions to reduce commissioned places for nursing students at universities.
5.2.4 Policy approaches to employing NQNs varies across the UK. In Scotland, the Health Department guarantees all NQNs a job although not necessarily where they live or trained. There is also a scheme to help those unable to find employment through their own efforts and the Scottish Executive also recently launched the Flying Start programme, a development programme for NQNs, midwives and Allied Health Professionals. The average age of a NQN is now 29 compared with 21 in the 1960s. This ageing phenomenon raises issues about mobility as these days more students are likely to have children or other dependants and more keen to find local employment opportunities.
5.2.5 In the 1990s, a lack of effective workforce planning across and within the 4 UK countries caused a major shortage in nursing staff, which the NHS has only just recovered from. There is a difference in perception between the Department of Health, which sees the current job situation for NQNs as the nursing labour market coming into balance and the RCN, which considers that there is still evidence of a continuing underlying shortage, for example, working beyond contracted hours has remained broadly stable in the last 10 years at around 60% of full-time nurses working approximately 44 hours per week on average, i.e. an additional 6 hours and 20% of all respondents work more than 50 hours per week.
5.2.6 In addition to difficulties finding a job in the first place, some NQN’s are finding that their employers are paying them below the appropriate level for the job, or that their employer is not allowing them to have the accelerated progression provided for in the Agenda for Change Terms and Conditions Handbook (TCH). Paragraph 1.8 provides for NQNs to progress through the first two points of Band 5 in six monthly steps (that is they move up one pay point after six months and a further point after twelve months) providing those responsible for the relevant standards in the organisation are satisfied with their standard of practice.
5.2.7 In some places across the country, nurses are being placed on transitional points (TPs) below Band 5. The minimum pay point for a newly qualified nurse is the bottom point of pay band 5 (£19,166, £19730 from 1.4.2006). Where employers have attempted to pay less (Hull, East Lancashire Hospitals NHS Trust), the RCN is challenging locally and will continue to do so.
5.2.8 In other parts of the country (Oxford) employers are resisting the accelerated progression for NQNs provided for in Agenda for Change. The RCN believes that financial difficulties currently being experienced by employers are the key motivating factor.
5.2.9 The RCN is concerned that if newly qualified nurses are facing the prospect of no employment, this will serve as a disincentive for future potential nurses entering training.
5.3.1 Specialist Nurses
Since the publication of the NHS Plan , nurses have been encouraged to take on a range of extended and advanced roles as part of a patient-centred service and modernising the NHS. The new posts which have been developed include Modern Matrons, Lecturer Practitioners and Nurse Specialists. Under Agenda for Change these posts have been valued highly with nurses being graded at bands 7 and 8 in recognition of the increasing accountability and advanced skills. However, as Trusts seek to reduce costs, financial recovery plans have resulted in a number of strategies which have had a negative impact upon nurses who practice in these advanced roles.
5.3.2 Workforce and Process Re-engineering
i) Downgrading
The downgrading of posts is being achieved through two means;
a) Where services have been closed or reconfigured because of a need to overcome financial deficits, jobs have been lost and posts made redundant as managers seek to reduce service costs. As a result, existing post holders have been redeployed and offered “suitable alternative employment” at lower grades as an alternative to compulsory or voluntary redundancy, effectively downskilling the workforce. Anecdotally the RCN is aware that some of these nurses are actively considering opportunities to move overseas, and particularly the USA, where specialist nursing skills are in demand.
Example
Chesterfield Royal Hospitals NHS Foundation Trust have put the post of Endoscopy Nurse “at risk” due to organisational change. The post is graded at AfC band 7 and the reorganised structure contains only one nursing post in endoscopy services at AfC band 3.
a) Where nurse specialist posts are frozen or lost via “natural wastage” through restructuring, the elements of the job role are being broken down and passed on to existing staff at lower grades. For patients this could well impact on waiting times as throughput falls and there will be an increased reliance on medical staff.
Example
Restructuring at Kingston PCT will result in the loss of the Lead Nurse in Sexual Health post with the subsequent loss of clinical and managerial responsibilities. The managerial roles will have to be picked up by the remainder of the team and the specialist nursing practice will be lost which is concerning given that sexual health has been identified as a priority service.
ii) Re-rolling
This feature of deficit management takes two main forms;
a) Where Trusts have been required to reduce costs but retain services they have redrafted the content of job descriptions and/or restructured the roles of practitioners and managers or the parameters of their role.
Example
The Royal Liverpool Children’s Hospital has altered management arrangements so that Ward Managers will now cover 2, rather than 1 ward.
b) Where a nurse has a combination of clinical and managerial roles within their post, the clinical component is being reduced or removed so that they can focus on their managerial function. This has particularly been the case in respect of Modern Matrons. The RCN is concerned that this approach could undermine the essence of care benchmarks of best practice for healthcare practitioners promoted by the DH.
Example
At Great Ormond Street Hospital, a review of senior grade posts has led to the loss of 3 Modern Matron posts and 2 Assistant Director of Nursing posts.
5.3.3 Revised Funding Priorities
Independent Sector Partnerships
Encouraged by government health policy, partnerships have been formed between NHS organisations and voluntary not-for-profit providers as well as private healthcare companies. Some deficit recovery plans require commissioners to reconsider the funding for these partnerships with a potential reduction in the number and range of specialist nursing posts that they have created, particularly in services for people with long term conditions.
Example
Through the Leicester City West PCT, the Rainbow Foundation employs a Specialist Nurse as a Palliative Care Consultant. The post is funded for a period of three years through a donation from charities and at the time of establishing the post it was agreed that Leicester PCTs would pick up the cost of the post in December 2006 when the initial funding runs out. Although the service given by the post-holder is county-wide and one of only two such posts in the country, due to financial recovery plans, none of the PCTs have the funding to continue the employment of this individual. This has the potential to seriously frustrate the policy of extending the range of service providers.
ii) Partnerships with Institutes of Higher Education.
Practice based learning and consolidation of theory are essential features of nursing practice and is achieved by Lecturer Practitioners. The need to establish posts of this nature has led NHS Trusts to enter partnerships with Higher Education Institutes to create posts as lecturer practitioners and practice educators. These posts are now being reviewed as part of service reconfigurations arising from financial recovery plans within the NHS. Post holders are also at risk and as a result of reductions in the level of funding for organisational and personal development being invested by NHS Trusts in HEIs.
Example
Kettering General Hospital are making 2 Practice Educator posts redundant, one in acute services graded at band 8 and funded by the Trust; and one in medical services graded at band 7 and funded by the University.
iii) Use of discretionary funding
When funding is attached to projects which have impacts upon patient healthcare and public health targets they do not always have a “ring-fenced” status. This enables commissioners to exercise discretion in the way that they are spent. One such initiative is “Choosing Health” whereby funds were established to enable commissioners to develop health promotion and public health initiatives, in support of government targets. These monies were not ring-fenced but have helped to develop posts in areas related to health needs as diverse as Chlamydia screening in Hertfordshire, to contraception services in Lincolnshire. Funding which is not ring-fenced is being used to achieve deficit recovery targets.
Example
Staffordshire Moorlands PCT has published a report “Balancing the books - Emerging Proposals for Service Changes” which seeks to inform community organisations of their plans for expenditure for 2006/07 but does not offer opportunity for consultation. Within that plan is a statement;
“ Health Improvement; Suspend commitment of unallocated Choosing Health monies and therefore suspend further progress on the Choosing Health agenda. Saving £112,000.”
5.4.1 Nursing Workload
The annual employment survey of nurses is commissioned by the RCN and undertaken by Employment Research Ltd. In 2001 and 2002 the survey asked nurses working in in-patient settings to give details of the number of staff and patients. From this data patient to staff ratios were calculated and the results are contained in Table 1.
Table 1: Staffing and patient data for NHS hospital wards 2001 & 2002
2001 2002
Day Night Day Night
Number of beds 24 24
Total number of patients 22 22
Number of Registered Nurses (RNs) 3.2 2.3 3.2 2.4
Number of HCAs/Auxiliaries 2.1 1.3 2.2 1.3
Mix - % of nursing staff that are RNs 62% 65% 61% 65%
Patients cared for by respondents 10.6 14.6 10.6 14.7
Patients per RN (across ward) 8.0 11.1 8.0 11.5
Patients per nursing staff (across ward) 4.4 6.3 4.4 6.6
Source: Employment Research/RCN 2002
5.4.2 In 2002 nurses working in NHS hospital wards typically cared for 11 patients each during a day-time shift, and there was an average of 8 patients per member of staff on duty. The difference between these numbers is because one of the members of staff reported to be on duty will be in charge of the ward for the shift and therefore have fewer or no patients in their care. There was no change in staffing relative to patient numbers between the 2001 and 2002 surveys.
5.4.3 Table 2 contains the results of the staffing data for the 2005 survey which in addition includes an analysis for respondents working on Independent hospital wards and in Care homes as well as NHS wards.
Table 2: Staffing and patient data 2005
NHS Wards Independent wards Care homes
Day Night Day Night Day Night
Number of beds 23.4 22.7 26 - 36.2 38.6
Total number of patients 22 21 20 - 30 34
Occupancy 96% 95% 86% - 94% 92%
Number of registered nurses 3.3 2.4 3.9 - 2.0 1.6
Number of HCAs/auxiliaries 2.1 1.3 1.6 - 4.9 2.6
Total staff on duty 5.4 3.7 5.4 - 7.0 4.2
RNs as % of all nursing staff 62% 66% 74% - 32% 42%
Patients cared for by individual respondent (mean) 10.3 13.5 7.8 - 18.1 23.3
Patients per RN
(mean across all RNs) 7.7 10.1 5.5 - 17.2 24.6
Patients per member of nursing staff (mean) 4.4 6.1 3.8 - 4.6 8.8
Weighted cases 822 316 55 14 240 112
Source: Employment Research/RCN 2005
5.4.4 Independent hospital wards were better resourced both in terms of overall staffing levels and in terms of skill mix. Registered Nurses (RN) made up 74% of the staff on duty during a day shift compared to 62% on NHS wards. During the day, respondents working on independent hospital wards cared for an average of 7.8 patients and the NHS figure was 10.3.
5.4.5 The overall figure of the number of patients per member of nursing staff on NHS wards was unchanged in 2005 when compared to the 2001 and 2002 surveys (4.4). There was a slight reduction in the number of patients per RN from 8.0 in 2001/02, to 7.7 in 2005. Fractionally more RNs per ward (3.3 compared to 3.2 in 2002) were reported to be on duty.
5.4.6 What is clear is that despite the headline increases in the number of nurses this has not resulted in significant increases in nurse staffing levels in NHS wards. It is for this reason, coupled with increased patient dependency and workload intensity that the nursing workforce cannot afford to lose further nursing resources either through the deletion of nursing posts or nursing redundancies.
5.4.7 Finally an analysis of attitude statements for respondents working in the NHS is presented in Figure 1. The results show that in general more respondents are negative about workload issues than positive.
Figure 1: Views of workload and staffing (NHS only) - percentages
Source: Employment Research/RCN 2005
5.5.1 The relationship between Nursing Inputs and Patient outcomes
There is growing evidence of a relationship between registered nurse workforce numbers and patient outcomes. The RCN commissioned an independent review of this evidence of the impact of registered nurses on patient outcomes from the London School of Hygiene and Tropical Medicine, University of London. The researchers reviewed 15 high quality studies that met strict methodological criteria. They concluded that :
Higher numbers of registered nurses and a higher proportion of registered nurses in the nursing workforce are associated with reductions in:
• Patient mortality
• Incidence of respiratory, wound and urinary tract infections
• Number of patient falls
• Incidence of pressure sores
• Medication errors
And improved outcomes in:
• Patient functional independence
• Patient experience and perception of health care
5.5.2 Professor Anne Marie Rafferty at Kings College, University of London has conducted primary research in general surgical wards of 30 NHS trusts that confirm some of the above findings (to be published in the International Journal of Health Care Management, October 2006). The risk of mortality for the patients studied was increased by 12 to 49% in wards with the lowest registered nurse to patient ratios. That is patients had an increased risk of dying when there were fewer registered nurses on the ward.
5.5.3 Birmingham and Black Country Strategic Health Authority commissioned a review of the research literature related to initiatives which may reduce unscheduled admissions to hospital. They assessed 65,812 studies of which 186 met strict methodological selection criteria – mainly structured reviews and randomised controlled trials. They conclude that the evidence from nurse-led clinics, and specialist nurse input, suggests these both contribute to a reduction in unscheduled hospital care.
5.5.4 A Cochrane review of research that evaluates substitution of doctors by nurses in primary care concludes that nurses can achieve equivalent patient outcomes and indeed score higher on patient satisfaction.
5.6.1 Impact on Patient Services
The RCN is concerned that measures to address financial deficits are and will continue to impact on patient services in a number of ways.
5.6.2 Examples of the impact of recovery plan and restructuring initiatives on services and patients include;
- Increasing distances and travel times to services, especially in rural areas, where services and facilities have been closed, consolidated on specific sites or relocated in rural areas, further exacerbated where Ambulance Trusts are reducing non-emergency services. (United Lincolnshire Hospitals Trust/ Gloucestershire Partnership Trust)
- Loss of or reduced access to specialist services when Nurse Specialist and Modern Matron posts are reorganised. (Queen Mary’s Sidcup/ North Tees and Hartlepool NHST)
- Loss of access to local specialist services due to site closures and service consolidations. (North Staffs NHS Trust/ Kingston PCT)
- Failure to meet 18 week waiting list targets due to a need for all services to meet cost improvement targets. Pioneer Trusts have already identified extensive waiting times of up to 9 months for some diagnostic and specialist services and concerns are expressed that cost improvement plans will make it impossible for Trusts to meet 18 week waiting time targets until 2009/10. (HSJ 5th April 2006)
- Increased travel and reduced access where services have reduced from 7 day to 5 day services including medical and minor injury services. (East Lancashire/ Royal Cornwall NHS Trust/ Gloucs Partnership Trust)
- Loss of potential benefits of nurse led initiatives. (Cheltenham General Hospital)
- Loss of rehabilitation and healthcare services with the extension of closure programmes for Community Hospitals in rural communities. (Wiltshire/ Gloucester/ North Yorkshire/ Yorkshire Wolds and Coast PCT)
- Loss of mental health in-patient and day care services putting increased pressure upon carers and patients and the potential for the establishment of large institutions through the consolidation of services and rationalisation of in-patient sites. (East Lancashire/ Gloucestershire SHA)
5.6.3 Rethink, the mental health service users organisation, have accused health trusts and local authorities of singling out mental health for cuts in services to meet with cost saving programmes (10th May 2006). They highlight £30m of enforced and potential cuts to services in England. Rethink are especially concerned that this level of cuts will add to the pressure created by the chronic lack of high quality in patient mental health beds in this country.
5.6.4 Controlling the criteria for access to services
Revising the criteria for access to services, is one way of achieving increased control over demand.
5.6.5 An example of how this can be achieved is the document “Commissioning Effective, Efficient and Necessary Care Pathways” which has been produced by the North Yorkshire and York Primary Care Trusts. This document sets limits on the types and levels of conditions that can be admitted into secondary care via the Accident and Emergency Departments of acute hospitals. It also sets criteria for access to services on the basis of clinical need without consultation with relevant practitioners.
5.6.6 Whereas existing criteria for admission to acute care is based upon the clinical evidence presented by the patient and their evident ability to cope with their condition, the criteria being introduced prescribe that;
“Patients should not be admitted solely to avoid a breach of the four hour target… Patients who do not need admission include;
- Minor strains/ wounds
- Upper limb fracture
- Minor fractures
- Musculoskeletal injury
- Soft tissue injury
- Back disorders
- Neck Injury.
5.6.7 The report goes on to identify a further group of patients;
“… who may need more in-depth assessment than A&E can provide within the four hour target but do not necessarily need hospital admission;
- Minor head injury
- Headache
- Abdominal pain
- Collapse
- Ingestion/ poisoning
- Angina
- Arrhythmia
- Other chest pain/Asthma
- Other respiratory
- Urinary Tract infection
- Epilepsy.
5.6.8 Although the report recognises that final judgement on which patients should be admitted should be made by the senior clinical decision maker in the emergency department;
“Where a special need has been identified, which falls outside these commissioning guidelines, the PCTs will consider each request on a case by case basis.”
A process which hardly befits the nature of clinical decision making in an emergency service.
5.6.9 The RCN is concerned that the application of these forms of criteria could exacerbate health inequalities as commissioners develop varying standards of entitlement to services, as well as generally reducing access to services.
5.7.1 Staffing and Patients Perception
The Healthcare Commission has provided evidence of a relationship between improved patient satisfaction and higher numbers of registered nurses, and a correlation between lower patient satisfaction and the amount spent on temporary nursing staff – bank and agency nursing staff.
5.7.2 In addition the recent Healthcare Commission survey of patients who stay overnight in hospital found that 58% said there were “always”, or “nearly always” enough nurses on duty to care for them in hospital. Therefore over 40% did not believe there were enough nurses on duty.
5.7.3 The UK NHS Centre for Reviews and Dissemination also found that the number of registered nurse hours correlated to patient complaints.
5.7.4 A report by the National Consumers League which represents consumer interests in the US commissioned Opinion Research Corporation to conduct a randomised telephone survey of health care consumers in March 2004. They conclude that consumers who had been hospitalised or had a family member who had been hospitalised believed that there were too few nurses caring for too many patients.
5.7.5 In the public consultation phase of the Our Health, Our Care, Our Say White Paper the general public were clear about the benefits of nurses and the value of the nurses first contact skills.
5.8.1 Consultation
The principle of consultation over changes to health services is important to the RCN. Any national proposals for changes to the NHS require consultation with professional and patient interest organisations. This principle of consultation enables these organisations to provide expert consideration to the Department of Health in a joint approach to ensure that health services are maintained or improved. This principle is so strong for the RCN that it issued an application for judicial review in 2005 over the failure of the Department of Health to consult on a national basis on a decision that Primary Care Trusts were to end the provision of NHS services.
5.8.2 Any local proposals for changes to the NHS require consultation with staff and the public, so that the impact of potential changes can be assessed in an objective manner by the local NHS. The Government has recognised the importance of local consultation in the health democracy with s.11 Health and Social Care Act 2001 which places a statutory duty on all NHS health providers to consult over proposed changes to services.
5.8.3 The impact of deficits can provide a dilemma for local NHS bodies which also have a duty to protect and promote the principle of consultation. The RCN is concerned that these two duties may be incompatible. For example Trusts may decide that that financial stability is a greater priority than a risk assessment carried out by local public consultation of the impact of cuts on patient service.
5.8.4 The RCN is concerned that some Trusts are taking a tactical approach and looking to cut services that are small enough to appear to avoid the need for s.11 consultation. Where this is happening specialist nursing posts are being targeted. In an acute Trust there may be only between 1-3 specialist nursing posts for different long term conditions, such as MS or rheumatology. Trusts have told local RCN offices that local consultation under s.11 is not required because the cuts do not amount to a substantial variation in the service. Again, this is a distorted logic; for the Trust looking at the service overall, it may be insignificant. For the patients with long term conditions, cuts to specialist nursing posts and preventative community services mean their whole world is turned upside down.
5.8.5 One unintended consequence of the need to achieve financial stability is that there is now a distortion of the health services priorities of PCTs. In practical terms, patient services are being cut without a full assessment of the medium to long term health impact of those cuts. This is a distorted risk assessment for any local health economy. The RCN warns that short term cuts may mean long term health problems are being shored up for many local health economies.
5.8.6 A further concern is that many cuts are taking place in preventative services, particularly those provided by specialist nurses. This is the policy aim of the Government to reduce the focus (and cost) of unplanned acute admissions. These policy aims are endorsed by the RCN and provided by specialist nurses.
5.8.7 This lack of consideration of the need for consultation about the impact of cuts on patient services is of course, not taking place where redundancy is an issue. The evidence being provided to the RCN is that redundancy consultation is taking place and that many nurses are being told this is the same as the consultation needed under s.11. This is a further distortion of the principle of consultation. Redundancy consultation focuses on the post and does not consider the impact on patient care across a Trust.
5.8.8 One reason that redundancy consultation is taking place in a scrupulous manner by Trusts is because there are significant financial penalties which can be imposed if the Trust fails to carry out redundancy consultation appropriately. There is no such penalty on any Trust if it fails to carry out a s.11 consultation. The only remedy open to a patient who feels that his or her service reduction or cut is under threat, and has not had a consultation, is by way of judicial review. Further, if the service has been cut or reduced by the time of the hearing, there is no remedy open to the court to require that the Trust reopens the service.
Royal College of Nursing
6 June 2006
Appendix 1
Summary table of NHS posts to be lost as reported to the RCN
Notes:
- All announcements are subject to consultation with staff and their representatives although there is little doubt that cuts will be made to the total number of posts.
- The ‘total posts lost’ figure refers to the predicted number of posts deleted from the existing compliment. This figure includes voluntary redundancy, compulsory redundancy and the deletion of vacant posts.
- In some cases, Trusts have reported that the total number of posts lost will be within an estimated range. In this case, the lower estimate has been used.
- A number of NHS Trusts have announced that there will be posts cuts but have not released how many.
- The funding uplift for the coming year after efficiency returns and adjustments to the NHS Tariff is only 1.5%. This has prompted some Trusts to already declare a deficit for the year 2006/7 unless substantial cuts to services and staff are made.
NHS Trust (inc PCT & FT) – italics denote recent changes Total posts lost
1. AIREDALE NHS TRUST ↓ 0
2. BARKING, HAVERING AND REDBRIDGE HOSP NHS TRUST 650
3. BARTS AND THE LONDON NHS TRUST 330
4. BIRMINGHAM WOMENS NHS TRUST 90
5. BRIGHTON AND SUSSEX UNIV HOSPS NHS TRUST ↓350
6. BUCKINGHAMSHIRE HOSPITALS NHS TRUST ↓15
7. CAMBS & PETERBOROUGH MH PARTNERSHIP NHS TRUST 180
8. CHESTERFIELD ROYAL HOSPITAL NHS FOUNDATION TRUST 133
9. CITY AND HACKNEY TEACHING PCT 40
10. COUNTY DURHAM AND DARLINGTON PRIOR SRV NHS TRUST 700
11. EAST AND NORTH HERTFORDSHIRE NHS TRUST 100
12. EAST SUSSEX NHS TRUST 250
13. GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST 50
14. HAMMERSMITH HOSPITALS NHS TRUST 300
15. HOMERTON UNIVERSITY HOSPITAL NHS FOUNDATION TRUST 99
16. IPSWICH HOSPITAL NHS TRUST 105
17. ISLE OF WIGHT PCT 6
18. JAMES PAGET HEALTHCARE NHS TRUST 150
19. KINGSTON HOSPITAL NHS TRUST 50
20. KINGSTON PCT 150
21. LEEDS TEACHING HOSPITALS NHS TRUST ↓430
22. MEDWAY NHS TRUST 160
23. MID STAFFORDSHIRE GEN HOSPITALS NHS TRUST 92
24. NHS DIRECT ↑1000
25. NORFOLK AND NORWICH UNI HOSP NHS TRUST ↓145
26. NORTH STAFFS COMBINED HC NHS TRUST 200
27. NORTH TEES AND HARTLEPOOL NHS TRUST 74
28. NORTH WEST LONDON HOSPITALS NHS TRUST 250
29. OXFORD CITY PCT ↓0
30. OXFORD RADCLIFFE HOSPITAL NHS TRUST 600
31. PENNINE ACUTE HOSPITALS NHS TRUST 800
32. PETERBOROUGH AND STAMFORD HOSPITALS NHS FOUNDATION TRUST 185
33. PLYMOUTH HOSPITALS NHS TRUST 200
34. POOLE HOSPITALS NHS TRUST 40
35. QUEEN ELIZABETH HOSPITAL KINGS LYNN NHS TRUST 145
36. QUEEN ELIZABETH HOSPITAL NHS TRUST 100
37. QUEEN MARY'S SIDCUP NHS TRUST 400
38. ROYAL BERKSHIRE AND BATTLE HOSPS NHS TRUST 312
39. ROYAL CORNWALL HOSPITALS NHS TRUST 300
40. ROYAL FREE HAMPSTEAD NHS TRUST 480
41. ROYAL UNITED HOSPITAL BATH NHS TRUST 300
42. ROYAL WOLVERHAMPTON HOSPITAL NHS TRUST 300
43. SANDWELL & WEST BIRMINGHAM HOSPS NHS TRUST 800
44. SHREWSBURY AND TELFORD HOSPITAL NHS TRUST ↑210
45. SOUTH TEES HOSPITALS NHS TRUST 60
46. SOUTHPORT AND ORMSKIRK HOSPITALS NHS TRUST 200
47. SOUTHAMPTON UNIVERSITY HOSPS NHS TRUST 500
48. ST GEORGE'S HEALTHCARE NHS TRUST 150
49. SURREY AND SUSSEX HEALTHCARE NHS TRUST ↑400
50. SUTTON AND MERTON PCT 40
51. SWALE PCT 27
52. THE MID CHESHIRE HOSPITALS NHS TRUST 150
53. THE ROYAL WEST SUSSEX NHS TRUST 200
54. UNITED LINCOLNSHIRE HOSPITALS NHS TRUST ↓0
55. UNIVERSITY HOSPITAL OF NORTH STAFFORDSHIRE HOSPITAL NHS TRUST ↓500
56. WEST HERTFORDSHIRE HOSPITALS NHS TRUST 500
57. WEST SUFFOLK HOSPITALS NHS TRUST 200
58. WESTON AREA HEALTH NHS TRUST 29
59. WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST 750
60. YORK HOSPITALS NHS TRUST 200
Grand Total 14,847
↓↑ Denotes increase or decrease from original announcement
Announced over the last 2 months
Previously announced