28 April 2006
As the axe falls on thousands of frontline NHS posts, the government faces a huge row over the impact on clinical care. Seamus Ward visits a health trust about to shed 1,200 posts – and hears both sides of the argument
On a typical April Monday, when all the seasons seem to collide in a single day, 15 people are huddled under a Unison banner outside Stoke City Council's civic centre to protest against job losses at their local hospital. A mix of frontline staff and concerned citizens, they are united in their condemnation of the 1,200 proposed redundancies at the University Hospital North Staffordshire Trust – the biggest single cut in any of the estimated 7,000 job losses announced by NHS organisations recently.
Inside, Antony Sumara, the trust's chief executive, is being questioned about his recovery plan by the city council's health oversight committee. The plan is one of 18 put together by NHS organisations in financial difficulty with the help of external turnaround teams. The 30 or so seats laid on for the public are full as the protesters seek to have their views heard.
Events in North Staffordshire are a microcosm of what is happening throughout the NHS in England. Patients are increasingly worried that staff cuts will lead to services being downgraded or disappearing altogether. Both major opposition parties claim government mismanagement has created a crisis in the NHS. One estimate, by the think-tank Reform, suggests that the government's policies will lead to 100,000 job losses – around 10% of the total staff.
As the storm clouds were gathering, the prime minister was forced to step in to lend his backing to the reform programme and an increasingly helpless-looking health secretary. At a breakfast seminar earlier this month, attended by Sumara and the chiefs of other financially troubled trusts, Blair insisted there was no crisis and that his reforms were merely highlighting inefficiencies in the system. Once these were driven out, services would improve still further. It was a typically Blairite 'no gain without pain' message – but his efforts to prop up public confidence are weakened each time a new round of redundancies is announced.
Sumara is a patient man, willing to explain the recovery plan to anyone who is interested. After the meeting with councillors he spent a further hour talking to campaigners and journalists before rushing off to be grilled by the trust's senior doctors. He has been North Staffordshire's chief executive for around three months and knows the trust is in trouble. Its deficit for 2005/06 will be at least £15m and, without action, is set to rise in the current financial year to around £30m. He plans to have a £13m deficit at the end of 2006/07 and balanced books by March 2008. But to do this 1,200 jobs must go, along with other cost-cutting measures.
Around 1,000 whole-time equivalent posts in all types of roles will be shed but most of the staff to be lost work directly with patients: 15 consultant doctors; between 11 and 20 other medical staff; 371 nurses; 202 health care assistants; and 23 allied health professionals. Seventy-three medical scientists plus 23 clinical support staff will go. The trust will lose 63 managers, 180 administrative staff (such as medical secretaries) and 60 other non-clinical support staff.
Further cuts in line management and secretarial roles are planned. Back-office functions, including finance and IT, will be reviewed and possibly outsourced. As in other parts of the country, the proposed job losses are subject to a statutory 90-day consultation period, and no cuts will be made in North Staffordshire until September at the earliest.
Although there are fewer managers and administrators to lose in the first place, it is still hardly surprising that local people are worried by the much deeper cuts in clinical staff (more than twice as many as managerial staff).
Anthony Hodgkinson, a former local health authority board member, says he is upset and cannot see how patient care will be unaffected. 'I was in the hospital as a patient last year and the staff there were rushed off their feet. Now they will suffer because of financial mistakes,' he adds.
Pat Bovell, a nursing assistant at the trust, is concerned that staff will go soon, even though the trust has a two-year recovery plan. 'These are all valuable staff and I think the cuts will affect patient care. These are not just figures on a piece of paper.'
Ministers insist job losses will not affect the quality of care in any part of the NHS. Sumara believes this is true in North Staffordshire because the changes are about rectifying inefficiencies. In other words, the trust will provide a better service with fewer staff.
'It should not affect waiting lists or waiting times because our proposals impact on inefficiencies in the system, such as length of stay and day case rates. We're not doing anything special or discharging patients early. Savings will be found by working at the average – the number of beds would be reduced by 167 if we applied the national average length of stay to our hospital,' he says.
Fewer beds mean fewer nursing and domestic staff, while increasing the number of day cases will also cut nurse numbers – the trust plans to perform 80% of its operations as day cases. Theatre staff numbers will be affected by plans to reduce spare capacity – though they might be saved if the hospital can attract additional work.
The trust expects to lose 310 posts through replacing only a proportion (currently 20%) of the 50 staff who leave each month, plus 116 through voluntary redundancy and 24 by reducing the hours of those approaching retirement. This leaves around 750 compulsory redundancies – it is not yet clear which staff this will apply to. Staff leaving will be helped to find other jobs and training. The trust will also operate a clearing house to match those made redundant with job opportunities in other parts of the organisation and the local NHS.
Sumara insists the trust is not presenting a rigid plan and is looking at other efficiencies to reduce the number of redundancies. 'Every million pounds I can save in areas that don't impact on staff saves around 35 jobs,' he says.
For example, a plan to save £2m in procurement would save 70 jobs. 'We are actively looking at areas that do not impact on staff numbers. It is difficult for the staff – they are the people that are suffering – and we will do everything we can to get the number of redundancies down.'
Traditionally, clinical staff have joined the service as a job for life with a natural career progression but this may no longer be the case (see boxes). One doctor, who asked not to be named, is coming to the end of her training in ophthalmology and this summer is due to take up a 12-month fellowship post in a hospital while applying for consultant jobs.
The fellowship leaves her in the grey area between training and a consultant's job. Now, instead of looking forward to a consultant's starting salary of £69,000, she will receive a basic of between £18,000 and £28,000, with supplements for on-call work.
'I don't think the promised consultant expansion is happening,' she says. 'Departments are advertising replacements but not new jobs and this may be due to the uncertainty over what's happening in the NHS.'
The reform programme, which has introduced private sector operators to speed up access to NHS cataract surgery, is one of the reasons for this uncertainty, she believes. 'Independent sector treatment centres are destabilising various NHS units and people don't know what's going to happen in the short term.'
Health Secretary Patricia Hewitt believes the recent spate of job losses is inevitable, as NHS reforms take hold. These will force NHS hospitals to be more efficient and ensure that more patients are treated in the community and in independent sector units. This argument holds some water – Sumara insists his trust's plans effectively bring forward the implementation of the white paper published earlier this year Our health, our care, our say, which calls for more care in GP surgeries, community hospitals and patients' homes.
The Royal Cornwall Trust announced 300 job losses recently, partly in response to a projected £8.1m deficit but also to deal with falling income as local PCTs move more patients into the community or independent hospitals.
However, the redundancies cannot be fully attributed to the reforms as their real effects have yet to bite. Some organisations say the job losses are due to 'over-heating' – hospitals have taken on too many new staff to cut waiting times and grab a greater share of the extra money being poured into the service. However, higher pay and PCT cash shortages have left them in deficit.
Certainly, this is the view of John Rostill, the chief executive of the Worcestershire Acute Hospitals Trust, which is shedding up to 720 posts in an attempt to recover a £30m deficit. The trust has taken on almost 1,000 extra staff since it was formed in 2000, helping it meet successive waiting times targets.
'Taking on hundreds of extra staff, paying many of those staff more money, treating more patients, more quickly, with more expensive drugs and equipment – and doing all that on three separate sites – is where the money has gone,' Rostill says.
Whatever the reason for the redundancies, the public and staff will be sceptical about whether the NHS can maintain its level of service. The government can expect more political flak, with the Royal College of Nursing due to hold a march in Westminster on May 11. General secretary Beverly Malone says: 'Losing nurses will affect patient care, pure and simple. The government has to give trusts more time and flexibility to balance their books so that this scorched earth policy of cutting patient services and jobs is stopped.'
With Tony Blair voicing his support for the reforms in recent weeks, it is unlikely there will be a U-turn. In the end, the best result for the health service will be to minimise redundancies so it continues to meet waiting times targets. But it seems inevitable that reductions in the number of people on the waiting lists will slow down and patients will have to wait a little longer.
That is not good news for the government or patients.
Cut to the quick
Announcements of redundancies in the NHS seem to have become a weekly event but it is difficult to discover where cuts will fall, how many staff are affected and whether the quality of patient care can be maintained.
Many of the announced cuts are estimates. Others refer to whole-time equivalents or head counts; some to both. Most involve a degree of compulsory redundancy and cuts in clinical staff. With this health warning in mind, here is a selection of 7,000 potential cuts across England:
- University Hospital North Staffordshire Trust: 1,200, including 750 through compulsory redundancy
- Royal Cornwall Trust: 300, some will be compulsory
- Surrey and Sussex Healthcare Trust: 400, including 300 temporary staff
- Worcestershire Acute Hospitals Trust: 720, the trust insists the quality of care will not be hit
- York Hospitals Trust: 200, by replacing only half its vacancies over this financial year. The trust maintains that key posts will not be lost, though it admits some compulsory redundancies are possible
- James Paget Healthcare Trust: 100 by not filling vacancies
- County Durham and Darlington Acute Hospitals Trust: up to 700 over three years
- West Hertfordshire Hospitals Trust: 500 over the next 12 to 18 months
- NHS Direct: unions warn up to 1,000 jobs could go but firm proposals are due in May
- Sandwell and West Birmingham Hospitals Trust: up to 800, although the trust insists it will maintain standards of care
Starting with the specialists
Specialist services have been among the first to feel the pinch as the NHS tries to balance its books. This week the Royal College of Nursing said services for older people, children and people with mental illness were at risk. Four children's hospitals, including Great Ormond Street, have warned the introduction of payment by results would cost them £22m this year and could lead to cuts in services. And Public Finance understands that one of two dedicated multiple sclerosis nurses in North Staffordshire will be made redundant.
The RCN surveyed 660 senior nurses, 45% of whom reported redundancies or workforce reductions in their hospitals. Sixty per cent said they did not have enough staff to give their patients the care they would like.
In a dossier on the effect of the financial difficulties, the RCN said children's cancer services had been cut in Taunton, community beds had been axed in the Cotswolds and Felixstowe and minor injuries units were being closed or their hours reduced.
The Multiple Sclerosis Trust charity has been funding a number of specialist nurse posts that would be lost without its support. Nicki Ward, a lecturer-practitioner in MS in Birmingham, says laying off specialist staff is a false economy and will reduce the quality of service.
'MS nurses generate income in acute trusts. Every patient we see in clinic generates a payment from the PCT.' She says that in an admittedly small study, an MS specialist nurse was shown to save £64,000 in a year. The nurse treated patients who would otherwise be waiting to see a doctor and prevented acute episodes that would otherwise have led to the patient presenting at the Accident & Emergency department (at a cost of £104 each time).
'We can't stop the disease's progression but we can deal with many things that affect patients' day-to-day lives. This will hopefully keep them and their partner in employment.'
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