Select Committee on Health Written Evidence

Evidence submitted by the Chartered Society of Physiotherapy (Def 16)


  1.  The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the 47,000 chartered physiotherapists, physiotherapy assistants and students in the UK. The CSP is pleased to give written evidence to the Health Committee and would wish to provide oral evidence if called upon.


  2.  The CSP strongly refutes the allegations made in some quarters that the main reason for the financial deficits is the cost of implementing the Agenda for Change agreement, or that the costs of the consultants' contracts is the real cause. As both the Health Service Journal and the former director of human resources at the Department of Health, Andrew Foster, have commented, "there is a series of urban myths of why we are in the situation we are in" and "quite a blame game going on" (`Consensus on the reform agenda has broken down', HSJ, 27 April). In his outgoing HSJ interview, Mr Foster described the current situation as follows:

    "Within the `commentariat' [media commentators] you will see the assertion that pay reform has caused the overspend the NHS is suffering, that it has been badly thought out, was never properly modelled, that it was conceived of in the ivory tower of the DoH without involving NHS managers and that it has produced little or no benefits . . . Every single one of those is completely untrue. I'm very concerned that they are becoming too widely accepted."

  The CSP, having been involved in the Agenda for Change negotiations right from the start, shares this concern. One of the main aims of the NHS pay reforms has been to achieve fair and equal pay in the NHS and, as NHS Employers acknowledge,[18] this has been "long overdue". Pay modernisation must, therefore, be fully funded by the Government and properly implemented by all NHS employers. In our view, it is essential that Ministers and NHS Trusts themselves take responsibility for allowing the NHS to fall into this state where the constant talk of financial "crisis" and failure is damaging staff morale and patients' confidence in the Service, and that they do not take the easy option of blaming pay modernisation for the deficit problems.

  3.  A less disingenuous view would acknowledge that the current financial situation has not been helped by the insistence that overspending should be paid for from the 2006-07 budgets. The CSP believes that organisations should be given a longer, more realistic timescale to address their deficits.

  4.  It should also be acknowledged that the Government's new centrally fixed pricing system (payment by results) has also caused serious problems for Trusts in setting budgets for this financial year—because of delays in setting tariffs and the sudden withdrawal of the original tariffs at the last minute before implementation was due. This is illustrated by the experience of four children's hospitals—Great Ormond Street, Alder Hey, Birmingham and Sheffield—who reported a shortfall of £22 million because of an "inaccurate and highly insensitive tariff" ("Children's hospitals warn ministers of £22 million funding crisis", The Guardian, 18 April).

  5.  A further contributory factor to the cause of the NHS deficits is the siphoning off of NHS funds to the private sector as the Government constructs a competitive market in health. It is notable, for example, that Patricia Hewitt's maiden speech as health secretary was to announce that £3 billion was to be made available to Independent Sector Treatment Centres to help reduce waiting lists. While supporting the objective of reducing waiting lists, the CSP is concerned over the broader policy of introducing greater competition into the health service and, more specifically, the future role of alternative providers in delivering NHS services and how this will further impact on NHS resources. We are unaware of any evidence-base to support the policy decision of introducing greater competition in the health service with the aim of improving quality. In the absence of such evidence, we do not believe that the risks—including financial risks—of introducing a multiplicity of service providers have been properly thought through. What will happen when outsourced NHS contracts come up for renewal, in a fully competitive market, is of particular concern. For example, the consequences of a social enterprise company employing staff transferred from the NHS under the TUPE[19] regulations losing a future contract have not been fully explored. This represents a massive gamble with precious NHS resources, a gamble which has potential implications for fragmentation and destabilisation of services; making joined-up care harder to provide; the erosion of local accountability, governance and standards; and the undermining of staff pay, jobs and training and development opportunities.

  6.  In the light of the consequences for the NHS of services and staff being cut back as a result of the current financial situation, we question the wisdom of the Government continuing with its policy of outsourcing work to the private sector at preferential terms, for example through Independent Treatment Centres which, in some cases, have been documented to be six times more expensive than the NHS rate ("PCTs paying ITC six times normal cataract rate", HSJ, 23 March). The cost to the NHS of providing adequate rehabilitation—including physiotherapy—to patients who receive treatment such as hip operations from non-NHS providers needs to be taken into account when judging value for money and when assessing the appropriateness of the ITC programme.

  7.  Similarly, concerns exist over the cost of PFI projects and the long-term financial burden that they are posing to NHS organisations.

  8.  It is perhaps the case that the organisations of the NHS are suffering from not being sufficiently championed, and that the focus of debate is overwhelmingly on the negative. It should not be forgotten, amid all the concerns over the deficits, that the NHS possesses an established resource of highly skilled and experienced staff and we should concentrate on the many positives of the NHS, promoting and encouraging good practice, before we abandon the NHS for the road leading to greater `privatisation'. We therefore call on the Government to rethink its policy of introducing greater competition into the NHS. Private and voluntary sector providers should be used to enhance NHS delivered services rather than replace them.


  9.  During the early months of 2006 the CSP received strong anecdotal evidence from our members of the detrimental impact on services that NHS deficits were causing. As a result, we undertook a survey of CSP workplace representatives to establish concrete evidence of the extent and nature of the problem.

  10.  At the beginning of April 2006 questionnaires were sent to CSP trade union representatives in all 405 NHS organisations across the UK in which physiotherapists are employed. The representatives (workplace stewards) were asked to co-ordinate their responses locally to ensure that we received one completed survey form from each organisation. The survey was undertaken in conjunction with the Royal College of Midwives who undertook a similar survey of their members.

  11.  The CSP received responses from representatives in 199 organisations across the UK (a response rate of 49%) with the majority (172) coming from NHS employers in England.

  12.  Our survey revealed that across the UK, 65% of employers were heading for an overspend. This reflected the results for England (65%), but the situation was worse in Wales where 88% of those who responded reported that their organisation was going to be overspent. In Scotland and Northern Ireland the situation was not quite as bad but still poses a serious cause for concern, with figures of 54% and 34% respectively.

  13.  In answer to questions about how much information stewards were receiving from their employer on the financial situation, we found that across the UK the majority of stewards (59%) felt that they had been kept very well informed, with only 7% saying that they had received little or no information. Northern Ireland had the worst record, with not one of the respondents saying they were very well informed and the vast majority (83%) saying that they would have liked more information.

  14.  Our survey also asked for detailed information about the impact that the financial situation was having on physiotherapy services. Only a tiny number of respondents said that there were direct threats of redundancies for physiotherapy staff—just three in England and one in Scotland (although several expressed concern that this could be a possibility in the coming 2006-07 financial year). Since carrying out the survey the CSP has become involved in consultations with NHS organisations about a number of potential redundancies and so we expect the numbers of physiotherapists actually made redundant to increase during this financial year.

  15.  However, the financial deficits are having an even more serious impact on vacant posts. One in five respondents to our survey across the UK and within England reported that vacant physiotherapy posts were being permanently lost from funded establishment. The situation in Scotland and Northern Ireland was only marginally better. Over a quarter of all respondents reported that vacant posts were automatically being frozen and this was having a particularly severe impact in Northern Ireland with 50% of respondents affected.

  16.  In the CSP's written evidence to the Health Select Committee inquiry into workforce planning in the NHS earlier this year, we highlighted the fact that inadequate workforce planning had led to unprecedented numbers of newly qualified physiotherapy graduates being unable to find employment as junior physiotherapists in the NHS. Research undertaken by the CSP in the past has shown that over 95% of graduates take up employment in the NHS on qualifying in order to be able to undertake a range of rotational placements in various clinical areas to allow them to consolidate their undergraduate education.

  17.  Since 2004 the CSP has been tracking the employment status of all physiotherapy graduates in the UK. Our latest survey (undertaken in January 2006) has shown that of the 2,172 students who graduated in 2005, approximately one third have been unable to find work within the NHS. Each of these graduates has cost the taxpayer an average of £28,500 to train. The financial situation, the loss of vacant posts from funded establishments and the lack of flexibility that tight financial controls have brought about mean that it is likely to become even more difficult for physiotherapy managers to be able to fund junior posts for newly qualified physiotherapists. In 2006 approximately 350 more physiotherapists will be graduating than in 2005 and it is imperative that job opportunities are created for them otherwise these graduates are increasingly likely to seek alternative careers. The NHS is in danger of losing them altogether, which would result in an enormous waste of public money and talent that the NHS will need in the future.

  18.  Our survey into the NHS financial situation found that even where funding for posts was available there were severe delays in filling vacant posts. The majority of UK employers (52%) had instigated some form of control mechanism which was leading to delays such as setting up review panels to review all requests to fill these posts. One of the most significant impacts was the restrictions being imposed on the use of agency and locum staff, with two thirds of respondents' organisations affected across the UK and within England and Wales and nearly half of Scottish respondents. The combination of these cutbacks is resulting in increased workload for remaining staff, with resulting increases in stress and sickness absence along with a significant deterioration in staff morale.

  19.  The CSP is also very concerned that physiotherapy training budgets have been hard hit with nearly half of UK and English respondents reporting that they had experienced cuts and two thirds affected in Northern Ireland. Several of our workplace stewards commented that the costs of training were funded from surpluses in budgets and with these disappearing so too was finance for training courses, highlighting the fact that many physiotherapy departments do not have money ringfenced for training purposes. This raises serious concerns about how physiotherapists will keep up to date with CPD requirements and how the Knowledge and Skills Framework (KSF), which the CSP strongly supports, can be properly implemented. The KSF underpins the whole Agenda for Change pay framework and the increased career development opportunities it would bring was one of the major reasons why CSP members voted overwhelmingly in favour of Agenda for Change in 2003. The long-term consequences of an easy, short-term expediency—a squeeze on training—should not be underestimated: training cuts are detrimental to NHS physiotherapists and their patients.

  20.  In terms of withdrawal or suspension of services as a result of the deficits, Wales reported the most severe impact with 38% saying that some specialist services had been suspended or withdrawn altogether. Across the UK as a whole this was reported in 16% of organisations, and again, we expect this impact to worsen during the 2006-07 financial year. Services which were particularly badly hit included those that have traditionally suffered from a lack of investment such as care of the elderly, paediatrics and domiciliary services. Out patient services had also been badly affected in some areas and this can only have a detrimental effect on achieving the Government's targets to reduce waiting times.

  21.  Further to our postal survey on the impact of the NHS deficits on physiotherapy services, and in order to put some "flesh on the bones" of our raw survey data, we undertook a follow up telephone survey of over 30 CSP stewards in England. The information received from the telephone follow up confirmed the picture initially obtained, namely:

    —  Significant increases in waiting times for physiotherapy treatment are being experienced, with musculoskeletal outpatients the worst affected, but also access to paediatric services, learning disabilities, older patients and those with long- term conditions. Examples include:

—  in North Staffordshire, waiting times for musculoskeletal outpatients were reported to have increased from 36 weeks to 47 weeks, and waiting times in respiratory from zero to four months;

—  one trust in the West Midlands reported community physiotherapy waiting times to have increased from one week to six weeks;

—  in Kent and Yorkshire, waiting times increased to six-seven weeks from two weeks previously, with musculoskeletal, rheumatology and neurology patients most affected;

—  a doubling of waiting times from four to eight weeks in Thames Valley, Kent and the North West;

—  in the North East, outpatient waiting times increased up to three months;

—  in the East Midlands, routine waiting lists reported to have increased to 43 weeks and rising

    —  In terms of services being cut or withdrawn, outreach community work in GP surgeries and patient homes were mentioned the most frequently, but also hydrotherapy services, women's health, mental health, respiratory rehabilitation, amputees, falls and exercise clinics were also being affected.

  22.  In our telephone survey, we asked whether our stewards would be willing to go "on record" with their comments about the impact of the NHS deficits on their physiotherapy services. Regrettably, very few felt confident to have their comments attributable to them. This reflects badly on the atmosphere currently prevailing in the NHS where openness on the impact of the deficits is actively discouraged. The few exceptions to this came from stewards in trusts where, thanks to public campaigning, information on the deficits is already out in the public domain (eg University Hospital North Staffordshire). Below are a selection of comments received—suitably anonymised—which illustrate the reality of how the deficits are being felt "on the ground" by physiotherapists:

    "There's no strategy"

    "We're cutting services. We've less staff and more referrals. Our inpatients' is running on a skeleton service. The GP's are going for private physios because they're fed up with the service they're getting"

    "The GP's are looking towards private providers if our waiting lists don't improve. We've lost staff through stress and vacancies are not being filled"

    "It's a bit of a disaster. There's nowhere for juniors to move up"

    "We've been told that if waiting times aren't reduced there'll be trouble. It's all negative. The situation's very bad. Nobody's happy"

    "Consultant referrals have gone up a lot with no extra resources and GP referrals are suffering as a result. We're understaffed by all national guidelines"

    "We have a vacancy appeals panel but vacancies are not being released, therefore waiting times are going up"

    "Our waiting time target was 5 days for urgent musculoskeletal but we're struggling with them"

    "We're not able to offer as good a service as we'd like"

    "It's affecting our professional autonomy because everything's based on finances and not efficacy. We're worried that if we provide a sub-standard service then PCTs will not commission us because we're not operating to best standard—standards and patients' recovery are definitely under threat. It's ruining the relationship between physio and the GP surgery"

    "Consultants are getting angry. Patients are frustrated. Staff are upset"

    "Our situation is very bad. There's no cause for optimism. We can't even order Bic pens it's that bad. I'm looking to jump ship as soon as possible"

    "We're no longer accepting pain clinic referrals"

    "We've got longer waiting lists, more stress. We're working on a reduced number of physios, recruitment's not happening and retention is difficult"

    "Patients are getting frustrated. Staff morale is affected. There's no time for in-service training. Services are being reduced to the minimal amount—patients are seen in classes rather than individually, where appropriate"

    "The PCT is contracted to send work to the ISTC and patient `choice' is being influenced that way, which will result in a decreased income for us. I think it is a disgrace that the trust is going to lose business to a foreign-owned ITC as they are ringfenced while NHS employees are being threatened with job losses"

    "We definitely feel threatened with our jobs, although there are no planned losses at present. New posts are being advertised as temporary, and temporary staff will be the first to be `axed'. This will give an unstable staff base to the trust with employees being unable to get mortgages and feel stable"

    "We've joined the Government `turn-around' programme. We're getting nice communications but our good will is being played upon, and its quickly being eroded"

    "We have a `turn-around' plan developed and are undergoing lots of `change management' stuff, but its only slowly filtering through. Communications are not brilliant. We're just keeping our heads above the water"


  23.  From our survey it appears clear that the Government's agendas on choice, waiting times and health promotion are all being affected by the current financial situation in the NHS. As yet, fortunately, we can report very few redundancies amongst CSP members in the NHS, but this looks likely to change in the current financial year. An absence of current actual redundancies in physiotherapy, or staff being immediately forced out of the door, however, does not equate to a harmonious situation where there are no problems. Both our members and their patients are directly affected by the removal of vacant posts and restrictions on recruitment and the use of temporary staff. We are particularly concerned, as an organisation which is supportive of and committed to the four main goals set out in the White Paper `Our health, our care, our say: a new direction for community services', about how this will impact on the employment of new physiotherapy graduates—some 2,300 of whom are due to graduate in June/July—and how in turn this will affect the ability of the NHS to meet these goals.


  24.  We appeal to the Health Committee to encourage an open and honest culture in the NHS where the deficits and their impact can be discussed, without fear of reprisal.

  25.  The CSP would like to see NHS organisations being given more realistic timescales to address the deficits.

  26.  The CSP calls for physiotherapy managers to be given more support in their efforts to create job opportunities for newly qualified physiotherapy graduates. The NHS is in danger of losing for good expensively trained physiotherapists. This would represent an enormous waste of public money and talent that the NHS will need in the future.

  27.  The CSP calls for the `quick-fix' expediency of cutting training courses to be abandoned immediately. Squeezing training is a short-term gain with a long-term cost. Training for staff is vital for patient care and should be fully resourced, with training budgets ringfenced for protection. Staff development and support is key to the realisation of the Government's goals for health care and should be respected accordingly.

  28.  The CSP believes that the expensive distraction of competition should be reviewed as a matter of urgency.

Phil Gray

Chief Executive, Chartered Society of Physiotherapy

5 June 2006

18   "What's happening with the NHS workforce? The facts", NHS Employers' website: Back

19   Transfer of Undertakings (Protection of Employment) Regulations 2006. Back

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