Coming to Britain

The Windrush scandal (1) is certainly shocking. When I first heard it I was both sickened and angry, was this the way to treat people who had given their lives working for this country, many of them in not very well paying public service jobs. It was disgusting. But as the scandal progressed I got a horrible sinking feeling. The Windrush scandal was replaying the British attitude to immigrants, we will let them come here to do the jobs we cannot get anyone else to do but we will not fully welcome them into our country and don’t want to give them full citizen rights.

Fortunately there was a loud public outcry against the Windrush scandal, many members of public saw the injustice of deporting Windrush people now that they were elderly, no longer wanted after giving Britain a life of service. The outcry was so loud that the Government finally had to act. The Home Secretary resigned (2), though it was over misleading parliament and not actually the Windrush scandal. Sajid Javid replaced her as our first black and Muslim Home Secretary (3), though Javid voted against releasing all the government papers relating to the Windrush scandal (3), so no open government there.

At the time all this broke there was another immigration scandal that slipped under the radar. Last month 100 doctors from Indian had their visas refused and were turned away from entering the country (4). Those doctors already had jobs, they were part of a scheme to place doctors with North-West NHS Trusts (5), and NHS Employers have said that since December there have been 400 other cases (5).

The Home Offices has monthly quotas for the numbers of visas it issues for skilled non-EU workers wanting to enter the country (6). Two-thirds of these are skilled medical professionals coming to work for the NHS (6). Yet last month that quota was reached for the third month in a row (6) and anyone else who wanted to come and work here was automatically denied a visa, even if they were desperately needed medical professionals coming to work in the NHS. A whistle blower, in December. Claimed that the Home Office prioritises visa applications by how much money they will earn the department, i.e. which visas carry the highest fees (7). The fees for student visas and spousal visas are much higher than the fees for a working visa (7).

The NHS is short of 100,000 staff (8), which is 1 in 12 posts or 8.3% of all NHS posts are

empty. Of those 100,000 empty posts, 35,835 are empty nursing posts, or 10.3% of all NHS nursing posts, and 9,676 of the empty posts are medical posts, 7.9% of all NHS doctors’ posts are empty (9). This is a shocking state to be in, between 8% and 10% of the main roles of an organisation are empty. If between 8% and 10% of all MP’s posts were empty then both main political parties would not shut up about it, yet they are happy for the NHS to carry on with this skill deficit.

Traditionally the NHS has recruited from aboard, especially from Europe and the Commonwealth, when it has been short of staff. Many of the women in the Windrush migration were nurses and midwives coming to work in the NHS. When I started my nurse training, nearly 28 years ago, 4 out of the 30 members of my intake were non-British, that was 13% of us. The most recent figures I can find show that 9% of NHS doctors are from the EU and 16% are from the rest of the world, while 7% of NHS nurses are from the EU and 8% are from the rest of the world (10). With the current state of empty posts in the NHS we cannot afford to lose any more staff. If the number of empty nursing post rose to 20% it would create an unsafe and toxic working environment, seriously putting patient care at risk. But that is the risk we are facing.

Since the referendum vote we have seen a shocking fall in the number of EU nurses coming to work here, and a rise in them leaving, shown by the Nursing and Midwifery Council (NMC) numbers. Between April 2017 and March 2018 29% more EU nurses left Britain than the year before (11), and that was three times higher than in 2013-2014 (12), the first time the NMC recorded these figures. The numbers of EU nurses coming to Britain, between April 2017 and March 2018, was 87% less than the previous year (11). We have been haemorrhaging EU nurses since the Brexit vote. Janet Davies, the chief executive of the Royal College of Nursing, has blamed this exodus on the badly organised nature of Brexit (12). She said that the Government’s refusal to state what the rights of the three million EU citizens living here will have when we leave the EU is causing so many EU nurses to leave ahead of it all (12). And I have to agree with her, since the referendum, Brexit has created a toxic environment for EU citizens living here and our Government seems intent on doing nothing about it.

We are seeing many attempts to recruitment nurses from outside the EU. Oxford University Hospitals NHS Foundation Trust (13), North West London University Healthcare NHS Trust (14), the Heart of England NHS Foundation Trust (15), Whittington Heath NHS Trust (16) and Barts Health NHS Trust (17) have all been recruiting nurses from India and the Philippines, and these are only the ones I found on a simple Google search. I am certain there are many, many more Trusts also trying to recruit nurses from non-EU countries. Even the Department for Health and Social Care is getting in on the act. Through Health Education England, a scheme was announced last year to recruit 5,500 overseas nurses, from India and the Philippines (18). The scheme was expanded to include Jamaica (19). But there is an uncomfortable fly in the ointment here. Oxford University Hospitals NHS Foundation Trust (13) reported that 40% of overseas nurses offered jobs would not unlimitedly take up those offers due to the immigration processes and language checks. This is a very high and very expensive drop-out rate, back in 2015 it cost £3,000 to recruit a non-British nurse (20) – I wasn’t able to find anymore up-to-date figures than these, it’s as if Trusts no longer want it known how much they are now paying to recruit overseas nurses. Oxford University Hospitals didn’t say how many recruited nurses dropped because of difficulties with getting a visa and how many were rejected for visas, but a 40% drop-out rate is shockingly high.

There is another issue to consider with all this overseas recruitment, Britain isn’t the only country with a shortage of nurses. The World Health Organization (WHO) estimates there will be a global shortage of 12.9 million healthcare workers by 2035 (21). The International Council of Nurses (ICN) interim chief executive Thomas Kearns warned Western countries not to “drain” developing countries of their nurses, but to focus on their “homegrown” nurses (21). As British Trusts actively recruit nurses from India, the Philippines and Jamaica, what affect will this have on their own healthcare systems. We have 40,000 empty nursing posts and the NHS is not coping with this burden, how will a developing country cope with this shortage of nurses, they certainly cannot recruit from over countries the way we can, the shear expensive of doing so. Britain isn’t the only country recruiting nurses from developing countries. Do we have the right to just see these countries as a mere stockpile of nurses to be recruited from, and “drain” them of their own resource, their nurses.

For as long as I have been a nurse, the NHS has recruited nurses from abroad, mainly from EU but also from non-EU countries too, long before Brexit, but we need to develop an ethical approach to this. The Department for Health and Social Care scheme to recruit nurses from India, the Philippines and Jamaica is being painted as “ethical” recruitment (19). Nurses will be recruited from these countries for a fixed term, and while here they would work and learn new skills, skills that they will then take home. How affective this will be is still unproven. The nurses will work here for three years. How many employers will want to invest in sending these nurses on specialist training when they will work for the Trust for only three years? Their skills training may boil down to “on the job training”, just working as a nurse in Britain, which also sounds rather patronising.

The Government needs to take seriously the skill shortage in the NHS and make the process user friendly. All nursing posts are on the Shortage Occupation List (22), the list of occupations the Home Office gives priority to when considering issuing working visas, doctors are considered by the specialist skills they have. There are 150 different Standard Occupational Classification (SOC) codes on the list, the different jobs and occupations that the Home Office gives priority to when issuing working visas (22) (I physically counted them and there maybe occupations on the list that I missed, it wasn’t an easy list to count). Actors, dancers and musicians are also on this list. The Government web page about Shortage Occupation List (22) does not state that any occupation is given priority, so when the monthly quota is met people are flatly denied visas, no matter what their profession is or how despair we are for people with their specific skills (doctors and nurses).

But Theresa May does not seem to be taking this issue seriously. At the end of April, she overruled calls from members of her own cabinet to relax visa quotas for doctors coming to work in the NHS (23). She was lobbied by the Health Secretary, the then Home Secretary Amber Rudd, and the Business Secretary, but May ignored them all and refused any visa quota relaxation for doctors, what hope is there she’d consider nurses as a priority? Neither has Theresa May and her government clearly stated what rights EU citizens, living in the UK, will have after Brexit (24). In some statements EU citizens will have less rights and in other statements EU citizens will have the same rights as they do now (24). There are so many contradictions coming out of this government that no wonder EU citizens living here fear for their rights post Brexit (25), especially now post the Windrush scandal (25). If the government can treat Windrush people in the way they have done, what is there stopping them treating EU citizens in the same way post Brexit? No wonder we are seeing an exit of EU citizens, especially nurses who are in demand in other EU countries (26).

This government certainly does not seem interested supporting “homegrown” nurses as Thomas Kearns warned (21). After eight years of pay austerity the government’s pay offer to nurses, this year, takes away more than it offers (27), and could see nurses losing more pay in real terms. The government’s reaction to the 40,000 empty nursing posts has been pitiful. They abolished the bursary for nurse training (28) and since then 14% fewer people have applied for the September 2018 intake than did last year, and last year saw a 30% reduction on 2016 (29). The government has done NOTHING to encourage nurses to stay working for the NHS, many Registered Nurses are leaving because of the high workload, poor working conditions and stagnating pay. 

Nursing and the NHS are in crisis (30) and still this government does NOTHING about it. Is Brexit taking up all the government’s ability, time and resources? If so then this is the worst government on record. A government should be able to multitask, that is the nature of government, governing requires being able to do many different things all at the same time, and hopefully all of them well. This government is blindly ignoring the crisis in nursing and therefor ignoring the terrible cost this is taking on patient care. But why they doing this? Was Theresa May treated harshly by a nurse when she was a child and this is her revenge? Or is it more likely that they are ignoring it all because they are too incompetent to actually tackle the problem head-on? Whichever way patients will suffer until they do something… But I do not hear any action coming from this government any time soon.

Drew Payne

Boris Johnson and the Art of the Headline Grab

Boris Johnson has never been shy of grabbing the headlines, he has certainly never knowingly turned away from a photo opportunity. When he was Mayor of London, it sometimes felt like all he did was try and grab the headlines, with one stunt after another.

At the end of January the press revealed that Boris would be demanding an extra £100 million a week funding for the NHS, at a Cabinet Meeting (1). That would have resulted in an extra £5.2 billion a year. Now he was quickly slapped down by both Theresa May and Philip Hammond, the Chancellor (2). Since then Boris does been very quiet on the subject, it obviously didn’t get him the good headlines he was after, but it did highlight this government’s failure to fund the NHS or even look realistically at future NHS funding.

This Government has under funded the NHS since 2010. Since 2010, when the Conservatives came back into Government (In coalition then), they have cut the increase in NHS funding to 1.1% (3), after last year’s autumn budget the NHS yearly increase in funding was increased to 1.2% (4). Previous to 2010 NHS funding was increased by, on average, 4% a year since the NHS was founded. NHS funding increases have been cut by nearly 75% and yet demand has not decreased. A&E attendance in December 2017 was up 3.7% on December 2016 (5), and that was just A&E attendance. All areas of the NHS have seen increases in demand, year on year.

This all has had a knock-on effect on the service the NHS can deliver, it’s now failing at all its mayor targets. The four hour A&E treatment target hadn’t been met since July 2015, the 62 day target from urgent cancer referral to treatment hasn’t been met since 2014 and the 18 week target for referral-to-treatment for elective care hasn’t been met since February 2016 (6). Good quality healthcare is not cheap, and repeatedly providing the NHS with below inflation funding increases has a direct affect on patient care. There are no more “efficiency savings” to be made, the fall in funding cannot be absorbed in any other but by cuts to patient care.

The Government had a chance to at least begin turning around this chronic under funding with November’s Autumn Budget. In the run up to the budget there was active campaigning for more NHS funding, at least £4.6 billion to stop the shortfall in NHS funding (6). Simon Stevens, head of NHS England, called for extra funding too, warning that NHS waiting lists will soar to five million by 2021 if its funding isn’t increased (7). Yet when Philip Hammond announced his budget, in November, the NHS only received an extra £1.6 for the next year (8). Officials at the Treasury have leaked to the press that Philip Hammond was angry at all the campaigning for extra funding, especially that of Simon Stevens, and this is why he didn’t provide all the funding the NHS needs (9). I am left speechless with disgust and anger at his petty and vindictive actions. Instead of listening to the reasoned arguments, he followed his ego. What kind of politician is he? Unfortunately he’s typical for this government.

Boris Johnson’s attempt to grab the headlines pushed a much more important NHS policy story out of the back pages. A cross-party group of ninety MPs wrote a letter to Theresa May calling for a cross-party convention on the future of the NHS and care social and the funding they will need (10). The letter was organised by Sarah Wollaston, Conservative MP and chair of the Commons health committee, Norman Lamb, Libdem MP, and Liz Kendall, Labour MP (11). It was signed by 90 MPs from all parties, a third of them were Conservative MPs (11). This was a golden opportunity for Theresa May to tackle the problems dogging the NHS and to do it with the full support of Parliament. This would have provided cross-party support for raising taxes to fund the NHS. So far the Conservative party has shied away from raising taxes, seeming to fear losing political face doing so, but with cross-party support all parties would have taken the “hit”. This was a political initiative that has been long overdue. But Theresa May, in her usual limp-handshake-way, dismissed this call for cross-party action, saying the government were managing the NHS themselves (12). Another typical failure and missed opportunity by Theresa May, and I’ve lost count of how many there have already been.

70% of Conservative voters, in a recent pole, said that the NHS was their main concern (13), and yet this government constantly ignores the problems of the NHS staring them in the face. Even when their own supporters are worried about it, it still doesn’t appear as a high priority for this government. Theresa May does not seem very bothered about it and rarely comments on the NHS. What have we done to deserve politicians so apathetic and uncaring about the NHS? For so many voters, the NHS still remains such a major concern, but to listen to our politicians you would think that there were no great problems with the NHS, beyond a few people moaning about it.

What can we do to finally make this government take the NHS’s problems seriously? Yet another winter crisis in the NHS certainly hasn’t done that (14).

As for Boris Johnson. During the 2016 EU referendum the Leave campaign, which he was the leading light of, claimed that £350 million a week extra funding would go to the NHS (15). Last month Boris only called for an extra £100 million a week for the NHS. So it seems his concern for the NHS has fallen by over 70%. As I said, what can we do to make these politicians take the NHS seriously?

Drew Payne

Mrs May and the Act of Scapegoating

In the first week in January, over a quarter of patients in Accident and Emergency waited longer than four hours and only one hospital met the target of treating 95% of patients within 4 hours, a leaked report to the BBC showed (1). More than ten hospitals issued mayor alerts that they were under “unprecedented pressures”, while 66 out of 152 trusts raised the alarm over bed shortages in the same period (2)

January has always been one of the busiest months for the NHS, cold weather always aggravates chronic health conditions, such as respiratory and heart conditions, and icy conditions can cause falls and broken bones, and it is flu season. This year has seen one of the busiest Januarys that people can remember, but this wasn’t without warning. The A&E targets were missed throughout all of last winter (3).

Our government has been slow to act though. Theresa May only admitted that the NHS under pressure yesterday afternoon (Friday 13^th) (4), previously she’d avoided saying anything. Jeremy Hunt did make a statement to parliament on Monday, January 9^th, but it was a very typical Jeremy Hunt statement (5), slow on any actual help. In it he claimed that the 4 hour waiting time target could be reviewed and only apply to “urgent” patients, and that 30% of people attending A&E “do not need to be there”.

Now we have a new policy change from Theresa May to deal with this whole NHS crisis, but this new policy has left me feeling, what?

Theresa May says she’ll force GP Practices to open 8am to 8pm, seven days a week (6). If they do not do so they could lose extra funding that they deeply need. But will this relieve any of the pressures on hospital A&Es?

The reality is this will not provide any extra GP appointments because this isn’t employing anymore GPs, (Already there are over 4,600 empty GP posts, 12% of the workforce (7)), it is just stretching the current number of GP appointments over seven days instead of five. The reality will see less GP appointments during the week, and will there even be a demand for all these weekend appointments? A BMJ survey from November 2015 found only 2.2% of patients would choice to see their GP at the weekend (8). Also, with all these extra bookable appointments to cover GP Practices will not be able to offer as many emergency appointments. If people cannot get an emergency GP appointment where will they go? A&E?

Also, will these weekend GP appointments prevent all these people who need admitting to hospital? How can GPs manage at home people who need hospital admission? How will these GP appointments prevent the chest infections, the pneumonias, the chest pains, the broken bones that all need admitting to hospital? How will these GP appointments provide the extra social care that is needed to allow patients to be safely discharged home?

This crisis is due to a shortage of hospital beds, there are less than half the number of hospital

beds than there was 1978 (9), we have the second lowest number of beds per head of population of European countries (10), and these beds are filling up with patients who cannot be safely discharged. Social services budgets have been cut by 40% since 2010 (11), which has left social care in a dangerously underfunded state. It can just about fund the people it already cares for, there is little to no spare funding for new people, for home care or residential/nursing home care. This lack of funding has created a bottleneck in hospitals. There is a large number of elderly patients who cannot be safely discharged home because they need social care and there is no funding for them. It is also creating another problem, there are elderly people at home who need social care and are not receiving it. Because they are not receiving it their health is deteriorating and soon they will need admitting to hospital, but there are not the beds available.

Helen Stokes-Lampard, chair of the Royal College of GPs Council, has said general practice is "skating on thin ice" (12). The cut in resources in General Practice and the low numbers of GPs means that people with non urgent problems are waiting four weeks or longer for a GP appointment. In this time a non urgent problem can soon become an urgent problem, a problem that could easily no longer be treatable in a GP surgery. The government’s plan will only add to this problem.

This crisis is down to funding, or the lack of funding of the NHS. Simon Stevens, chief executive of NHS England, described it as, “In the here and now, there are very real pressures. Over the next three years funding is going to be highly constrained and in real-terms NHS spending per person in England is going to go down, 10 years after Lehman Brothers and austerity began.” (13)

88% of acute trusts are forecasting a deficit at the end of this financial year (14). Demand on NHS services has increased by 3-4% on last year (14a), much higher than the current inflation rate, which is 1.2% (15), yet the NHS’s funding is only increasing 0.9% a year (16), and this doesn’t take into account the £22 billion of “efficiency” savings the Department of Health is demanding from the NHS by 2021 (17).

This crisis is due to funding and resources cuts and yet the government reacts by almost bullying GP Practices into working seven days a week, without any extra funding. Our NHS is on its knees and this government is still demanding more for less from it. They are not taking responsibility for the mess they have created and they are doing nothing to sort it out. They are offering no leadership in this crisis.

In November last year I was admitted to hospital with pneumonia, this was not because I couldn’t get a GP appointment. My GP had been treating my pneumonia but, because I had caught an antibiotic resident strain, my GP soon reached the end of the treatment options open to him. He had me admitted to hospital because I was too ill to be safely treated at home. How would a Sunday afternoon GP appointment have prevented this?

So where the hell did the government come up with such a useless policy in the fist place? A crowing article in today’s Daily Mail may give the clue, its titled “Open all hours, PM orders GPs: After the Mail exposes half-day surgeries, doctors are told to open from 8am-8pm - or lose cash” (18). Again we see the emergence of that dangerous Government move, policy creation by Daily Main headline. Our politicians are being dictated to by the worst newspaper in the country.

Theresa May has shown that the NHS is a very low priority to her, otherwise why did she leave Hunt in post as Health Minister, and her reaction to this very avoidable crisis only is further proof of this. How will bullying GPs solve the shortage of available NHS beds? Who the hell voted for her?… Oh yes, no one.

Drew Payne