Memorandum submitted by the Royal College
of Nursing (PCT 37)
EXECUTIVE SUMMARY
0.1 The Royal College of Nursing has a membership
of over 380,000 registered nurses, midwives, health visitors,
nursing students, health care assistants and nurse cadets. The
organisation is the voice of nursing across the United Kingdom
and the largest professional union of nursing staff in the world.
The RCN promotes quality patient care 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.
0.2 The RCN supports and is working to develop
strong commissioning at PCT & practice level. As such we recognise
the need to separate commissioning and provision of services in
some cases.
0.3 Essential to this is a system of robust
and effective clinical leadership and engagement at practice,
PCT and SHA level. This should encourage innovation, inform the
reform agenda and support practitioners in the delivery of high
quality, patient centred services.
0.4 Good health and social care services
are based on a strong workforce that is engaged, consulted and
which receives proper investment and fair reward.
0.5 The public are entitled to receive seamless
services and should not be aware of artificial boundaries between
those services. RCN supports a health economy which is characterised
by shared good practice, cooperation and collaboration to achieve
shared health goals and consists of a broad range of integrated
services, freely available at the point of delivery regardless
of race, ethnicity, faith, culture, sexuality, gender, age, personal
wealth, mobility or social status.
0.6 RCN supports the continued development
of a strategically planned, properly funded, effectively delivered,
and joined up public health service. This is key to improving
the health of the nation, enhancing productivity and promoting
social cohesion.
0.7 RCN believes that vulnerable people
and services should be protected from the worst excesses of the
market and that there should be in place a clear framework of
regulation, inspection and protection. This would be concerned
with controlling entry and exit to the market; protection of services
and staff in the event of market failure; and the promotion of
the provision of a broad range of high quality services, universally
accessible and relevant to local needs.
1. RATIONALE
BEHIND THE
CHANGES
1.1 The document Commissioning a Patient
Led NHS follows on from the policy outlined in CPLNHS which
was launched in early 2005. It has also been widely seen as a
precursor to the forthcoming White Paper "Health care outside
hospital".
1.2 The stated rationale for the contents
of the "Commissioning a patient-led NHS" document is
as follows;
— Strengthen the function of commissioning
through larger strategic Primary Care Trusts (PCTs) and more localised
practice based commissioning structures.
— Separate the commissioning and provider
functions.
— Make £250 million financial
savings by reducing management costs achieved through mergers
and organisational reconfiguration.
— Ensure closer working between PCTs
and local authorities.
— Develop more pluralistic models of
primary care provision, by inviting alternative, non NHS organisations
to provide services. PCTs are to remove their provider function,
by 2008 unless there are no other suitable providers.
1.3 While the RCN supports any action aimed
at improving public health and patient care we are concerned to
see that the imposed pace and nature of change has caused uncertainty
within PCTs and other parts of the NHS. This is neither in the
interest of the public or the staff employed by the NHS. The timescales
set by the letter from Sir Nigel Crisp do not allow for meaningful
consultation or intelligent, measured and reasoned thinking.
1.4 In summary, the letter from Sir Nigel
Crisp (DH gateway reference number: 5312) calls for:
— Practice based commissioning (PBC)
to have 100% coverage by December 2006.
— PCTs to only provide services where
a case cannot be made for them to be provided by another agency
(independent, voluntary sectors and local government). Where PCTs
continue to provide services, there will need to be a split within
the organisation to ensure that commissioning and service provision
are separated so that any conflict of interest is prevented (However
the RCN wishes to point out that within practice based commissioning
both provision and commissioning will be taking place).
— Contestability is to be introduced
into the system, with the aim of improving quality and enabling
a level of choice within primary care.
— PCT's and Strategic Health Authorities
(SHAs) to be reconfigured and aligned with government office boundaries.
— All Acute trusts are required to
achieve Foundation Trust status by the end of 2008.
1.5 Since the publication of the Nigel Crisp
letter the RCN has been made acutely aware of the uncertainty
felt by nurses who strive to provide the best possible care in
often difficult circumstances. The suggestion that NHS Primary
Care services should basically be put out to tender has raised
alarm among many community nurses. This anxiety and uncertainty
will inevitably distract staff attention away from their core
business serving the public good in primary care.
1.6 The announcement of CPLNHS has caused
numerous nurses to contact the RCN and voice their grave concerns
over the future of community services. We support the widely held
view that the significant challenge of implementing CPLNHS will
ultimately impact upon Primary Care teams' ability to deliver
upon other significant and challenging Primary Care initiatives
such as improving public health (via the choosing health delivery
plan); reducing health inequalities; improving the management
of long term conditions; developing integrated health and social
care teams; improving access to services; and delivering the various
elements of the GMS contract.[34]
2. LIKELY IMPACT
ON COMMISSIONING
OF SERVICES
2.1 The RCN fully supports the development
of strong commissioning, in the knowledge that effective commissioning
aims to ensure that all services address local health needs, diminish
health inequalities, promote health and improve patient care.
"Commissioning is a strategic activity concerned
with the development of new look services to meet the identified
health and health care needs of local populations"[35]
2.2 Where effective commissioning is achieved,
the public should expect:
— Improved health experience.
— Solutions to their local community
health problems.
— Quicker and easier access to services
regardless of their age, ethnicity, ability, social class, gender,
race or health status.
— Their complex care needs to be met
by the most appropriate people.
— Seamless and co-ordinated care from
the multi disciplinary team. The patient will be unaware of organisational
structures and false boundaries.
— The opportunity to influence the
provision of local services—people need to be listened to
and their views respected.
2.3 In order for commissioning to be effective,
nurses need to be involved at all levels—PCT, PBC and SHA
and contribute to the following essential functions:
— Providing strategic leadership on
the new PCT and SHA boards through strong professional networks
and provision of evidence-based clinical advice.
— Having clear clinical leadership
roles in the commissioning process especially in developing care
pathways across traditional boundaries (community, general practice,
hospital, local authority (LA), independent and voluntary sectors).
— Contributing to contract specifications,
monitoring and the evaluation of services.
— Ensuring partnership working between
all relevant agencies.
— Making certain that front line nurses
are actively engaged with practice based commissioning and that
they hold budgets for nurse led initiatives and specific services
for patients and community groups.
— Ensuring that explicit governance
arrangements are in place so that clear relationships are defined
for SHA, PCT, LA and general practice personnel.
— Facilitate cohesive working between
PCT commissioners and those involved in practice based commissioning.
2.4 For many years the RCN has called for
more effective commissioning and for the process to focus on improved
community health as much as the contracting of secondary care
services. Historically primary care services have been financially
marginalised in order for acute hospital activity to be funded
to meet increasing demand for in-patient services. It is not uncommon
for provider budgets in primary care services to be "raided"
so that the cost of increased activity at the local acute hospital
can be paid for. In this sense we can support the separation of
the provision and commissioning of services.
2.5 The RCN supports the Department of Health
view on practice based commissioning, which, if executed properly,
will enable greater patient choice over services and allow patients
with long-term conditions to have access to better and more effective
support than previously and thus prevent unnecessary hospital
admission.
2.6 Unfortunately the current instability
within PCTs could result in nurses and other clinicians not being
well placed or have the enthusiasm necessary to fully engage with
the new commissioning structures. To put it simply, this could
hamper the aspirations of CPLNHS from being achieved.
2.7 The RCN has published much literature
on commissioning and run numerous workshops on commissioning with
the intention of equipping front line nurses and nurse managers
with the skills and knowledge necessary to be effective. We plan
to continue this work.
3. LIKELY IMPACT
ON PROVISION
OF LOCAL
SERVICES
3.1 Community services are difficult to
understand without the experience of working within the community.
They can be complex and on appearance, disconnected and disorganised,
often because people live chaotic and marginalised lives requiring
services from a number of agencies. The needs of patients being
cared for in the community can be far more complicated than their
disease or condition would suggest, on account of their personal
relationships and living conditions. One justified fear of the
recent reforms is that community services are in danger of becoming
more fragmented, thus posing genuine danger to people who are
ill, needy and living in socially excluded communities.
3.2 Sound and co-operative partnership working
between agencies is key to successful community services, making
it essential for all reform to focus on improvement in this area
not potential compromise.
3.3 Responsible health reform must reflect
demographic trends, the need to prevent illness and improve public
health, manage long-term conditions better and diminish the need
for hospitalisation. This can only be achieved through the development
of comprehensive community services which are well resourced and
able to employ properly trained, educated and supported staff.
It is difficult to see how a variety of small alternative providers
can meet this challenging agenda.
3.4 The RCN is currently exploring the issues
around contestability so that we have the opportunity to identify
what checks and balances may be needed to prevent any potentially
inadequate provider of community services being allowed access
to the market.
3.5 While the RCN welcomes all efforts to
improve innovation within communities, it is essential for commissioners
to understand the needs of the people they are there to serve
and concentrate particularly on the needs of the most vulnerable
people living within their boundaries. One main concern is that
provider plurality and market pressures may lead to competitive
tensions which do not foster a sense of shared innovation, collaboration
and partnership. In this sense, community services, under pressure
to compete, will not "join up".
3.6 Front line community nurses work closely
with the public, community groups and individual patients and
are therefore well placed to influence the shape and design of
local services. For some years now it has been noted by many NHS
managers and policy makers that, for the main part, it has been
nurses who have taken the lead in helping to redesign services
and, in doing so, have improved access to services and the quality
of care for patients. The joint RCN/Department of Health document,
"Maxi Nurse" offers many examples on how nurses have
expanded their roles and reshaped services to better meet patient
needs and wishes.
3.7 Despite the obvious benefits of nurse
led services highlighted in the above publication, the RCN has
genuine concerns regarding the impact that CPLNHS will have on
patient care and how, in the near future, some nurse led and specialist
services could be further diminished.
3.8 It has been reported to the RCN that
many community nurses who are near to retirement are so dismayed
at the prospect of community services being damaged that they
will choose to go for early retirement, rather then being forced
to work outside the NHS.[36]
4. LIKELY IMPACT
ON OTHER
PCT FUNCTIONS, INCLUDING
PUBLIC HEALTH
4.1 The RCN welcomed the "Orford letter"[37]
which clearly set out how Public Health functions should be protected
from the financial cuts described in Sir Nigel's letter and further
expressing the need to develop, rather then diminish the public
health function. Many community nurses, such as health visitors
and school nurses have a public health function within their roles
which needs to be expanded if choosing health is to have the impact
we all wish to see.
4.2 There are a number of statutory functions,
such as public health, child protection, prescribing, workforce
planning and development which need serious consideration during
this time of major reconfiguration and uncertainty.
4.3 There is still ambiguity around the
level of risk sharing in public health between SHA, PCT and Practices.
Our concern is that market type mechanisms have in the past failed
to act to coordinate public health initiatives or contribute to
joined-up strategies for health improvement. We would welcome
a more robust debate around how public health needs might be address
in a mixed market economy (assuming of course that it is agreed
that a mixed market approach to health delivery is appropriate
and evidence based).
4.4 In terms of future workforce planning,
it will be very difficult to develop a "fit for purpose"
health care workforce unless the community is able to provide
high quality clinical and learning placements. Fragmenting community
services could, the RCN believes, seriously damage workforce planning
and the development of a future workforce which is able to function
with competence and knowledge in the community.
4.5 PCTs currently employ community nurses
and provide an important Human Resources function. Nurses have
begun to question the value of Agenda for Change and Improving
Working Lives in the light of the government call to put community
services out to tender. We are already aware from several comments
made by the Department of Health that they are unwilling to set
commissioning standards for pay, terms and conditions for staff
who may work for independent sector providers, even if those staff
are engaged in delivering NHS services. This raises a very real
concern about this policy acting to undermine the investment and
hard work undertaken to create an equal and transparent system
of pay, terms and conditions (Agenda for Change). This risks creating
differing standards of employment across the health economy, to
the detriment of recruitment and retention and strategic workforce
planning.
4.6 Evidence and experience tell us that
organisations which provide the best possible HR, governance and
clinical governance engender staff with high motivation and morale,
while at the same time providing high quality patient services.
4.7 PCTs provide community services which
are highly valued by people who live better and healthier lives
because of them. They can be difficult to define and harder to
measure, but nevertheless lie at the heart of health and social
care and often enable people to enjoy a reasonable quality of
life and sometimes, when inevitable, die well at home. Community
services can be invisible to the majority and therefore all too
easily forgotten by those who develop policy and those who hold
the budgets.
4.8 The RCN is anxious to support reforms
which patently aim to enhance and expand community services and
address health inequalities. But we cannot support reforms which
are not supported by empirical evidence and appear to fragment
and diminish services.
4.9 Much of the evidence around the use
of market-based services points to the inevitable outcome that
there are always "winners and losers" in such market-based
system unless there are a series of robust checks and balances,[38],[39]—these
checks and balances, if indeed they exist in the proposed UK model,
have not been debated or disclosed in CPLNHS.
4.9.1 Whilst there are a range of models
of mixed market health economies to learn from which aim to prevent
the excesses of the market,[40]
our concern is that CPLNHS represents a rushed experiment with
the "marketisation" of primary care in England which
may result in the neglect of people who are not in a position
to demand, shout or complain.[41]
4.9.2 The Government's current policy position
of driving reform through the generation of economic instability
and the assumption of consumerist values in the delivery of healthcare,
whilst having some merits in certain circumstances, has not been
supported in the main through empirical research and public debate.
We would want to draw the Committee's attention to the fundamental
difference between "consumers" of goods and services
and "patients". Consumers enter markets with economic
power and are able to make choices over services and goods.
4.9.3 Patients however do not generally
seek to be ill or to receive health services and in that sense
there is a need for health services rather than a desire,
and those needs are unpredictable in the main. Public health poses
particular challenges in this respect in that health needs are
often unknown so the desire or need to enter the market for services
is dependent on access to information, health advice, mobility
and peer support. Information supplied and required by both sides
of the exchange is often imperfect in health care, solutions are
often high cost and markets can be dependent on any number of
externalities which may distort clinical priorities. This may
result in selection bias (cream skimming), inequity of provision
and moral hazard.[42]
4.9.4 In their study of US Chronic Disease
Management, the Kings Fund found that where there was competition
between MCOs (Managed Care Organisations), it could lead to a
focus on attracting young healthy enrolees at the expense of people
with chronic disease. They also noted a distinct lack of focus
on social care and wider pubic health issues.[43]
5. CONSULTATION
ABOUT PROPOSED
CHANGES
5.1 The RCN has issued an application to
be granted permission to apply for a judicial review of the Government's
failure to carry out a public consultation on the proposed changes
to the role of Primary Care Trusts in England.
5.2 The consultation that has occurred has
been about how to implement the change not on the merits of the
policy shift itself. The government proposals, outlined in CPLNHS,
stated that PCTs' role in provision of services will be:
"|reduced to a minimum and that primary
care trusts will act as the provider of services only where it
is not possible to have separate providers."
5.3 The RCN believes the implications of
the document could fundamentally change the nature of the NHS.
No longer will it be a provider of service and employer of staff
but instead a commissioning agent behind an NHS logo.
5.4 The significance of the document issued
by Sir Nigel Crisp, is that, by stating that PCT's will only have
a "minimum" provider role, it appears to dramatically
redistribute the balance between public and private services in
favour of the latter.
5.5 The Secretary of State, Patricia Hewitt
said on October 25:[44]
"District nurses, health visitors and other
staff delivering clinical services will continue to be employed
by their PCTs unless and until the PCTs decide otherwise. The
terms and conditions of staff will of course be protected."
5.6 The problem here is that people making
these local decisions have already had a very clear instruction
on 28 July to reduce their provider role to a minimum and the
initial reconfiguration plans to facilitate this were to be submitted
to the Department of Health by the 15 October, 2005. We know from
our members that there is a great deal of anxiety about the lack
of consultation around these proposals and indeed about the future
of primary care services.
5.7 For these reasons, we feel that we have
to challenge the government's policy in court. A judicial review
is not something we take lightly. The RCN is not against reform
and never has been. However, we believe the Government has to
undertake genuine consultation on its proposed reforms.
6. LIKELY COST
AND COST
SAVINGS
6.1 The NHS is already facing unprecedented
financial challenge as a result of several factors in combination:
— Increase in staffing costs related
to overspend on Consultant and GP contracts. There have also been
net increases in staff numbers in certain areas to meet demand/increased
activity—estimated to have cost around £2 billion.
There has been an increase of approximately 89,000 more clinical
staff employed in the NHS since 1999; 67,880 of which are nurses/midwives/health
visitors.[45]
That some of these are likely to lose their jobs or not be able
to find employment on qualification is a tragedy and a waste of
public money.
— Drug costs—these continue to
rise and are up 5.6% on last year; by 46% since 2000.[46]
— IM&T—total costs for IM&T
have increased to £6.2 billion over 10 years.[47]
Overspends in meeting the technical challenge of linking up thousands
of different organisations from SHAs to Hospitals to GP surgeries
are commonly reported.
— Payment by Results—this averaging
out of costs undertaken in drawing up the NHS tariff has left
some Trusts with up to 20% less income than they would normally
receive for the same or increased levels of activity. There are
also some Trusts who have benefited from the same process.
6.2 In addition to the challenges brought
about by the above, the demand to make rapid savings of £250
million is a challenging one and is already having a negative
impact on front line services and relationships between PCTs and
Acute Trusts. Frontline clinical and nursing posts have been frozen,
nursing redundancies have been made and newly qualified nurses
are finding it difficult to find jobs.
6.3 The RCN recently announced the findings
of an exhaustive survey of PCT and Acute Trust Board financial
reports and recovery plans in which we discovered a predicted
NHS wide deficit of around £1 billion and the loss of around
3,000 posts. We also know from previous experience that mergers
and reconfiguration rarely achieve the desired savings to the
extent planned—the fact that many large deficits reported
by individual Trusts have a significant historical element supports
this view.
6.4 Whilst there is some evidence to suggest
that limited competition promotes efficiency and cost reduction
in some services, there is little evidence that supports this
in primary care in the UK setting. If anything there are a number
of studies which point to slight deterioration in the quality
of services under previous approaches to a market based system.
6.5 Developing a competitive market in primary
care is going to require significant investment; careful planning
in terms of distribution of services and entry into the market;
and robust, patient centred regulation to ensure services remain
focused on local needs. This whole system approach needs to be
underpinned by a wide spread consensus on the direction of travel
and proper evaluation of each stage of the process to ensure that
patient outcomes and the principles of the NHS are maintained.
Any efficiency or cost savings delivered through a competitive
healthcare market must be derived from innovation and creativity
in service design and delivery and not through downward pressure
on quality or on the terms and conditions of the staff delivering
the services in the NHS.
Royal College of Nursing
9 November 2005
34 Dixon, J,. Walshe, K., Smith, J., Edwards, N.,
Hunter, D J., Mays N., Normand, C., Robinson, R. (2005) "Primary
care trusts premature reorganisation, with mergers, may be harmful".
BMJ, Oct 2004, no 329, pp 871-872. Back
35
S. Antrobus and Brown (1997). Royal College of Nursing, London. Back
36
This is a view reported widely by our members through the discussion
zones and regional contacts, but has also been picked up in some
consultation papers from Strategic Health Authorities such as
West Yorkshire SHA (W Yorkshire SHA-CPLNHS "The Way Forward"). Back
37
Department of Health (3 October, 2005). Letter from Kevin Orford,
Deputy Director of Finance (Strategy) to SHA Finance Directors.
http://www.dh.gov.uk/assetRoot/04/12/08/52/04120852.pdf. Back
38
Applied Economics (9th Ed)-Griffiths and Wall, 2001. Back
39
Lewis, R., Dixon, J,. and Gillam, S. (2003) "Future Directions
for Primary Care Trusts". Kings Fund, London. Back
40
See for example in the Netherlands and Sweden where provider
plurality exists in a framework of legal restraints on competition;
contractual and service protection for patients and staff against
market failure; and effective national collective bargaining with
local flexibility. Back
41
Dixon, J, Le Grand, J., and Smith P (2003) "Can Market
Forces be used for good?". Kings Fund, London. Back
42
op cit. Back
43
J Dixon & R Lewis et al (2003). "Managing Chronic
Disease-What can we learn from the US experience?" Kings
Fund, London. Back
44
Hansard 25 October 2005. Back
45
Department of Health, Sept 2004. "Staff in the NHS 2004:
An overview of staff numbers in the NHS". Government
Statistical Service. www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsStatistics/ Back
46
NHS Confederation, 2005. "Money in the NHS: the facts". Back
47
Department of Health, 2005. "Investment in IM&T in
the NHS". Back
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