Evidence submitted by UNISON (WP 62)
1. IN CONSIDERING
FUTURE DEMAND,
HOW SHOULD
THE FOLLOWING
BE TAKEN
INTO ACCOUNT
— recent policy announcements, including
commissioning a patient led NHS;
— an ageing population; and
— the increasing use of private providers
of services.
1.1 UNISON is the major union in the health
service. Its health care service group represents more than 400,000
employees in the NHS and staff employed by private contractors,
the voluntary sector and general practitioners. We recognise fully
the importance of workforce planning to the effective delivery
of health services and welcome the opportunity to contribute to
the Select Committee's inquiry.
1.2 An ageing population and technological
advance pose significant but not insurmountable challenges to
the health service workforce. In this submission we set out how
recruitment and retention, changing roles, improving skills and
effective planning all have a part to play in meeting the challenge
of delivering a patient led NHS.
1.3 Recent policy announcements and increasing
use of private providers of services clearly do need to be taken
into account in considering future demand. As we explain below,
reforms set out in Commissioning a Patient Led NHS and Our
Health, Our Care, Our Say threaten to fragment the health
service, forcing providers to compete rather than co-operate,
causing financial pressures and damaging workforce morale. This
in turn will undermine the ethos of universality and make workforce
planning ever more difficult. These policy announcements should
be contrasted with the NHS Ten Year Plan and Agenda for Change,
which facilitated a partnership approach to workforce planning
for the longer term.
2. HOW WILL
THE ABILITY
TO MEET
DEMANDS BE
AFFECTED BY
— the European Working Time Directive;
— increasing international competition
for staff; and
2.1 Financial constraints
It is axiomatic that financial constraints will
impact on workforce planning. UNISON take the view that such constraints
are an inevitable consequence of the introduction of a competitive
commercial market within the NHS.
2.1.2 Despite record levels of investment,
the NHS is facing a major financial crisis. It is not for us,
in this submission, to examine the reasons for this financial
crisis. However, we do feel that it is important to highlight
our concerns that, by encouraging a multiplicity of providers
and introducing a payment system where money follows patients,
financial constraints can only become more pressing. Providers
will inevitably choose to provide the most financially attractive
services and patients and will avoid those where they risk making
losses, compromising the principle of equal access for those in
equal need. Competition between providers undermines collaborative
working and the sharing of good practice. Evidence from other
countries shows that the transaction costs of administering such
a system will be high. Healthcare provision requires substantial
capital investment and long-term workforce planning, both of which
are undermined by the constraints of a competitive market.
2.2 Working Time Directive
The Working Time Directive has had a positive
impact on work life balance for many health service workers. We
note, however, that it is not yet fully operational and that its
implementation masks the continuation of long hours culture. As
the 2004 Healthcare Commission NHS national staff survey revealed,
71% of staff routinely worked more than their contracted hours.
What's more, 55% of all staff worked unpaid additional hours.
Forty three per cent of all staff worked between one and five
additional unpaid hours per week, 9% worked between six and 10
additional unpaid hours, and 3% said they worked more than 10
hours unpaid overtime in an average week.
2.2.1 UNISON continue to monitor the operationalisation
of the working time directive, but most definitely does not see
meeting the requirements of the directive as a problematic issue.
2.3 Increasing international competition for
staff
UNISON note that competition for health service
staff is a global phenomenon and that recruiting staff from developing
countries raises profound moral and economic issues. However,
we also recognise that as a consequence of the demographic issues
facing the health service, the UK needs to recruit staff from
abroad. To address this problem we should permit the immigration
of unqualified health service workers from overseas and train
them in the UK. We note that this planned approach was pursued
successfully by UK governments during the 1960s and 1970s. We
believe that this would benefit both our health service and, potentially,
the countries of origin of migrant workers. It is important, however,
that a planned expansion of the workforce in this way will need
to be linked to protections, high standards of training and clear
career paths.
2.4 Early retirement
UNISON is acutely aware of the demographic challenge
facing the health service. This is demonstrated by the increase
of 74,907 registered nurses since 1997, against the 100,000 who
are due to retire by 2010.
2.4.1 The implications of the aging workforce
are significant for the future of nursing. Only 7.5% of midwives
are under 30 years old, 60% of nurses are over 40 and 1:4 of nurses
are over 50 (this figure is even higher in midwifery and community
nursing). This has to be addressed by a combination of effective
recruitment and retention, valuing staff, changing roles and improving
skills of the existing workforce.
2.4.2 UNISON welcomes the NHS commitment to flexible
retirement set out in "Improving Working Lives". The
opportunity to change working patterns, or move to a less demanding
role is particularly important to staff, such as paramedics and
ambulance staff, who have been working in very demanding and stressful
frontline services. Similarly the opportunity to undertake forms
of further work after retirement is an opportunity that some staff
value. However, we do remain concerned that early retirement can
mask wider issues. Why, for example, do people retire early from
the health service? Is this linked to the stress of work in the
health service? Are all workers equally placed to retire early?
Do low paid women, for example, have the same opportunities to
retire early as other groups of staff?
3. TO WHAT
EXTENT CAN
AND SHOULD
THE DEMAND
BE MET,
FOR BOTH
CLINICAL AND
MANAGERIAL STAFF,
BY
— changing the roles and improving
the skills of existing staff;
— the recruitment of new staff in England;
and
— international recruitment.
3.1 Changing the roles and improving the skills
of existing staff
As a union representing clinical occupations
and grades across the health service UNISON welcomes opportunities
to work in partnership with the health service to meet future
demands through changing roles and improving skills of existing
staff.
3.1.2 UNISON prides itself in being at the
forefront of developing new educational pathways and increasing
access to continuing education for all NHS staff. We are a board
member of Skills for Life and of the KSF Development Group. UNISON
is a partner in both the NHS Institute for Innovation and Improvement,
which is responsible for training and education policy across
the NHS, and the Widening Participation Unit. UNISON participates
in this work, not simply because this can improve the lives of
our members, or because we are invited to do so by employers.
We do so because we believe that working in partnership on workforce
planning issues is the most effective way of delivering an optimum
service.
3.1.3 We have worked with partners, including
employers and the Open University, to put in place a skills escalator.
This ranges from Skills for Life and Health (including English
as an Additional Language), through "second chance"
learning and onto work-based professional qualifications. We also
serve as a "broker" for learning opportunities provided
by further and higher education providers through our Open College
and train and develop a network of workplace learning representatives,
who provide advice and guidance on learning opportunities to their
colleagues at work.
3.1.4 We welcome the funding that the government
has provided for training and learning opportunities including
NHS Learning Accounts, NVQs and Skills for Life Frameworks. We
note that between April 2001 and March 2005 this funding has supported
around 240,000 learners.
3.1.5 However, we are increasingly concerned
that this driver of workforce development is under threat. We
note that the separately designated Department of Health funding
stream which supports NHS Learning Accounts, NVQs and Skills for
Life Frameworks has not yet been finalised. Posts supported by
this funding are already falling vacant or coming under threat
and planning for provision beyond March is proving difficult.
Failure to finalise the funding stream also threatens proposals
to attract match funding from the Learning and Skills Council.
3.1.6 UNISON take the view that learning
and skills budgets need to be ring fenced nationally so that improving
workforce skills can play an appropriate part in meeting the workforce
demands of the future. As explained in more detail below, training
unregistered staff, such as Healthcare Assistants, is vital to
meeting future workforce demand. This will only be achieved if
education and training is appropriately funded.
3.2 Better retention
Making staff feel valued is a pre-requisite
to ensuring that they remain in the health service. Unfortunately,
the sense of being valued at work is seriously at risk from the
uncertainty caused by financial difficulties and policy change
across the health service. As a consequence of Commissioning a
Patient Led NHS and the Our Health, Our Care, Our Say White Paper
many staff in primary care face uncertainty about their future
terms of employment and, indeed, who their future employer will
be. We note evidence that continual organisational change in the
public sector has a negative effect on morale (CIPD survey 2004).
3.2.1 UNISON accepts that there have been
some improvements in recruitment and retention. Overall vacancy
levels have improved and turnover has declined. The transition
to Agenda for Change pay scales may have temporarily stabilised
staffing, as staff may be reluctant to leave their current position
until after assimilation.
3.2.2 UNISON would however draw attention
to the fact that most employers have significant recruitment and
retention problems according to the Office of Manpower Economics
survey of NHS employers (OME 2004).
3.2.3 Wastage has also worsened slightly
and remains at an unacceptable level of 9.2% for registered staff
and 12% for Non Registered staff.
3.2.4 We are also concerned about high attrition
rates for student nurses. These continue to be an average of 20%
and as high as 24% in London. We are concerned at this level of
wasted public spending and the negative impact on students.
3.2.5 For Professions Allied to Medicine
the highest vacancy rates are found amongst Therapeutic Radiographers
(6%) and Occupational Therapists (3.9%). Occupational Therapy
employers also face significant recruitment and retention problems
with 76% of employers reporting problems. UNISON recently made
the case to the Pay Review Body that there should be a national
recruitment and retention supplement for Occupational Therapy
to tackle the national problems.
3.2.6 UNISON fears that the financial problems
being experienced in a substantial minority of Trusts are leading
to cutbacks in staff numbers which will exacerbate current problems
and this will have an adverse effect on the ability of the NHS
to attract staff in future.
3.2.7 UNISON supports the improvements in
non pay terms and conditions of service that have been introduced
through the Improving Working Lives programme but believes improving
pay remains a central issue for staff who leave. Employers cite
pay as an important reason why staff leave. The NHS does not systematically
collect information on leavers and their destinations. UNISON
believes that there should collection of such data as part of
proper planning.
3.3 Recruitment of new staff in England
The NHS needs to develop a comprehensive strategy
to release the untapped potential of its non-registered workforce
as the future pool of registered recruits. We represent over 90,000
Healthcare Assistants and see this group of staff as key to meeting
future workforce demand.
3.3.1 Healthcare Assistants currently make
up 17% of the NHS workforce and are the staff group displaying
the greatest growth. This is also a highly aspirational group
of staff. A recent UNISON survey revealed that 75% of Healthcare
Assistants were interested in accessing professional training.
The survey also found that 82% would consider undertaking a secondment.
Where Healthcare Assistants have undertaken secondments the attrition
rates have been negligible in comparison with bursary students.
3.3.2 UNISON have recommend to the Department
of Health that the secondment rate of Healthcare Assistants into
nurse training be increased on a systematic nationwide basis,
that a national induction programme be introduced for all Healthcare
Assistants, and that NHS Learning Accounts be continued. We have
also recommended that Healthcare Assistants be regulated by the
Healthcare Professions Council, as discussed in more detail below.
3.3.3 UNISON welcomes Agenda for Change,
which has led to increases in NHS pay in recent years, particularly
for low paid staff, and addressed equal pay for work of equal
value issues within the service. Through working together in partnership
with employers, 97% of staff have been assimilated into the national
framework, guaranteeing equal pay (England only). This contrasts
with the situation in local government where there is no national
framework and where only 16% of staff have been assimilated into
equal pay frameworks. The TUC say that all employers should aspire
to being an employer of choice. In many respects the NHS has achieved
this, and we think that the government and the NHS should do more
to trumpet their achievements.
3.3.4 We note, however, that there remains
an historical legacy of low pay, and poor pay relative to other
public service occupations. This must be addressed if the NHS
is to recruit and retain sufficient staff in the future.
3.4 International recruitment
Analysis of the recruitment of overseas nurses
has shown that without the doubling of the rate of overseas recruitment
the NHS would have barely maintained the numbers of nurses it
employs despite the expansion of nurse training places and better
recruitment and retention (Kings Fund 2003). The substantial recruitment
and retention of overseas nurses has allowed the NHS to fill the
vacancies created by the expansion of services. UNISON believes
that overseas nurses have played a pivotal role in allowing the
NHS to deliver the Governments targets. However, as a result of
international recruitment some developing countries are now struggling
to maintain their own health infrastructure and it is incumbent
upon us to help those countries.
3.4.1 We strongly support the protocol "A
Guide to Ethical Recruitment". We note, however, that its
effects are too often undone through blanket recruitment by the
private sector and so called "back-door" recruitment
to the NHS. This occurs when health sector professionals are recruited
outside of the protocol, and, following an initial period working
in the private sector, switch to the NHS.
3.4.2 As explained above we also support
the immigration of unqualified health service workers from overseas,
where this can be carefully planned, and where such workers can
be suitably protected and supported. This can be beneficial to
both the UK health service and to the country of origin of such
workers. Along with our sister unions we are also supporting a
Public Services International project to develop a trade union
passport, so that overseas health service workers receive the
same protections and representation as UK health workers, as well
as access to English courses when they arrive in the UK.
3.4.3 We note that there are potential recruitment
issues within the UK, as a consequence of devolution of health
services to Scotland and Wales and that there is currently scope
competition for staff within the UK. We would be interested to
learn whether the Committee has considered this issue and whether
any arrangements could be put in place to ensure that health service
workforce planning could be appropriately co-ordinated in England.
4. HOW SHOULD
PLANNING BE
UNDERTAKEN
— to what extent should it be centralised
or decentralised?
— how is flexibility to be ensured?
— what examples of good practice can
be found in England and elsewhere?
4.1 To what extent should it be centralised
or decentralised?
If the health service is to remain a universal
service and achieve its historic mission of providing equality
of care, overall workforce planning must take place within a centralised
framework. Without such an overarching strategic approach shortfalls,
gaps and unevenness in provision are inevitable.
4.1.1 We note that countries in which there
is no national health system, such as the USA, are more dependent
on attracting healthcare professionals from overseas.
4.1.2 We would be interested in learning
whether the Committee has undertaken any research into historic
trends, and the extent to which centralised workforce planning
has been used to meet demand during previous periods of expansion.
4.2 How is flexibility to be ensured?
UNISON recognise that flexibility is needed
to meet the future demand. However, if flexibility is to be ensured
it has to take place within a framework of universality and consistency
of standards.
4.2.1 The post code lottery of duties provided
by Health Care Assistants demonstrates how flexibility outside
of a national framework has led to an inconsistency that if not
addressed will make it extremely difficult to deliver on future
workforce demand.
4.2.3 The title Healthcare Assistant was
created in the 1993 Health Act, which enabled NHS trusts to offer
local terms and conditions to this group of staff. This has resulted
in inconsistency, with Healthcare Assistants performing different
tasks across the country. At a recent UNISON Healthcare Assistants
conference, we heard from a delegate who had been trained in female
catheterisation by her ward manager. However, when the manager
left, her new manager was not happy for her to continue to undertake
this task despite being trained and deemed competent to perform
it. UNISON continues to lobby for regulation of Healthcare Assistants
by the Health Professions Council, so that we can guarantee consistency,
transparency and standards of care on a nationwide basis.
4.2.4 We also note the example of teaching
assistants. As with Healthcare Assistants, this group of staff
remain outside of a national structure. However, as the Government
have recently pointed out in their Education White Paper, this
situation is leading to untenable inconsistencies, which it is
proposing to address in the first instance through a national
dialogue with the trade unions.
4.3 What examples of good practice can be
found in England and elsewhere?
Agenda for Change, the NHS framework for pay
and conditions, has had a major impact on the workforce across
the health service. It has fostered a partnership between health
service managers and employees which has in turn facilitated steps
being taken towards guaranteeing equal pay for work of equal value.
As such Agenda for Change is an example of a framework that supports
effective workforce planning.
4.3.1 We would welcome the opportunity to
give oral evidence to the Health Select Committee on how Agenda
for Change is working, and on how policy changes will impact upon
its future operation.
Karen Jennings
UNISON
17 March 2006
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