Memorandum by the Royal College of Nursing
(SAV 08)
VALUE FOR MONEY IN THE NHS
1. INTRODUCTION
1.1 With a membership of 400,000 registered
nurses, midwives, health visitors, nursing students, health care
assistants and nurse cadets, the Royal College of Nursing is the
voice of nursing across the UK and the largest professional union
of nursing staff in the world. RCN members work in a variety of
hospital and community settings in the NHS and the independent
sector. The RCN promotes patient and nursing interests on a wide
range of issues by working closely with the Government, the UK
parliaments and other national and European political institutions,
trade unions, professional bodies and voluntary organisations.
1.2 The RCN welcomes the opportunity to submit evidence
to the one off Health Select Committee inquiry on value for money
in the NHS.
1.3 This submission will demonstrate how the nursing
profession can deliver value for money and high quality care whilst
illustrating the hugely detrimental effect cutting frontline services
will have. The RCN firmly believes that efficiency and value for
money in the NHS can be found through investment and support for
services like specialist nursing that focus on quality. This submission
highlights specialist nursing as a case study in which the nursing
workforce demonstrates cost saving measures whilst delivering
the highest quality of care.
1.4 The RCN recognises that an effective way
to cut costs is to reduce hospital admissions. One way to do this
is to treat more patients effectively in the community by skilled
staff who are able to keep patients as healthy as possible in
their own homes. Making the shift to treating more conditions
in the community will require a long term consideration of what
patients need and an assessment of the impact on the quality of
care.
1.5 The solutions to this will be complex, involving
all parts of the health service working together in the shift
from acute to community care. With many hospitals already running
at capacity, simply cutting bed numbers without planning for the
long term would be irresponsible.
1.6 The economy is changing and as we move out
of a recession we must look to protect health care spending at
the same time as focusing on the services which provide value
for money and will in the long term bring down health spending.
The NHS is a massive economy and change will not be seen overnight
or even in the short term.
1.7 In order to see long term reform and reduction
of the huge costs involved with issues such as smoking, obesity
and expensive long stays in acute trusts there must be consistent
and continued funding of services now. This can only be done through
examining fields such as specialist nursing and public health
which take a holistic approach to patient care.
2. NURSING AND
THE ECONOMIC
CONTEXT
2.1 The RCN recognises that the NHS is facing
one of the most significant financial challenges in its history.
Government borrowing and economic conditions have resulted in
significant public sector borrowing and a massive budget deficit
that the Government will have to address. The NHS Chief Executive
David Nicolson has stated the need to secure substantial "cash
releasing efficiency savings" in the NHS budget of between
£15 billion and £20 billion between 2011 and 2014, a
message that was recently conveyed directly to clinicians by the
Department of Health.[14]
2.2 There is concern that funding cuts and the drive
for efficiency savings could result in "slash and burn"
tactics, bed closures, cancelling of new services and staffing
reductions. During the NHS deficit crisis of 2005-06 training
budgets were one of a number of targets for savings. This resulted
in periods of "boom and bust" workforce planning with
consequent knock on effects for the nursing workforce.
2.3 Staff could not be replaced quickly when
the cycle returned to "boom". Vacancy freezes resulted
in fewer jobs for newly qualified nurses and nursing roles considered
expensive, such as specialist and nurse consultants, were also
targeted for savings. Lessons must be learned from the past about
the damaging effects to the entire health sector caused by short
term cuts in order to achieve financial gain.
3. CASE STUDY—SPECIALIST
NURSES
3.1 An example of nursing innovation and how
the nursing workforce can actually save the NHS money, whilst
delivering the highest quality of care, is in specialist nursing
posts. A recent RCN report[15]
set out the benefits that specialist nurses provide, benefits
in the quality of care and also the economic savings which can
be made by their employment.
3.2 During the NHS deficit crisis of 2005-06 specialist
nursing posts were hit hard by trusts attempting to save money.
The RCN is concerned that under current financial constraints
history will repeat itself in the shape of cuts to these highly
skilled and highly valued nurses. Cuts to these services would
effectively result in a down-skilling of the nursing workforce
and the undermining of patient care.
3.3 Specialist nurse posts save millions of
pounds from health budgets through a variety of means including:
— avoidance of unnecessary hospital admission/readmission
(through reduced complications post-surgery/enhanced symptom control/improved
patient self-management);
— reduced post-operative hospital stay
times;
— the freeing up of consultant appointments
for other patients;
— services delivered in the community/at
point of need;
— reduced patient treatment drop-out rates;
— the education of health and social care
professionals;
— the introduction of innovative service
delivery frameworks; and
— direct specialist advice to patients
and families.
3.4 For example, the Parkinson's Disease Society
states that specialist Parkinson's nurses save the NHS £56
million.[16]
By treating multiple sclerosis flare ups at home rather than in
hospital an estimated £180 million could be saved[17]
and £84 million could be saved by using epilepsy specialist
nurses rather than using GP services to manage the condition.[18]
3.5 Today's specialist nurse takes a leading
role in making sure patients get the best care possible. Several
studies have shown that as a substitute for other health care
professionals, including doctors, specialist nurses are both clinically
and cost effective. As an increasing number of people in this
country are diagnosed with long term conditions, these experts
will become even more invaluable to the health of the nation.
4. FINANCIAL CONSTRAINTS
ON SPECIALIST
NURSING
4.1 The potential of specialist nurses to drive
up safety and the quality of care, and to improve patient outcomes
is under threat. Specialist nurse posts should be supported through
robust long term funding. Short term funding of up to two years,
which is increasingly popular, makes these posts extremely vulnerable
to cut backs by trusts looking for immediate savings.
4.2 Despite the evidence of the positive impact in
terms of patient care enshrined in national guidelines, no other
group has been targeted to such a degree in the wake of NHS financial
pressures. Specialist nurses were one of the groups hardest hit
by the NHS deficits crisis of 2005-06. A poll of specialist nurses
(RCN, 2008) showed:
— more than one third of specialist nurses
reported their organisations had a vacancy freeze in place;
— 47% reported they were at risk of being
downgraded;
— 68% reported having to see more patients;
— one-in-four faced risk of redundancy;
— half were aware of cuts in services in
their speciality; and
— 45% were being asked to work outside
their speciality to cover staff shortages in general clinical
settings.
4.3 Two years later, a further poll (RCN, 2010)
has demonstrated that more than a third of respondents to the
RCN survey have seen cuts in services over the last 12 months,
and 57% are concerned that posts will be threatened in the near
future. 95% of the respondents who have seen cuts in services
say it is the NHS who have cut or reduced funding for specialist
nurses. This raises significant concerns that posts and services
could be lost altogether as funding streams dry up.
4.4 As we enter another period of constrained
public spending, many specialist nurses now face serious organisational
and funding challenges that are inhibiting their ability to deliver
high quality care. Specialist nurses add value to patient care,
while generating efficiencies for organisations through new and
innovative ways of working and must be protected.
5. THE VALUE
OF NURSING
Nurses are involved in almost every facet of
care. Over recent years nursing teams have reengineered their
roles to assume a higher range of clinical responsibilities, and
successfully adapted to using new systems to improve patient care.
Therefore, the nursing contribution to care needs to be explored
further in the context of the incentives described above and not
just aggregated as a simple workforce cost.
5.1 The total "value" of nursing will
depend upon the current number, skill mix and the ways that the
workforce is deployed. There is increasing weight of evidence
showing the negative consequences of reducing nurse numbers leading
to increased mortality rates. In order to combat this, the RCN
has called for regular staffing reviews, which are then reported
to Trust Boards, to guarantee safe staffing numbers and the highest
level of care for patients. Skill mix is just as vital, it is
not just overall numbers which matter.
5.2 In this new challenging financial climate
the NHS will have to make even more difficult trade off decisions
about what it will and will not offer. Decision makers must avoid
making short term decisions, ensuring that they consider the full
value of nursing, and the negative consequences when nurse numbers
are reduced, when considering how to best allocate scarce resources
in the health care system.
5.3 Alongside this, it is vital that the voice
of nursing is adequately represented at all levels of governance
of the NHS to identify how the NHS can become more efficient and
to curb any unnecessary and inappropriate changes to staffing
levels.
6. BENEFITS OF
INVESTING IN
PUBLIC HEALTH
6.1 Nurses have a significant ability, and are
ideally placed, to influence behavioural change within a health
promoting environment.
6.2 Nursing achievements in the public health sphere
are visible and measurable, impacting on individuals, specific
groups and the population at large. The RCN Document Nurses
as partners in Delivering Public Health identifies a number
of aims in delivering public health through nursing services:
— increased life expectancy by influencing
healthy behaviours;
— reduced health inequalities—for
example, targeting vulnerable populations to improve health out
comes and access services;
— improved population health—For
example, reducing obesity, alcohol abuse, improving sexual health
behaviour;
— increased awareness of positive healthy
behaviours in communities; and
— engaging with individuals, families and
communities to influence service design.
6.3 The benefit from achieving these goals is
significant and reduces the future burden to the NHS by delaying
or preventing illness. Alcohol misuse, smoking and obesity is
largely calculated at costing the NHS over £11billion per
year. While there are many visible examples of public health nursing
that make a substantial contribution to this, there is a lot of
good public health nursing practice that is carried out locally
but does not achieve the widespread recognition which it deserves.
7. PAYMENT BY
RESULTS AND
NURSING
7.1 Although efforts have been made within the
Payments by Results system to wholly quantify nursing, nursing
costs are still too often treated purely as workforce costs, allocated
on the basis of the amount of time spent with the patient, for
example, theatre hours or bed days. There is little recognition
of nursing efforts/inputs, patient dependency and skills. The
RCN believes that this absence of a full and comprehensive understanding
of nursing costs and contribution to the overall process of patient
care, may lead to nursing workforce numbers and skill mix being
subject to inappropriate cuts as was seen during the deficits
crisis of 2005-06.
7.2 The costs of nursing are all too often identified
simply as the wage bill for nursing staff. The precise costs of
nursing reflect both central and local decisions about wage rates,
nurse numbers, skill mix (a higher skilled workforce will typically
cost more), education, training, and international, national and
local labour market conditions.
7.3 The benefits of nursing are somewhat more
difficult to identify. The term benefit is used interchangeably
with value. There are a number of reasons why identifying the
value of nursing is a challenge:
— the value of nursing includes both tangible
and non-tangible components and intangible components are inherently
difficult to identify and measure;
— it can be difficult to separately identify
the contribution of nursing to health (alongside the wider issues
of measuring the contribution of the health care system in general,
to the production of health); and
— the value of nursing includes the impact
on patients, their carers, the health care system, and the wider
economy. This poses a challenge to capture the value to each of
these stakeholders in the system.
Royal College of Nursing
March 2010
14 The NHS Quality, Innovation, Productivity and Prevention
Challenge: an introduction for clinicians. Department of Health,
March 2010. Back
15
Specialist nurses, Changing lives, saving money. Royal College
of Nursing-February 2010. Back
16
Parkinson's Disease Society, 2006. Back
17
Estimate based on a saving of £1,797 per patient from a scheme
to treat patients at home, developed by the University College
London Hospital Foundation Trust. Back
18
Estimate based on a saving of £184 per patient per year from
correct specialist diagnosis and reduced GP visits. Back
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