MEMORANDUM
BY THE
ROYAL COLLEGE
OF NURSING
(PEX 19)
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 to this Health Select Committee inquiry into Public Expenditure.
2. EXECUTIVE
SUMMARY
— The RCN welcomes the Government's commitment
to protect the NHS budget and increase it in real terms over the
life of this Parliament. However, with increased demand on services
the RCN believes the NHS will effectively have to do far more
with less.
— High quality and safe patient care in
any setting depends on there being the right number of nurses
with the relevant skills for the specialism they work in.
— The RCN also welcomes commitment from
the Government to protect frontline services and staff during
its drive to make £15-20 billion worth of efficiencies savings
within the NHS. However, we have evidence that cuts are being
made locally; contradicting the national message that services
and staff numbers will not be affected.
— The RCN believes the decision to implement
efficiency savings of between £15-20 billion in the NHS over
the next four years will inevitably impact upon the level of care
and services it is able to provide.
— The RCN believes that by addressing waste
and using innovation and new ways of working large financial savings
can be made in the NHS.
— Nurses should be involved at all levels
of discussion and decision making to do with reorganisation of
services in order to ensure the highest level of healthcare is
delivered.
— The current social care system is not
fit for purpose. It is unfair and overly complex. The RCN is concerned
that cuts to local authority services will exacerbate these problems
in the current system.
— Specialist nurses deliver a higher level
of patient care whilst reducing readmissions and actually saving
money. They should not be earmarked for cuts.
— Any surplus in the NHS budget must be
reinvested now into frontline services.
3. STRATEGIC
ASSESSMENT
3.1 What level of commitment is national government
making to the NHS, and how does it compare with long term trends
of demand, cost and efficiency?
3.2 The RCN recognises the importance of
the commitment made by the Coalition Government in its "Programme
for Government" to increase health spending in real terms
over the lifetime of this Parliament. We also welcome pledges
made on a number of occasions by the Government to protect the
NHS budget at a time when other public sector funding is facing
central spending cuts.
3.3 Demand and expectation of the level
of service patients should receive from the NHS has increased
greatly over recent years. This has occurred at the same time
as an increased level of Government funding. Whilst welcoming
the Government commitment to increase spending in real terms,
the RCN believes that future demand is set to rise due to people
living longer, often with long-term conditions, and will lead
to the NHS needing to do far more with far less.
3.4 The large majority of the increased
demand on the NHS will be focused on elderly patients or those
with long-term conditions whose care is provided primarily by
the nursing workforce.
3.5 What are the implications of "£15-20
billion efficiency challenge" described in the Revised Operating
Framework for the NHS as "absolutely critical"?
3.6 The RCN recognises that the NHS is now
facing one of the most challenging financial periods in its history
and acknowledges that there are savings which the NHS can make
and ways that it could work more efficiently. However, the RCN
believes the decision to implement efficiency savings of between
£15-20 billion in the NHS over the next four years will inevitably
impact upon the level of care and services is able to provide.
3.7 Whilst we welcome the commitment made
at a national level to not NHS cut services the RCN fears that
this is not the case at a local level. We have evidence that NHS
Trusts are making short-term "slash and burn" cuts,
which have historically been made to battle financial shortfalls,
which are leading to the erosion of effective, safe and quality
patient care in the NHS.
3.8 The RCN is committed to working with
the NHS and the Government in finding solutions and innovations
to save money and improve patient services. The RCN understands
the severity of the current financial climate and budgetary constraints
to other Government Departments. However, savings should be made
by eliminating waste, inefficient ways of working and implementing
new innovations, not through cuts to staff, which we believe is
happening across the country.
3.9 It is with this in mind that the RCN
has set up our "Frontline First" campaign. This allows
our members to inform us as to where cuts to workforce and services
are being made, where waste is apparent and where innovations
are found. Already the campaign has generated thousands of examples
of waste in the NHS and provided a large amount of detail on local
cuts and innovative ways of working.
3.10 Contrary to Government guarantees to
protect frontline services, the RCN is aware that NHS Trusts across
the country are making short sighted cuts to the workforce and
services simply to save money which are ill thought out and likely
to damage patient care.
3.11 The RCN understands that already nearly
10,000[27]
posts have been earmarked for removal based on information gathered
from one hundred Trusts facing financial pressure. Many of these
posts will be removed by not replacing staff that leave or retire.
3.12 Changes to skill mix are also being
looked at to reduce staff pay bills. For example the South Central
Strategic Health Authority, in a draft report, has discussed and
proposed in detail, re-profiling the workforce allowing overall
labour costs to be reduced. The report explores only the monetary
savings and not the impact upon patient care of reducing over
700 full time equivalent Band 5 (typically Staff Nurse) posts,
and replacing them with Band 4 (Senior Healthcare Assistants,
non-registered) employees.[28]
3.13 High quality and safe patient care
in any setting depends on there being the right number of nurses
with the relevant skills for the specialism they work in. Reduced
staffing levels and an inappropriate balance between registered
and unregistered nursing staff reduces quality of care and, through
increasing pressures, puts patient safety at risk.
3.14 As a result of the Frontline First
campaign our members have submitted over a thousand examples of
waste in the NHS. The five main topics of complaint where our
members see money and their time wasted are: improper disposal
of clinical waste; wasting of medicines; improper purchasing arrangements
and practice; excess paperwork; and inefficient working practice
systems. The RCN would welcome the opportunity to share in more
detail these examples of waste with the Committee.
3.15 "Frontline First" is not
just about identifying the problems in the NHS, it is also about
finding the innovative solutions that will protect services and
improve care. We have had hundreds of innovations and suggestions
sent through to us which could potentially change ways of working;
improve standards of care and save the NHS money. The RCN knows
that on wards and in communities, nurses are finding innovative
ways of working to save money whilst maintaining the highest standards
of patient safety and care.
3.16 Again the RCN would welcome the opportunity
to share in more detail the innovations that our members have
identified which are saving the NHS money.
3.17 Finding billions of pounds of savings
within the NHS cannot be made through cutting waste and introducing
efficiencies alone. It is inevitable that tough decisions will
have to be made and questions asked over which services are prioritised.
It is essential that nurses and other health professionals are
involved at every stage of this decision making process.
3.18 We are aware that providers increasingly
are developing eligibility criteria to control access to services.
We are concerned that the process and outcome of determining such
criteria is clinically led and transparent and that there is consistency
in the use of eligibility criteria between different providers.
3.19 What level of commitment is national
and local government making to Social Care, and how does it compare
with long term trends of demand, cost and efficiency?
3.20 National and local government have
long recognised that the social care system has been in urgent
need of reform to ensure that it meets the long term trends of
demand, cost and efficiency. Yet a lack of political consensus
on the direction of this reform has meant this recognition has
not been able to deliver the changes needed.
3.21 The long term trends are not simply
about the financial pressures resulting from an ageing society
and an increasing number of people living longer with long-term
illnesses. These trends also include increasing service user expectations
and agreement that the current system is inherently unfair, overly
complex and the cause of significant problems for the NHS.
3.22 In light of the role nurses play in
delivering social care and in dealing with its impact on the NHS,
the RCN carried out a survey with 1,500 members on social care
and long term trends. Members told of how the current system prevents
integrated health and social care delivery and leaves many social
care needs unmet. On a daily basis our members have to deal with
issues like bed-blocking, whilst NHS demand rises in the face
of inadequate social care provision.
3.23 Members were also concerned by the
complexity of the current social care funding system, by the postcode
care lottery and resulting inequalities across England. They felt
it was unfair that some people have to sell their homes or use
their lifelong savings to fund their care, as eligibility criteria
for free social care gets tighter thereby excluding more and more
people.
3.24 The previous Government showed commitment
to build a National Care Service but failed to commit to a funding
solution. The RCN welcomes the establishment of the Commission
on the funding of Long Term Care by the current Government and
looks forward to giving evidence to the Commission. In our survey,
members indicated a clear preference for a comprehensive National
Care Service (62.8%), funded either through state insurance system
(57.9%), or general taxation (29.9%).[29]
The RCN is hopeful that this Commission will result in the political
commitment needed to create a social care system that our members
want to see: one based on fairness, equal access, transparency
and simplicity and, integrated, high quality care.
3.25 What are the implications of the
government's plans for the interface between the NHS and Social
Care?
3.26 Greater integration of the NHS and
social care is welcomed by the RCN: as it is an issue that has
been identified by our members as requiring urgent attention.
The RCN is keen to learn more details about the Government's plans
in this area, particularly on funding. Both the NHS and social
care systems are stretched financially, with both requiring adequate
resources of their own to provide high quality care.
4. CENTRALLY
FUNDED HEALTH
SERVICES—TOP
SLICED SERVICE
PROCUREMENT
4.1 An example of services procured from
"top-sliced" funding is the Independent Sector Treatment
Centres (ISTC) programme. The RCN submitted to the 2006 Health
Select Committee inquiry into ISTC.
4.2 The initial aim of the ISTC programme
was to purchase additional capacity for elective surgery. Strategic
Health Authorities in conjunction with local clinicians were asked
to identify gaps in capacity by speciality. It is not clear as
to the level of involvement local clinicians including nurses
had in the capacity planning process. During the procurement process
a number of changes were introduced. These include an additional
guaranteed contract for 250,000 cases and an agreement to transfer
existing activity from NHS Trusts to the ISTC.
4.3 The initial agreement proved to be flawed
with referrals to the ISTC at a far lower level than predicted,
leading to a far greater cost per operation, resulting in the
programme proving to be deeply uneconomical.
4.4 Following the Health Select Committee
inquiry of 2006 the Department of Health amended its working and
ceased to offer guaranteed contracts to independent sector providers.
The ensuing second wave of contracts reflected this change.
4.5 The ISTC programme was implemented as
a measure to tackle rising waiting lists, but in actual fact the
NHS took sufficient and successful measures itself to bring down
waiting lists. It was also predicted that innovative ways of working
would be shared from the independent sector with NHS providers,
however, the NHS was able to come up with its own innovations
and solutions to the problem of rising waiting lists.
4.6 The RCN believes that a major problem
with the ISTC agreement was the neglect to fully engage with clinicians
in the commissioning stage. This backs up the RCN view that clinical
engagement must be put in place to ensure the viability and quality
of any commissioning services. Including this within centrally
procured services and within the independent sector is vital to
the success of commissioned services. The RCN's submission to
the current NHS White Paper consultation will further detail proposals
for future commission models.
5. RESOURCE ALLOCATION
WITHIN THE
NHS
5.1 The RCN believes that any resource allocation
approach must be balanced, representative of need and demography,
and it must be sustainable in the long term.
5.2 When decisions of funding are made it
is vital that they are made with the long term in mind. A welcome
approach would be not to judge allocation and commissioning simply
upon costs but upon the sustainability and long term impact of
resource allocation.
5.3 Monitor demands that Trusts hold back
a proportion of their budget as a defence against over spend,
a surplus. The RCN believes it is right that Trusts have a reserve
of money, however, the RCN believes that it is right, in the current
financial climate and in light of the £15-20 billion of required
efficiency savings, that any surplus is reinvested swiftly into
frontline services.
6. LOCALLY COMMISSIONED
HEALTH SERVICES
6.1 The RCN firmly believes that efficiency
and value for money in the NHS can be found through investment
and support for locally commissioned services, such as specialist
nursing that focus on quality.
6.2 In previous periods of financial constraint
we have seen the NHS cut jobs and services to save money, decisions
that in the longer term may well have cost the NHS more than they
saved in the short term. For example, specialist nursing posts,
often one of the first to be cut in times of financial constraint,
actually save the NHS money in the long term by delivering better
patient outcomes, preventative care (which reduce hospital admissions
and cost) and higher levels of patient satisfaction.[30]
6.3 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.
6.4 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.
6.5 For example, the Parkinson's Disease
Society states that specialist Parkinson's nurses save the NHS
£56 million.[31]
By treating multiple sclerosis flare ups at home rather than in
hospital an estimated £180 million could be saved[32]
and £84 million could be saved by using epilepsy specialist
nurses rather than using GP services to manage the condition.[33]
6.6 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.
6.7 As has been highlighted specialist nurses
can, where properly supported, play a huge role in reducing expensive
hospital admissions. Another 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.
7. SOCIAL CARE
RESOURCE ALLOCATION
7.1 What is the expected impact of the local
authority settlement on social care budgets?
7.2 If local authorities look to social
care services in meeting the Government's target of cutting expenditure
by 25%, the current problems of social care system will be exacerbated.
Eligibility criteria for free social care are likely to be further
strengthened, and many vulnerable people will have to find the
way to fund significant social care needs or go without, placing
additional pressures on the NHS.
7.3 For this reason, the RCN strongly cautions
against making any cuts to social care services. Such cuts would
be short-sighted and only lead to increased demands on resources
elsewhere.
7.4 How does the local government funding
formula reflect differential demand for social care services in
different areas?
7.5 The formula recognises and reflects
greater needs in deprived areas for some services. Yet since social
care is not ring-fenced how this money is spent is decided locally.
Social care is inadequately funded throughout the country, and
hence the local government formula and the way in which it is
granted, fails to fully account for the demand of social care,
regardless of area.
7.6 What is the impact of this system on the
budget allocations of a representative sample of social service
departments?
7.7 The RCN does not have access to this
information, yet it would reiterate that the underfunding of the
social care system impacts in the same way across the country.
8. SOCIAL CARE
SERVICES
8.1 What scope exists for social care services
to manage demand, cost and efficiency within constrained budgets?
8.2 Social care services currently manage
demand and cost within constrained budgets by increasing the eligibility
criteria for social care—ie by only providing care for those
people with substantial care needs and with very little savings
to fund care themselves. The result is an unfair system, which
seems to penalise those people with savings, which does not cater
for many people with significant care needs and who may not be
able to fund care themselves and, since local authorities can
decide on how much to fund social care services, sees significant
variation across the country.
8.3 What are the implications of social service
budgetary pressures on the interface between health and social
care services in a representative sample of areas?
8.4 Again, the RCN does not have access
to information relating to a representative sample of areas. However,
as mentioned previously the RCN is aware that budgetary pressures
impact on health and social services throughout the country. The
question of how to fund a system based on fairness, equal access,
transparency and simplicity and, integrated, high quality care
must be urgently addressed to safeguard the well-being of all
communities and individuals.
September 2010
27 Information from the Royal College of Nursing, up
to date as of 30 June 2010. Back
28
Report on Shaping the future workforce A strategy to develop the
workforce in NHS South Central 2010-2015. Available from: http://www.nesc.nhs.uk/pdf/NHS<_>South<_>Central<_>workforce<_>strategy<_>2010<_>WEB.pdf Back
29
There was little preference for making contributions to a private
insurance scheme (6%). Back
30
Specialist Nurses: Changing Lives, Saving Money, RCN February
2010. Back
31
Parkinson's Disease Society, 2006. Back
32
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
33
Estimate based on a saving of £184 per patient per year from
correct specialist diagnosis and reduced GP visits. Back
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