Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 180 - 199)



  180. I just wanted to ask Robin or Stephen if they wanted to comment on the question. It is very complicated, you hare bed numbers and PFI, the same things applies, it is flies pressure on clinical, stress on workers. Is that anything to do with PFI in your opinion?
  (Mr Moss) You asked earlier about turnover in the hospital, there is a huge turnover problem and a huge staffing problem within this hospital at the moment. I will take one ward, ward 10, there are ten beds closed on ward 10 because of staff shortages, five trained staff have disappeared out of that wards in recent weeks.

  181. What we are really trying to do in this inquiry, you blamed a lot of this on PFI, I want to see what evidence you can adduce for that?
  (Mr Moss) It goes back to the affordability question with regard to the staffing levels. In 1996-97 there was an acute affordability crisis. Various figures came out of that but the figure that was quoted at the time there was an affordability gap of £3.8 million. That was subsequently added to and in the last three years it became a £5 million acute affordability gap. The way in which that translated itself into staffing numbers was that the clinical staffing budget, i.e. doctors and nurses were cut by 22 per cent. In the year 2000 as a result of cut upon cut upon cut to make this affordability gap 13 per cent fewer trained nurses were employed.

Julia Drown

  182. We are trying to identify this to PFI. We have already been told you were going through a major reappraisal to deal with financial problems; how much of these affordibility problems can you really say is due to the PFI option against the public option? I accept it was different in 1994. We want to identify the difference due to the private sector involvement.
  (Mr Weeks) It is difficult to isolate the PFI set because there is no comparable to compare it with. The number of public sector hospitals publicly financed has been reduced to such a small proportion. We believe we have given circumstantial evidence on repeated effects that we believe are directly linked to PFI. The government is changing assumptions about bed numbers and we welcome that, and we welcome the National Beds Inquiry change the overall direction on bed numbers and to some extent they change the assumptions about staffing and about absolute numbers of nurses, and again we work on that. What that means is the schemes are having to go back and revise upwards their bed numbers and revise upwards in some cases their staffing levels, that has a cost implication because the original schemes were based on different assumptions.

Siobhain McDonagh

  183. It would on both sides.
  (Mr Weeks) We cannot test that because there are no publicly funded hospitals, with a handful of exceptions, to test it against. We believe there is a direct PFI link.

John Austin

  184. Whether or not the pressure is on beds as a result PFI I would like your view, we now have a PFI scheme, if there was a decision to increase beds the PFI existence would make it more difficult for that to be proceeded with?
  (Mr Weeks) We believe it makes it more costly for that to be proceeded with because the assumption is built into the costing of PFI. Some extra money would have to be found from somewhere, and the Trust are looking at providing extra beds, albeit by buying them in the private sector.

  185. If the Trust was looking to provide extra beds, whether there was a PFI scheme or no PFI scheme, there would be extra resources essentially. In terms of achieving and increasing the beds and staffing levels increase do you believe there are more problems because the hospital is a PFI one?
  (Mr Weeks) We believe that a contractual relation with a private sector consortium and a guaranteed income stream does create additional problems.

Dr Taylor

  186. Can I go back to nurse staffing and nurse morale. I was delighted when we went to the medical admissions wards because to my absolute amazement they said they were well staffed. Going back to that article in the Guardian, that I am sure you all remember, we had impassioned pleas from nurses, "I keep having to say I am sorry, you are just going to have to wait. We do not have time to watch people. It is every day basic care. The pressure of beds is intense and as a result normal, good practice is often compromised." Was that so at the beginning, and you have got over it, or is it still so? Did we see the one well staffed ward in the place?
  (Mrs Lemmon) I think you will find the staffing levels vary from ward to ward?

  187. You do have tremendous pressures in some?
  (Mrs Lemmon) One of the surgical wards I can think of particularly because they took all of the inpatients with them when the moved happened, they took patients with them that could not be discharged or could not be put else where, so they hit the ground running, if you like, and they set up their wards and they made it work from day one with the patients, with all of the pressures. I think it was just last week, when they had an unforeseen lull in patient admissions, maybe due to consultants being on holidays, they actually had some empty beds, and last week and, this is now towards the end of October, was the first time those girls had a chance to go round and make the ward as they wanted it. They got a chance to sort out cupboards, they got a chance to reorganise things, they got a chance to sit back and take stock and actually set the ward up as they wanted to run it. That is six months it has taken them to have the time to do that. Up until then they ran on a system of organised chaos, things had been put in cupboards but they were not quite sure where they were because nobody had the time to do that because they too busy looking after the patients. They have had, I think, four or five staff leave since the new hospital opened.

  188. From that one ward?
  (Mrs Lemmon) One, because some of them were specificically urology trained nurses and were led to believe from years ago that we would have a urology unit within the hospital, this did not happen, it was combined with surgery. When they moved the combined urology and surgical unit they decided this was not what they wanted to do but also because the pressures were intense. The work load was intense.

  189. In some areas those comments would still be made?
  (Mrs Lemmon) Some areas, yes, yes. I have to say some areas are still very badly staffed.

  190. Is that because there has been an overall reduction in staff?
  (Mrs Lemmon) I think it has just happened, we have lost some staff. I do not think it is deliberate.

  191. It is not related to the PFI and the reduction in money for salaries?
  (Mrs Lemmon) I do not think so because when we moved up we did not have enough staff. You share out what you have to where you can put them. If people still feel pressured then they leave or they get on with it.

John Austin

  192. One of the complaints we received about PFI schemes generally is a decline in the standards of some of the services, cleaning, food, et cetera, et cetera. Would you say there has been a decline in cleaning standards? Could you also comment, I have always thought that it was the manager's responsibility to ensure the cleanliness of the ward, do you think there is a particular problems for nurse manager's enforcing cleaning standards when the staff are not employed by and large by the NHS and work for another employer?
  (Mrs Lemmon) In this situation the staff who are responsible for cleaning on the wards are employed by the Trust, they are team assistants, support level staff. These used to be ladies—mostly ladies, I beg your pardon for being sexist—who are the domestics on the wards mostly. They now do the domestic duties, the cleaning, et cetera. They are responsible for heating up the meals and serving the meals. They are responsible for portering patients from the ward to different areas, unless they are going on a bed or to theatre, they take the patients.

  193. They are not part of the PFI?
  (Mrs Lemmon) The services are led from the ward. The only time we have contact with cleaning services, the PFI people clean the main corridors and the public access areas. The ward cleanliness is solely the responsibility of the ward staff. We do not have any cleaners, other than, I think, the other week we had some Hayden people come in to clean the air vents and things like that. The general day-to-day cleanliness of the wards is totally the responsibility of the ward manager, who allocates her team assistant support to do the ward cleaning. It is slightly different from the old system where the domestic services cleaned the whole hospital and could be found wherever the need was. If you have group of six team assistant supports who work on your ward and you have a couple people off with sickness—I think there may be a bank now of team assistant supports—your responsibility is to keep the ward clean. I have known in one situation where there was a sudden fall, people left or whatever, in the team assistant supports I know one weekend the nursing staff were cleaning the wards because they did not have anywhere else to get the service from.

  194. From UNISON's and RCN's point of view generally is this a unique or unusual situation?
  (Mrs Lemmon) It is certainly new to us, it is a whole new system to us. Whether it happens elsewhere I really do not know. I think this is where we had problems when it comes to the boundaries, say something goes wrong, I have a problem on the ward with the doors. I will give you an example, our main access doors to the ward are fire doors, they have a little blue plaque to say "fire door keep shut". A couple of months ago on the other side of the door a little blue plaque arrived "open both doors in the event of fire". We could not comprehend that one side of the door was a "fire door keep shut" and the other was "open both doors in the event of a fire". In fact it was Hayden who had come and put these little black plaques on. When I asked the fire officer for the hospital he had had no input into this and he did not know who had given this order. To this day I have not found out why that happened. It is a lack of communication, whereas before I would have picked up the phone and spoke to somebody in the estates office and said, "what is going on", I was diverted and I could not find the route of why that had happened. That concerns me, that I do not have a direct line of communication. I can get day-to-day jobs done but when something like that happens I cannot find out who is responsible.
  (Mrs Bottrill) You used the term "modern matron" and also the term "senior nurse" which has been a very vital part in ensuring teamwork and co-operation. It is our belief if you had a group of senior nurses working on a PFI project they would have given you all of the early warning signals and said, X amount of feet between the beds, swing doors going to theatre. Somebody with a broad clinical view if they had been involved at the design stage would have saved people an awful lot of heartache and, similarly if you are talking about team workers, everyone revolves round the patient, and that is where you have to have seamless care. If you have people responding to different masters they do not then come under the authority of either the ward manager or the senior nurse or the modern matron, use whatever title you like. That is what it should be all about, having somebody with senior clinical experience to actually advise people right from the start before you even put the plans down.
  (Mr Weeks) In terms of the overall record obviously this Trust pioneered an approach to keep cleaning a part of the ward team, and we warmly welcome that and worked with that to try and make it work, notwithstanding our other differences of view with the Trust. In terms of overall rapport with the private sector in terms of cleaning services—obviously the Committee will be looking at that later on—recent evidence from the Government's Cleaning Order is that private sector contractors accounted for 20 out of 23 of those Trusts that failed cleaning standards. As far as the PFI is concerned, in terms of functioning PFI schemes, five out of the ten regarded as fully functioning failed. They are obviously all cleaned by private contractors. We accept there may be some marginal improvements compared to traditional market testing but it certainly has not solved the problem. We were promised, again it is one of the arguments for PFI, the integration of cleaning with design and operation would lead to a higher standard of cleaning standards. We think you can say from the evidence so far that is not proven.

Julia Drown

  195. I want to ask the RCN about some of the concerns you raised, things like staff facilities perhaps not being there initially, being charged more for car parking and meals, and so on. I wondered if that is something directly related to PFI hospital or are there new build hospitals where you have the same problems with accommodation and changes. Can you link that directly to the private sector involvement?
  (Mrs Lemmon) I would think almost certainly the car parking services are related to PFI, that was part of the contract with PFI that they got the money for the car parking.

  196. You do think that would happen in the public service model?
  (Mrs Lemmon) When car parking charges were introduced we were told it was in line with the government initiative to try and get people back on to public transport and then we were told, no, it was part and parcel of the contract for the PFI and that it was built into that contract and there was no room for negotiation, the costs was as it appeared and there was nothing that we could do about it. We were never involved in those negotiations. If you are looking for a sore point in this Trust then that is the one.

Sandra Gidley

  197. I would just like to explore your feelings about the transfer of staff. We are all very pleased that the retention of the cleaning staff has worked well, but there is a feeling there might be a move in future PFI projects transferring clinical staff. Although that was hotly denied in April now we think there is one or two happening, so watch this space on that one. We talked to UNISON in particular and you stated your concerns about the creation of a two-tier work force, in which the NHS transferred staff for newly recruited staff but they are going to carry out exactly the same job with different terms and conditions. Has that been resolved, because the further down the route we go the bigger that gap is.
  (Mr Weeks) We believe that the best way of resolving that is by not transferring the staff. There may be other ways of resolving it and obviously we will pursue those if we not able to pursue the nontransfer of staff. We are exploring with the Department of Health a model known as the Potential Employment Model, which would allow the majority of staff to remain NHS employees. Examples of places like North Durham, where some sections of the staff have been retained, shows that is very successful and we are hopeful that the discussions round that will prove productive and the pilot scheme that is being proposed will be implemented and extended throughout. Obviously there is a whole issue round the duty of work and Robin Moss can highlight some examples of that. Obviously the most glaring one is the NHS pension scheme we have secured with the government, and we pay credit to the government on that, protections for transfer staff allow a broadly comparable pension scheme. It has to be said that new employees in most contractors do not access to a pension scheme of anything like the same level as NHS staff, and transfer staff in particular. We will put on record that Hayden is better than a number of contractors in that it does actually have a pension scheme for its staff but I do not think they claim it can be or is as good as the NHS pension scheme.

  198. You are basically saying that over a period of 30 years it is impossible to keep the staff in line because of that. I use 30 years because that is the length of the average PFI contact.
  (Mr Weeks) I am a trade union negotiator so I would never say impossible. I think it would be very, very difficult to find a mechanism to do that if the staff become employees of another organisation. I know business service associations have touted quite widely in the papers its proposal, they may have some way to do that but we remain convinced that the best approach and the one that deals with the issue of retaining the NHS staff team, as well as the questions of the condition of service, because conditions of service are only one issue, the key issue is to remain part of the clinical team, working side by side with the nursing staff to pursue the retention of employment model so that staff remain NHS employees.
  (Mr Moss) Our solution within the Trust to avoid the two-tier work force was to ask Hayden to agree to NHS terms. For some strange reasons they declined that offer repeatedly. It was not such a big problem within Durham because of patient focused care. Had patient focused care not been there something like 400 or 500 staff would have transferred. As it was 250 were supposed to transfer but in the end, because of our work with the Trust, a significant number of staff were redeployed before transfer so only 100 staff went over. However, there are still problems. You have a portering work force employed by Hayden where three quarters of the staff are ex NHS, the other quarter are Hayden staff, and the NHS staff are paid £35 a week more, because the NHS staff get paid bonus, they get shift premiums, the get shift enhancements, there are differences in sick pay, there are differences in holiday, there are differences in bank holidays, there are differences in the length of the working week, Hayden staff work 40 hours and our members work 39. What you have within the areas where there are these crossovers domestic, porters, catering staff you have a lot of resentment and it does cause friction and it does cause problems. It also causes problems to Hayden, their problems in terms of running two sets of conditions of service, two payrolls are enormous. It is only in the last few weeks that we have not had enormous problems with getting pay wrong as a result of the complexities of Hayden absorbing NHS terms and conditions, the way in which protection is interpreted, et cetera. Things are very difficult, they do cause industrial relation problems, they do cause friction on the ground amongst the work forces concerned. It is a nonsense that you have two sets of people working side by side, doing the same job paid entirely different pay rates and different conditions of service.

  199. You would be in favour, presumably, of the government's proposal to retain staff within the NHS whilst working for the private sector, do you think that is a viable alternative?
  (Mr Weeks) Absolutely, if it can be made to work. Despite our objections to the private sector managing services we are willing to work with that proposal.

  Dr Naysmith: How did the concept of patient focus care come about in Durham?

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