Home Tags Posts tagged with "health boards"

health boards

Politicians should respond with "maturity" says Theresa Fyffe

By Theresa Fyffe, director of RCN Scotland

As a light was briefly shone on the state of our NHS yesterday morning, with the Scottish Parliament’s health committee grilling a selection of health boards on their finances, now seems as good a time as any to take stock of NHS Scotland’s financial situation. While the noughties saw record increases in the NHS budget, the more recent past is not so positive and the future looks likely to be austere.

It seems churlish to complain about the NHS budget and there is no escaping the oft-repeated mantra that it has been “protected” by the Scottish Government while funding for local government, for instance, has been cut. However, the reality of the situation is that the budget for the NHS has been effectively flatlined, while both costs to the NHS and demand for health services are on the increase.

One of the reasons costs are going up is spiralling drug budgets, as confirmed at yesterday’s committee session. And, inevitably, demand for services is going up because of our ageing population and the fact people are living longer with more complex conditions – a welcome sign of advances in our health service, often working in partnership with social care, improving people’s health and quality of life. But the consequence of this is that our NHS is in a self-perpetuating cycle of financial pressure: it supports people with complex conditions to live longer and healthier lives, which in turn means demand on health services continues for longer.

So, instead of the “NHS budget is protected” soundbite coupled with health boards being told to carry on as usual, the future direction of our health service needs to be clearly set out. Otherwise cuts will continue, the workforce will become more and more overstretched and patient care will suffer. Since 2009, for example, almost 2,200 nursing and midwifery staff have been lost. And with nurses delivering the vast majority of care, this is bad news for patients and bad news for the overstretched nursing staff left behind.

When it’s been clear that proposed changes would be bad for patient care, we’ve challenged this tactic of heath boards making “easy” savings by cutting nursing and other posts to save money. While we recognise that change is needed and are willing to play our part, we’ve now reached a tipping point and chipping away at the workforce is unsustainable.

And with “efficiency savings” – made to provide the same or better services for less money – being the only way health boards can shift money about within their budgets to keep afloat, it is worrying that most now report meeting efficiency targets as one of their highest financial risks. Indeed, this time last year many health boards had set efficiency targets to be met by the end of the financial year but in many cases had not identified how these savings were going to be made. It is no wonder that such savings can often be cuts by another name.

So, what about when the time comes, surely due soon, when a health board proposes to close a hospital department and move services, such as rehabilitation for people with strokes or brain injuries, to the community? While shifting health services closer to people so they can be supported to live at home would be in line with the Scottish Government’s vision for the NHS, will it support health boards when they try to do this? Or will the closure of totemic local hospital departments or even entire hospitals be too much for politicians and the public to swallow?

With much of the NHS estate in desperate need of refurbishment or renewal this would seem a good time to change the way healthcare is delivered. But the Scottish Government’s 20:20 vision for the NHS to be interpreted locally by health boards, revealed last year without fanfare, is not going to give much support to boards when they start to seriously contemplate these difficult decisions.

Indeed, point-scoring over such decisions can be just too attractive to politicians of all parties, and the significance of such political interventions cannot be overstated.  Just look at the political impact of the planned downgrading of Monklands and Ayr A&Es and the planned – and later delivered – changes to Stobhill Hospital services in 2007.

The true test of how committed the Scottish Government and opposition parties are to the future of the NHS will be their reaction to any future plans by health boards to redesign services to be delivered in the community, thus resulting in hospital closures. While we will scrutinise such decisions to ensure they will result in better patient care and not be about cutting bills, we expect politicians to do the same. And if the conclusion is, yes, this plan will improve things, then politicians must respond with maturity rather than a knee-jerk reaction focused on winning votes at the next election.

So, let’s end this impasse on the state of Scotland’s NHS – it shouldn’t be a matter of claim and counter-claim about whether its budget is protected. The public and the overstretched staff of the NHS deserve better. Health boards need clear parameters in which to operate. This will allow them to make the difficult decisions, which are becoming urgently needed, to balance the books – and provide top-class health care for Scotland’s communities. It’s time to shine that light very brightly on those making the decisions about our NHS.

NHS Scotland logoNursing leaders have accused Scotland’s health boards of providing reports which are inconsistent, generally inaccessible and which “obscure what’s really happening on the ground”.

This makes it difficult for the public and for campaigners to scrutinise what health boards are doing and whether their decisions take into account patient care and safety, the Royal College of Nursing Scotland says.

In a report published today, the RCN says that there is not nearly enough information publicly available to judge whether health boards are acting in the best interests of patients.

And it calls on health boards to make their financial plans and reports public “in a transparent and timely manner” so that difficult funding choices can be fully understood and debated.

The report, Taking the Pulse of NHS Scotland, tries to build up a picture of NHS boards’ financial and workforce issues. The union concedes that the document has some limitations – partly because of a deficit of available information.

Nevertheless, it reveals some interesting snippets. For example, although official figures show that all NHS boards broke even (financially) in the year 2009/10, 10 of the 14 built up a recurring deficit over the year, which they had to offset with underspends in their non-recurring budgets.

The report also says that boards’ own local delivery plans raise clear warnings about financial challenges, particularly in how they will achieve the required efficiency savings at a time when public sector finances are being squeezed.

The report also queries the apparent inconsistencies in approach taken by different boards. For example, the planned pay bill for NHS board employees ranged from 39 per cent to 61 per cent of expenditure at March 2010.

Theresa Fyffe, the RCN Scotland director, said: “Despite claims that the NHS is protected from the budget cuts now facing the wider public sector, what we were able to find out shows that many health boards are already facing real financial difficulties. Demand for health services is rising, key healthcare costs are running ahead of general inflation and GP prescribing budgets, for example, were overspent last year by over £20m.

“With NHS funding under a great deal of pressure, we’re already seeing health boards cutting their staff, particularly nursing and midwifery staff, as they are the largest staff group at just under half of the NHS Scotland workforce. What is not clear is whether the consequences of such headline cuts to staff have been properly assessed – or whether they are simply short term solutions to financial pressures.”

Ms Fyffe rejected any suggestion that the RCN might be motivated to challenge what’s happening because it is its members which are affected. “We do not believe you can keep cutting staff in this way, without affecting patient care. It’s not protectionism that’s driving us to challenge what’s happening; it’s for the protection of the public. Rather than short-term, financially-driven responses – which focus on reducing the workforce – we need to find longer term, sustainable solutions. This means we have to have enough clear and consistent information so that a proper debate can take place about what kind of future we want for our NHS.”

By Stuart Crawford

The Scottish Government has just announced its performance targets for access to mental health services in the NHS. These HEAT targets (the acronym stands for “health improvement, efficiency, access and treatment”) reflect the government’s priorities for the health services in Scotland and are set for all aspects of healthcare delivery.

The aim is to deliver faster access to mental health services by delivering 26 weeks referral to treatment for specialist Child and Adolescent Mental Health Services (CAMHS) services from March 2013; and 18 weeks referral to treatment for psychological therapies from December 2014.

The rationale is that timely access to healthcare is a key measure of quality and that applies equally in respect of access to mental health services. Early action is more likely to result in full recovery and in the case of children and young people will also minimise the impact on other aspects of their development such as their education, so improving their wider social development outcomes.

The intention is to agree a target of 18 weeks referral to treatment for specialist CAMHS services from December 2014 for inclusion in HEAT next year. Psychological therapies have an important role in helping people with mental health problems, who should have access to effective treatment, both physical and psychological. It is generally accepted that these therapies can have demonstrable benefit in reducing distress, symptoms, risk of harm to self or others, health related quality of life and return to work.

The announcement has been given a qualified welcome by the British Association for Counselling and Psychotherapy (BACP), the leading professional body for counselling and psychotherapy in the UK, which has over 1,500 members in Scotland. Members are employed in a range of services and work with people who have wide ranging needs such as relationship problems, addiction, stress and bereavement through to mental health problems such as depression and anxiety.

Its welcome is qualified because BACP has concerns that the new target refers only to a narrow range of psychological therapies for specific diagnosed conditions. Therefore, an unintended consequence of the HEAT target is its potential to draw funding away from services offering a range of therapies. BACP is committed to patient care as the centrepiece of mental health service design, and is therefore strongly encouraging the Government to widen its view of the mental health and wellbeing needs of the population and the therapies that meet these needs.

Shane Buckeridge, BACP Lead Advisor for Scotland, said: “It is admirable to see that the Scottish Government has developed a target for access to mental health services. It is estimated that at any one time there are some 850,000 Scottish people with mental health problems, and until now it has been a postcode lottery in terms of what is available, leading to a huge disparity in service provision across Scotland.

“The new target makes health boards accountable, and will hopefully ensure that all patients have access to the services they need in a timely manner. However, BACP is concerned that existing services which are excluded from the narrow range of acceptable therapies within the target, may find themselves under threat. These services are often used by GPs to help people with multiple issues which do not fit the referral criteria for current secondary care mental health services.”

BACP points out that many users report wanting choice about what is most appropriate to their needs. The research evidence also suggests that no one approach in this field will be effective with all patients. The Association is therefore continuing to urge the Government to incorporate choice into the new targets to make mental health service provision accessible for all.

A stethoscopeGPs’ leaders have warned that there is no going back to the days of Dr Finlay model of general practice, but have acknowledged that out-of-hours care is “by no means perfect”.

The BMA in Scotland urged the Scottish Government and health boards to do more to develop and implement quality standards in care at nights and over weekends, and to improve co-ordination.

In particular, the BMA said that more needed to be done to promote NHS 24 as the first point of contact for non-emergency calls.

Doctors were speaking out ahead of a planned debate on rural out-of-hours services, which was due to take place in the Scottish Parliament today. The issue was to have been debated two weeks ago, but was postponed due to the need for emergency legislation on police questioning.

Dr Andrew Buist, deputy chairman of the BMA’s Scottish GP committee said that there needed to be a comprehensive out-of-hours system which did not rely on “over-tired GPs bearing the brunt of the work”.

He also stressed that the new GP contract – which allowed GPs to opt out of 24-hour care for patients – was not to blame for problems with services.

“There is a perception amongst politicians and the public that the problems with out-of-hours care stem from the introduction of the GP contract in 2004. This is not the case. In many areas, such as Greater Glasgow, the service that operated prior to 2004 is the same service that continues to operate, albeit the service is now directly managed by the NHS board.”

He said that prior to the new contract, morale among GPs was at an all-time low, that GPs were planning to retire early and recruitment was becoming “impossible”.

“Doctors were working excessively long hours, and rural communities in particular were at risk of losing daytime GP service at the expense of out-of-hours availability. There is no going back to the old ‘Dr Finlay’ model of general practice. In today’s modern service much more complex care is provided to patients in hours and there needs to be a comprehensive out-of-hours service that does not rely on over-tired GPs bearing the brunt of the work.”

He said that patients continue to receive high quality health care round the clock, but that it was “by no means perfect”.

The BMA added that NHS 24 had improved significantly but that more needed to be done to educate patients about who to call when surgeries were closed.

The organisation also said the Scottish Government should commission research to find out why demand for services out-of-hours was increasing, in particular what beliefs prompted decisions to call.

In its report into rural out-of-hours healthcare, published in April, the Health Committee warned that trust and confidence had been lost and needed to be rebuilt.

<em>Picture: comedy_nose</em>

Picture: comedy_nose

Nursing leaders have compiled a guide – open to the public – which shows how much money each health board needs to save to break even in the current financial year. The RCN Scotland’s Frontline First website, due to go live today, also shows how many posts are set to be lost in NHS boards, with a particular focus on nursing jobs.

Although the information isn’t new – it’s actually based on the Scottish Government’s own information on health board budget allocations, and on boards’ workforce predictions – it’s the first time it has been brought together in this way.

Overall, the figures suggest that NHS boards will have to save around £250 million in 2010-11, although the RCN says that this could well be an underestimate, as some boards have said they will need to make additional savings.

Among the hardest hit, according to the website, will be NHS Forth Valley, which will have to save £26.5 million or 6.6 per cent of its basic allocation to break even in 2010-11. The board is projecting a reduction of 96 whole time equivalent nursing and midwifery posts over the year, a decrease in 3.5 per cent, and an overall reduction of 154 posts across all staff groups.

Two of the smallest boards, NHS Orkney and NHS Western Isles, face the biggest challenge in percentage terms. They face making cost savings of eight percent and 7.6% respectively.

In financial terms, NHS Greater Glasgow and Clyde (as the biggest board) has to find the most savings at £54 million, although this equates to just 2.9 per cent of its budget allocation. It plans a 3.6% decrease in nursing and midwifery posts (553 whole time equivalent) this year, 44% of reductions across all staff groups.

Norman Provan, associate director of RCN Scotland, said the union was in no doubt that politicians genuinely want to protect frontline services, but that there seemed to be a gulf between rhetoric and reality. “That is why we have used information from a range of publicly available sources to establish just how severe the problem is that health boards across Scotland are facing,” he said. “This reveals that health boards need to save a total of at least £250m this financial year, in addition to two percent efficiency savings, just to break even.”

He said RCN members would be encouraged to come forward with examples of where cuts are being made and asked for ideas on how money could be saved.

“Nurses are realistic about the need to tackle the severe financial challenges facing the NHS, and they know how to do it. By sharing innovative care and helping to reduce waste we can help meet these challenges.”

Nicola Sturgeon, the health secretary, said that the Scottish Government had increased NHS funding in real terms, despite a £500 million cut in the Scottish budget.

“As part of their workforce planning processes, boards have considered their future service delivery and workforce needs,” she said. “However, I have made clear that ensuring a quality service for patients must be at the centre of these plans and I have also given a guarantee that there will be no compulsory redundancies. I’m also confident that by the end of this parliamentary session there will be more staff in the NHS than there were at the start of it.

“In these challenging financial times, with the toughest settlement since devolution, we have protected health in the budget. NHS boards must ensure they use all their resources efficiently to secure best value for money.”

Nicola Sturgeon. <em>Picture: Deadline Press & Picture Agency (c)</em>

Nicola Sturgeon. Picture: Deadline Press & Picture Agency (c)

Earlier this month Nicola Sturgeon took the extraordinary step of writing to every one of the Scottish health service’s 170,000 employees to tell them their jobs were safe.

This is what the Health Secretary told them: “There will be no compulsory redundancies in the NHS. In other words, none of you will ‘lose’ your job. That is job security that few others have in this economic climate but it is job security I think you deserve.”

Less than two weeks later, John Swinney, the Finance Secretary, wrote to all health board managers and everybody else in charge of public sector departments.

His message was rather different. “The challenges we face will impact on every man, woman and child in Scotland,” he said, adding “No part of the public sector will be immune.”

Mr Swinney told all managers to review all staffing and vacancies and to share back-office functions across sectors where possible.

So what’s going on?

Let’s start with Mr Swinney’s approach. He knows how bad the cuts are going to be. Budget reductions of between 16 and 25 per cent for each department will hurt. Realistically, this cannot be done without redundancies.

Ideally this would happen voluntarily, after all turnover in the public sector is high.

However, it is all very well looking at staff turnover and saying: “We already have a turnover of nine per cent a year, we need cuts of nine per cent a year so we don’t need to do anything.” That is just not going to work.

Firstly, staff turnover projections in the public sector are hopelessly out of date. Departments, bodies and organisations which used to have turnover rates of nine or ten per cent or more per year a year or so ago have seen these drop to two or three per cent, at most.

Staff are staying where they are. They are not moving on to other jobs because there are not other jobs to go to and the sensible thing to do in this climate is to hang on to what you have.

Secondly, even if staff turnover results in budget savings, they are rarely in the right place. Take a health board, for example. It may lose dozens of nurses, midwives and doctors but no-one in IT or human resources.

What it needs to do is shut down human resources and combine both HR and IT with another health board but it cannot do it. It also needs to replace the nurses, midwives and doctors who have left or face having to close wards and impact on frontline services.

Mr Swinney knows this, which is why he has not painted himself into a corner by guaranteeing the security of any jobs in the public sector, not even those on the frontline.

But Ms Sturgeon does not seem to know this. Indeed, her decision to guarantee the job security of everyone in the Scottish health service seems political, at the very least, and probably even downright foolish.

She really has painted herself into a corner. Not only that, she has restricted the ability of health boards to respond to staff vacancies and turnover in a rational way which protects frontline services and forced other departments to take a bigger hit to make up for the ring-fencing in health.

The most extraordinary thing about this was that she had options. She had told the Scottish Parliament there would be no compulsory redundancies, she could have left it that. If any compulsory redundancies did happen, she could then have blamed them on the health boards.

Ms Sturgeon could have gone further, she could have written to all those on the frontline in the health service: doctors, nurses, midwives, ambulance staff, paramedics and other health professionals and told them their jobs were safe. By doing that, she would have protected frontline services but left health boards with room to cut back on back-office functions and share resources with other bodies.

But no, she decided to guarantee the jobs of all Scottish health service personnel, all 170,000 of them, including each one of the 52,000 administrative and support staff.

This may give her something to fight the election with, when it comes round, but it will not go down well with any of her ministerial colleagues in charge of other government departments who are unable to make any such guarantees of their own.

Nor would it, one suspects, go down that well with Mr Swinney, who knows the scale of the cuts to come and the need for the maximum flexibility.

It may have seemed a good decision at the time but it may not quite as inspiring in the very difficult weeks and months ahead.

<em>Picyure: Waldo Jaquith</em>

Picyure: Waldo Jaquith

A model currently used for temporary nurses could soon be applied to the use of locum doctors in Scotland’s hospitals, the health secretary has revealed.

“Doctor banks” could be formed to help the NHS fill medical staffing gaps without spending as much money as it does at present, Nicola Sturgeon said, and could also improve quality.

Ms Sturgeon revealed that the proposal was being considered by health board chief executives as Audit Scotland was due to publish a critical report into the use of medical locums in NHS hospitals.

The report, published today reveals that spending on medical locums has doubled in real terms since 1997, and that NHS boards could save £6 million – almost 15 per cent of the money it spends on locums annually – through better planning and procurement.

Health boards spend some £47 million per year on temporary doctors, who are taken on for a variety of reasons, including covering for sickness and unfilled vacancies. Most of this (£27 million) is spent on agency locums, with the remainder on existing NHS staff providing internal locums.

In many cases, the report says, hospitals cannot say why locum doctors are being hired and for how long, and better information is needed.

The spending watchdog also warns that health boards need to be consistent in the way they screen and induct locum doctors and in the way they manage their performance.

Feedback on locums’ performance is mainly verbal, says auditor general Robert Black, and there are no formal systems for sharing information about individual locum doctors between boards.

Nicola Sturgeon, the health secretary, acknowledged that spending on medical locums had increased since 1997, but said it had remained steady over the last three years. “That is a step in the right direction, however we have more to do.”

She said the government was currently consulting health board chief executives on a package of measures designed to reduce demand for temporary medical staff and, where their use was unavoidable, ensure they were high quality and affordable.
Proposals include using existing NHS staff in “doctor banks” – similar to nurse banks – and steps have already been taken to improve procurement of agency medical staff with a new national contract, she said.

“These proposals, developed by a group which includes key stakeholders including NHS representatives and the British Medical Association, draw on the benefits of using nurse banks, where existing NHS staff undertake temporary work for their board,” the minister said. “Use of bank staff helps to maintain quality standards and has resulted in substantial savings in spending on agency staff. Guidance for boards on the implementation of the proposals for temporary medical staff is expected to be published later this year.”

The proposed move to a bank system was backed by Theresa Fyffe, director of RCN Scotland. “The report reveals a patchy approach to the use of hospital locum doctors, with health boards not sharing information about the performance of locum doctors, some health boards not knowing if they are using agency or in-house locum doctors and some not providing inductions for locum doctors,” she said. “In the interests of patient safety and reducing costs, the use of locum doctors clearly needs to be addressed as a matter of urgency.”

She said that nurse banks were not only helping to drive down health board costs, but also meant that health boards can be confident in the skills and ability of the nurses available to them.“The Scottish government and health boards must drive forward with the implementation of ‘doctor banks’ to ensure that the problems uncovered in today’s report are addressed and the money saved is reinvested in improving patient care.”

The BMA, which is part of the short life working group on temporary medical staffing, welcomed the report. Dr Charles Saunders, deputy chairman of Scottish Council, said: “We welcome this constructive report and believe the recommendations form a solid foundation for more cost effective use of locums.”

Theresa Fyffe

Theresa Fyffe

Theresa Fyffe, director of RCN Scotland, sets out what she wants from the new “scrutiny group” which will review proposed job cuts in the NHS – and says the government must act on any problems it identifies.

After weeks of speculation and leaks we finally have the workforce projections for every health board in Scotland. And in response to the frenzy that has built up, and to the concerns that we have consistently raised with health boards, MSPs and the Scottish Government for some time, Nicola Sturgeon is now to lead a “national scrutiny group” to review the workforce plans for all of the health boards. However, there is a fine but important distinction here: the information provided on Thursday are workforce projections which contain no explanation of how cuts in numbers of nurses and other staff groups are to be made and whether these reflect redesign of services. We need this information – which is contained in the full workforce plans – in order to engage in this new group.

As the director of the largest nursing trade union, I am quite clear that we must work with the Scottish Government and health boards to ensure that their workforce plans do indeed reflect new approaches to the provision of services and that the safety of patients will be paramount. We will also do everything possible to save jobs, but recognise that there will be some changes and reductions in the workforce if services are properly redesigned. However, we will do everything we can to stop the current unsustainable cost-cutting measures that are being used by health boards in an incoherent manner. Tactics being employed include not recruiting new staff when people leave or retire, reducing hours and redeploying much-needed specialist nurses to hospital wards.

We have agreed to take part in the scrutiny group in principle, but only if the health secretary demonstrates that she is prepared to intervene and stop health boards implementing their workforce plans if they do not reflect service redesign. There is no point in scrutiny if problems are identified but not acted upon.

All health boards must demonstrate explicitly that they have identified and mitigated any risks to patient care as a result of changes to their workforces. If the scrutiny group finds this information to be lacking the workforce plans must be sent back to health boards to be reworked through the “partnership” process with trade unions, in order to ensure patient safety.

I am particularly concerned that health boards such as NHS Greater Glasgow and Clyde are already beginning to replace registered nurses, ie those on “Agenda for Change” bands 5 and above, with nursing and healthcare assistants, ie bands 3 and 4, without giving due consideration to the implications for patient care. Nursing assistants have a valuable role as part of healthcare teams, however, a simple downgrade of registered nursing posts to nursing assistant posts is not a solution. Nursing assistants must have appropriate training in order to ensure registered nurses can delegate care duties without compromising quality and safety of care. Any such changes to the “skill mix” as it is known, must be supported by the national workforce tools.

The nursing workforce is an easy target because of the relative size of this staff group, but all groups of staff should be considered when making changes to the workforce. Otherwise the skills and expertise of the workforce are not considered holistically and gaps will appear.

While these are some of our “lines in the sand” which will form the basis of our participation in the scrutiny group, I am sure that there will be a number of other questions to consider over the next few weeks. For instance, do the figures in the workforce projections, which are for the entire nursing and midwifery staff group, mask a greater cut in registered nurses, partly compensated for by an increase in nursing assistants?

There is no doubt that this crunch time for Scotland’s health boards, but this should not mean it is crunch time for Scotland’s patients. Continuing to squeeze the wage bill using the short-term measures outlined above can only lead to an overstretched and demoralised workforce. This could potentially be extremely bad news for standards in patient care. We will use our position on the new scrutiny group to press home our concerns on behalf of our members and on behalf of patients. It will then be up to Nicola Sturgeon to take action and ensure that health boards make any necessary changes to their workforce plans in the interests of good quality and safe patient care.

<em>Picture: Salim Fadhley</em>

Picture: Salim Fadhley

Back in January, Nicola Sturgeon told The Caledonian Mercury that budget cuts could be good for health services because they help to drive reform.

I wonder if she’s thinking that today.

NHS Greater Glasgow and Clyde has confirmed that it plans to axe more than 1,200 jobs in the next 18 months; doubtless it won’t be alone in this.

All Scotland’s NHS boards have drawn up workforce plans, or are in the process of doing so. These plans are supposed to provide useful information on, for example, how many clinicians will be needed to meet service needs in the short, medium and long term and how much money will be needed to pay for them.

Obviously these projections also inform such things as how many nurses, doctors and allied health professionals should be trained to fill available posts in the future.

Indeed, student intake figures were one of the first signs that fairly substantial cuts would be coming Scotland’s way. Last year, so informed rumour had it, there were plans to cut the number of student nurses in the coming financial year. This was never confirmed officially, although it is the case that the draft budget for registered nurse training was to have been cut by some £5.8 million.

In January, however, Ms Sturgeon confirmed that the number of student nurses trained in Scotland would, after all, remain the same.

The Caledonian Mercury understands that this decision was made as a result of Ms Sturgeon’s intervention – officials, perhaps with an eye to the financial, rather than political bottom line, might have come to a different conclusion.

So will Ms Sturgeon act now to slap Glasgow down – and, indeed, should she?

The Herald this morning extrapolates from the Glasgow figure – 1,252 whole-time-equivalent posts – to suggest that the NHS in Scotland stands to lose 5,000 jobs over the same period.

We don’t know yet what the other health boards have said, or will say, in their own workforce projections; indeed, this is likely to be affected by the reception given to Glasgow’s plans.

As the biggest health board – and also the one with arguably the most macho management style – it is perhaps less afraid than some of its smaller siblings to stick its head above the parapet.

To be fair to Glasgow, its workforce projections are pretty firmly tied to service redesign. Healthcare simply isn’t delivered in the same way as it was 30, 20 or even five years ago, and it is right that staffing is changed to reflect this.

Senior nurses and allied health professionals, such as physiotherapists, are taking on roles traditionally carried out by doctors and, in many cases, are making services more efficient. Specialist clinics led by physiotherapists, for example, have led to shorter waiting times for patients and have freed up consultant time for the people who really need to see a doctor. I’m thinking of two specific examples which were highlighted at a Chartered Society of Physiotherapy conference, one in Lanarkshire where physios saw patients with suspected vascular disease and one in Dundee, where a physio-led clinic for incontinence was showing great results – and saving money.

And, with more people being treated in the community, patients who are actually admitted to hospital often need more specialist care. So it might be that rather than a general nurse, a patient would benefit more from seeing a specialist nurse in breast care, or in multiple sclerosis.

The problem occurs, however, when staff changes are made, not to meet new and changing demands, nor to give patients a better and more efficient service, but simply to save money.

Not that there’s anything wrong with saving money – but there is if it turns out to be a false economy.

The RCN has been (rightly, as it turns out) jittery about nurses’ jobs – they are the largest staff group and, as such, potentially the easiest target. NHS Greater Glasgow and Clyde has already come under fire for its plans to replace some registered nurses with healthcare assistants – a move which the union has warned could cost more, a little further down the line.

Doctors too have been in the firing line, particularly hospital consultants. Again, the health secretary had to step recently in to solve a dispute between NHS employers and the BMA over how consultants spend their time. The BMA wanted the terms of the consultant contract – which generally allows 2.5 sessions of “supporting professional activity” (such as keeping up-to-date, teaching and redesigning services) to 7.5 sessions of “direct patient care”. Managers (particularly those in Glasgow, funnily enough) wanted this cut to one supporting session to nine of direct patient care).

All of this, lest we forget, is taking place in a year when the NHS in Scotland has never had so much money and when budgets increased across the board.

Compare the situation in Scotland to that just across the water. In Northern Ireland, trusts are having to make huge efficiency savings. Unlike the situation in Scotland, where boards have to make 2 per cent efficiency savings, but are allowed to keep them to plough back into frontline services, the Northern Ireland cuts will leave the health budget altogether.

And a few miles south in the Republic of Ireland the situation is even more acute. As a result of the financial crisis in the former Celtic Tiger, hospital beds are being closed, thousands of posts are being axed and public sector salaries – including those of consultants – have been cut by up to 15 per cent.

I wonder if they’re thinking that the cuts are helping them to drive reform?

Hippocrates. <em>Picture: Shakko</em>

Hippocrates. Picture: Shakko

The health service in Scotland will be expected to go back to basics – millennia-old ones at that – in implementing the quality strategy which is published today.

The long-awaited plan aims to shift the emphasis from things like waiting times to people’s actual experience of the NHS and, in doing so, to “give people a new confidence” in the health service.

Although it was trailed earlier this year, the actual publication of the strategy was delayed until health boards had provided tangible examples of how they would make it work. These are many and varied (it’s a very long document) and range from a scheme in Lothian to help patients manage their chronic obstructive pulmonary disease at home with the use of touch screen technology, to programmes which cut infections in intensive care units.

More generally, however, the strategy has lots about making care person-centred, and the importance of communication, compassion and safety.

Its three stated “ambitions” possibly sum the whole strategy up – and two of them at least could almost be seen as an updating of the Hippocratic Oath.

“There will be no avoidable injury of harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times,” the second ambitions states. This isn’t a million miles away from Hippocrates’s urging that physicians should “abstain from harm”.

The third ambition also echoes the so-called father of western medicine. He said “I will prescribe regimens for the good of my patients according to my ability and my judgement”. The Quality Strategy says (a little less poetically) that “the most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated”.

At this morning’s launch of the strategy, at Hairmyres Hospital in Lanarkshire, the Scottish Government chose to play up the “eradication of wastefulness” bit of this ambition.

The health secretary Nicola Sturgeon saw for herself how a scheme which aims to free up nurses’ time for direct patient care is working, and said it would be rolled out across Scotland.

The Releasing Time to Care (RTC) initiative, similar to a project in England called “The Productive Ward” has shown positive results in pilot areas, including parts of Lanarkshire. The idea is that everything that is done on a ward or clinical area is scrutinised to make sure it is being done in the most efficient way possible – for example, so that nurses aren’t having to make unnecessary journeys to several different places for things like linen.

People with long memories may recall that RTC was trailed last year by NHS Greater Glasgow and Clyde, which said it had given pedometers to staff to measure distances being walked during shifts to see if things could be organised better.

The pilot sites – in eight health boards – have shown an increase in time spent on direct patient care by up to 40 per cent, as well as reduced sickness absence and improved efficiency and staff morale.

Ms Sturgeon said this was exactly the sort of thing she wanted to see more of as the Quality Strategy develops. “All too often I hear people say of their dealings with the NHS that the clinical care was good, but that the food or communication could have been better or that they didn’t feel they were treated with enough dignity and respect,” she said.

“The task facing us all is to ensure the way patients are treated becomes as important to everyone delivering healthcare as how quickly they are treated. The Quality Strategy will enable us to achieve this.”

One big challenge will be in measuring quality of care, so that boards can prove they are implementing the strategy. There will be a group overseeing it – called the Quality Alliance” and current and future targets for the NHS will be aligned to the quality strategy. Boards will also be judged on what patients themselves say about health services.

So what of the first of the three “ambitions” (note: not “promises” or “commitments”)? This is for “mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values, and which demonstrate compassion, continuity, clear communication and shared decision-making”.

Hippocrates didn’t exactly say that, but probably would have agreed.