1.  UNISON welcomes the opportunity to submit evidence to the House of Commons Health Select Committee Inquiry into the future staffing requirements of the NHS. As the largest union in the NHS, embracing the varied occupations which make up the health team, UNISON believes we can assist the Committee in investigation into this vital issue. The NHS is one of the largest employers in Europe and depends for its success in a committed, motivated and highly skilled workforce.

  2.  It is therefore essential that it has an effective policy for ensuring that, in the words of the recently launched Human Resources Strategy, it:

  "has a quality workforce, in the right numbers, with the right skills and diversity, organised in the right way to deliver the government's service objectives for health and social care." Working Together: a New Human Resource Strategy for the NHS 19981.

  3.  The NHS faces major staffing problems including a potential recruitment and retention crisis in the workforce. The Human Resources Strategy and the other staffing initiatives taken by the Government, including those announced as part of the comprehensive spending review, although welcome are not sufficient to overcome these problems. UNISON believes that, unless these issues are addressed the Government's ambitious agenda for modernising the service will not be achieved.

  4.  In our evidence therefore UNISON reiterates our call for urgent action to address recruitment and retention problems using pay and non pay measures, for a new pay system and a new agenda for training and development in the NHS.

MAIN TRENDS SINCE THE INTERNAL MARKET

  5.  Since the creation of the NHS internal market in the early 1990's the NHS workforce has been subjected to constant organisational changes, periodic cutbacks in staff and the continuing pressure of market testing and contracting out, and latterly the Private Finance Initiative (PFI). In addition the NHS has transferred significant sections of its services to non NHS providers, so that, for example, the majority of elderly care is now provided in private nursing homes and much mental health and learning difficulty/disability services by the voluntary sector of local authorities and an increasing proportion of primary care services are provided in General Practice. The NHS is therefore often not the employer of staff providing its services. This process will be accentuated by the Private Finance Initiative (PFI) and makes it difficult to plan and implement NHS wide policies.

  6.  In addition, the nursing workforce has been affected by the switch to Project 2000 nurse training, which removed nursing students from the workforce, adding to the workload of staff. Since 1990 the new Health Care Assistant (HCA) grade has been created, taking on new roles. Nursing assistants have also increasingly taken on areas of work previously undertaken by registered staff. Professional staff have extended their roles to areas previously covered by doctors. For all staff the constant pace of technological change has continued to create demand for new sorts of staff, as has the general long term trend to deliver care in a community setting. Workloads have risen and there is far greater collaboration with other agencies and accountability of users. These positive changes have placed great pressures on staff.

  7.  The interplay of these trends can be seen in the differing consequences for various sections of the NHS workforce, based on the latest available statistics for England from the Department of Health. In the period 1992-97 the total NHS non medical workforce fell by 6 per cent. Over the 10 years 1987-97 it fell by 7 per cent. By contrast the total number of employees in the healthcare sector, has according to industry observers, gone up with significant growth in the private hospital and nursing home sectors. The proportion of nurses working for non NHS employers has increased significantly2.

  8.  NHS Nursing and Midwifery staff numbers fell by 9 per cent from 1992-97. The largest falls occurred in the earliest part of the decade as many trusts implemented job cuts as part of rationalisation measures and a number suffered financial crisis. There was a small increase due to reclassification of nurse managers as nurses in 1995-96, followed by a small rise in 1996-97. Total numbers fell by 13 per cent in 1987-97 largely due to the phasing out of student learners as a result of the shift to Project 2000 nurse training. There have been shifts in the balance between qualifies and non qualified groups, partly due to the growth of health care assistants. The proportion of registered staff has fallen slightly. The number of traditional nursing assistants has fallen as the number of healthcare assistants has grown. UNISON believes based on its own surveys of members and trusts that the actual total number of healthcare assistants is nearer 50,000 rather than the 17,000 shown in the department figures.

  9.  The picture for NHS ancillary staff by contrast is one of dramatic cuts. The number of directly employed NHS ancillary staff has fallen by 48 per cent since 1987 and by 24 per cent since 1992. The almost invariable result of market testing, whether it leads to contracting out or the retention of services in house, has been fewer jobs. Where services are retained in house the continuation of requirements for 3 per cent cost efficiency savings, the effects of benchmarking based on private sector models and the application of techniques such as business process re-engineering has reduced staff numbers. The NHS does not keep information on the staffing levels of private contractors but UNISON estimates that the main contractors employ some 40,000 staff which would mean total ancillary numbers 15-20 per cent lower than in 1987. The PFI is now leading to further transfers of staff and fewer jobs. The continuing pressure for cutbacks combined with the enduring problem of low pay contributes to poor morale. There is a persistent undervaluing of the role of ancillary staff in the health team, evidenced for example in the lack of collection of data on their numbers, turnover levels and training. Where the local labour market is buoyant, for example in London and the South East turnover levels amongst ancillary staff of 20-40 per cent according to UNISON research.

  10.  Ancillary staff work under greater pressure than ever before and in some trusts have taken on a wide range of new roles but continue to suffer from casualisation, contracting out and a neglect of their skills and potential. There have been similar effects on works and estates staff, whose numbers have fallen by 31 per cent in 1992-97 with more losses anticipated due to PFI. There has been some growth in the number of generic ancillary support workers.

  11.  Two groups which have grown during recent decades are scientific and professional staff and administrative staff. The growth in scientific professional and technical staff reflects the fact that in the NHS direct substitution of people by machinery is more difficult than in manufacturing, and new technological developments generally bring with them the need for skilled staff to operate them. Changes in the approach to health care have increased the demand for many of the Professions Allied to Medicine, especially Occupational Therapists and Physiotherapists. There continue to be shortages of these groups, highlighted in the staff side evidence to the Pay Review Body and to the Select Committee3.

  12.  The creation of the internal market led to an increase in the administrative infrastructure of the NHS as the market based system needed contracts with their associated invoicing, an expansion in finance based employment and some growth in managers as the result of devolution of responsibilities to individual units. Groups of professional staff, notably senior nurses, were transferred to managerial pay scales and then back again to be counted as nurses in the early 1990's. Administrative staff numbers grew most rapidly in the early 1990's and by 5 per cent in the period 1992 to 1997 as managerial cost reduction programmes were instituted. The inconsistency of policies toward administrative staff have been a major cause of concern for UNISON. After instituting policies which inevitably increased the number of managers and administrative staff, government policies then sought to arbitrarily cut numbers through a cost reduction programme targetted especially at health authorities. This programme seems to have little regard to the content of jobs and often seems to be pursued regardless of the damage it does to the ability of the NHS to plan and monitor developments. UNISON believes this target based approach should be abandoned. The government now recognises the need for management and the role administrative staff can play in assisting health care delivery.

  13.  Given the significant expansion in patient numbers and other workloads during this period the fact that the nursing workforce has fallen has put tremendous pressure on the remaining staff. All available survey evidence, whether from staff side organisations or the NHS Confederation, highlights the high levels of demand on staff. For example, using the very crude indicator of number of patients treated, there was growth of almost 4 per cent in terms of number of patients treated in 1996-973. This level of growth is unprecedented in a labour intensive sector and NHS productivity compares well with that in the private health sector.

  14.  UNISON, in conjunction with the Trade Union Research Unit, has recently carried out a major survey of all NHS staff—looking at morale, staff shortage and workload. This will be supplied to the Committee in due course. UNISON's evidence to the Nursing Pay Review Body is enclosed with this evidence. These surveys by UNISON have shown the influence of staff shortages on morale. Research by the Nuffield Institute4 has shown the link between workload stress and ill health and shows that work related stress is a major cause of sickness absence. Recent UNISON surveys have shown it is also a reason why staff leave5.

CURRENT PROBLEMS AND POSSIBLE SOLUTIONS

  15.  The methods the NHS uses to plan its workforce were radically revised in the 1980s, with adverse consequences (eg of undertraining). There was not an NHS wide approach. There is now an attempt to reverse this policy with the requirement for Health Improvement Programmes to seek to integrate service and human resource strategies and a reviewed role for Local Consortia to plan workforce requirements. Government has also decided to expand the number of nurse training places and intends to increase the number of nurses. NHS employers now acknowledge that there is a recruitment and retention problem especially amongst nurses in grades D and E6. UNISON welcomes these developments.

  16.  The new Human Resource Strategy and the promises of a new approach to training set out in the White Paper "a First Class Service" also represent a significant move toward a more coherent policy. The initiatives announced since the comprehensive spending review are steps in the right direction. But much more needs to be done.

DEVOLUTION DISASTER

  17.  In the 1980's the NHS instituted a workforce planning policy based on each Trust estimating the number of recruits for professional groups it would need based on its own analysis of future needs. Local Consortia and REDGs then commissioned places from training providers, principally nursing colleges, based on these estimates. As was predicted this led to consistent shortfalls as each provider felt constrained by its financial position to underestimate what was needed. Nurse training places were also often undersubscribed as school leavers found nursing increasingly unattractive as an option. The higher than expected drop out rates from Project 2000 courses exacerbated problems. From 1996 efforts began to be made to rectify the situation through the commissioning of 14 per cent more training places. Further measures have followed, including most recently places for enrolled nurses and health care assistants to train as registered nurses7.

  18.  However the NHS still leaves planning of the non professional workforce largely to individual units. For example, conversion courses for enrolled nurses—and access to National Vocational Qualifications—are determined at local level. One by-product has been the under-participation by the NHS in government employment initiatives such as the New Deal/Welfare to Work, where the NHS is only providing 1,000 places.

 PROBLEMS LOOM

  19.  The nursing workforce is the largest single group within the NHS workforce. It is of great concern that:

—  there continues to be a large number of nurse vacancies, and that in UNISON's most recent survey of nurses 75 per cent indicated they would not recommend nursing as a career, and over half said they were seriously thinking of leaving8.

—  Up to one in three existing nursing staff will retire by 20079. The number of entrants to the nurse register has fallen from 17,984 to 16,382. In addition it is widely acknowledged, including by the NHS Confederation, that there are already severe national shortages of Grade D and E staff. The private sector continually acts as a drain on the NHS.

—  UNISON's most recent investigation into nursing assistants indicates that there are impending shortages in the groups traditionally recruited as nursing assistants. In addition there are continuing shortages of Professions Allied to Medicine, especially Occupational Therapists and Physiotherapists, which have been identified in evidence to the Pay Review Body10.

—  Recruitment and retention problems are also being experienced amongst groups of clerical and technical staff, and there are high levels of turnover amongst ancillary staff. There are problems amongst ambulance staff caused by lack of recognition of the skilled nature of their work, and an absence of career structures for control assistants which leads to them switching to police and fire services or air traffic control. Managerial staff feel under-valued and under pressure to deliver on what can be conflicting policy objectives.

  20.  The NHS therefore faces a looming staffing crisis in the NHS which needs to be tackled as a matter of urgency.

DATA COLLECTION

  21.  The current systems of data collection for workforce planning are wholly inadequate. Statistics for planning workforce requirements are not collected centrally and have to be aggregated from the work of the Local Education Consortia. The methods of predicting staff demands are not available to public scrutiny, and trusts use variable assumptions. Figures for total numbers of staff are collected, but using occupation categories which have been manipulated for political reasons under the last government. These aggregate differing groups under broad headings such as "support staff". They underestimate the number of health care assistants and do not include staff employed by GPs (except practice nurses) and those employed by contractors and the voluntary/independent sector. There are no national figures for numbers of staff on each pay point or for spending on training.

  22.  The Office of Manpower Economics vacancy survey is the only regular national survey on recruitment and retention other than those conducted by staff side organisations. It only covers nurses in a limited sample of trusts and there are some methodological problems with it. UNISON believes it should be improved and extended to cover all staff groups. There should also be national statistics on turnover and staff morale, and proper workforce planning across the NHS.

 THE NEW HUMAN RESOURCES STRATEGY

  23.  On 23rd September the NHS launches "Working together securing a quality workforce for the NHS" the new Human Resources Strategy for the NHS. UNISON was involved in the discussions that led to this document and welcomes its overall direction11.

  24.  The strategy sets out ambitious aims for the NHS to achieve. Its main aims are to ensure that the NHS is able to "plan effectively at national and local level to recruit and retain a workforce which has the capacity, skills diversity and flexibility to meet the demands of the service." (p7) and "to make the NHS a better place to work" (p7) 12.

  25.  UNISON supports both these aims. We believe a new pay determination system is necessary to achieve these aims together with a new approach to training and education which seeks to provide lifelong learning opportunities for all staff, giving them the skills to tackle the demands of a changing service.

  26.  The explicit acknowledgement that there is a clear link between quality of service and quality management of staff is welcome. Poor treatment of staff has historically been a major cause of retention problems in the NHS. The recognition that there is a positive "business" benefit to progressive human resource policies is a move forward.

  27.  The strategy goes beyond generalised objectives to propose a series of specific actions which UNISON believes will, if achieved, go a long way to producing a better NHS with improved recruitment and retention.

  28.  Under the plans every NHS organisation will have to have a workforce plan for all staff and training and development plans for professional groups. Organisations will need to show annual improved retention rates for professional staff. Also, workforces must become more representative at all levels, and policies must be introduced to tackle racial and sexual harassment by staff and service users.

  29.  We support these targets and hopes they will be as important an indicator of performance as financial targets, national reference costs and the rate of return. We also believe that they will be critical in achieving quality targets.

  30.  UNISON has consistently called for a new family friendly agenda but recent survey evidence indicates there is a long way to go before this can be said to be the case. 13. Action is also needed to tackle racial discrimination and to ensure equal opportunites for disabled people. UNISON is working with employers on these issues.

  31.  The current round of NHS mergers and the setting up of Primary Care Groups also has a danger of displacing staff and sapping morale. UNISON welcomes the approach that has been taken in most areas on these developments, but believes the NHS needs to be aware of the strains that organisational change is placing on staff as individual trusts operate autonomously. The fact that large sectors of the workforce are not directly employed by the NHS exacerbates problems of workforce planning. The fact that the new Human Resource strategy will apply to all the NHS family, and eventually to those seeking to provide services to the NHS, is therefore welcome.

 THE COMPREHENSIVE SPENDING REVIEW, NEW HUMAN RESOURCES STRATEGY AND OTHER ANNOUNCEMENTS

  32.  As part of the Comprehensive Spending Review the Government announced that it would be creating 15,000 additional nursing posts, 7,000 more doctors and commissioning 6-7,000 more training positions for nurses. Although extremely welcome, these measures are not in themselves sufficient to alleviate understaffing. They do not tackle the high level of existing vacancies as they will be largely consumed by the expansions in NHS services also announced in the Review, and will take some time to feed through. The measures will, however, help to offset some of the problems in the medium term. They only apply to professional groups. The "supernurse" proposal also misses the point.

  33.  This expansion in the number of nursing posts does nevertheless highlight the need to make nursing more attractive to potential recruits and to retain existing staff. The Department of Health therefore announced on 23 September a series of measures designed to address this issue, including 2,700 places for enrolled nurses on conversion courses and 1,000 places to help HCAs to enter Project 2000 courses. The Government also intends to target efforts to attract back 19,000 nurses who have left the NHS but are still interested in returning. The proposals for more family friendly policies will also assist in dealing with staffing problems. UNISON has welcomed these initiatives, especially as they follow campaigns by us for these groups to be recognised, but we do not believe they will be sufficient. Retraining existing staff groups will take time, and creates a need for posts to be filled. The reviewed focus on the issue of returners is also to be welcomed, but UNISON believes pay is the most significant cause of staff leaving the service and must be addressed if staff are to be attracted back into the service.

  34.  We are also concerned at the almost exclusive focus in recent announcements on nursing. It is widely acknowledged, for example, that there are significant problems amongst Professions Allied to Medicine groups. However, no expansion or recruitment plans have been announced for these groups. This is despite the fact that some of them are experiencing major problems as severe as nursing's.

  35.  Non nursing groups feel that little or no attention is paid to the staffing problems they face, and that the NHS is content that they can be easily replaced or contracted out. There are potential recruitment problems amongst health care assistants and many other staff groups are facing problems arising from early retirements and the lack of a career structure.

ACHIEVING EMPLOYMENT SECURITY

  36.  One of the main problems affecting the NHS is the lack of employment security. There has been a shift in policies by local trusts toward greater use of casual agency staff and short-term contracts, and a willingness to cut posts and even make redundancies. Non clinical staff are subject to periodic market testing and now compulsory transfer to the private sector under PFI, in which the workforce is generally even more insecure than the NHS. This atmosphere of insecurity exists at a time of rapid organisational change. It undermines staff morale and hinders the ability of the NHS to provide quality services.

  37.  A national joint NHS/staff side working group is currently examining this issue. UNISON believes the NHS needs to adopt the principle of employment security ie that all those who wish to continue working for it should have the right to do so and that employers/staff should accept the responsibility of ensuring they can adapt to the changing demands of the service through redeployment and retraining. As an interim measure the NHS should have a programme to reduce the use of casual staff, including Bank nurses. The use of short-term contracts should be restricted to cover for periods of defined absence such as maternity leave—or in exceptional circumstances for time limited project work. Most importantly the NHS should abandon the use of market testing/contracting out and end the transfer of staff to the private sector under the PFI. (New forms of PFI have been suggested and piloted which exclude staff so this could be done without abandoning PFI completely.) These measures would go a long way toward bringing the NHS into line with best practice, restoring staff morale and facilitating staff co-operation with the major changes currently underway14.

CREATING A SAFE AND HEALTHY WORKPLACE

  38.  UNISON particularly welcomes the commitments in the document to improving health and safety in the NHS. The strategy calls for year on year improvements in sickness absence rates and monitoring of accidents and violence against staff and strategies to achieve reductions in incidents. It also requires trusts to put in place Occupational Health Services and make counselling available for all staff.

  39.  These are positive initiatives building on best practice at local level. UNISON believes that the main cause of sickness absence in the NHS is the unhealthy nature of far too many NHS workplaces and the high levels of stress for staff. UNISON believes policies should concentrate on preventing ill health not controlling absence. The government policies for improving occupational health should start with the NHS.

  40.  Policies aimed at tackling these root causes rather than harsher attitudes towards absence will be most successful. UNISON has some concerns over a target based approach to absence as there is no consensus on what levels of absence should be. Crude comparison of NHS absence rates with those of non NHS employers ignore the special features of health care work.

  41.  UNISON has long called for proper compliance with reporting procedures, and the requirement for policies to reduce violence is especially welcome. Considerable investment is taking place in physical safety systems such as CCTV. We would, however, also highlight other issues that need to be addressed such as working alone, sleep ins and staffing levels. Workplace injury is a major cause of staff shortages, and retirement on ill health grounds contributes towards NHS retention problems. This is a particular problem amongst groups such as ambulance staff who are on the front line of abuse and all too frequently attacked.

  42.  The full implementation of the Working Time Directive will clearly have staffing implications which the NHS will need to address. It should also however reduce the stress on staff and therefore alleviate some of the factors that influence staff to leave.

A NEW AGENDA FOR NHS STAFF TRAINING AND DEVELOPMENT

  43.  UNISON has welcomed the proposals contained in "A First Class Service" for a new approach to training and development for NHS staff15. We believe the proposals for Continuing Professional Development do have the potential to improve the quality of NHS Services and opportunities for NHS staff. We believe these opportunities should be extended to all staff groups through "lifelong learning" not restricted to professional groups. The new approach should be based on principles of open access, lifelong learning and funding based on ability to benefit from training, not just on occupational group and past practice. It should focus on improving occupational competence and enhancing shared transferable skills. Training should link all NHS staff and the NHS should review its educational qualifications so as to open entry gates to all suitable applicants. UNISON's ideas for how this could be applied to the main staff groups are outlined below.

HEALTHCARE ASSISTANTS, NURSING ASSISTANTS AND OTHER CLINCIAL "SUPPORT" STAFF

  44.  There are now a wide variety of staff employed in clinical support roles including Health Care Assistants (HCAs: please note that the term HCA is used throughout as the most convenient one to embrace a wide range of non-registered staff including nursing assistants, OT helpers, physiotherapy helpers and generic support workers). These groups are not covered by statutory regulatory bodies and the training provided to them is largely determined at local level, although an increasing proportion have acquired National Vocational Qualifications. The term HCA is used as the most convenient one to embrace this wide range of non-registered staff. UNISON believes there needs to be a new approach to their training.

  45.  UNISON believes that there is a strong case that HCAs should be registered by a new statutory multi-disciplinary body. Such registration will require some training, but we do not believe that only those with a vocational qualification should be registered. The new body would be the first national one to have responsibility for HCAs' development. We have outlined a "10 Point Plan" in our evidence to the Secretary of State's Health Legislation Review. (Copy attached as Appendix 1—see pp 27-29) 16. We would be pleased to elaborate further on this in oral evidence. Recent studies of these groups have shown how they are extending their role to areas that were previously the preserve of registered staff. Provided staff are properly trained UNISON supports role development, but there needs to be an appropriate regulatory framework to ensure quality and accountability.

  46.  We believe that the relevant Care NVQs/SVQs should be implemented in every trust, primary care setting and indeed the independent sector. These qualifications are formed from the national occupational standards of good practice, and the public should know, particularly when hands-on care is being delivered increasingly by currently "non-registered" staff, that those people are trained and assessed against the national standards. UNISON's research shows major inequalities in access to NVQs17.

  47.  Our view is that the NHS has shamefully neglected its "support work" staff in the past regarding training. Particularly as there are problems recruiting to traditional professional courses in nursing and PAMs, we should seize this opportunity to allow workers from support grades to fully develop their potential through greater use of NVQs as entry gate criteria, together with greater availability of suitable access courses to develop the academic skills of these recruits. The recent government initiative to help 1,000 health care assistants to train as registered nurses is therefore a welcome step. However some other current policies appear to be going in the opposite direction and damaging these workers' opportunities to progress: eg the down-grading of skilled Occupational Therapy Technical Instructors into generic HCA posts which lessen their chances of progressing on to in-service courses leading on to registration programmes.

  48.  There needs to be shared training with social care agencies to facilitate integrated service delivery and sharing of skills. This will assist the proposals in the consultation paper Partnership in Action for more integrated service delivery.

ANCILLARY STAFF, PROFESSIONAL AND TECHNICAL AND ADMINISTRATIVE AND CLERICAL STAFF

  49.  Ancillary Staff are central to the effective delivery of healthcare but are all too frequently regarded as disposable. UNISON believes this attitude must change. Theatres and instruments cannot be used unless they are cleaned and patients need to be fed and moved. The work of the staff who carry out these tasks is a vital part of the healthcare.

  50.  For traditional ancillary staff UNISON believes that there needs to be a review of roles and responsibilities in a post market testing environment. Where trusts wish to retain traditional ways of organising ancillary work such as separate cleaning, catering and portering for example, the NHS should extend training opportunities and utilise industry based NVQs. In this respect the NHS could examine the practices of companies such as ISS. In order to improve the skill level of this undertrained section of the workforce of the NHS, UNISON believes the NHS should undertake more initiatives such as the Return to Learn Programme, which UNISON has operated jointly with many trusts with positive results. These initiatives have increased staff morale, productivity and been especially beneficial for ethnic minority and other disadvantaged groups. Lifelong learning opportunities should be available to all those who can benefit from them.

  51.  The NHS has traditionally not had a service wide approach to training for professional and technical and administrative and clerical staff. With the new requirements of a "First Class Service" this need to change and a similar approach should be adopted for these groups. Considerable work has already been done on training needs for some PTB groups and Ambulance training should be reviewed.

  UNISON would also point out that investment in administrative support staff can free up the time of clinical staff and administrative systems are central to effective use of resources. The NHS also needs to address the issue of management training.

Registered Staff in Nursing, Midwifery, Health Visiting and PAMS

  52.  UNISON believes that the current UKCC Education Commission reviewing Project 2000 should tip the balance back towards assessed clinical competence (in pre- and post-registration courses) and away from academic based knowledge.

  53.  UNISON favours the integration of Project 2000 and degree courses with relevant Care NVQs/SVQs (particularly those at level 3) and also incorporating newly-developed national occupational standards linked to particular clinical placements students. (Considerable ground-work for this has already been undertaken as part of the 1995 NHSE Study entitled "Utilising National Occupational Standards as a Complement to Nursing Curricula"—Executive Summary attached as Appendix 2.) This means that nursing assistants/auxiliaries and support staff entering such courses will be in the fast lane on the clinical front and will be able to focus more on developing their knowledge, communication and cognitive skills. In the higher grades UNISON supports the development of extended role through nurse practitioners, clinical nurse specialists and so on although we do not see so called "supernurses" as addressing the problem of proper recognition for all nursing staff.

  54.  The widespread development of more qualified support staff will mean the acceptance of different "levels" of care staff. However, UNISON has always been in favour, for example, of retention of E/Ns, and only wished to get rid of the abuse of them, eg via Rule 18(2). Opportunities need to be opened up for enrolled nurses to be recognised for developing their role as well as opportunities for conversion.

  55.  We believe there should be a proper system which allows people to progress fluidly into further training and qualifications, whilst at the same time properly rewarding them for the skills they can already demonstrate. This goal can partly be realised through the new NHS pay framework, with a common pay spine, and this is fundamental to this evidence.

  56.  We are advocating the removal by consent of artificial barriers wherever they hinder effective working and an individual's ability to progress either upwards within the same discipline, or sideways into a new field. This will give the NHS the flexibility it needs as well as providing opportunities for staff. The hallmarks of sound career structures and education/training systems are flexibility and openness of access. The former term was discredited under the previous government because it became a management euphemism for multi-tasking and exploitative and inappropriate skill-mixes. We believe that flexibility as described in this paper would be welcomed by our members, particularly those in lower grades. However, forcing staff to extend their role is not only exploitative but ineffective.

  57.  As mentioned above, we are arguing for this to evolve in a gradual way rather than for more radical shake-ups to be inflicted on a change-weary NHS workforce. We are supportive of the direction of travel indicated in the Schofield Report's (Executive Summary attached as Appendix 3) espousal of more pilots and trials of shared inter-disciplinary education at pre- and post-qualification level. The Standards in Common Between Six Health Care Professions initiative, originally developed by the Care Sector Consortium, is another example of how different health care professions can work together imaginatively to produce shared, clearly-written standards of current and future relevance to the workplace. In addition, the NHS should receive compensation from the private sector which poaches staff without contributing toward their training costs through a training levy on the private sector.

Medical Training

  58.  UNISON believes that professional power (or professionalising power) has negative as well as positive effects. We accept that untrammelled professional power can have tragic implications and cost society dearly—as the cases of poor paediatric cardiac surgery practice at Bristol has demonstrated with tragic consequences.

  59.  For too long training of medical staff has consumed a disproportionate share of NHS training resources. These resources need to be shared on the basis of need.

  60.  Reform of medical training is long overdue. We still produce doctors whose main track record centres around the ability to memorise scientific theory which is then regurgitated in examinations and then largely forgotten unless utilised in practice after qualifying. This will not be acceptable in the new environment.

  61.  Medical CPD is also flawed in that it is unregulated and can involve, in its crudest form, a drugs company sponsored lecture. In this regard the UKCC's PREP model of CPD for nurses, midwives and Health Visitors is superior in that it emphasises linking learning to current practice through reflections explicitly—outlined in a Personal Professional Portfolio.

  62.  There are hopeful signs that even medical education may be moving towards a greater emphasis on competence and standards which can be explicated. The competencies developed for Senior House Officers via the Northern and Yorkshire Region project under the auspices of Irene Ilott is another useful example of different bodies coming together (the initiative was joint-sponsored by NHSE and DFEE) to produce a new approach of high comtemporary relevance. (A summary of this project is included as Appendix 4).

  63.  Whilst this latter example focussed on post-registration skills, UNISON believes that the future should be characterised by more pilots of shared learning at PRE-registration level also in order to ensure that opportunities for career progression are possible, rather than parking practitioners in occupational cul-de-sacs which they (and their managers) feel constrained by in future.

  64.  We are thus advocating a modular system of greater numbers of shorter, skills-focussed courses which staff, regardless of their original discipline, can use as building-blocks for career development. We wish to put the acadamic value of degrees in proper perspective as one facet of healthcare education, not a talisman which transforms an individual's practice. There is currently too much pressure on individuals to gather academic qualifications as tickets and this is often done as a defensive move to defend against perceived threats to job, status and credibility.

  65.  UNISON is supportive of "lifelong learning" as a better approach than Continuous Professional Development (CPD) and this is emphasised in our response to "A First Class Service." The principle of a lifelong "portfolio" will not only tie in with the national curriculum and the government's lifelong learning agenda but will also further harmonise the continuing education structure of those undertaking NVQs/SVQs and those following further care qualifications. The methods of delivery for personal development plans needs to be adaptable but in principle they.

  66.  In summary, we believe that if one was starting with a blank sheet of paper, the current demarcations between traditional health care disciplines would not have been created. The territorial power rivalries between these different professions is not in society's interests.

  67.  Rather we should work in an evolutionary way to encourage the coming together of these occupational groups to recognise the reality: that is, that they have much more in common than many of them would profess. So, higher education institutions must be encouraged to develop more multi-disciplinary common-care health care courses as a foundation on to which further skills-based, practice-oriented modules can be built.

  68.  Such further courses or modules should be designed to meet the needs of the service and not those who are self-interested and partisan in propagandising the superior merits of one particular occupational group. They should be funded by employers perhaps assisted by partnership programmes with unions.

  69.  Such shared training should be conducted at all stages and levels wherever possible with one of the hallmarks of its success being the long-overdue reform of medical training. This emphasis on common interests is not only central to UNISON's own philosophy, but will help address the oft-lamented problem of poor communication between different care agencies.

MODERN PAY FOR A MODERN NHS

  70.  UNISON will be submitting pay claims for all staff groups as part of the 1999 pay round. In its evidence for the Pay Review Body we have already highlighted the need to tackle low pay and bring nursing staff more in line with comparable occupations through a substantial pay increase. For non Review Body groups we are consulting on a suggested claim of £1,000 or 10 per cent whichever is the greater and a minimum hourly rate of £4.61. Increases of this level are needed to address the staffing problems of the NHS.

  71.  In its 1999 pay campaign UNISON will be stressing that the NHS needs to recognise the skill and value of its staff. We will be highlighting the pay gaps between NHS staff and comparitor occupations which contribute to recruitment and retention problems, and arguing that the NHS needs to provide fair reward for its staff. Action needs to be taken to avert a recruitment and retention crisis. We hope the Committee will support these views.

 A NEW PAY SYSTEM

  72.  UNISON believes that it will be possible to secure a long-term solution to the staffing problems of the NHS and ensure that the NHS has a pay structure which assists it to meet the demands of a changing world. The new system should ensure:

—  basic pay for all NHS staff set in a uniform fashion: that is to say the present division between PRB and non-PRB groups would have to cease;

—  fair pay for all staff;

—  there should be a common incremental spine;

—  terms and conditions of employment would need to be harmonised across all the present functional Councils;

—  the system should be underpinned by a national job evaluation scheme to be applied at local level;

—  a nationally agreed structure for pay and conditions for all NHS staff regardless of their present contract of employment;

—  harmonised conditions of service for all staff;

—  the end of low pay in the NHS;

—  equal pay for work of equal value;

—  equity of treatment for all staff.

  73.  Discussions on these ideas have been taking place with the NHSE and we will be able to update the Committee on progress at oral evidence.

CONCLUSION

  74.  UNISON welcomes the House of Commons Health Select Committee inquiry into NHS staffing. In our evidence we have sought to identify the key issues that the NHS needs to address. We welcome the positive steps that have been taken in the comprehensive spending review and the new direction set out in the Human Resource Strategy. These need to be complemented by action to increase NHS pay levels, progress toward a new pay system and a new agenda for staff training and development. We hope the Committee will support these aspirations and that we can work toward a new agenda for staff in the NHS.

October 1998

 REFERENCES

    1  Working together: a new Human Resource Strategy for the NHS

    2  Department of Health Statistical Bulletin 1998

    3  PTA Staff Side evidence to the House of Commons Health Select Committee 1998

    4  Evidence from the NHS Confederation to the Pay Review Body 1998

    5  Improving the Health of the NHS Workforce Nuffield Trust London 1998

    6  Evidence from the NHS Confederation to the Pay Review Body 1998

    7  Department of Health Press Release 98/396 1998

    8  Paying the Price UNISON evidence to the Pay Review Body 1998

    9  UNISON evidence to the Nursing Pay Review Body. (Ibid)

  10  PTA staff side evidence to the Pay Review Body PTA Staff Side 1998

  11  Working Together a New Human Resource Strategy for the NHS NHSE 1998

  12  Ibid

  13  Survey of equal opportunities policies in NHS trusts Industrial Relations Services London 1998

  14  Back in the Team UNISON submission to the review of market testing in the NHS 1997

  15  UNISON response to the Consultation Paper a first class service quality in the new NHS UNISON 1998

  16  UNISON evidence to the Review of Nursing legislation UNISON 1998

  17  Pay the Price UNISON London 1998

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