House of Commons - Health

Select Committee on Health Third Report

FUTURE NHS STAFFING REQUIREMENTS

NHS Management

102. The current style of management in the NHS came in for a good deal of adverse comment during our discussions. A psychologist in Darlington told us he believed that there was "self imposed ignorance" at the top. During its visit to Birmingham we heard that the move to trust status had created a more aggressive, insensitive managerial approach, uncaring and unheeding of staff who were treated like 'cannon fodder'. There was a strong feeling that trusts should begin to realise how staff felt and to consult them properly. One recommendation was that each trust board should contain a member of staff. During the evidence session with DoH officials on 26 November the Head of Workforce Planning said:

129

Mr Bob Abberley of UNISON believed that:

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103. In its memorandum the NHS Confederation announced that:

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Mrs Heather Ballard of the CDNA described NHS management as:

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Miss Louise Silverton of RCM argued that there now existed: "a whole generation of managers who were appointed and brought up in that [the internal market] environment." whose pressures had created poor practice. Inculcating a cultural change would, she believed, "be a very major exercise."[133]

104. Mr Roger Kline of MSF, believed that:

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This was a view echoed by Sir Alexander Macara, representing the BMA.[135]A contributory factor to this was the gagging clauses which had been a feature of trusts' contracts. The Government's insistence on the removal of gagging clauses from NHS staff contracts should materially reduce this problem.

105. The Director of Human Resources at NHSE acknowledged the need to develop "managerial leadership capacity in the NHS'. He told us that:

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DoH has recently launched a leadership development programme for chief executives and leadership training programmes are available to senior medical staff and nurses. The belief is that more effective training should be developed and we endorse this initiative.[137]

106. There clearly has to be an immediate and fundamental alteration to the management culture in trusts. Staff involvement is crucial to progress in this area. A working climate which encourages participation in the decision making process amongst its staff is bound to benefit from improved morale. The DoH knows this. The Director of Human Resources at NHSE told us that although the new HR framework required the systematic testing of staff attitudes and concerns an appropriate methodology had not yet been devised.[138] A Taskforce has been set up to identify and explore new approaches to staff involvement and disseminate best practice.[139]

107. Involving staff in decisions that affected them would almost certainly prove to be beneficial for the Service. For example, on matters related to difficult or unsocial shift patterns perhaps involving internal rotation, allowing staff the opportunity to arrange a timetable amongst themselves, with suitable oversight and guidance, would, we believe, help to improve morale. DoH believes that self-rostering:

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108. In written evidence Professor Sir Colin Campbell, Chairman of the Medical Workforce Standing Advisory Committee suggested that:

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Managers must have demonstrable skills that are directly applicable to the NHS. They should be committed to staff involvement in decisions and improvements in staff morale if there are to be long-term benefits to patients. We would not wish to perpetuate the conditions whereby the only route to senior promotion for the majority of NHS staff is via management. Those with clinical ability who wish to advance in that setting should be allowed the opportunity to do so.

Nurse and Midwifery Training

109. In commencing this section we wish to acknowledge the separate nature of the two professions under discussion. They are grouped here for reasons of concision. The majority of nurses are currently trained under the Project 2000 programmes. These were first established in 1989 following work carried out by the UKCC. The UKCC and the government of the day were clear that the education of nurses should not be significantly removed from the patients' bedside, but should be supplemented with a sound educational underpinning.

110. Project 2000 has been criticised for being too academic. Certainly it has resulted in nurses' direct experience with patients being delayed. One consequence of this has been the wholesale removal of new student nurses from wards. These lost hands have been replaced by alternatives in the form of healthcare assistants.

111. However, patient care in hospitals is increasingly sophisticated. It requires greater use of high technology and requires nurses, who are the main carers over any 24-hour period, to be educated in these fields. We would encourage education consortia, universities and the NHS to collaborate to ensure that the opportunity exists for student nurses to experience clinical practice in a safe and supervised environment as early in the training programme as possible.

112. It is important to create as many access routes to a nursing or midwifery career as possible. No one with a vocational competence should be excluded. It is our view that one way to achieve this is via NVQs. We welcome the recent Government initiative to help 1,000 health care assistants train as registered nurses. The RCN, whilst advocating the award of a first degree as the goal of nursing education said:

"The Government's recent emphasis on widening the entry gates to nursing, including bursaries for enrolled nurses to retrain and return to the NHS, special bursaries for existing NHS staff, such as health care assistants, to enable them to train as nurses, and more part-time pre-registration nursing and midwifery courses are particularly welcome. The RCN believes that a greater emphasis on NVQ level entry to nurse education, coupled with fast-tracking for experienced health care staff, could also give wider access to nursing as a career."[

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113. The UKCC is currently reviewing pre-registration nursing and midwifery training through a Commission for Education which is due to complete its work in the summer of 1999. Its work will clearly have an important influence on recruitment and retention practices. We hope that the use of NVQs and modules of training will feature largely in its recommendations.

114. During our visit to Birmingham we learned of the Cadet Nursing Scheme which was being run by Sandwell Healthcare Trust.[143] The scheme started in September 1997. It was developed after the Trust had experienced recruitment difficulties with qualified nurses. It provides pre-qualification training and sponsored professional training. There is open entry to the course. In the absence of relevant qualifications a written test equivalent to GCSE level maths and English which is acceptable to Wolverhampton University is undertaken. The programme is based on NVQ standards which have criteria and learning outcomes. Each cadet is required to give a written undertaking to work for the Trust as a trained nurse on completion of training, otherwise a percentage of the cost of training is refundable. Cadets receive early experience of work on the wards. Their progress is monitored with a view to assessing suitability for eventual entry into the Project 2000 programme.

115. We consider that an advantage of such a scheme lies in the fact that early clinical experience places the subsequent educational setting into a realistic perspective We commend this scheme which demonstrates innovation and initiative. Similar projects could well be tested in other trusts. It is an example of good practice which we hope will be widely shared.

Healthcare Assistants

116. Similar imagination is required in looking at the career progression of healthcare assistants. UNISON believed there were many more healthcare assistants working in the NHS than DoH figures showed.[144] Healthcare assistants perform an essential role in a variety of ways. We recommend that healthcare assistants working with nurses should be called "Assistant Nurses" to reflect their role and be registered with the UKCC. Healthcare assistants working with other professional groups should also be registered appropriately. Registration in such circumstances would provide professional motivation for the individual and would act as a necessary safeguard for the public who could then be assured that at all times care was being delivered by people whose competence was known and recognised.

Grading Structures for Nursing and Midwifery

117. When the current grading and pay structures were introduced, nurses and support workers were graded A - I. There were descriptions for each of the grades, but they were sufficiently broad to allow for a wide variety of opinions regarding which nurse should be on which grade. Consequently, nurses and midwives undertaking comparable roles, but working in different hospitals could (and continue to) receive different grades for their jobs. There was often significant disharmony caused by the grades individual staff actually received, with appeals against designated grades still being heard 10 years later.

118. The grading system has never been very popular. It tried to differentiate between the roles and responsibilities of nurses and midwives within the NHS and to reward accordingly. It took into account such things as: individuals' staff management responsibilities, their capacity to act as a team leader, supervise learners, manage a budget, and give care under supervision. As a rule, a newly-qualified registered nurse was put onto a "D" grade and the most senior clinical manager would be put on a "H" or "I" grade. Some employers would not give "I" grades, in which case "H" became the most senior grade in that hospital or community.

119. Mrs Heather Ballard, Professional Officer, CDNA articulated the anomalies in the current system:

"What we have not got at the moment in the community is any consistency in terms of grade and skill mix...around the country, there are huge variations which do not seem to bear any resemblance to local needs; you might have one trust where they have a grading structure which consists of B grade auxiliary nurses, D grade staff nurses and G grade district nurses, and, next door, they may well have B grades, Cs, Ds, Es, Fs, Gs, and Hs, and there does not seem to be any rhyme or reason to that."[

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She later added:

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120. Although Mrs Ballard was enthusiastic about discretionary awards, this view was not shared by all of our witnesses. In written evidence MSF stated:

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121. Miss Louise Silverton of the RCM said:

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She added:

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Miss Christine Hancock of the RCN argued that:

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122. We are aware that managers need to assess skill and grade mix and that that assessment leads on occasions to changes in the skill mix of staff. Financial pressures have squeezed the grading system. Posts have been down graded, higher graded posts have been lost and lower graded jobs increased, sometimes in a regrettable way with an impact on the quality of patient care provided. Instead of rewarding staff appropriately it has become a way of controlling budgets. We recognise that when huge pressures are brought to bear on any grading system this is likely to happen. However, in many places there is no confidence in the current grade mixes.

123. An improved system is required. Although we recognise that there are complexities for certain staff and more work needs to be done, we believe it is very desirable to move towards a single pay scale for NHS workers. We will deal with this point when we discuss pay later in the report . Such a scale should be linked to agreed competencies, with a "bar" at various points along the pay scale and incremental points within each "barred" group. We further believe there should be Continuing Professional Development for all staff and ready opportunities for staff to achieve the educational qualifications relevant to their career development.

124. To achieve this each trust would need to carry out detailed workplace planning to define the number of staff they require at what the appropriate level of competence to care for the type of patient they have. Some trusts are already doing this.[151] Such an approach should lead to a wide entry gate and multiple exit points for professional programmes. There would need to be a comparison of occupational standards and levels of competence and academic achievements across the professions.

Working Conditions

125. The Government is determined to reduce violence towards staff in the NHS. But not all of the unwarranted problems confronting staff are the result of direct aggression. The question of patient behaviour arose when we spoke to staff informally. The tension between individual patients' rights and a therapeutic regime for all patients is particularly acute in accident and emergency and psychiatric units. Having to cope with patients' individual routines must cause additional pressure on busy staff. Methods of approaching this sensitive area will need to take full account of the rights of all concerned. The dignity and rights of patients must be maintained at all times, and a degree of independence is likely to aid recovery. But we believe it is reasonable to expect in-patients in hospitals to co-operate in a structure of care that offers them the best possible treatment, takes account of the needs of other patients and promotes due respect to staff who are often over-worked.

126. Staff at the Royal London Hospital also raised the question of the provision of mobile phones for nurses and midwives working in the community. Guidance on reducing the risks from violence and aggression issued to NHS managers and staff by the NHSE and RCN in September 1998 said staff in the community should be provided with the means of contacting base:

"Methods of communication must be viewed, and evaluated, as tools in both preventative and reactive strategies to reduce the risks for those working in the community. They can assist employees to carry out their normal duties more efficiently and therefore reduce frustration in themselves and their patients; they allow staff to inform base of their whereabouts and report at the end of a shift."[

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127. However, on 10 December 1998 Miss Louise Silverton of the RCM explained:

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128. There are growing numbers of NHS staff working in the community. Their colleagues in hospitals or doctor's surgeries have quick access to help and advice. It seems to us unacceptable that managers allow valued members of staff working in sometimes difficult locations and at awkward hours to be without a quick and efficient means of being in contact with the home base or, if necessary, calling for assistance. We recommend that every member of the NHS staff alone on duty in the community or otherwise at risk should have access to a mobile telephone or other means of establishing emergency contact with colleagues.

Agency and Bank Staff

129. According to figures supplied by DoH, the financial cost to the NHS in 1997/98 of employing agency nurses was £216,338,567.[154] During a period of acute staff shortages their use has increased dramatically. Using 1997-98 prices the cost to the NHS in 1991/92 was £121,127,306.[155] Contract nurses frequently undertake agency work on their days off in order to supplement their income. ( Indeed many staff in the NHS have a second job in order to make ends meet.) Thanet Healthcare NHS Trust told us that like many hospitals it found itself:

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130. We received a great deal of anecdotal evidence to support this. Leaving aside the question of the impact of staff fatigue this situation does at least allow the possibility of continuity of care for patients. Mr Bob Abberley of UNISON considered that the biggest threat to patient care was the lack of continuity caused by the use of agency staff.[157]

131. Agency staff whose competence is often unknown are regularly put into stressful and unfamiliar environments where they are not easily able to function as part of a team. Miss Louise Silverton told us:

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Mr Roger Kline of MSF said:

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132. We learned during our visit to the Royal London Hospital that experienced nurses working for an agency in a strange hospital were often allocated the most menial role because there was insufficient time or opportunity to involve them appropriately and fully utilise their skills. We also heard of agency staff whose paths crossed on their way to work in each others' contract hospital. This is clearly an absurd situation; bad for the patient, expensive and inefficient for the system, but profitable for the individuals and agencies concerned.

133. Miss Christine Hancock of the RCN described succinctly to us the historic basis of the bank nursing system which was established to:

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In her view the bank system has been "grossly abused" forcing nurses to work for agencies rather than being exploited under the bank system.[161]

134. We recognise that in areas where there are substantial staffing shortages, agency and bank staff are at present a necessity.[162] We also accept that there will always be a role for agency staff in the NHS, for example to provide cover for maternity or other leave. But we would like to see an immediate reduction in the use of agency staff. We believe that employing agency staff on a more or less continuous basis to prop up an organisation sagging from personnel shortages is no solution to the problem. We share the belief of Ms Jocelyn Prudence of PAMs that:

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135. The payment of appropriate overtime rates should amount to a simple and effective way to allow proper financial reward when extra hours have to be worked. It would also create additional commitment to a regular team and improve patient care. Accordingly, we recommend that overtime payments should replace undue reliance on agencies as soon as possible. Moreover, the bank system should not be used as a method of cheap labour but should instead be used as a useful flexible working practice to cover unexpected shortages.

Continuing Professional Development (CPD)

136. The memorandum from DoH recognised the need for a "culture that values lifelong learning."[164] It also referred to high quality services being underpinned by continuing personal development.[165] Currently there does not seem to be agreement between theory and practice in this regard; the responsibility for keeping up with developments in patient care appears to rest solely with staff. For example, the Royal College of Nursing said "Nurses frequently have to fund their own CPD activity and participate in their free time."[166] PAMs described "very little support for continuing personal development."[167] The Conference of Clinical Scientists' Organisation bemoaned a lack of funding for such development,[168] whilst Macmillan Cancer Relief suggested there was a lack of opportunity[169] for it.

137. In Darlington we heard that, in circumstances where funding for courses was available, time was not. Even cover for maternity leave causes major difficulties. A paediatrician in Darlington told us that, historically, doctors had been given protected time and money for continuous learning, which is why they were treated differently. He believed that the NHS needed to encourage CPD for other staff. Miss Louise Silverton of the RCM told us there were 60,000 midwives on the register but not practising.[170] It was hard to see how they could be encouraged to return if they had to pay for a return to practice course.

138. The Government's Consultation Paper A First Class Service points out that currently "Most health professionals share financial responsibility for their own professional development."[171] We have made reference in our report to the extraordinary pace of change in healthcare technology and the consequent impact on patterns of care. A corollary of this is the need to keep staff in touch, so far as possible, with the most modern techniques. The pressure to continue learning is stressful, particularly when the well-being of others depends on the skills involved. Study requires finance, time and effort. Staff in the NHS often have to put in the time and effort on top of their daily work routines. We believe that they should not have to pay for the necessary courses out of their own salaries. We recommend that the NHS finances in full the relevant professional educational needs of its staff. We also believe that current study arrangements are inadequate and need to be extended.

139. Acceptance of this recommendation would, of course, increase the cost of running the Service, both in terms of the provision and the need to introduce cover for those on study-leave. But we believe the benefits to patients, staff and the NHS of a more efficient and motivated staff would far outweigh the financial investment. We also believe that such an initiative would encourage those who have left the service to return, and that this would result in value for money savings when set against the cost of recruiting new staff or employing staff from agencies. The knowledge that professional skills were nurtured in the NHS would increase its allure to potential employees.

129 Q18. Back

130 Q126. Back

131 Ev. p161. Back

132 Q150. Back

133 Ibid. Back

134 Q151. Back

135 Q154. Back

136 Q16. Back

137 Ibid. Back

138 Qq2 and 3. Back

139 Ev. p8, para 4.30. Back

140 Ev. p14, Annex C, para7. Back