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,
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 yearbecause 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 hospitalsGreat Ormond Street,
Alder Hey, Birmingham and Sheffieldwho 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
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 risksincluding
financial risksof 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
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
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 rehabilitationincluding
physiotherapyto 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.
NHS FINANCIAL SITUATION
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
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 staffjust
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 expediencya squeeze
on trainingshould 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
receivedsuitably anonymisedwhich illustrate the
reality of how the deficits are being felt "on the ground"
"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 standardstandards
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 amountpatients 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
"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 graduatessome
2,300 of whom are due to graduate in June/Julyand 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.
Chief Executive, Chartered Society of Physiotherapy
5 June 2006
18 "What's happening with the NHS workforce?
The facts", NHS Employers' website: http://www.nhsemployers.org/workforce/workforce-1011.cfm Back
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