The Government's
Plans
.
11. The Government has committed itself to reforming
the NHS. Developments in primary care, notably the creation of
Primary Care Groups (PCGs), Health Improvement Programmes (HimPs),
Health Action Zones, NHS Direct, National Service Frameworks and
Clinical Governance will have a considerable impact on the role
of staff and the numbers involved; so too will the pressure to
reduce waiting lists.
12. The implications for the NHS of the New Deal
for junior doctors and the EU Working Time Directive[7]
will also have to be properly monitored and accurately assessed.
MSF told us that the impact of the Working Time Directive on laboratory
staff could "make the difference in some places between the
Service working properly and it seriously not working properly".[8]
The British Medical Association (BMA) estimated that 4,000 extra
consultants would be needed to implement the Calman changes (which
improved training programmes for junior doctors and created a
unified training grade) and New Deal reforms, aimed at reducing
the hours worked by junior doctors. This expansion in consultants
has not occurred so far. The BMA also argued that the Working
Time Directive and general social change would render long working
hours "increasing unacceptable".[9]
Mr Nigel Turner of the NHS Confederation believed that there was
need for forward planning to overcome the impact of a reduction
in junior doctors' hours.[10]
Some nursing staff we met spoke of the extra work, and consequent
additional pressure, that devolved to them as a result of the
change in junior doctors' hours. This same point was made in respect
of the professions allied to medicine (see paragraph 87 below).
It was also suggested to us that shortage of nurses could impact
on the tasks performed by junior doctors.
13. Details of the Government's plans can be found
in the policy documents and consultation papers already listed;
a summary of the Government's objectives is included in the memorandum
from DoH.[11] We accept
that the Government has shown itself to be aware of the problems
facing the NHS and has indicated its intention to overcome them.
All the areas of concern to staff outlined in paragraph 6 above
are familiar to Government and we acknowledge the DoH's desire
to bring about substantial improvements. We recognise that many
of the staffing problems currently besetting the NHS are long-standing;
it is partly because of the failure of successive Governments
to tackle them that they have now become serious to the extent
that the quality of healthcare provision is at risk.
14. Staff representative groups were generally supportive
of the Government's approach. Mr Bob Abberley of UNISON said:
"The Government I think,
in the whole range of areas - new pay system, new human resource
management strategy, looking at staff involvement, looking at
family-friendly policies - is saying almost all the right things."
He added the caveat that it would not be easy to
implement such "good intentions" in the hospital ward.[12]
15. We too generally welcome the Government's policy
goals for the NHS in relation to staffing. But we believe that
these policies may be undermined by the Government underestimating
the number of staff needed to achieve its targets. The NHS Confederation
argued:
"Policies like the implementation
of Calman for junior doctors, or the implications of Health Improvement
Programmes of greater emphasis on mental health, cancer and heart
patients have not been translated into the need for specialist
resources."[13]
This point was reiterated during oral evidence.[14]
16. The Director of Human Resources at
the NHS Executive (NHSE) frankly accepted that a problem existed
with current staff calculations when he told us:
"We need a stronger
alignment in practice between policy development...and assessing
the workforce implications of it...It is very easy and tempting...to
develop policies which for all the best reasons are social priorities
or whatever without necessarily thinking through all the workforce
implications of them. That is something which we recognise we
need to do better."[15]
The NHS Team
17. The NHS has always been able to rely on the loyalty
and commitment of its staff. As the Director of Human Resources
at NHSE noted:
"We still retain huge
staff loyalty. There is a very strong adherence to the values
of NHS and what it stands for, which is a huge asset for us."[16]
Representatives of MSF and UNISON both listed reasons
why people had once wanted to work for the NHS. These included
job satisfaction, security of employment, responsibility for decision
making and a feeling of being valued.[17]
They saw these features as being undermined. During our visit
to the Royal London Hospital, hospital consultants enthusiastically
endorsed the importance of team work. They argued that all staff
were at the front line of patient care, a sentiment we endorse.
It was suggested that such esprit de corps was being eroded by
declining staff loyalty to the NHS and the Service's reduced commitment
to staff, trends which would be difficult to reverse. The move
from consensus[18] to
general management in the early 1980s, the advent of trusts and
the internal market, the over-use - indeed abuse - of agency and
bank nurses and the attendant lack of continuity of care is felt
by those who have given evidence to us to have created a climate
not conducive to overall organisational cohesion.
18. We regret the dilution of the collective ideal
in the NHS. The Government's intention to increase co-operation
and share best practice should prove a welcome step towards reversing
this trend, along with its efforts to improve the management culture
in the NHS. But we believe that much more needs to be done. In
particular we feel that the Government's continued support for
the Private Finance Initiative (PFI) as it currently affects the
Health Service might further diminish staff morale. We will discuss
the impact of the PFI more fully later in the report.
1 Your Country Needs You
by James Buchan, Health Service Journal, 16 July 1998. Back
2
The Green Paper, Our Healthier Nation; The NHS White Paper,
The New NHS; A First Class Service - Quality in the
new NHS; The new Human Resources Framework, Working Together
- Securing a quality workforce for the NHS. Back
3
Ev. p104, para 32. Back
4
Q50. Back
5
Appendix 5. Back
6
Ev. p17, Annex D, para 7. Back
7
The Working Time Regulations 1998 SI No 1833, were laid
before Parliament on 30 July 1998. They came into force on 1
October 1998. Back
8
Q200. Back
9
Ev. p155. Back
10
Q236. Back
11
Ev. p10. Back
12
Q177. See further the comments of the Royal College of Nurses
(RCN) and Royal College of Midwives (RCM) at Q145; and those of
Professions Allied to Medicines (PAMS) at Q111; see also, for
example, the article by James Buchan, Your Country Needs You
in Health Service Journal, 16 July 1998, which links the present
nursing shortage to the reduction in the number of nurses in training
in the early 1990s. Back
13
Ev. p162, para 2.10. Back
14
Q224. Back
15
Q56. Back
16
Q7. Back
17
Qq142 and 143. Back
18
Consensus management was a triumvirate of views between the administration,
the head of the medical divisions, and the head of nursing. It
was abandoned in 1983 following the Griffiths' reorganisation
and replaced by general management. Back
