When the Care Quality Commission suggested in its recent State of Care report that ‘safer, better care does not necessarily cost more’, the inclusion of the word ‘necessarily’ was important.
In our report, Financial failure in the NHS, we found that taking NHS trusts out of special measures as quality of care improves may come at the cost of increasing deficits, as many trusts invest in additional nursing staff to drive up quality. We cited examples including that of George Eliot Hospital NHS Trust, which ended 2013/14 with a deficit of £10.2 million against a plan of £7.9 million, and was forecasting a further £12 million deficit for 2014/15, based on ‘continuing cost pressures related to additional capacity used and higher than planned levels of agency staff’ (although in the end, the trust achieved a surplus of £0.4 million in 2014/15, following support from the Department of Health amounting to £12 million). For 2015/16, the trust’s deficit is forecast to be even higher, with a revised financial plan to deliver a £13.9 million deficit.
Likewise, between 2013/14 and 2014/15 (including a year in special measures between July 2013 and July 2014), Basildon and Thurrock University Hospitals NHS Foundation Trust moved from forecasting a year-end surplus of £0.1 million and ending 2013/14 with an actual deficit of £9 million, to a deficit of £23.8 million in 2014/15. For these trusts, it would appear that the only way to return to acceptable levels of quality is to invest in staffing.
A recent analysis by The Independent of the Care Quality Commission’s inspection reports of acute hospitals from 2014 and 2015 found that, of 89 hospitals, 68 highlighted concerns about being short-staffed on one or more wards. This is not an issue limited to those in special measures. But safe staffing comes at a cost, particularly when gaps in some staff groups (especially nurses) mean that trusts are forced to plug vacancies by paying more expensive agency and bank staff. This has contributed to the deterioration in hospital finances, with the recent financial reports from Monitor and the NHS Trust Development Authority showing that 96 per cent of acute trusts are reporting overspends contributing to a combined deficit across NHS providers of £930 million at the end of the first quarter.
Yet hospitals are under increasing pressure to cut staffing costs to reduce deficits. Last week, the Department of Health announced further attempts to cap agency staffing costs. Subject to consultation, from 23 November, trusts’ capped rates for clinical agency staff will be set at a maximum of double the pay level of permanent staff, and will be gradually reduced to 55 per cent higher by April 2016. Although ‘exceptional breaches’ will be considered, trusts will be required to seek advance agreement.
While the anticipated savings (£1 billion over three years) will not do nearly enough to cover off the already unprecedented overspend, the interaction with safe staffing has yet to be seen. Many organisations may now feel trapped between the Care Quality Commission on one side, continuing to draw attention to staffing shortages, and Monitor and the NHS Trust Development Authority on the other, trying to bring down spending on temporary staff.
How will the Care Quality Commission respond? It was clear from its recent State of Care report that a major reason for the failings in safety it observed was an insufficient number and mix of staff. Yet the Care Quality Commission was also included as a signatory to the recent letter from the national leaders to NHS providers, which stated that nurse to patient ratios are never the sole determinant of their ratings and should not be unthinkingly adhered to. All this leaves NHS trusts none the wiser about how to manage staffing, making Lord Carter’s commitment last week to establish ‘clearer guidance’ on the issue a priority.
If staffing numbers do indeed fall, there are also important implications for existing NHS staff given the relentless focus by the system on quality in the wake of the Francis report into Mid Staffordshire NHS Foundation Trust. For staff and their managers, overseeing quality of care in the face of these new controls may be a very difficult place to be.
How will all this play out? We do not know. What does appear clear though is that the NHS is heading towards an overspend and that one of the main levers to reduce this potential overspend – control on agency staff – risks conflicting with the priority placed on safe staffing.
Greater clarity is needed for those planning and providing services. Does the NHS cut its cloth to meet its financial challenges at the expense of staffing levels? Or should quality of care, at whatever the cost, be the main driver. I am surprised that other avenues are not being openly explored. Perhaps we need to start to have an open discussion nationally about rationing the care we receive.....
Workforce imbalance is very expensive. Under supply drives up labour market costs through expensive agency and temporary staffing costs. We should bear this in mind when we are tempted to save money by cutting training numbers for the future health and social care workforce.
Events of the last five years prove that it is impossible to balance financial targets and good care. The majority of acute trusts are now in deficit; in our part of the world (Kent and Sussex) the majority of acute trusts are in special measures. Attempts to balance finance and staffing have failed to work ever since I became a consultant in 1983. Acute Trusts cannot meet their waiting time targets if CCGs that are short of money ask them to delay seeing patients; A&E will fill to overflowing if social service provision is insufficient to get treated patients back home. It is time to accept that the present system cannot and will not work, and we must seek an alternative model - or increase funding - or stop providing some aspects of care. It doesn't matter how good or bad managers are; not even a genius can rescue a bankrupt organisation.
A perfect storm is looking likely. The majority of doctors qualifying are women, who one suspects will want a family life, which in this country is still based on a Monday to Friday week, whatever policy makers may prefer. With agency fees being capped, cover will be more difficult to find and, in the absence of more funding, the only option will be to cut services when staffing levels become unsafe.
We continue to recruit on an on-going basis. As an inpatient unit we have started to look at the skill mix we have and our establishments. We have some exceptional band 4 support workers who are very gifted people, a drive on their training has meant they are now able to co-ordinate shifts allowing is to look at the number of nurses on shift. Band 7s and 8s have a greater presence on our wards meaning the nurses on shift continie to be supported in these very challenging times.
I believe your funding problems stem largely from four events;
- NHS requirement that nurses obtain a university degree taking three years ,costing I believe £220,000 and preceded by a one year access course even for those with 'A' levels. Nursing is a vocation and the old combination of on site training and college training was perfectly adequate. Foreign sourced nurses cost I believe £60,000 so a no brainer. However is it feasible and cost effective to check the qualifications/universites attended/standards of education of every foreign nurse?
- Replacement of state enrolled nurses so nothing in between an RGN and a Health Care Assistant. SENs are perfectly capable of undertaking probably 75% of nursing duties. Their re instatement would also allow very capable HCAs to undertake in house training and college day attendance to promote to SEN rather than undertaking a one year access course + a three year university course to achieve RGN status. A move logistically, financially and in some cases professionally unrealistic for most HCAs.
- Finally the NHS structure contains far too many so called managers. These are largely unecessary and untrained in management and cover anyone who is a level beyond those whom they are supposed to manage. My wife was a sister for 25 yrs and reported directly to one of the multitudinous directors of a then Primary Care Trust. The current sister now has four levels of management to report through!
I am not sure I follow Ian's argument. It doesn't follow that just because a career is vocational, a degree isn't required. Would he advocate doctors or teachers without degrees for instance. Second, I can't think of any other profession (Pharmacy? Paramedics? Physios? Speech and Language Therapists? Radiographers? Bomb Disposal Experts? Airline Pilots? Engineers?) where the solution to structural problems is LESS training? I am no sure why nursing is different. Surely we want people educated to a high level to be delivering care. The animus against degree level nursing (a bit like the idea that you can just drop a bright graduate into a classroom with minimal training and they can teach) seems to reflect a lack of respect for the skills and knowledge nurses require to deliver safe, high quality care.
I realise that in Ian's own profession, some of the greatest engineers of years gone by (Brunel for instance) learned on the job rather than by degree level training, but I am sure he would' be advocating that now
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- NHS requirement that nurses obtain a university degree taking three years ,costing I believe £220,000 and preceded by a one year access course even for those with 'A' levels. Nursing is a vocation and the old combination of on site training and college training was perfectly adequate. Foreign sourced nurses cost I believe £60,000 so a no brainer. However is it feasible and cost effective to check the qualifications/universites attended/standards of education of every foreign nurse?
- Replacement of state enrolled nurses so nothing in between an RGN and a Health Care Assistant. SENs are perfectly capable of undertaking probably 75% of nursing duties. Their re instatement would also allow very capable HCAs to undertake in house training and college day attendance to promote to SEN rather than undertaking a one year access course + a three year university course to achieve RGN status. A move logistically, financially and in some cases professionally unrealistic for most HCAs.
- Finally the NHS structure contains far too many so called managers. These are largely unecessary and untrained in management and cover anyone who is a level beyond those whom they are supposed to manage. My wife was a sister for 25 yrs and reported directly to one of the multitudinous directors of a then Primary Care Trust. The current sister now has four levels of management to report through!
I realise that in Ian's own profession, some of the greatest engineers of years gone by (Brunel for instance) learned on the job rather than by degree level training, but I am sure he would' be advocating that now
David Oliver
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