Examination of Witnesses (Questions 180-199)
MS SIAN
THOMAS, MR
DAVID AMOS,
MR WARREN
TOWN, PROFESSOR
SIR ALAN
CRAFT AND
MS JOSIE
IRWIN
18 MAY 2006
Q180 Jim Dowd: Where has that happened?
Ms Irwin: That has happened in
a number of places. It is well-documented across the UK.
Q181 Jim Dowd: It was in one or two
places.
Ms Irwin: I do not have the details
off the top of my head. I do have a list with me which I am happy
to make available to the Clerk subsequently. To return to the
key question you asked, which is why is there an obsession with
posts, I think that we have to be concerned, do we not? The RCN's
annual employment survey, which we submitted as part of our evidence
to the Review Body, highlighted that 25% of the nurses that we
surveyed, and it is a statistic exam survey, said that they were
concerned that their workload meant that they were not able to
deliver the quality of care that they would like to deliver. From
the patient's perspective, clearly we have to be concerned that
if posts are reduced that will further add to the nurses' workload
and that in turn has an impact on the quality of patient care.
Mr Town: The AHPs have not so
much been subject to redundancies yet. If it were in, say, radiotherapy,
then the last person to leave should please turn off the light
because there would be no-one left. Our problem is that there
are a number of frozen posts within the establishments. Those
frozen posts are not being taken up.
Q182 Charlotte Atkins: You are taking
about frozen posts because of the deficit?
Mr Town: Yes, because of the deficits.
Q183 Dr Naysmith: Do you mean newly
frozen posts?
Mr Town: Yes, the job freezes.
Q184 Dr Naysmith: I remember being
in the Health Service just a few years back and going round and
visiting hospitals and nearly every establishment I visited had
empty posts that were being kept empty in order to keep within
budget. Nowadays, meaning in the last 18 months, this is virtually
absent. You are saying it is starting again, are you?
Mr Town: It is starting again
and it started in the middle of last year. We have noticed that
a number of our members within the AHPs have been subject to frozen
posts; in other words, job freezes, so that there is no-one going
into the vacant posts. One of our constituents, the Chartered
Society of Physiotherapy, conducted a survey and found a reduction
in vacant posts at a time when there are graduates coming out
ready to go into posts. These are new graduates, and it costs
£28,000 to train someone. If they are not going to go into
a post, where are they going to go? If they do not go into the
NHS, they will go somewhere else. If you are not going to put
people into posts but you want to reduce waiting lists, you want
to reduce waiting times, then you cannot have it both ways. A
high proportion of the junior posts, the posts that are being
frozen which are not being filled, are the ones that do the majority
of the work. In physiotherapy the juniors do most of the work.
In radiography, it is the juniors who do most of the work and
a lot of the out-of-hours work as well. In truth, by job freezing,
you are also impacting upon the quality of the care that should
happen in the NHS. So people are being diagnosed but they are
not then necessarily being treated because there are not sufficient
people in the jobs to do treat them.
Q185 Charlotte Atkins: So we have
very few actual redundancies. I wonder if the employers' organisation
would like to come in here because clearly there have been huge
numbers identified, including in my own North Staffordshire University
Hospital. The actual numbers of compulsory redundancies, although
obviously there will be some natural wastage over time, is not
as great, but still I have to say that is very serious and very
serious for the individuals concerned. I am also a bit concerned
about the RCN campaign. I appreciate you are a nursing-only organisation
but the implication is that only nurses jobs are important and
the rest are not. I would like the employers' organisation to
come in here.
Ms Thomas: I will make three very
important points, and then I will ask David Amos to talk from
a local perspective about his own situation and his understanding.
The first thing to say is that obviously patient care is paramount.
Any trust board that makes a decision to go through an exercise
to review its workforce in the way you have seen people do takes
that into account. We, the NHS Employers, did a recent survey
on the ground with employers to understand what the situation
is. I think it is disingenuous to say that the only reason for
these changes is deficit. There is a whole raft of reasons, many
of which we have talked about today. The world is changing. There
is a world of technology. That is what we do: we review what our
workforce is doing, what our skill mix needs to be, and we do
that every day. That includes how many numbers of people we need.
Q186 Charlotte Atkins: Are you saying
that the NHS deficits are being used as a sort of smokescreen
for reorganisation within hospitals?
Ms Thomas: No, I am not saying
that. Only this week we heard of an example in Nottinghamshire.
I spoke to the Director in QMC at Nottinghamshire who has just
announced over 1000 posts will be going from that organisation,
but they are merging two big hospitals together. They have always
planned to do that. They will be more efficient by doing that.
They want to redesign their services. The second point is that
there are many types of change and certainly some of them are
not about taking whole posts out of an organisation but doing
the very thing people have described as skill mixing. Now that
we have reached this equilibrium, many organisations are narrowing
gaps between supply and demand. Now they have to articulate what
their optimum balance of flexible to permanent staff should be.
It is safe to say that at this time that really is an important
issue for many employers because we now have many more people
who want permanent jobs. I would like to say something about graduates.
This is not to say that any individual situation is not important;
of course it is important and the number of compulsory redundancies
in our survey was very minimal. A significant minority of people
are going through what are very difficult times. Some of those
local situations, and there is a handful, are more challenging
than others. We, the employers, want to do everything we can to
make sure that every graduate, particularly in nursing as a profession
and as an example and physiotherapy where we know there is an
over-supply of graduates, gets a job this year. We will be working
in partnership with the RCN and the Chartered Society of Physiotherapy
to overcome some of those issues. We met recently with 40 physiotherapy
professionals and the CSP to discuss that very issue six weeks
ago and we have an action plan in place to overcome some of those
problems. We will do a similar thing for nurse graduates and find
innovative ways in which we can take all those graduates into
the workforce wherever we possibly can. It cannot be right that
we train people who then cannot get a first entry job in the service.
Q187 Charlotte Atkins: It has been
suggested that up to 10,000 nursing students graduating this year
may face unemployment.
Ms Thomas: We have not seen any
evidence of a figure anywhere like that. Currently, we are conducting
our own review of the local situation.
Mr Amos: The evidence, as I see
it on the ground and I know it is our experience at UCLH and Barnet
and Chase Farm and at trusts across London, is that, with some
considerable effort, they are able to take on all the nurse graduates
that are forecast to come out this year. That was certainly the
case earlier on this year and last year. At Barnet and Chase Farm,
for example, it is estimated that there will be 80 nurse graduates
coming out later on this year. They are all going to be taken
on. That is also the case for UCLH. It is important to recognise
that that is done in partnership with the individuals, with departments
and staff side representatives working hard to find perhaps in
the first case temporary appointments before permanent placements
can be made. In line with a general observation around the headlines
currently being portrayed, we need to hold our nerve; we need
to take the situation very seriously but to actually look at what
is going on on the ground, as Sian has indicated. I wanted to
give you one other example, which I think illustrates the amount
of reform going on, where staff, staff side representatives, technology
and training are helping to deliver reform. At UCLH and number
of trusts we have introduced technology for the transfer and storage
of radiological images, formerly known and loved as X-ray films.
That has transformed the working lives of clinicians and vastly
improved the quality of patient care in all settings in acute
care. That has had a dramatic effect on people who, often for
decades, have worked in hidden basement areas filing X-ray films.
In our case, and I know it is true right across the NHS, we have
worked with those individuals as we have not wanted to make them
redundant, We have given them training and trial periods in other
roles. I am glad to say that we have found them work. For those
individuals and their colleagues, that is a huge amount of reform.
It may be difficult to calibrate at this level and at a national
level but, through commitment and hard work on the part of everybody
(the individual, their representatives and their line managers)
we can pull off that reform which is good for staff and patients,
and good for cost-effective care.
Professor Sir Alan Craft: I want
to go back to how you started this by asking the nurses whether
the quality of care has deteriorated in spite of having an extra
30,000 or 40,000 nurses.
Q188 Charlotte Atkins: It is 75,000
since 1999 and up to 85,000.
Professor Sir Alan Craft: It is
important to recognise that the delivery of health care has changed
dramatically.
Q189 Charlotte Atkins: Has it changed
for the better or for the worse?
Professor Sir Alan Craft: It has
changed for the better. Nurses are doing a lot more things and
have helped to restructure the NHS, particularly through things
like the European Working Time Directive crisis that we had. If
we had not had nurses taking on extended roles, we would have
fallen flat on our faces. It is very difficult to look at one
particular bit of the Health Service in isolation. We are all
now incredibly dependent. Physiotherapists are taking on roles
doing things like physiotherapy-led back pain clinics that is
freeing up orthopaedic surgeons. It really is difficult to look
at each of the different bits in isolation.
Ms Irwin: I wanted to flag one
of the dangers, to return to a point being discussed with colleagues
about the student intake this year. There are indications, particularly
from the West Midlands and the East Midlands, of real difficulties
about graduate students of nursing getting their first jobs. Whilst
I think it is reasonable to say that there should not be an expectation
necessarily that an individual should get a job where they have
trained, we have to recognise that the majority of nursing students
these days are much older than they were. The average is 29. Many
of them will have local ties, children and partners with jobs
in the local community. The danger is that if we lose this year's
intake or this year's graduate cohort because of the short-term
difficulties that the NHS is experiencing, added to what I was
describing right at the outset of this inquiry about the ageing
of the nursing workforce, there is a danger that this short-term
blip will become a bigger problem for the future. I would like
to highlight that to the committee and make the additional point
that workforce planning somehow has to capture that. Our concern
is that it is not and that the short-term blip that we are experiencing
now will turn into a bigger problem for the future.
Q190 Charlotte Atkins: What should
Government do about it then?
Ms Irwin: In our evidence, we
have set out ways that the committee might ask the Government
to look at improving workforce planning. We have described models
that exist in Scotland, for example, which is a much more all-embracing
model of workforce planning that also looks to social services,
for example, in terms of getting information. Our solution, and
the solution we would like to suggest to the committee, is that
there is a much more robust way of looking at the workforce from
a national perspective by incorporating the UK perspective and
being much more robust at local level too.
Q191 Charlotte Atkins: That is fine
for the long term but what about the short-term deficit, for instance
in my own local hospital, the University Hospital, in North Staffordshire?
Ms Irwin: My colleague, Sian Thomas
from NHS Employers has already alluded to some discussions that
are about to be embarked upon in partnership with the trade unions.
We welcome that. We certainly welcome, for example, looking at
ways in which we can encourage those who may be losing their jobs
in the acute sector to re-train and for there to be a proper programme
of transition to allow them to work in the community where we
know, for example from your inquiry last week, that there is a
shortage of skills in community staff. We want to embrace that
change and work with NHS Employers to deal with that short term.
Q192 Charlotte Atkins: That would
require transitional funding, which is unlikely to come from the
National Health Service.
Ms Thomas: Perhaps I could give
an example of where we need to build on the success of what is
already happening. When we met with the physiotherapists, for
example, and I hope we are able to embark on some of these ideas
in partnership with the RCN, we heard that in community services
in particular we have perhaps been too narrow in our thinking
about what physios can do in the community and what supervision
they need in their roles. I think we can overcome some of those
issues by placing perhaps more junior professionals into the community
with better supervision so that the transition is easier for them.
Q193 Charlotte Atkins: But that would
have to be funded by the primary care trusts. If they are already
in deficit, how do they fund that?
Ms Thomas: It is certainly true
to say that there are many deficits in the primary care trusts
as well. However, many of them have told us that they are working
on designing new ways of patient care in the community. There
certainly are examples of where new technician roles, community
matron roles and junior district nursing roles, are changing the
way they work. I think that will evolve over the next year to
18 months as the White Paper is implemented and those models of
care will be seen to be happening. All the announcements about
post reductions have been in the hospital sector. It is only right
that that happens if care now needs to be delivered in the community.
Q194 Charlotte Atkins: If the primary
care trusts cannot come up with the extra funding, how do they
transfer to the community?
Ms Thomas: The challenge for them
now is to redesign what their workforce does and how it looks
and to change the way those people work.
Ms Irwin: To support what Sian
Thomas has just said, there are all sorts of examples where nurses
are working in different ways with associate practitioners in
the community. The fact that associate practitioners are then
able to be paid in a different way because of the change to the
pay system through Agenda for Change has meant that people
who would not previously have done those jobs have been attracted
to them and primary care trusts have then been able to save money
because they have not had to fork out for agency staff costs.
There are small examples like that which, aggregated up, could
become quite powerful in terms of not costing primary care trusts
extra money to make changes.
Q195 Chairman: Could I ask a specific
question about this whole area before we move on to something
else? It was said a few weeks ago in the public domain that the
safety net was being withdrawn from NHS patients. Was that an
unfortunate expression or is it evidenced? Does anybody have any
evidence that the safety net is being withdrawn from patients
because of the current situation?
Ms Thomas: We certainly have had
no evidence in our survey with employers that there has been detriment
to patient care from these changes. There is certainly change
but no evidence that was presented to us by local employers.
Q196 Jim Dowd: To take the other
side of that coin for a moment, do you have any view on the idea
that a lot of the reductions have been accompanied by assurances,
and I am generalising here, that that will not have an effect
on patient care? What were these people doing before then?
Ms Thomas: Can I qualify that
by saying that the reductions, in the vast majority of cases,
were in non-clinical roles and in roles, as David has described,
where people were supporting teams; the way those services are
now being delivered has changed. Many of the posts are managerial
posts, and that is only right. The evidence we have is that there
are minimal reductions in patient care and, where that happens,
it is through closure of beds because people are staying in hospital
a lot shorter time, or there are more day case operations instead
of people staying in overnight. Those sorts of examples mean that
it is only right to move those jobs to another part of the health
system. I hope that helps you.
Ms Irwin: I said earlier that
there are issues and concerns about the quality of care. I challenged
a comment made about concern for patient safety. We certainly
have some anecdotal evidence, and some of that was talked about
in the lobbying session last week, that specialist nurses are
being withdrawn from services that they provide. For example,
a specialist nurse who may be delivering arthritis care or rheumatism
care, traditionally Cinderella services, or providing care to
elderly patients is being required to work within a more general
setting. Whilst it would not be fair to say that that compromises
patient safety, it certainly has an impact on the quality of care
being provided.
Chairman: I am sure that unfilled posts
bring a tremendous amount of pressure on people working inside
the service. I have no doubt in my mind at all about that but
that is a big leap from then saying that we have no safety net.
The concept of a safety net being withdrawn from under patients
is something beyond that. I was concerned to hear that. Obviously,
if there is evidence out there, we would like to know about it.
At this stage, we have no hard evidence; it is only anecdotal.
Q197 Anne Milton: I declare an interest
because I am a member of the Royal College of Nursing. I just
wanted to challenge what you said, Ms Thomas, and apologise because
I might have missed this if it came up earlier. To say that there
will be no damage to patient care is a desperately glib statement.
I am thinking about what Josie Irwin said. There is one line about
"nobody dying because of..." The trouble is that in
the quality of patient care the scale is huge from the very best
and highest quality of care down to what is just about adequate.
I have to challenge the statement that patient care will not suffer.
I think you have to say what that means. It needs to be qualified.
Mr Amos: That is one way of describing
it. It is seen in two ways. I would go a step further and say
that the whole point of reform is to improve the quality and volume,
if I can describe it in that way, of patient care. I know that
is what boards and organisations are determined to do whilst making
sure that they listen to staff and staff side representatives,
local MPs and others for views on those changes. I think it is
the prospect of change that brings uncertainty and worry and makes
people sometimes think the worst. I do not say that glibly or
that those are not legitimate concerns. We need to distinguish
between those two prospects. What does the prospect of change
feel like? We are getting some headlines about worries as to what
that might mean for patient safety and working lives. The determination
is to manage that change in a way that does not reduce patient
safety but delivers on the real objective, which is to improve
working lives. That is a good end in itself but it is a means
to an end to improve the quality of patient services and the overall
volume of services that the NHS and other health care providers
can deliver.
Q198 Anne Milton: Mr Amos, I think
it is very easy to dismiss the concerns of a workforce about reform
as being about self-interest and say that nobody likes change
and that is why they do not like it while missing the fact that
a lot of professional staff are raising valid concerns about reform.
Mr Amos: My sense on that is that
if you acknowledge that that is the case, then you can do something
about it. That includes staff side representatives and staff themselves.
I think you are right; if you dismiss it, then you can get into
a situation where people get seriously de-motivated and leave
and you do put safety and other matters in jeopardy. As leaders,
if you acknowledge that is how people react to change, and it
happens to all of us whether we are front line staff or not, then
you can do everything in your power to work with staff, consult,
communicate, listen and give support and training, certainly in
the midst of change in the early days of post-reform, in order
to make sure that you meet the concerns expressed here this morning.
Q199 Anne Milton: Mr Amos, I think
you and I need to go away and have this argument outside the committee.
Mr Town: I think there is a difference
between releasing the safety net and what is detrimental to the
patient in the longer term because if patients are left to wait
for their treatment much longer than they expect, then there is
an immediate detriment. If there are not people there to take
the responsibility for diagnosing or providing a therapy service
to them, they will suffer. That is the one point that you made
quite eloquently and one that we would endorse. It concerns our
members quite a lot and is a frustration for them.
| 
