Andrew Lansley’s legacy of crisis in NHS nursing care, and nurse’s pay in NI…

I’m probably not the best person to be writing about nurses’ pay. They have something akin to special category status in our family. My late mother was certified as a state registered nurse by the City Hospital in Belfast in 1943 after four years of intense study and practical work on the wards.

In that time, she had (literally) been blooded as a student in the makeshift morgues hurriedly convened in the city’s swimming pools during the Blitz two years earlier. Student nurses then, as now, were paid a pittance whilst training and working towards their qualifications.

So in his column yesterday Newton Emerson caused a bit of a stink by picking up on a snippet from the Mail on Sunday suggesting that ‘roughly ten to 12 nurses’ were taking up the offer of ‘working weekends’ involving a 360-mile round trip from Northern Ireland to Sunderland.

Of course there is a much broader context to this issue barely alluded to in the Mail piece. It has its roots in Andrew Lansley’s haste to convert NHS Trusts across England into Foundation Trusts, in part to facilitate the smoother working of his radical 2012 reforms.

Trusts preparing to undertake the transformation had to sign up to a Tripartite Formal Agreement (TFA), which included a set of commitments around financial control. Faced with such a tight timetable one of the first things that many trusts did was to cut recruitment.

The knock on effect on training and graduation has quickly developed into a wicked problem of under training and under recruitment. In the West Midlands, for instance, a 17 per cent drop in commissioned places for standard nurses was reported in the very early stages.

Initially English Trusts relied on agency nurses to plug the growing gap. But that gave way to a new initiative at the end of 2013. At the end of 2014 three quarters of NHS hospitals were forced to look elsewhere to recruit almost 6,000 overseas nurses in just 12 months.

RCN spokespeople warned even at that point that the recruitment issue was a ticking timebomb. Then last October the government added nursing to the Shortage Occupation List on an interim basis, which for now at least allows Trusts to recruit beyond the EU.

None of this speaks for a moment to the high turnover of such recruits or the difficulties experienced both by incoming and established staff in tackling the cultural and linguistic issues which arise in what are already highly challenging work situations.

During this time of cuts in training and recruitment the trend for referrals and admissions in the English NHS has been on the same steady upward curve as before, making it pretty obvious that this crisis originates within the management (or rather mismanagement) of the system.

What the Mail and other mainstream media miss in stories like the one about a dozen nurses from Belfast going to Sunderland to dig the local Trust out of what we must presume is a deep structural hole is the self inflicted nature of this mess at government level.

As for RCN’s campaign for the local Health Minister to implement a modest 1% pay rise, well the figures quoted by Newton do suggest nurses here are paid marginally better than those in the south (who have been going through their own series of structural crises).

But here the last UK government made a nursing degree an entry level qualification. Osborne now plans to remove the bursary (which replaced the Student Nurses’ salary) forcing them to pay for their own third level education. Not a problem if you become a nurse manager, Sister or Matron.

But who exactly needs to pay for a degree level education on £20k+ salary?  You’d almost be tempted to believe this was a scenario setup to fail. For the record, health expenditure in the UK was 8.46% of GDP in 2013, compared to 16.43% in the USA, 10.98% for Germany and 8.77% in Italy.

For his part, the NI Health Minister Simon Hamilton is not the author of this crisis. Nor has he made up his mind on whether or not to pass on the pay rise. Certainly NI has not yet seen the levels of chaos seen in almost every trust in England, although I suspect some of it may be coming shortly.

We know from the Mid Staffs investigation just how crucial it is to have a functioning and well provisioned nursing care. I don’t know if a 1% pay rise is too much. I do know there are no fat cats in nursing. And yet there may be better calls on that money here.

In truth we rely on the majority of registered nursing staff who work at the base of the pay scale to make the whole NHS thing work when resources are cut. We owe it to them and ourselves to admit there’s a much bigger problem here at play.
But then again, I would say that, wouldn’t I?

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  • Ozzy

    The problem I had with Newton’s article was how it seemed to suggest that every nurse would somehow end up on 98k per year by the end of their career. Promotion and specialisation won’t be an option for the majority, most will be left on 27k per year. A good wage when compared with many others, but when the actual demands of the job are broken down it more than justifies a modest increase. And don’t get me started about paramedic pay!

  • Korhomme

    The government at Westminster has proposals to limit the time “foreigners” can work in the UK; if after 6 (?) years you aren’t earning > £35k/year you can expect to be deported. In Britain, many nurses are “foreign”; expect to see another crisis in nursing levels fairly soon.

  • Old Mortality

    I find the whole issue of nursing shortages incomprehensible. What do all the expensive agency nurses do when they’re not needed by the NHS? Just stay in bed? It’s not as if there’s much demand from the private sector in NI (or Sunderland for that matter). Why can’t the NHS exercise its monopsony power to squeeze out the nursing agencies?

  • mickfealty

    They work, as nurses OM, which make it a flexible resource that can be scaled up or down depending on the demand.

    The Mail tells us that these nurses already work full time in the Royal and the City. Then they go to England to work at the weekends, presumably because they are ‘decadent, or something’.

    Actually it’s not particularly useful to speculate on the reasons why such a small group would do this but I would imagine there’s some kind of financial necessity driving it.

    The shipping in of nurses from overseas has plugged the biggest gaps (and eased the financial burden since employed nurses are cheaper than agencies, but it cannot plug them all.

  • notimetoshine

    Using the mail as the source for this is hardly ideal though, its not known to be sympathetic to the nursing profession. Uppity nurses, is the general theme, Newton Emerson seems to be following the same general theme

  • Brendan Heading

    A thing that is actively going on is the stealth privatisation of the NHS. But it’s happening in a very subtle way, right under the noses of the left wing activists who campaign to prevent it and waste their time focussing on substantially imaginary threats, such as TTIP, and cling tightly to the ideological axiom that the need for the health service to be free at the point of use overrides all other concerns.

    It’s becoming increasingly common for employers in professional occupations to provide a private health insurance policy. These are taxable, but due to the low risk associated with office workers in particular, they tend to be very affordable. Queues can be easily and quickly jumped, especially by those who have surplus cash to pay for a procedure to be done at short notice – surgery that has a one year waiting list on the NHS can often be scheduled within weeks. NHS dental cover has been gutted too.

    I’ve also seen, over the past year or so, ads for private clinics popping up in pubs and restaurants, usually in the WC where readers are encouraged to get themselves checked over quickly in a modern private facility. I also notice that a new private, dedicated MRI unit has opened in South Belfast. This expensive facility could only be opened if its owners felt that there was a demand for it.

    As private sector hospitals expand to meet these demands, staff such as nurses, as well as doctors and other specialists, are likely to be attracted away from the NHS. The point will eventually come when large sections of the population begin to loudly question why they’re paying national insurance to support an NHS that they don’t use because it is too slow and suffers from too much underinvestment.

    I don’t necessarily agree with this course of events but hard choices need to be made. If we want a sustainable health service that works, we’re going to have to pay a lot more for it than we are now, one way or another.

  • mickfealty

    The first reference to it is in the Bel Tel. I just wanted to get some wider context around it.

  • OneNI

    All those saying the nurses ‘deserve’ their 1% should tell us were the £40m is coming from? Lets remember that all public sector staff continued to get ‘natural increments’ when private sector pay was at best static. Also there have been no compulsory redundancies while in the past 5/6 years 15,000 jobs have been lost in construction.
    Many construction workers now travel to GB – not to top their income up at weekends but Mon-Fri to get an income at all.
    Our nurses seem to want their cake and want to eat it. They want ‘UK wide’ pay rates but I understand dont have the same terms and conditions and refuse to countenance changing
    Also the McKinsey report pointed to very poor productivity amongst NI nurses compared to GB – esp at the Royal
    Finally national pay deals are surely an anchronism – pay should take in to consideration the cost of living in an area

  • mickfealty

    Oh, I don’t know OneNI, slashing recruitment is a way of creating a similar effect to redundancies: albeit followed by a bout of panic buying round for anyone else to do the job you had imagined expendable, but wasn’t.

    Don’t reckon too much to your defence of the indefensible. Nice try though.

    For my money I doubt it was intentional. More likely the Health Secretary at the time was ball watching rather than listening to what health care professionals were telling him before implementation.

    It’s a classic case of a politician overdoing the ministerial haste for fear of not getting a second term. The speed he forced through the changes at are exactly what’s broken the system.

    I don’t know if you caught it, Mr Cameron had a Conference dig at some of the very nurses Mr Lansley’s reforms sucked in from southern Europe for cycling out quickly of the NHS and doing other jobs instead. Slick that.

    Where was the Labour party to raise these concerns before they got carried through on the whim of an enthusiastic amateur?

  • Tot

    For those with access behind the times paywall Matthew Parris article from November on the desanctification of public servants is worth a read. http://www.thetimes.co.uk/tto/opinion/columnists/article4607189.ece

  • barnshee

    “were the £40m is coming from? ”

    From the bloated salaries of the managerial class in (particulary) Local Authoritys and the NHS

  • mickfealty

    I’ll snip a key passage for those who don’t…

    Be it by lawyers, doctors or hospital porters, the insinuation that to serve the public somehow elevates you above the argument about what can be afforded, warps our attitudes. It sentimentalises. It turns employees into glorified charity workers who just happen to be drawing a salary.

    Implicitly it insults those who work in the private sector. But the private sector is a public service provider too: it provides our population with food and drink, with cars, with fuel, with clothes, with most of the necessities of life. There are no important moral differences.

    In theory, I agree with him. There is no value in sentimentalising these professions and forsaking efficiencies and aiding proper and proportionate investment. It is not how they arrive at a world class health system in Denmark for only a slightly higher proportion of GDP.

    But there’s a wee bit of a sleight of hand going on here. It’s not the staff burning public value in this case, it’s incompetently introduced reforms.

    And indeed instead of just comparing the public unfavourably with the private sector we should also note that there is still much the public second to learn from the private sector (and remain substantially publicly owned). High turnover in retail staff for instance is often interpreted by management as a clear signal that staff remuneration is set too low.

    And if we really cannot afford proper remuneration, we may be doing some other important thing(s) wrong. Given the current chaos it’s likely that Mr Lansley has done rather a lot of things rather badly wrong.

    This piece (http://goo.gl/pFUKDR) is one of the best I’ve read in the last few years in this regard:

    Supermarkets didn’t just hope for the best. They designed ways to flow groceries into their stores with extreme care, setting up advanced signalling systems to tell them exactly what was needed where and when. To do this, they’ve moved well beyond checklists, using simulation and modelling to design their logistics and advanced computing to predict what will happen next. In the same way, we need to focus on the flow of patients into and around our centres of service.

    Our intuition to meet demand by creating more posts, or more beds – or to run for longer hours – is simply likely to delay the point at which demand inevitably overwhelms our ability to provide a service. We need to design and implement much deeper solutions. Just as getting rid of supermarket storage was a measure that ran counter to normal intuition, so our intuition and experience in health are unlikely to help us find the best interventions for healthcare.

  • John Collins

    Not so much the bloated salaries as the sheer outrageous numbers that are now in ‘managerial class’. Down here we once, prior to 1971, had 32 Health Authorities. They were then replaced by 8 Health Boards. One would have thought that the managerial class would have been substantially reduced with these changes. One would have been disappointed. The number of clerical staff and higher management personnel grew out of all proportion which every excuse was made to reduce the numbers of those working at the cliff face. Each of the boards for example had a personnel department and a salaries department. Surely one of each of those nationally would have been sufficient, especially with the advances in IT etc that has taken place over recent decades. I presume the same problems more or less exist north of the border.

  • John Collins

    Agency nurses may suit the management agenda for the following reasons. They may be allocated at the times the organisation need them while permanent nurses are on a set rota. They may not be entitled to sick leave pay. They may have to arrange and contribute to their own pensions.

  • mickfealty

    Yes John but they don’t and never will work on this kind of scale.

  • T.E.Lawrence

    “Where was the Labour Party to raise these concerns before they got carried through on the whim of an enthusiastic amateur” I would go further Where was the Unions and that other nice group of people called Civic Society ?

  • T.E.Lawrence

    As the law stands at the moment after six years working and being a resident in the UK a non British Citizen can apply for UK Naturalisation. I just can’t see the practicalities of such a proposal being workable for the UK !

  • chrisjones2

    People spending their own money where they want. Shocking!!! Shouldn’t be allowed

  • chrisjones2

    As you say they also dont go sick for 3 months on full pay and dont retire early through illness / have a 20%+ on cost for pensions Above all you can bring them in and let them go as you need them as demand changes

  • chrisjones2

    Many are brilliant and skilled and committed . Some are not. I have seen both recently.

    The system seems incapable of dealing with the poor performers

  • chrisjones2

    “privatisation of the NHS”

    Why shouldn’t it? Take eye and hearing tests for example? Or hip and knee operations? Cataract surgery? GP radiology tests? Lots of chiropody, physio and other services?

    The private sector might deliver cheaper, faster more flexibly and more locally than the NHS. Why do I have to wait 12 months for a hearing aid for example? Or perhaps 3 months for a first physio appointment?

    Ultimately the question is , what is the NHS for?

    The fast effective treatment of patients / relieving of suffering or the careers of its staff and keeping the unions quiet.AT the moment there is far too much of the latter but that wont change in a NI dominated by parties desperate for the last few votes

  • chrisjones2

    Perhaps most of them are needed a lot of the time

  • chrisjones2

    ….many more of our nurses seem to be from the rest of the EU eg Portugal and Spain

  • mickfealty

    They have no direct political power or the means to get things done or stop them. This is why politics (as opposed to single issue campaigning) still matters.

  • chrisjones2

    Whoops my apologies. Read all the posts first and dont just jump in and inadvertently repeat what others have said

  • Reader

    CN Parkinson famously pointed out that bureaucracy grows as a result of a natural law in all organisations. And that efficiency drives and reorg’s were powerless to reverse this process – the only solution was to rip everything up and start over again. This happens naturally in the private sector.
    I think very few of us are ready – yet – to take that approach to the NHS; but instead there is a move afoot to try to circumvent Parkinson’s laws by introducing a degree of privatisation.

  • OneNI

    This thread unhelpfully conflates NI and England situation.

    ‘slashing recruitment’?There were 18,432 more NHS nurses in England in 2014 compared to ten years ago.

    My comments referred to NI in the main. Another job article in Irish News today about their relatively comfotable position

  • Jeremy Cooke

    Why don’t we attach a nurses’ home to each major hospital then recruit youngsters with good “O”-levels every year and take them in to a structured training program with day-release to the local technical college for “A”-levels leading to a recognized nursing qualification ?

  • Turgon

    That might well be appropriate for health care assistants. It worked years ago for nurses. However, nursing now is a complex business simply because health care is vastly more complex than it was years ago. Nurses need to be able to process large amounts of information, work highly complex pieces of equipment etc. In addition following the basic general nursing training a nurse might specialise in theatre nursing, ICU, CCU, caner nursing etc. etc. Each are very different and very complex and as such a high standard of basic training is needed.

  • hugh mccloy

    All that including the same set up for doctors are being or have been done away with, and we wonder why other countries produce more top medical staff than we do ?

  • hugh mccloy

    There have been forced retirements via service cuts, I think you need to understand what is happening in health a little more to make that call.

  • hugh mccloy

    I done this a few years ago – and this is just exe board http://savethemid.weebly.com/news/executive-health-board-memberssalaries-pensions-201112

  • hugh mccloy

    The Labour party introduced 4 spending reviews, 2 in the expectation of a market crash and 2 after it, thats before the tories even got their hands on anything

  • mickfealty

    That’s exactly the kind of problem that allowed Labour to take is eye off the ball on this and other issues…

  • Jeremy Cooke

    I’m sorry I plain don’t believe that; any experienced nurse with a few years on the ward would be able to be trained up in any of the equipment in use with a bit of good will and the appropriate course.

    There are “O”-level Sgts flying multi-million pound attack helicopters, there are Naval Officers with degrees in English or History commanding nuclear submarines, the are Corporals with no qualifications from school using highly complex, encrypted communications equipment.

    This rubbish that nurses require degrees is utter and complete self-serving nonsense on stilts – sorry.

  • mickfealty

    So it’s misleading to explain why 10-12 nurses from the City and the RVH get on a plane for Sunderland is it? We’re just supposed to think they’re doing it for badness are we?

    It’s a broader context for the cosh that nurses are under OneNI. NI has some means (as do Wales and Scotland) for filtering out the worst effects of Lansley’s impulsiveness.

    But there’s a lot of this stuff (which no one in England or anywhere else voted for btw) coming down the line. The training situation is potentially crippling.

    A 3rd level education is expensive and someone has to pay for it. But if you shift fees onto a group most of whom will spend a lot of their career on base pay levels who exactly do you think is going come into the profession?

    As for the gross numbers being so much higher, see the graph embedded above on referrals and admissions. I’d also be willing to bet the gross figures include a high turnover in overseas nurse cycling out.

  • mickfealty

    Yes, but so’s this. You needed to study for four/five years in 1939. How far back do you want to put the clock?

  • Turgon

    The problem being that nurses do not just work on wards. They also work in out patients roles; working with chronic disease patients; in theatres.

    Even in terms of “wards” a day procedure surgical ward is very different nursing to an Intensive Care Unit, a Coronary Care Unit is very different to a Cancer ward.

    The basic tasks done by health care assistants are probably fairly interchangeable. The tasks society expects of modern nurses are much more complex.

    You can of course believe whatever you want. However, believing in such a thing when you are not an expert in the subject area simply makes you deeply silly.

  • Jeremy Cooke

    I may be deeply silly but I can recognize self-serving cant when I see it in action. The RCN pushed Project 2000 for their own benefit and we’ve seen plummeting standards ever since.

    One of my pals from Uni recently retired as as Sqn Leader (or something big anyway) in RAF Engineering; when I knew him poor old Tom could barely wire a plug despite a three year Electronics degree course. Lucky the RAF invested in his training for what he did need to know and he obviously was able to master that.

    And how long is a technical Degree supposed to last in any field – three, four years ? What happens to a nurse who qualified five years ago – do they suddenly become stupid and incapable of learning.

    The people who design and manufacture the equipment mostly have degrees but the idea that a poor Third automatically makes it easier to learn how to operate it rather than an “A”-level holder – nope.

  • Jeremy Cooke

    Not sure what you’re saying here ?

  • Turgon

    Comparing a plane to a human is indeed even sillier than your last remark.

    The complexity of an RAF plane is actually trivial as compared to a person. Furthermore you can pull a plane to pieces and reassemble it and manufacture any new parts fairly easily. Trying that with a person might be somewhat more problematic.

    Also a technical degree in a field may last only a few years because technology moves on. People, however: their physiology and how it goes wrong on the other hand does not change.

    Thank you for proving how little you know about the subject.

    My views are not self serving: I am not and never have been a nurse. However, having watched nurses work for more than 20 years I am well aware of how complex and changing nursing is.

    Also and no disrespect to Mr. Fealty’s late mother but nurses who qualified in the 1950s would be completely lost today. Indeed in the early 1990s when I first observed nursing close up it was clear that some of the older ones without the degrees etc. were begining to struggle.

    As I said I am not a nurse and indeed frequently find them pretty irritating but objectively yes you need degree level training to do much of what they do. I would not want myself nor members of my family nursed by people with a bit of on the job training and no theoretical understanding of human physiology etc.

  • Jeremy Cooke

    I’m glad that physiology and our understanding of it doesn’t change – my humours must have been out of balance. I probably need a good bleeding.

    Oh well since you’re confident that all is going so swimmingly in the NHS and the nurses are better and better, and patients are happier and happier, and complaints and concerns are just so much ill-informed chatter from the people who use and pay for the service I’ll just swan off and leave it in your capable hands.

    HNY

  • Brendan Heading

    That’s not how I feel Chris.

  • mickfealty

    That everything should be simple as possible, but not simpler.

  • Turgon

    You are now simply being dishonest.

    The understanding of human physiology develops and improves. Human physiology itself, however, does not change much if at all. In contrast to take your example of a technical degree the technical aspects of many devices etc. changes completely as new devices / models are introduced. As such your comment is nonsense. A car or plane today is a very different thing from what is was in the 1950s. A person, however, is not different.

    All is not entirely well in the NHS but I assure you it would be wiser to leave the matter in experts (including nurses) hands than to try to pontificate yourself on what is happening.

    As an example Northern Ireland would be well advised to follow Sir Liam Donaldson’s report and close a large number of its hospitals – centralising on a much smaller number which can each deliver more of the specialist services. Unfortunately many non qualified non experts are standing in the way of that for a variety of reasons.

  • Reader

    Ozzy: Promotion and specialisation won’t be an option for the majority, most will be left on 27k per year.
    But Newton pointed out that the nurses who traveled *were* specialists. That puts them on a scale £7000 higher.
    And aren’t they lucky they can schedule free weekends from their main jobs, and that they have the energy to work weekends for triple pay?

  • Old Mortality

    Turgon. I don’t doubt that many aspects of modern nursing demand a higher standard of intellect but the requisite knowledge and skills could easily be acquired on the job. Nursing degrees, like all trade degrees, are a pure conceit.

  • Old Mortality

    Just to be clear, John, are agency nurses in NI usually purely freelance or are they moonlighting nurses employed by the NHS?

  • Old Mortality

    The Mail tells us that these nurses already work full time in the Royal and the City. Then they go to England to work at the weekends, presumably because they are ‘decadent, or something’.

    Or they just fancy earning a bit more cash just like an employed electrician doing jobs in the evenings.

  • mickfealty

    I’d be wary of extrapolating too much there Reader, other than the structure of need within the system…

  • John Collins

    Old Mortality
    I did not work in NI, but in the South of the ROI. Generally speaking there is little or no nurses in the South who work for the health Boards and are available to do agency nursing on their off time. However some nurses work overtime down here. I have no first hand of the situation north of the border, so I cannot comment,

  • mickfealty

    Worth sharing from Facebook from a US friend…

    I have a British Nursing License for which I pay an annual fee that is 3 times as much as either of the US licenses that I have (Pennsylvania/Massachusetts).

    Both US states require nurses to have proof of continuing education credits and attestation of no arrest record for a felony offense to maintain their licenses.

    The Nursing and Midwifery Council not only requires proof of 35 hours per year of continuing education, but also, the following: 5 pieces of practice related feedback;5 written reflective accounts; a written reflective discussion;health and character declaration; professional indemnity arrangement; confirmation.

    This is bureaucratic nonsense. I know what would happen if physicians were required to right “5 reflective accounts” and a “reflective discussion”; and it wouldn’t be a physician crisis or physician shortage.

    It would be a crisis for the bureaucratic sycophants on the licensure board because they would be out of work!!

    The other issue is that intelligent well educated women/ men can make a lot more money in fields other than nursing. In the US a BSN Degree in Nursing costs between $60,000 – $120,000.

  • Reader

    I don’t get you – where’s the extrapolation? The traveling nurses, being specialists, were certainly on good money by local standards. They were able to get their free weekends; and their working week left them with enough energy to travel and work at the weekends, instead of leaving them drained.
    If there is a “structure of need within the system”, the traveling nurses certainly don’t illustrate it.

  • mickfealty

    My wariness is conditioned by the fact we know next to nothing about the nurses in this scenario. How often do they go for instance? Once a month, once a fortnight? Once every six weeks?

    It all has a bearing on the sustainability issue.

    I’ve known nurses who have done private work at weekends one and off for most of their career, often on night shifts when the burden of work can be acute and stressful, but often less taxing overall.

    Within Northern Ireland, Wales and Scotland there is much less stress and human resource need within the nursing system. The structure of need is as I see it in this story, a major deficit in Sunderland brought on by the drastic cutting back of recruitment by English trusts.