Evidence submitted by the Royal College
of Nursing (Def 27)
1. INTRODUCTION
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. SUMMARY AND
RECOMMENDATIONS
Summary
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[39]
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. THE SIZE
OF THE
DEFICITS AND
THE SAVINGS
WHICH EACH
TRUST HAS
TO MAKE
IN 2006-07
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 3,000 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 4,000 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 managers 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 1,000 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 managers
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. 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."[40]
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 and staff capacity
There are two 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. THE CONSEQUENCES
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.[41]
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%
of those surveyed reported "oversubscription" of vacant
posts.[42]
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 work-force
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.[43]
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.[44]
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
work-force planning across and within the four 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[45]
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, ie an additional six hours and 20%
of all respondents work more than 50 hours per week.[46]
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
12 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, £19,730 from 1
April 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,[47]
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
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.
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.
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.
This feature of deficit management takes two
main forms:
(a) Where Trusts have been required to reduce
costs but retain services they have edrafted the content of job
descriptions and/or restructured the roles of practitioners and
managers or the parameters of their role.
The Royal Liverpool Children's
Hospital has altered management arrangements so that Ward Managers
will now cover two, rather than one 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.
At Great Ormond Street Hospital,
a review of senior grade posts has led to the loss of three Modern
Matron posts and two 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.
(iii) 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.
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.
(iv) 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.
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 AND 2002
| 2001 Day
| Night | 2002 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 DayNight
| Independent wards
DayNight
| Care homes DayNight |
| 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:[48]
Higher numbers of registered nurses and a higher proportion
of registered nurses in the nursing workforce are associated with
reductions in:
— Incidence of respiratory, wound and urinary tract
infections
— Number of patient falls
— Incidence of pressure sores
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).[49]
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.[50]
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
5 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
(10 May 2006). They highlight £30 million 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:
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;
— Other chest pain/Asthma
— Urinary Tract infection
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.[51]
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.[52]
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.[53]
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 s11 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
s11 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
39
Appendix 1 Back
40
NHS Plan, 2000. DH. Back
41
Buchan J & Seccombe I (2005) Past trends, future imperfect?
A review of the UK nursing labour market in 2004 to 2005,
Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN. Back
42
NHS Employers 2005 NHS Employers recruitment and retention
survey 2005 London/Leeds: NHS Employers. Back
43
Harrison S (2006) Data confirms drop in places Nursing
Standard Volume 20-Number 38, p 6. Back
44
Ball J (2005) Managing to Work Differently, Royal College
of Nursing, 20 Cavendish Square, London, W1G 0RN. Back
45
Oral evidence to the Health Select Committee 11 May 2006. Back
46
Ball J (2005) Managing to Work Differently, Royal College
of Nursing, 20 Cavendish Square, London, W1G 0RN. Back
47
NHS Plan, Department of Health, London 2000. Back
48
West, E., Rafferty, AM., Lankshear, A. (2004). The Future
Nurse: Evidence of the Impact of Registered Nurses University
of London and University of York RCN. Back
49
Birmingham and Black Country SHA (2006). Reducing Unplanned
Hospital Admissions: What does the Literature tell us? Back
50
Laurant, M. et al (2005). Substitution of Doctors by
Nurses in Primary Care Cochrane Library, Issue No 2 Back
51
Healthcare Commission (2005). Ward Staffing. Back
52
Westwood, M. et al (2003). Patient Safety: A Mapping
of the Research Literature. NHS Centre for Reviews and Dissemination:
University of York. Back
53
National Consumers League (2004). Consumer Perspectives: The
Effect of Current Nurse Staffing Levels on Patient Care Washington:
US. Back
| 
