Govt’s twisted view of NHS staffing – and 2 concrete examples

Depending how the rest of the day goes, this may be my last post of 2012. So let me briefly take the opportunity to thank everyone who’s visited my blog this year, and especially those who’ve gone to the trouble of spreading the word on Twitter, Facebook. It’s been a tough year for the UK under its present excuse for a government, and 2013 is likely to be as bad or tougher – but if we stick together, keep fighting and keep raising awareness, the clock is ticking on the robber-barons in government and those who back them.

To all readers of good will, may you be healthy, happy and successful in the New Year and beyond. Now, on with the post.

On 27 Nov 2012, during Commons Health Questions, Health Secretary Jeremy Hunt was challenged by Labour MP and former Shadow Health Minister Barbara Keeley about the impact of reduced staffing levels on patient care in the NHS – a direct result of government decisions (which have led to the loss of more than 7,000 nurse posts so far) . His answer was quite remarkable – and very telling:

Barbara Keeley: I thank the Secretary of State for that answer. The recent Care Quality Commission report found that 10% of NHS hospitals did not meet the standard of treating people with respect and dignity, and underpinning that poor care were high vacancy rates and hospitals that have struggled to make sure they have enough qualified staff on duty at all times. That shows us the real impact of losing those thousands of nurses. So does he agree that it is urgent that this Government take action when understaffing in the NHS results in poor care?

Mr Hunt: I absolutely agree with the hon. Lady that nowhere in the NHS should allow low staff numbers to lead to poor care. What was interesting about the CQC report, which was a wake-up call for the whole NHS, was that institutions under financial pressure, as the whole NHS is, are delivering excellent care in some places and delivering care that is unsatisfactory and not good enough in other places. On her specific question about nurses and nurse numbers, it is important to recognise that across the NHS as a whole the nurse-to-bed ratio has increased. Every NHS bed is getting an extra two hours of care per week compared with the situation two years ago.

Jeremy Hunt did not deny the loss of those nurses. But he claimed that the loss in numbers was not the most important point. In his opinion, what is important is that the ‘nurse to bed’ ratio has increased.

If nurse numbers have reduced, an increase in the ‘nurse to bed ratio’ can only mean one thing – and it’s not good news. But more of that presently.

I’ve written before about testimony given to the Commons Health Select Committee on 13 Nov, because it showed that NHS staff lost on average £647 as they bore the heaviest brunt of in year 1 of the government’s £20 billion ‘efficiency drive’, while the Foundation Trust Network (FTN) is hoping to gain the freedom to unilaterally change staff pay and conditions, rather than negotiating any changes, as they currently must.

But the testimony contained a lot more, including a very clear example of the government’s twisted attitude to NHS staffing, of the double-speak that it and senior NHS executives use to disguise what’s really going on, as well as of an unbelievably cavalier attitude taken by those executives to what is happening to patients and staff.

If you want to read the session in full rather than take my word for it, you can do so here. Otherwise, here are some of the relevant passages.

We start off with an exchange involving:

– FTN Chief Executive Chris Hopson
– Tony Spotswood, CEO of Royal Bournemouth & Christchurch Hospitals (RBC). RBC is part of the South West Pay, Terms and Conditions cartel (SWC), and Spotswood has been revealed as plotting to bring down NHS Employers (NHSE), the national negotiating body responsible for agreeing changes to Agenda for Change (AfC), the payscales, terms and conditions applying to NHS staff across the UK.
– Philippa Slinger, Chief Executive of Heatherwood and Wexham Park NHS acute foundation trust – a ‘financially challenged’ NHS Trust.

I’ll quote the exchange passage by passage, with some commentary where applicable, so please bear with me and I’ll try to make sure it’s worthwhile.

In the first phase, the three CEOs are responding to a question from the excellent Grahame Morris MP about staffing levels and their effect on standards of care and on staff morale:

Chris Hopson: I will pick up both of those questions. In terms of quality of care, we specifically asked our members whether the savings that they were making had impacted on quality of care last year and in the current financial year. As I said, again we were very struck by the overwhelming majority-and I mean all but one or two were-basically saying that they do believe that the savings that they are realising are not impacting on quality of care. We can give you specific examples in terms of our colleagues here.

Grahame M. Morris: How do you come to that conclusion? Is this a question that you have asked the finance directors of the NHS trusts in membership or have they commissioned a survey? How do they assess quality of care? Are you talking about waiting times?

Chris Hopson: We asked people to make a simple summary judgment. We put a copy of the questionnaire on the back of the submission. The question simply was, I think, “Making a summary judgment, do you think that the savings you have made in 2011/12 have had an adverse impact on the quality of care?” So it was asking people to make a summary judgment….Tony, do you want to pick up specifically in relation to your side?

Yes, you read that right. Morris’ question had referred to the ‘Nicholson Challenge’ to save a massive £20 billion over 5 years – from a budget of just over £100 billion, so the ‘challenge’ represents a huge portion of total NHS spending. In the context of saving almost 20% of NHS spending, and asked whether the savings were affecting care, what was the response of the FTN’s CEO?

He asked ‘people’ to make a ‘simple summary judgment’:

“Do you think that the savings you have made in 2011/12 have had an adverse impact on the quality of care?”

No criteria for measurement of care quality, no specific areas to consider. No surveys, no gathering of patient feedback or examination of clinical outcomes. Just ‘do you think?‘ – and that one, slackly unprofessional question allowed Hopson to feel entitled to answer Grahame Morris’ question, in front of an official Commons committee, that ‘all but one or two‘ of the Trusts (all NHS Trusts, not just FTs) across the whole country are maintaining care standards in spite of the massive ‘efficiencies’.

As Hopson seems to have a habit of doing, he then passes the ‘hot potato’ off to someone else, asking Tony Spotswood to take over, which he does:

Tony Spotswood: Yes. I have a couple of comments. One, we know from patient feedback that patients are feeling that the quality of care is improving, when we look at our patient feedback year on year. In terms of boards assuring themselves that these savings to date have not damaged the quality of care, we have done an independent piece of work, for example, looking at nurse stuffing levels, benchmarking those against what would be accepted parameters, and, as a consequence, making some further investment in nurse staffing levels. We are constantly calibrating how the quality of care feels in relation to the need for efficiencies and transformation.

Much of the efficiency so far has come from transformation. It has not been about cutting services. For example, in my organisation over the last three years we have reduced our bed base by 240. We have treated more patients. How patients report the quality of care has improved and it is a better allround experience for patients. Into the future, the key is that is going to be much more difficult and requires more substantial, complex and structural changes, as Jim was indicating earlier.

Spotswood’s claim is quite remarkable. In a year in which public satisfaction with the NHS fell from its record 70% under Labour to 58% – the largest single-year fall in over 30 years – Spotswood claims an increase in patient satisfaction at his Trust. And this in a year in which he cut 240 beds and still treated more patients.

Not only with fewer beds and more patients, either. In a separate passage of the session, Spotswood admits that

we have reduced our bed base by 240, we will need fewer nurses because we have fewer beds

Fewer beds, fewer nurses and more patients – and an improved patient experience. Sound likely to you? No, me neither. Hopson jumps back in:

It may also sound quite countercultural and counterintuitive, but I am very struck by the number of trusts that I talk to who say they have made very significant savings on the pay bill but have increased the number of nurses that they have employed. I was in the Chesterfield Royal Hospital for my first hospital visit as the new chief executive about two or three weeks ago and they have taken on 40 new nurses despite the fact that they have made very significant savings across their pay bill as a whole..please do not assume that a much lower pay bill equals fewer nurses or poor quality of care. We have three living demonstrations here of how making savings on the pay bill can give better quality of care.

Grahame Morris, like me, finds this difficult to believe, so he interrupts:

I cannot leave that without challenging it, when today a survey carried out by the Royal College of Nursing-and it was extensively reported on the BBC, on national news-indicates that 24,000 nurse posts have gone, with 37,000 under threat. That seems to undermine your argument that individual trusts are recruiting.

True to form, Hopson palms off the question:

Philippa, do you want to tell the story in terms of what you have done with your pay bill?

Philippa Slinger: Yes. About a year ago we were spending something in the region of £1.8 million a month on temporary and agency staff, which was completely unsustainable. That is now down to about £500,000 or £600,000 a month, and I have recruited 350 staff in the last year, including qualified nurses and midwives. The point is that it is actually about how you use your work force. I absolutely recognise that some trusts are reconfiguring posts within their trusts. Whether that means people is always the question you have to look at, because many of us have budgets built on very old-fashioned and historic establishments that do not reflect the skill mix that we actually need today and, when you reconfigure those, it looks like posts have gone. But whether or not that is people is another issue..That might mean that you have four nursing posts that you are not going to recruit to because you are making nurse consultant posts. We need to be careful how those things sometimes are reported and considered, because my experience is that I am certainly not making any redundancies at all.

Ms Slinger makes a concrete claim here – 350 new recruitments over the past year – yet goes on to talk about ‘posts [that] have gone‘. That set alarm bells ringing, so I submitted a Freedom of Information Act request to her Trust asking for details of the new recruitments – and for details of any unfilled positions. The response came back as follows:

New starters:

Staff Group WTE (‘whole-time equivalent)

• Add Prof Scientific and Technical 3.80
• Additional Clinical Services 119.53
• Administrative and Clerical 82.84
• Allied Health Professionals 29.64
• Estates and Ancillary 2.00
• Healthcare Scientists 5.00
• Medical and Dental 25.90
• Nursing and Midwifery Registered 90.65

Grand Total 359.36

Ms Slinger’s answer to Mr Morris was cleverly worded to sound better than it is: “I have recruited 350 staff in the last year, including qualified nurses and midwives“. The reality is that only 91 ‘whole-time equivalent’ posts were filled.

But the unfilled post information tells a different story:

• Medical and Dental, 24.29
• Nursing & Midwifery & Health Care Assistants, 206.57 wte
• Professionals Allied to Medicine, 22.54 wte
• Professional & Technical, 23.73 wte
• Scientific & Professional, 3.55 wte

90 nursing posts have been filled, but 207 posts – well over twice as many – are currently unfilled at the Trust. Care is taken to give the desired impression – but it’s not the real picture.

Now we come to a brief but very revealing sequence that bears on Jeremy Hunt’s pearler during those Commons questions, saying a lot about the government’s attitude to the reality of healthcare and the way in which it is prepared to use unrealistic measures to support its fallacious claims to be protecting the NHS. The key players in this sequence are:

– Tony Spotswood, Bournemouth CEO as already outlined
– Barbara Keeley, Labour MP and former Shadow Health Minister, who asked the key question of Hunt in the Commons
– Andrew George, LibDem MP

Tony Spotswood: ..In my situation, for example, where we have reduced our bed base by 240, we will need fewer nurses because we have fewer beds. The key here is to ensure that the nurse to staff ratios are appropriate to the bed base that we have going forward..

Barbara Keeley: But 6,000 jobs nationally is 6,000 jobs. That is 6,000 who were nurses and are not now. What I am saying is that at the same time as understanding that hundreds of my constituents have lost their jobs in the NHS, as nurses or midwives in some cases, some of my other constituents are telling me that as to the care they are receiving as patients, when they attend hospital for appointments, they are finding that midwives are rushed, they are being kept waiting and that the care is not as good as the last time they were pregnant. The evidence of my own constituency absolutely gives the lie to what you said earlier and I don’t think we can accept the position where you say more nurse posts are being created. They are not.

Well done Barbara Keeley for calling a spade a spade and making the slippery chief execs squirm. And she’s not finished yet.

Chris Hopson: It is very difficult for us to be able to comment on specific hospitals which are not represented around the table. I can give you the evidence that we have collected nationally and I can also-

Barbara Keeley: You can answer about the number of national posts. If you are sitting here and telling us that we have not lost 6,000 nurse posts nationally and that is some kind of “smoke and mirrors” trick with nursing staff ratios-

Chris Hopson: We are not saying that.

Barbara Keeley: I am glad you are not saying that.

There follows an exchange between Rosie Cooper MP and Chris Hopson, in which Hopson denies ‘cherry-picking’ the 3 CEOs he has brought with him to the meeting to be able to claim that things are getting better, when this is clearly the case, as Ms Cooper insists. Then Andrew George jumps in:

Andrew George: I want to come on to the flexibilities that you have in terms of pay restraint, but, just in passing, following Tony’s comment about acuity and nurse to patient ratios..Rather than answering questions about whether it is 6,000, 5,000 or some other figure, the issue should be patient safety at the end of the day and appropriate staffing levels, so trained nurse to patient ratio..for which the RCN has been calling for a very long time. Rather than ducking that one, that is possibly the issue which we need to be concentrating on.

‘Trained nurse to patient ratios’ is the key issue, according to Mr George – clearly singing the official government tune on what matters in the NHS.

The government likes this kind of logic. Back in October, I wrote about David Cameron’s astonishing statement during PMQs when he was confronted by Ed Miliband on his failure to keep his promise to maintain police numbers on the front line – that in fact there are fewer such officers now than there were when the coalition government took over:

The percentage of police officers on front-line duties has gone up. That is the key.

and pointed out that, by that logic, if the UK had only 1 police officer and he was on the front-line, we’d all be ok – because that would be 100% of our police force on the front line.

Of course, it’s ludicrous. One police officer cannot possibly cover everything that needs to be covered. Nor could 1,000, or even 50,000. We currently have around 135,000 officers (perhaps fewer since the linked article was written), and that’s the lowest number in a decade. But the government will still claim to have ‘protected’ police numbers – because the percentage on the front line supposedly went up.

Similarly with the NHS. If you cut nursing numbers, but cut beds by the same proportion – as Tony Spotswood says he has done at Bournemouth and Christchurch – you will maintain the nurse to patient ratio. But the number of sick people doesn’t reduce just because you cut beds – and if you try to force more patients through in spite of the bed reduction, then inevitably patient care will suffer, and so will staff morale, because resources will be stretched, bed availability will decrease and the amount of time each patient can stay in hospital will be reduced.

And if – as in the case of Ms Slinger’s Heatherwood & Wexham Park, you’re misrepresenting what’s happening to nurse posts and numbers, then the situation is even worse.

But Mr Hunt didn’t just say that the nurse-to-bed ratio had been maintained. He said it has been increased. If you reduce nurse numbers and want to increase the ratio, the only way to do that is to cut beds by a higher percentage than you’ve cut nurses.

That means even less availability for patients who need it – and even more stress for nurses trying to maintain care with even more tightly-stretched resources.

It’s clear from a proper reading of these passages and others from the session that the real picture in the NHS is of reducing bed numbers and constantly increased pressure to provide more from less, along with the commensurate impact on patient outcomes and experience and on staff morale.

But this government and many of those running NHS Trusts are prepared to use all kinds of double-speak and perverse logic to disguise the facts. Not only this, but the CEO of the Foundation Trust Network, which covers all NHS Trusts, is prepared to use frankly slapdash methods to come up with a story that the government wants to hear and wants to tell us.

The government will never say these things clearly, because they depend on maintaining a consistent, deceptive line they hope people will swallow. So we need to look closely at what they do say, and join the dots to see what it reveals about what they’re really up to.

Remember this every time you hear this government quoting statistics, and don’t be fooled. It’s their default position to use numbers to mislead rather than to enlighten.