Friday, 8 February 2019

The Healthcare Professional Will See You in Four Hours Plus

Two years ago I had pneumonia. After three weeks of antibiotics and resting at home my symptoms had not improved. I staggered to see my GP, that Friday morning, and he advised me that I needed to be treated in hospital, there was no more he could do for me and I wasn’t getting any better. Reluctantly I agreed with him and my husband took me to your local A&E. We arrived at 12.00 noon, at 1 o’clock in the morning I received my first dose of antibiotics.

At the time I was so angry and demoralised to be treated like this, as if they didn’t really believe I was that ill, but later I came to realise what had happened, after talking to other people and checking some facts. The whole hospital, not just the A&E Department, were short staffed and having to cope with a large increase in demand. Is it any wonder that the system cracked?

On Monday 28th January, the Government took a step that will make my experience happen more often and to more patients, they announced that they will scrap the four-hour waiting target for A&E treatment (1). The Chief Executive of NHS England, Simon Stevens, announced it the Health and Social Care Committee meeting, on the 28th (2). Matt Hancock, Secretary of State for Health and Social Care, was also giving evidence to the committee at the same time. Simon Stevens said the four-hour target would be significantly altered, political language for scrapped (1).

This has certainly come as a surprise to everyone working in the NHS because no one had been consulting on this, neither the Royal College of Nursing (RCN) or the Royal College of Emergency Medicine (RCEM) were consulted about this (3), the Government just dropped it on us. This isn’t a new idea from this Government, in January 2018 Jeremy Hunted had hinted at this, in the face of the winter pressures on the NHS (4). It seems that the Government is using Brexit, and all the chaos we are facing because of it, to push through something they have been wanting to do for a while.

The four-hour A&E target has been a thorn in the side of this Government for so long. The target is that 95% of patients are treated within four hours in A&E, but in December only 86.4% of patients were treated within this target, and since July 2015 the target has not been met once (3). This has been a constant indicator of how poorly this Government is resourcing and managing the NHS.

The four-hour target was not reached by plucking a number out of the air, but is evidence based (5). It was introduced in 2004, following extensive consultation by the then Labour Government, as a response to overcrowded A&E Departments were patients were faced with long waits for treatment (5). Yet now, when we are again being faced with overcrowded A&E Departments and patients facing long waits, this Government plans to scrap the four-hour A&E target. What is the logic in this?

Targets, when evidence based, have proved very useful in measuring healthcare outcomes and help improve the quality of care. The RCEM, in a report supporting the four-hour target, have found extensive worldwide evidence that time-based targets help improve performance and were associated with reductions in morality (5). This target has also proved useful in highlighting places that are under pressure and strain, but now what it is doing is repeatedly showing how much strain the whole NHS is under, month after month, and embarrassing the Government, month after month.

A&E Departments are under stress for a lot of reasons, not just an increase in demand, but since 2011 there has been 8.8% raise in people attending A&E, this is 23.4million more A&E attendances, or 5,100 more patients a day (6). These increases in demand have not been matched with an increase in resources, which have stagnated since 2010, but there are also other factors putting huge strain on A&E Departments, such as:

- Staff shortages. 10.9% of nursing posts (7) and 7% of doctors’ posts (8) in the NHS are currently empty. These figures are for across the NHS, but this does mean there are far less nurses and doctors available to work A&E Departments. Shortage of staff has been directly linked to poor care. 45% of NHS staff, involved in patient care, have reported that they are too short staffed to deliver safe, dignified and compassionate care (9), and A&E Departments are not immune to this.

- Loss of hospital beds. In the last 30 years the NHS has lost half of its in-patient beds, right across the broad, including medical, surgical, maternity and mental health beds (10). Since 2016/2017, hospital bed occupancy has been running above 90% and regularly exceeds 95% during the winter months (10), which is far higher than the recommended safe limit of 85% (11). The less hospital beds available, the less availability there is to admit new patients, the harder it is to admit patients from A&E, therefore the longer patients have to wait in A&E to be admitted and the four hour target is routinely broken.

- Underfunding of social care. Since 2010 social care budgets have been cut by £7bn and between 2018-2019 they will be cut by a further £700 million, 5% of the whole budget (12). This directly affects patient’s ability to be discharged, because there is less money for home carers, less money for care home funding, less money to adapt patients’ homes and therefore less support for patients living in the community. When there isn’t the social care support then those patients cannot be discharged, becoming delayed transfer of care (DToC) patients, and DToC’s caused by social care problems have increased 130% since 2014 (13). And if hospital beds are being occupied by DToC patients, how can new patients be admitted from A&E?

- Not being able to get a GP appointment. Currently we are short of 15% of the GPs we need, 6,000 GPs (14), and there is a huge difference in the availability of GPs across the country (14). In some areas there is three times the number of patients for each GP (14), making getting a GP appointment far more difficult. The BBC found that only 40% of patients could get a same day appointment (15), 60% were not, while 27% of patients were able to get an appointment within that week. Not all of those who cannot get a same-day appointment will have urgent health needs, but many will, and where can they go when they cannot get a GP appointment? 40% of NHS Walk-In Centres have closed since 2010 (16).

There are a lot of factors that have caused the increase in A&E waiting times and there isn’t one, easy fix to it. Like so much else in healthcare, there are a lot of interconnected factors.

Different NHS Trusts and Social Care Providers around the country are introducing strategies and services to try and reduce A&E attendance. Doncaster has set up a multidisciplinary rapid response team to treat patients in their own homes (17); in Dorset an advanced nurse practitioner acts as a “gatekeeper” to A&E, redirect non-urgent A&E patients to other services where they can be seen (18); at the Chesterfield Royal Hospital nurses have been placed in charge of assessing patients at the children and young people’s assessment unit, therefore streamlining the service and reducing unnecessary admissions (19). But these are only local changes, none of them are national strategies, and it could be even argued that they are only tinkering around the edges. None of them are trying to tackle the reasons behind the increase in A&E demand.

What we need are national strategies to tackle this problem. We need more community services that people can access near to their home when they have an urgent care need (An infection, a wound, a sprain, etc…), which are not just open Monday to Friday, nine-to-five. We need services that enable people to stay in their homes when they are ill or have a long-term health condition, not just social care but much more healthcare being delivered in or near to patients’ homes. I am a Community Nurse, and many of my housebound patients still struggle to get to and from hospital outpatient appointments because there is no alternative. We need to move to a more community-based healthcare system. When I was a student nurse (nearly thirty years ago now) there was a lot of talk about moving us to a community-based healthcare system, and since then that is all there has been, talk. There are some local-based initiatives, but that has been no national policy or political will to achieve this.

In their new NHS Long Term Plan, the Government has promised, by 2023, an extra £20bn in NHS funding, but only £6.9bn will be spent in the community (17). How the are we expected to develop all these new services to reduce hospital admissions with only 34% of the funding? I would say this is a joke but it isn’t funny.

A&E Departments are not coping with the rise demand for their services, which is caused by a lot of factors, and yet this Government’s sole response has been the scrap the A&E treatment target, and therefore remove the one thing that has highlighted the problems in A&E Departments. Do they think that by hiding the problem it will somehow go away? Because this seems all they have done about it.

Managing Brexit is not the only thing this Government seems incapable of doing.

Drew Payne

Sunday, 14 October 2018

As Small as a Nat’s Cough

When I opened my wage slip, after the much talked about and hyped NHS pay rise, I couldn’t see any increase. My pay had barely risen by a few pounds. I was not the only person to experience this, it wasn’t a payroll error, the vast majority of NHS staff were shocked by how little they received in their pay rise. Some people got as little as a 35p pay rise (1).

In June we (nurses) voted to accept a pay deal that we were told would give us a 3% pay rise (2), so why did we get such a small one, certainly not 3%?

Back in April I blogged about the pay deal (3), while it was still being offered to us, and I found it wanting. I actually found it a poor deal that took away far more than it gave (And to answer the question at the end of blog, in the end I didn’t vote for the deal because researching it showed me how bad it was), and that was when we were being told we would be getting a 3% basic pay rise. The reality turns out we only received a 1.5% pay rise in July (4), but how did this happen?

The advice the RCN issued to their members, they said nurses would receive a 3% basic pay rise for 2018-2019 (5). This briefing was were I took my information from, like many others did, but this information wasn’t correct. The actual deal stated that by the end of the next financial year (March 2019) all NHS staff will have received a 3% overall increase to their pay (6). This pay deal saw a restructuring of our Agenda for Change pay points, the yearly pay increases staff receive under the Agenda for Change deal (5), for most nurses their pay points will be cut from six to three, meaning people will reach the top pay for their pay bands quicker and then will only receive the yearly, negotiated pay deal (3). Most nurses will therefore be re-banded this year and will see their pay increase, but only when they reach their Incremental Date, the date they joined or re-joined the NHS. For most nurses their Incremental Date was not in July, mine wasn’t, and for many nurses they will not see a year’s worth of their new pay point when we hit April 2019. The government’s deal was that we would get a 1.5% basic pay rise this year and then our re-banding would see our pay increase by an average 1.5% and so by April 2019 our overall pay would have increased by 3% or so. This deal never contained the offer of a 3% basic pay rise (6). NHS Employers made this clear in a statement dated July this year (6). So why didn’t the RCN tell us this was the deal on the table when we voted on it?

In July, RCN general secretary Janet Davies wrote a letter to all RCN members (7), in it she said: “In good faith, we told all members they would receive a 3% uplift [??] this summer. I now find this is not the case for everyone. I can assure you I am demanding answers for you.” (7) The wording here is important. She wrote “a 3% uplift”, she didn’t say pay rise. Why didn’t she say “pay rise”? Did she already know that we wouldn’t be getting a 3% basic pay rise?

The RCN issued guidance to their reps (8), which was leaked in July, which stated: “The initial increase for most other staff will typically be 1.5% until they reach their normal incremental pay date.” (8) Clearly the RCN knew the vast majority won’t be receiving a 3% pay rise this July, and clearly the RCN was expecting large numbers of very unhappy members. This guidance document is very much a damage limiting exercise, fortunately it didn’t work.

NHS Employers statement contradicted Janet Davies’s letter (6). They issued a statement that stated: “The letter states that the RCN has in error told members in one of its documents that they would all receive “a 3 per cent uplift this summer.

The framework agreement, which is the document agreed by the NHS Staff Council that the RCN consulted its members on, does not make this claim.” (6) So, according to NHS Employers, the RCN knew that we wouldn’t be getting a 3% rise well before July, so Janet Davis shock and anger are at best misplaced, and at worst dishonest.

But all this still doesn’t explain why the RCN signed up to such a poor pay deal.

The RCN commissioned the Electoral Reform Services (ERS) (9) to conduct an independent review of how the RCN handled this. This was commissioned by the RCN as they were facing an Extraordinary General Meeting (EGM) were there was a call for a no confidence vote in the whole RCN leadership and calling for the RCN council to step down (10). I wonder how much they hoped this report would be another damage limitation exercise. If they did it failed.

The ERS published an interim report in early September (9), the full report is to come out later this autumn.

The ERS interim report (9) found that the RCN lacked communications leadership, and failed to successfully communicate the Government’s offer to its membership. This is shocking. An organisation the size of the RCN (It has 435,000 members (11)) should have a well-oiled communications machine. It represents nurses, midwives and healthcare assistants, it needs to be able to communicate complicated information to its members quickly and clearly, and yet it wasn’t able to communicate to its members that this pay offer contained a 1.5% pay rise and restructuring of our Agenda for Change pay points which would give most members an average rise in overall pay, by March 2019, of 3%? Why was that so difficult?

But this wasn’t the only finding from this ERS report. They also found a lack of scrutiny of the offered deal by the RCN leadership. On the 2rd March Josie Irwin, the RCN’s lead negotiator with the Government, tried to go through the offer, line by line, with the RCN’s executive team, but there hadn’t been enough time allocated to that meeting for her to do so (9). This I find shocking, the RCN’s executive team didn’t have the intelligence to allocation the time needed to do this. They were in negotiations with the Government for the first decent pay rise NHS nurses would see in eight years, and they could not or would not be bothered to make it a top priority, with the time it needed. It was certainly a top priority to the vast majority of RCN members.

At that meeting RCN Wales director Tina Donnelly wanted to scrutinise elements of the offer but was stopped by then General Sectary Janet Davies, saying the deal was only for England and Tina Donnelly’s input was “not required” (9). It seems that Janet Davies actually stopped scrutiny of the offer, which again calls into question the letter she sent out to RCN members, and what she said in it.

The worst thing to come out of this report was a briefing from RCN lead negotiator Josie Irwin to the chair of council on 21 February, which stated: “If the unions (this means Unison and/or RCN for all practical purposes as the two biggest trade unions) are not able to go out to members with a positive recommendation to members the Treasury will… consider it too risky to proceed and the framework will be off the table.” (9)

This is just breath-taking in its spinelessness. The RCN were giving in to Government demands that they accept the deal now or they would remove it altogether. The RCN gave into the Government’s threats and bullying, and they didn’t even tell their members about the Government’s actions.

Of course the Government wanted the unions to quickly and quietly accept this deal, without any public embarrassments coming from the unions. The junior doctors’ one day strikes in 2016, over another deeply unfair pay deal, were toxic for the Government, and left they marred under negative headlines and public support for the doctors. The Government certainly didn’t want any more industrial action from the rest of the NHS. And the RCN played right into their hands and gave the Government all the good headlines they wanted, all the positive press over a 3% pay rise for nurses. And even more cynically, the Government gave us our smaller-than-a-nat’s-cough pay rise in July, when Parliament was off on its summer holiday. So Theresa May didn’t have to answer an awkward questions, in the House of Commons, about robbing nurses of any sort of a decent pay rise. Nice (!!).

Heads have rolled at RCN, over this appallingly poor behaviour, and rightly so. Janet Davies, RCN’s General Secretary, resigned in August (12). Did she jump or was she pushed? I am not sure but her behaviour was deeply unprofessional. Following a vote of no confidence in them, at the EGM on 28th September (13), and the RCN Council have all resigned (14). I would say the Council did the “decent thing” but it took an EGM to force them to do so, and before it they produced an email, to be distributed to RCN members, claiming, “This is a potentially dangerous time for the college with [a] small group of members putting at risk what has always been a proudly non-party political organisation, acting on behalf of and representing members whatever their opinions or background.” (15) This is a breath-taking claim, when the RCN gave in to Government pressure to accept a pay deal, which they hadn’t fully scrutinised, which has actually left nurses worse off.

What about Josie Irwin, the RCN lead negotiator, who negotiated us into this mess? According to the RCN website and her twitter feed, she is still in post.

What next for the RCN? Nominations for the RCN council elections has opened (16), so we need people willing to stand. But we need new and dynamic people, not the same old people who are standing as a nice career move or people who have been hanging around the RCN for years and want the status quo to continue. We need new blood to shake up the RCN. We need an RCN that will actually fight for its members.

What I am hoping for is that RCN will take on the Government over this deeply unfair pay deal. There is already a campaign to Ditch the Deal (17) and I would really hope that the RCN will join it. I want the RCN to put pressure on the government to rip up this deal and start again. Nursing, in the UK, is in crisis, last year 33,000 nurses left the NHS (18), and there are over 35,000 empty nursing posts in the NHS, which is a little over 10% of all nursing posts (19). One of the reasons nurses are leaving the NHS the poor pay, a report to the Commons Health Select Committee found (20). The RCN should have been using this as a negotiating point, that the government needs to do a lot more to reverse the lose of nurses or else patient care will suffer, and patients denied care because there are no enough nurses to provide it makes for very poor headlines, and this government does not like bad headlines. Last week, the Salaries Review Body recommended that senior judges in England and Wales should receive a 32% pay rise (21), and one of the reasons for this huge rise is the poor recruitment to senior judge posts. How will 1.5% pay rise encourage people to stay in nursing, let alone recruit new people into the profession?

What I am I going to do? There have already been calls for us to strike over this, over the sheer contempt the Government has shown us (22). At he moment I am not sure. So firstly I am going to email my MP and call on her to support us (there’s a copy of the email below, feel free to copy and use it to email your MP), and then I am going to email my RCN rep, and the new council members and the new General Secretary, demanding that they Ditch the Deal and get us a decent pay rise. We all need to keep the heat on the RCN and on our MPs, they both rely on our support and we should make them work for it.

Theresa May, in her speech to the Tory party conference, claimed the end of austerity is in sight (23). This is not true for any of us in the NHS, and it’s her government keeping us in austerity.

Drew Payne

P.S. Find you MP’s name and contact details here

My Email

Dear _____

I am an NHS nurse and one of your constituents.

I am very concerned that again nurses have received a pay rise that sees us worse off in real terms.

This year classroom teachers received a 3% pay rise, the armed forces received a 2% pay rise (plus a one-off 0.9% payment), prison workers are receiving a 2% (plus a one-off payment of 0.75%) and junior doctors received a 2% pay rise.

Back in March we, nurses, were told we would be receiving a 3% pay rise but the reality was very different. In July we only received a 1.5% pay rise and a restructuring of Agenda for Change yearly pay increments, these were reduced from six to three, for most nurses, leaving most of us worse off in the long run.

Nursing is in crisis, last year 33,000 nurses left the NHS, and there are over 35,000 empty nursing posts in the NHS, which is a little over 10% of all nursing posts. One of the reasons nurses are leaving the NHS is over the poor pay.

We were sold this pay deal on false claims that we’d see a 3% pay rise, when the reality was much less. This less than inflation rise will see more nurses leaving the NHS, and we are the backbone of healthcare, without us so much patient would be impossible to deliver. 10% of nursing posts being unfilled is only increasing the workload of the other nurses in the NHS, and this pay deal will not encourage nurses to stay. If more nurses leave at the rate we have seen over the last five patient care will be irreparably damaged.

I am emailing you to ask for your help in supporting us nurses. Will you write to the Minister of Health, Matt Hancock, and ask him to relook at this pay deal that leaves most nurses worse off in real terms, and does nothing to encourage nurses to stay working in the NHS, were we are needed.


(My name)
(My address)

[Always include your address when emailing/writing to your MP, to prove are a constituent]

Public sector pay rise details (24)