Is the NHS in crisis? 3) staffing

This is the third in a series of comments on key issues in the NHS. They don't represent an agreed or formal position of SSONHS but are a collection of thoughts broadly consistent with views across the group's point of view.

Earlier in April the Daily Mail ran a campaign to show how badly the NHS is working - designed of course to soften up the argument for privatisation - choosing their examples carefully - like the lead off story about the £25 million which Trust bosses have apparently awarded themselves in pay rises over the last year. (In Sheffield, Sir Andrew Cash, (the second most highly rated Trust boss in England) has remained in the same pay band between 2011/12 and 2013/14 (but this is £215-£220,000 plus increasing pension and other benefits). However the Director of Finance saw his payband increase in 2012/13 from £150-155000 to £170-£175000 whilst the Director of Service Development saw her pay move from £125-130000 when first appointed in 2011 to 140-145000 last year.)

The party leaders have been proclaiming figures for extra recruitment of doctors, nurses and other front line staff, most of which make little sense, either in terms of where they would come from or where they would go. We've heard about the number of GPs likely to retire in the next few years, we know about the shortages of nurses on wards and in the community, and we know about the lack of staff willing to maintain A&E and ambulance services. Promises about recruitment make no sense if new staff pick up training and experience and then leave for the private sector or abroad - while Trusts are spending huge amounts on recruiting from abroad. (The same is happening with teachers.)

Meanwhile the Tories are playing confusing number games with staffing changes since 2010 (made all the more difficult by the number of staff they have fired and then rehired). Tory leaflets claim that 'Under David Cameron we've got 9,500 more doctors, 7,000 more nurses, and 2,200 more midwives caring for us, (since 2010).' Obviously with the ringfencing of the budget you would expect that overall numbers would not have declined - even with the redundancies in 2010-11. (Health minister Dan Poulter said last year that an estimated 3,950 NHS staff were made redundant between May 2010 and November 2013 and subsequently rehired, 2,570 of them having been employed on a permanent basis and 1,380 on fixed-term contracts.) Many of the 'efficiency' savings have come through reallocations or pushing people harder rather than staff reductions but, in the words of one Sheffield Trust Finance Director last year, there is nowhere to go other than squeezing staff still more.

However all the figures mean different things, and, for instance, depend on whether they refer to the actual number of employees (headcount) or Whole Time Equivalents. There may be more staff but working fewer hours so the WTE figure will vary accordingly. Figures are also affected by downbanding and outsourcing (when staff TUPEd over to a private contractor no longer count as part of the NHS workforce).

According to the NHS Information Centre the total number of medical and dental staff in 2010 was 97,636 (WTE) in 2010 and 104,501 in 2014. In general there have been increases in all specialties and in General Practice. (Incidentally among hospital and community health medical staff, 66% qualified in the UK, 8% in Europe and 26% elsewhere.) However among GPs, since 2004, there has been a 46% increase in the number of female GPs (headcount) and a decline of 4.7% in male GPs (headcount).

The employment count figures are rather different for nurses. In 2010 there were 323,783 total qualified nursing staff (WTE) but this number declined to 319,755 in 2012 before going up again (post mid-Staffs) to 322,635 (WTE) in 2013. The most significant and persistent decline is in mental health nursing (including community psychiatric nurses) and learning disabilities (where changes towards more community settings may have had an effect). A decrease in the number of nursing assistants was matched by an increase in the number of healthcare assistants. The number of midwives increased from 20,126 in 2010 to 21,670 in 2014 (WTE).

And of course the NHS spends a fortune on (around £2.5bn per year) on agency staff and locums - with a big proportion of that going to the agencies.

But the numbers game is probably not as important as the conditions. Although the NHS staff survey reports some increases in job satisfaction etc over recent years, it is astonishing that 24% of NHS staff said they had been bullied or harassed by managers or colleagues last year. A Unison survey of 5,000 nursing staff reported that half who responded (49 per cent) thought that staffing levels had got worse since May 2010. Nearly two-thirds (65 per cent) reported that patients missed out on care due to understaffing, while around half (49 per cent) reported not having enough time with each patient. 45 per cent felt there were not adequate staff numbers to deliver safe and dignified care; 70 per cent were unable to take all or some of their breaks that day; 65 per cent reported care was left undone due to understaffing; 75 per cent worked up to an hour of additional time, but only 8 per cent were paid for working overtime. One staff member surveyed said: “I could not offer adequate food or fluids due to workload. Another said: “I was unable to give pain relief immediately as it is a controlled drug and two nurses are rarely available to check drugs for long periods of time.”

Meanwhile 'fear stalks the corridors' as the relentless push from patients on the one hand and managers on the other squeezes the frontline workers in the middle. Clare Gerada wrote recently about the toxic effects of fear of annihilation, loss of jobs, loss of service, and humiliation (on doctors as well as nurses and other workers). Recently the huge London Trust Barts Health was put into special measures (with the subsequent resignation of senior management) and particular reference was made to the appalling and bullying working conditions at Whipps Cross. An occupational therapist, Charlotte Munro, who was a long standing trade unionist, had spoken out against conditions and against cuts to the stroke service in 2013 and was dismissed that November. However the better news is that a huge local campaign and a vigorous defence from Unison finally resulted in her reinstatement following a tribunal decision last month.

The lesson from all of this is that numbers, while important, are not the whole answer. Politicians need to recognise that the success of the NHS needs to be measured not just by numbers, nor even just by outcomes but also by the health of the organisation. And the health of the organisation is not just about wellbeing, it is about enabling staff to change practice to improve services or meet changing needs. When politicans can find ways of boasting not just about improvements for patients but about how they have made the NHS really worth working in, rather than staff being taken for granted, we will know they are getting somewhere.