NHS survey highlights safety concerns: Survey of NHS professionals indicates 'efficiency savings' are not working, staff morale is low and services are being cut
Patient care is being damaged by the NHS's efforts to meet the government's savings drive, according to two-thirds of respondents to the Guardian healthcare network's latest survey of NHS professionals.
Almost half of those surveyed believe patient safety is being affected by the need to save £20bn by 2015 (dubbed "the Nicholson challenge" after NHS chief executive David Nicholson), which many say has led to cuts to staff and services, while nine out of 10 say staff morale is being badly hit.
The findings also confirm that rationing of treatment has become widespread and that growing numbers of NHS services are being privatised as the spending squeeze coincides with rising demand for healthcare. In total, 1,183 members of the healthcare network took part in the survey during September and October. They do a wide range of clinical and managerial jobs across every type of NHS organisation, and include some health charity staff.
Asked to assess the impact of the Nicholson challenge, 66% of the 571 respondents to that question said it was affecting quality of care, 47% cited patient safety, and 91% mentioned staff morale.
The survey is a self-selecting snapshot of a tiny proportion of the NHS's overall workforce. But if respondents' experiences are in any way indicative of how the cuts are being achieved, ministers should be worried. The quest for efficiency savings was meant to encourage productivity and innovation. Instead it appears to be being achieved by job cuts, bed closures and fewer services.
"Reduced patient contact times, assessments carried out by 'cheaper' colleagues and fabrication of 'face-to-face' contact to meet waiting targets" were some of the consequences highlighted by one respondent. Another said: "Massive loss of funding resulting in job losses and reduced access to primary care services." While others cited: "Cutting nursing staff and replacing with HCAs [healthcare assistants]."
Many of the respondents echoed similar NHS workforce problems to those revealed last week in the Care Quality Commission annual report – job losses, high vacancy rates and the wrong mix of skills.
"Staff can't deliver the care they wish to as [there are] insufficient staff with [the] right skills; high level of temporary staff compromises care," said one. Another reported: "Quality of care questionable. Length of stay increasing. Early discharge targets not met. Bed closures mean that inpatients are often admitted to day surgery unit as a 'stopgap' measure."
Many flagged up a service they believe has suffered as a result of cost-cutting. For example, "end-of-life specialist inpatient care has now been devolved and distributed across wards rather than centralised, leading to a dilution of expertise and a reduction in access to dedicated care."
Some members recount direct threats to patient safety. A nurse said they had had to "report numerous safety issues to senior staff". On one occasion, no staff were able to use a particular defibrillator when a patient was in cardiac arrest; on another, essential anaesthetic equipment in three of the four resuscitation trolleys was not compatible with other equipment. They said they had also had to report "incorrect drug-checking behaviours and appalling attention to sterile injection practice".
These responses counter the insistence of ministers and NHS top brass that the £20bn can and should be saved by doing things differently rather than by doing less or doing the same but with fewer staff.
However, the survey also shows that in at least a handful of places the duty to make "efficiency savings" does appear to be prompting genuine innovation. "Positives are: much more integrated working between health and social care, and with voluntary organisations, and a wider focus on caring for people in their own homes," said one respondent. Another cited: "Improving support to patients with long-term ill health through greater use of telehealth technology. Reducing the number of urgent/unscheduled admissions to district hospital." And another said: "Investing in services such as reablement to reduce hospital admissions and readmissions and to manage patients with chronic conditions more effectively out of hospital and therefore making more efficient use of limited resources."
Dr Peter Carter, general secretary and chief executive of the Royal College of Nursing, says the survey findings underline his view that the Nicholson challenge is looking for savings in the wrong places, and NHS staff are bearing the consequences of ill-thought-through cuts dressed up as efficiency savings. "It's a false economy to be getting rid of frontline staff because demand and workload are definitely going up while staffing levels are going down," he says. The RCN has identified more than 60,000 posts in the NHS in England that have been lost or earmarked to go since the 2010 general election. If NHS organisations continue shrinking their workforce then patient care will inevitably suffer, Carter warns.
The survey adds to the rapidly growing body of evidence of how rationing is being pursued for clinical and/or financial reasons. Asked what types of treatment had been restricted in their area in the last year, fertility treatment was cited by 30% of the 491 respondents to that question, as was weight-loss surgery (30%), hip and knee operations (28%), tonsillectomies (19%) and eye surgery (17%).
"These findings present yet more evidence that rationing within the NHS is becoming a stark reality for many patients," says Dr Mark Porter, chair of the council at the British Medical Association. "It is inevitable that clinical services will be affected, given that the government is asking the health service to make £20bn in efficiency savings at the same time as undertaking a costly reorganisation of the NHS," he adds.
Just over half of respondents had seen private firms handed contracts to deliver NHS services in their area in the past year. More than half (54%) mentioned community health services, an area Labour opened to competition and that the coalition is expanding. Almost one in seven (13%) cited children's health services, while 12% mentioned sexual health services.
Who is getting all these contracts? Virgin Care was mentioned by almost a quarter of respondents, just over a fifth said Serco, and close on 20% mentioned Care UK – which is due to become an even bigger provider of NHS services through its recent acquisition of Harmoni, a major supplier of out-of-hours GP care.
Given the survey findings, it is no surprise that 64% said they do not think Jeremy Hunt will prove to be a better health secretary than Andrew Lansley, while 80% do not think the government's approach to health will improve.
Responding to the survey results, the health secretary says: "We have always been absolutely clear that being efficient does not mean cutting services – it means getting better services to more people. With the number of over‑85s set to double in coming decades, this is the only way we will ensure the NHS continues to meet people's expectations. Rationing services on the basis of cost alone is wrong and compromises patient care. Decisions on treatments, including suitability for surgery, should be made by clinical experts taking the needs of each individual into account."
Hunt adds: "We have already written to the NHS to set out clearly that access to services should not be restricted on the basis of cost." The Guardian
Patient care is being damaged by the NHS's efforts to meet the government's savings drive, according to two-thirds of respondents to the Guardian healthcare network's latest survey of NHS professionals.
Almost half of those surveyed believe patient safety is being affected by the need to save £20bn by 2015 (dubbed "the Nicholson challenge" after NHS chief executive David Nicholson), which many say has led to cuts to staff and services, while nine out of 10 say staff morale is being badly hit.
The findings also confirm that rationing of treatment has become widespread and that growing numbers of NHS services are being privatised as the spending squeeze coincides with rising demand for healthcare. In total, 1,183 members of the healthcare network took part in the survey during September and October. They do a wide range of clinical and managerial jobs across every type of NHS organisation, and include some health charity staff.
Asked to assess the impact of the Nicholson challenge, 66% of the 571 respondents to that question said it was affecting quality of care, 47% cited patient safety, and 91% mentioned staff morale.
The survey is a self-selecting snapshot of a tiny proportion of the NHS's overall workforce. But if respondents' experiences are in any way indicative of how the cuts are being achieved, ministers should be worried. The quest for efficiency savings was meant to encourage productivity and innovation. Instead it appears to be being achieved by job cuts, bed closures and fewer services.
"Reduced patient contact times, assessments carried out by 'cheaper' colleagues and fabrication of 'face-to-face' contact to meet waiting targets" were some of the consequences highlighted by one respondent. Another said: "Massive loss of funding resulting in job losses and reduced access to primary care services." While others cited: "Cutting nursing staff and replacing with HCAs [healthcare assistants]."
Many of the respondents echoed similar NHS workforce problems to those revealed last week in the Care Quality Commission annual report – job losses, high vacancy rates and the wrong mix of skills.
"Staff can't deliver the care they wish to as [there are] insufficient staff with [the] right skills; high level of temporary staff compromises care," said one. Another reported: "Quality of care questionable. Length of stay increasing. Early discharge targets not met. Bed closures mean that inpatients are often admitted to day surgery unit as a 'stopgap' measure."
Many flagged up a service they believe has suffered as a result of cost-cutting. For example, "end-of-life specialist inpatient care has now been devolved and distributed across wards rather than centralised, leading to a dilution of expertise and a reduction in access to dedicated care."
Some members recount direct threats to patient safety. A nurse said they had had to "report numerous safety issues to senior staff". On one occasion, no staff were able to use a particular defibrillator when a patient was in cardiac arrest; on another, essential anaesthetic equipment in three of the four resuscitation trolleys was not compatible with other equipment. They said they had also had to report "incorrect drug-checking behaviours and appalling attention to sterile injection practice".
These responses counter the insistence of ministers and NHS top brass that the £20bn can and should be saved by doing things differently rather than by doing less or doing the same but with fewer staff.
However, the survey also shows that in at least a handful of places the duty to make "efficiency savings" does appear to be prompting genuine innovation. "Positives are: much more integrated working between health and social care, and with voluntary organisations, and a wider focus on caring for people in their own homes," said one respondent. Another cited: "Improving support to patients with long-term ill health through greater use of telehealth technology. Reducing the number of urgent/unscheduled admissions to district hospital." And another said: "Investing in services such as reablement to reduce hospital admissions and readmissions and to manage patients with chronic conditions more effectively out of hospital and therefore making more efficient use of limited resources."
Dr Peter Carter, general secretary and chief executive of the Royal College of Nursing, says the survey findings underline his view that the Nicholson challenge is looking for savings in the wrong places, and NHS staff are bearing the consequences of ill-thought-through cuts dressed up as efficiency savings. "It's a false economy to be getting rid of frontline staff because demand and workload are definitely going up while staffing levels are going down," he says. The RCN has identified more than 60,000 posts in the NHS in England that have been lost or earmarked to go since the 2010 general election. If NHS organisations continue shrinking their workforce then patient care will inevitably suffer, Carter warns.
The survey adds to the rapidly growing body of evidence of how rationing is being pursued for clinical and/or financial reasons. Asked what types of treatment had been restricted in their area in the last year, fertility treatment was cited by 30% of the 491 respondents to that question, as was weight-loss surgery (30%), hip and knee operations (28%), tonsillectomies (19%) and eye surgery (17%).
"These findings present yet more evidence that rationing within the NHS is becoming a stark reality for many patients," says Dr Mark Porter, chair of the council at the British Medical Association. "It is inevitable that clinical services will be affected, given that the government is asking the health service to make £20bn in efficiency savings at the same time as undertaking a costly reorganisation of the NHS," he adds.
Just over half of respondents had seen private firms handed contracts to deliver NHS services in their area in the past year. More than half (54%) mentioned community health services, an area Labour opened to competition and that the coalition is expanding. Almost one in seven (13%) cited children's health services, while 12% mentioned sexual health services.
Who is getting all these contracts? Virgin Care was mentioned by almost a quarter of respondents, just over a fifth said Serco, and close on 20% mentioned Care UK – which is due to become an even bigger provider of NHS services through its recent acquisition of Harmoni, a major supplier of out-of-hours GP care.
Given the survey findings, it is no surprise that 64% said they do not think Jeremy Hunt will prove to be a better health secretary than Andrew Lansley, while 80% do not think the government's approach to health will improve.
Responding to the survey results, the health secretary says: "We have always been absolutely clear that being efficient does not mean cutting services – it means getting better services to more people. With the number of over‑85s set to double in coming decades, this is the only way we will ensure the NHS continues to meet people's expectations. Rationing services on the basis of cost alone is wrong and compromises patient care. Decisions on treatments, including suitability for surgery, should be made by clinical experts taking the needs of each individual into account."
Hunt adds: "We have already written to the NHS to set out clearly that access to services should not be restricted on the basis of cost." The Guardian
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