It is already clear that where there is competitive tendering to provide NHS services, contracts are almost always awarded to the lowest bidder, regardless of quality. If private companies are to make the lowest bid and still maximise profits, a common approach is to employ under-trained, or cheaper staff, and replace doctors with nurses, and nurses with auxiliaries (http://www.telegraph.co.uk/health/healthnews/9962195/NHS-reforms-From-today-the-Coalition-has-put-the-NHS-up-for-grabs.html).
At the same time, within NHS organisations, financial pressures (arising, for instance from PFI debt and government cuts) have led to redundancies and poor staffing levels. Apart from the impact on patient care, understaffing leads to intense pressure on staff.
The growing privatisation of the NHS means more and more NHS staff are moving to the private sector, often with poorer terms and conditions. Those who remain employed by the NHS may have to re-apply for their job on several occasions, and/or face wage cuts, if not downgrading. In addition, there has been a freeze on NHS pay. Along with other public sector workers, pay rises are now capped at 1% until 2020. Not surprisingly, morale in many NHS organisations is extremely low.
At the same time, wide scale reorganisation and fragmentation of the NHS make it difficult to ensure sound workforce planning.
Employment in the NHS
To take just the example of nursing, in 2013, a report by the Royal College of Nursing (“Running the red light“) estimated that the NHS was on the verge of a workforce crisis with, for example, an estimated 20,000 unfilled nursing vacancies across England. Barts Health NHS Trust, coping with the largest Private Finance Initiative debt in the country, provides one snapshot of what this meant. Following a nursing skill mix review in October 2013 the Trust announced that 161 whole time equivalent posts nursing posts were to be cut, and a further 472 posts for nursing and health care assistants were being down banded (i.e. put on a pay grade lower than the one already identified as appropriate for the role they are undertaking).
The effects of down banding are well known – loss of staff morale, eventual loss of pay once an initial period of pay protection has expired, heavier workloads, increased stress, and reduced quality of care provision. These effects are experienced along with long term anxieties about redundancy and career path. Unions point out that if nurses are down banded, they are no long obliged to undertake the duties associated with their previous grade. So nurses in this position are faced with ‘choosing’ between becoming de-skilled or using their skills without having these recognised (either financially or professionally).
During the years of the coalition government, NHS staff were urged to accept pay restraint as a part of seeing the NHS through hard times. As a result, nursing pay in England lagged behind inflation by up to 8% – an average real-terms cut of more than £2,600. In 2014, many nurses did not get a pay rise at all. At the same time, research showed that of all the Trusts that responded to a Freedom of Information request, 50% had offered pay increases of at least £5,000 to one or more of its executive directors. In addition, there were numerous cases where executives received bonuses on top of their salaries – with two chief executives getting bonuses of more than £40,000 or the equivalent of the annual pay of a district nurse or senior sister. http://www.rcn.org.uk/__data/assets/pdf_file/0008/580760/004674.pdf.
A more recent RCN report, The Fragile Frontline, finds that while the number of full-time nursing posts may have risen overall between 2010 and 2014, the number of nurses filling these posts has dropped – meaning that fewer staff are providing more care for a record number of patients. One indication of the shortage of nurses is the increase in the NHS nurse agency bill which has increased by 150 per cent in the last two years. It’s estimated that the NHS has spent £980 million on agency nurses over the 2014-15 financial year. There was also a reduction in the number of places funded for nurse training in recent years as Trust Chief Executives were trying to save money (http://www.nursingtimes.net/exclusive-disaster-warning-follows-12-drop-in-nurse-training-places/5049433.fullarticle).
Looking at what is happening in medicine, famously, the Department of Health and NHS Employers have been trying to impose a new contract on junior doctors. What is less well known is that contract negotiations, which began in 2013, coincided with the setting up of a Consortium of 13 NHS Trusts that tried to implement a local system for reducing pay, and introducing poorer terms and conditions for all staff– i.e. a scheme that was different to the existing nation-wide NHS agreement. Their plans included less maternity leave and sick pay, the end of some on-call payments and an increase in contracted working hours.
The Consortium’s plan, having met with strong opposition from unions and Parliament, was not implemented. However, there are strong links or overlap between some members of the Consortium on the one hand, and NHS Employers, advisors to the DoH, and other powerful NHS stakeholders on the other. And perhaps not surprisingly, there are strong similarities between the plans of the Consortium and the pay, terms and conditions proposed in the junior doctors’ contract. These include changes in on-call payments, the linking of pay progression to performance, and changes in what are classified as unsocial hours. Most significant perhaps is that the aim that the contract should be imposed – i.e. that it should be put in place before an agreement with existing staff has been met.
The usual reason given to the public for the new contract is that it enables a ‘7-day’ NHS – that the public deserves a safer service over the weekend (or sometimes, it’s because they deserve to have access to routine services over the weekend). However, the background to the deal suggests that it is really a cost cutting exercise, with dubious benefits for patients. (https://www.opendemocracy.net/ournhs/steve-topple/of-smoke-mirrors-cartels-and-7-day-nhs)
Moving to the private sector
Increasing privatisation of the NHS mean that, in future, many NHS staff will have to work in the private sector. Staff who are transferred from NHS to non NHS organisations retain their NHS terms and conditions at the time of transfer, at least for a while. However, staff are no longer covered by national negotiating arrangements in the NHS so, for example, they will loose future pay increases agreed for NHS staff. And if they move to another non-NHS organisation after this initial transfer, they become treated as ‘new staff’. New staff – i.e. those not (directly) transferring from the NHS – are not entitled to NHS terms and conditions, or access to the NHS pension scheme.
This means that a two-tier system is developing for staff working in NHS-funded services, with employees who are carrying out similar roles receiving different pay, and terms and conditions. Attempts to redress this unfair situation can lead to a renegotiation of all terms and conditions, which are then downgraded for all staff. (See http://www.unitetheunion.org/uploaded/documents/guidetonhsprivatisation11-10734.pdf)