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Crisis in the NHS: Downing Street on the Counterattack after the Presidents' Statement
1476
Commentary from Westminster Crisis in the NHS: Downing Street on the Counterattack after the Presidents’ Statement have circumstantial evidence that the Prime Minister was really jolted by last week’s statement from the presidents of the Royal Colleges that acute hospital services in the NHS have "almost reached breaking point".1 It did not come on the floor of the House of Commons, where Mrs Thatcher responded to their criticism by using her welltried (but increasingly ineffective) trick of reciting NHS growth statistics. Instead her attitude was revealed in an unattributable briefing by her press secretary, Mr Bernard Ingham, to the political correspondents of the Sunday newspapers. She and he were concerned enough about the political impact of what the presidents had been saying to launch a blistering attack on "top hospital consultants", accusing them of standing in the way of a better NHS by
WE
now
"restrictive practices and deeply entrenched attitudes". They were blamed for running hospitals on a "collegiate" basis and of spending too much time away from the NHS work doing lucrative private practice. It was the old, old story. She did not like the message, so she shot the
clinging
to
messenger.
There is
element of surmise in this observation. Proceedings Ingham’s collective lobby briefings are confidential and can be deduced only from what the journalists write afterwards. In this case the footprints of Mr Ingham were unmistakable. There was a tell-tale uniformity about reports in last Sunday’s papers that "senior Government sources" had attacked the doctors and had sarcastically observed that "trade unionism has moved up the social scale". It can now be concluded that the presidents of the Royal Colleges are to be regarded in the Downing Street bunker as enemies. Whatever power they and their institutions previously had, they now have rather less. There will be vengeance. This pattern of behaviour has become Downing Street’s customary response to a really effective attack. The spokesman quickly moves in to discredit the attacker. Perhaps the most celebrated recent example was the fate which befell Mr John Biffen, a Cabinet member and Leader of the House of Commons, before the last election. In a television interview he implicitly criticised Mrs Thatcher by arguing that the Conservatives’ fortunes would be better served by a "balanced ticket", with greater emphasis given to selective increases in public spending. He was immediately denounced (unattributably) by Mr Ingham, who described him on the Prime Minister’s behalf as a "semi-detached" member of the Cabinet. He was sacked in the post-election reshuffle. Mrs Thatcher cannot sack the presidents of the Royal Colleges. They should realise, however, that nothing they do can now reverse their fall from grace. They can only press on with their cause and take comfort in the company they keep. It is not obvious that Sir George Godber, the former chief medical officer, who wrote forcefully in their support in The Lancet last week (p 1400), has yet been rubbished by Mr Ingham, although all the faults of the NHS will no doubt shortly also be laid at his door. When the Prime Minister said that the NHS was safe in her hands, she did not add that she thought it was being corrupted by the restrictive some
at Mr
1 See: Lancet Dec
12, 1987, p
1411.
practices of the consultants. When she smiled on the development of private hospitals, she did not cavil at NHS doctors playing their part in them. Whatever the force of some of these arguments, methinks the lady doth protest a little too late. The unattributable briefings began after Mrs Thatcher’s least successful question-time appearance at the dispatch box for some while. Neil Kinnock began by asking if she agreed with the presidents’ remarks. When she answered with further data on NHS expenditure, he responded by accusing her of "incurable complacency" and "untreatable arrogance". Patient care was deteriorating, acute services were almost at breaking point, and morale was depressingly low. Was that not a crisis? he asked. In the exchanges which followed, the Prime Minister remained stuck in her statistical rut. The Tory backbenchers behind her looked glum. They seem to know that the recitation of figures is no
longer good enough. All this suggests that the Government is still uncertain what to do. The Social Services Secretary, Mr John Moore, returned to his desk at the DHSS last week still weakened after his illness. He is not expected to take a full workload until the New Year. There is concern among some officials at the Department that policy is being made up on the hoof by the Parliamentary Under-Secretary, Mrs Edwina Currie. On a radio phone-in she suggested that more people should seek private health care. "If people have got the money-and many people have done rather well out of this Government-then I would encourage them to seek their health care elsewhere." But in the Commons on Thursday Mrs Thatcher rejected a proposal for tax relief on insurance premiums for private health care. The one concrete development is that Ministers have decided on an initiative to relieve the shortage of specialist trained nurses. They announced that they had reached agreement on new grading arrangements for nurses and had submitted them to the nurses’ review body, which will report next spring. But the Health Minister, Mr Tony Newton, subsequently warned that there could be no short-term solution to the shortages of nursing skill. He said the Government could not guarantee to accept everything the review body recommends, because that would be like signing an open cheque. On a visit to Birmingham for talks with regional health officials, he acknowledged: "I can’t pretend there’s an immediate short-term answer that will suddenly produce nurses that are not there." A clue to the Government’s more fundamental thinking about how it should respond to the NHS crisis emerged from a report in The Guardiaii. It said that Mrs Thatcher had ordered Sir Roy Griffiths, deputy chairman of the NHS Management Board, to halt closures of hospital beds to take the NHS out of the political limelight. According to this report, the Prime Minister had ruled out extra funds and had commanded that health authorities should find money to keep beds open by delaying payment for supplies, refusing to accept price rises, and negotiating price cuts. The DHSS responded by denying any directive about late payment, but acknowledging that health managers were being given extra time to find ways of reducing spending without cutting services to patients. Amid all this uncertainty, there was one piece of good news last week. The Commons Select Committee on Social Services has been reconvened and is to carry out an inquiry into the resources of the NHS. The committee immediately identified the key paradox which we are all trying to understand. How can the Government’s legitimate claim to
1477
have increased NHS resources be reconciled with a perceived failure to fulfil long-held expectations about the level of NHS services? The committee, which is inviting interested parties to submit written evidence as soon as possible, is well placed to reach some valuable conclusions. Its two senior Tory members, Mr Nicholas Winterton and Sir David Price, have both demonstrated that they are more interested in securing a decent NHS than in pleasing their party whips. The committee’s new chairman, Mr Frank Field, former director of the Child Poverty Action Group, lost his Labour front-bench post and many of his political allies because of a tendency to speak his mind rather than mouth the party line. Between them they have the potential to produce a cracker of a report. DHSS Ministers and officials will not relish the prospect of being grilled before this cross-party combination. We may see some interim findings around Easter.
JOHN CARVEL
The survey showed that in the short term nurses are bearing the burden of understaffing and inadequate pay levels. NHS management did not emerge as "an enlightened or forwardthinking employer". It appeared all too ready "... to exploit the professional commitment of nurses and disregard the best interests of patients".
A New A
Grading
new
clinical
grading
structure
would enable clinical nurses,
midwives, and health visitors possessing advanced knowledge and skills and carrying particularly onerous responsibilities to have this
recognised increases
in pay
Existing scales must be given sufficient that staff started in their new scales at an
terms.
to ensure
appropriate level. The College asked for a common percentage increase for grades from enrolled nurses to senior nurse 7. It encouraged the Review Body to recognise that the introduction of the new structure represented a one-off opportunity to correct the combination of inadequate differentials and grossly overlapping scales which had plagued the profession for so many years.
Students
National Health Service The Nurses’ Case PUBLISHED this week, the Royal College of Nursing’s evidence to the Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine includes the following points: .
Shortages of Staff College’s survey of 152 RCN branches showed that staff shortages were now affecting most areas in nursing and hitting both hospital and community services equally. Of the 17 NHS Regions (14 English regions, Scotland, Wales, and Northern Ireland), 13 had problems in recruitment of staff, 14 believed that their staff establishment was too low to meet increased workload, 12 had underfunding of posts and resources, 7 had insufficient specialist trained nurses, and 7 had recruitment/vacancy frozen in specific areas to stay within budget. The
Overtime and
Secondlobs
Almost 60% of nurses had worked some overtime in the week survey conducted by the Institute of Manpower Studies. "The exent of overtime worked represents a ’hidden shortage’ of nursing staff, as working nurses feel obliged to cover for shortages by undertaking overtime. It also represents a hidden saving to the NHS in terms of the paybill, because nurses are working additional hours for inadequate compensation, or no compensation at all". Overtime was rarely paid; and time off in lieu could rarely be taken. "Management is only too willing to exploit the commitment of nursing staff by maintaining a situation in which excessive under-compensated overtime is required to sustain adequate levels of staffing and patient care." 20 % who responded to the survey had one or more additional jobs. This percentage was higher for younger nurses, male nurses, and nurses in the south-east. 71 % said their reason for having two jobs was purely financial. The majority worked in agency or bank nursing. Over 60% worked for an agency or bank in their own health authority.
preceding the
Job Dissatisfaction 31 % said they were fairly or very dissatisfied with the level of responsibility they had to bear. 36% related this dissatisfaction to staffing levels that were too low. 34 % said they were fairly or very dissatisfied with the standard of psychological and social aspects of care provision. The majority felt they had insufficient time to communicate with patients or to spend on counselling.
The low level of pay received during training was a major source of discontent among student nurses, acting as a significant disincentive to would-be students and a major reason why those in training might consider leaving. One student said: "The learner bears the brunt of the work but gets the crumbs of the salaries". Student contribution to the workforce often exceeded 60%. Many did other jobs such as agency auxiliaries in the NHS and in private nursing homes, work in bars, restaurants, and fast-food chains, distributing leaflets, and childminding. Students had consistently been awarded lower percentages than all other groups of nursing staff. Their financial plight would be increased if they had to pay the
poll tax. The review body should recognise the contribution of students to the NHS and "redress the use of students as cheap labour by
management".
International
Diary
1988
Aids and Sexual Diseases: Egypt, March International conference 3-5 (Medical Scientific Society, 5 Saray el-Manial Street, Cairo, Egypt). Symposium on Stress, Vulnerability, and Child Health: San Francisco, USA, March 12 (Extended Programs in Medical Education, Registration Office, Room 575-U, University of California, San Francisco, California 94143, USA). on
Course on Sampling and Evaluating Airborne Asbestos Dust: Utah, 11-15 (Rocky Mountain Centre for Occupational and Environmental Health, Continuing Education, Registration Coordinator, University of Utah, Building 512, Salt Lake City, Utah 84112, USA). Annual meeting of the American Lung Association and the American Thoracic Society: Las Vegas, Nevada, May 8-11 (Annual Meeting, American Lung Association, 1740 Broadway, New York, NY 10019, USA). Course in Magnetic Resonance Imaging: Trondheim, Norway, May 30-June 3 (Ingrid Susann Gribbestad, The MR Center, N-7034
USA, April
Trondheim, Norway). 4th annual meeting of the European Society of Human Reproduction and Embryology: Barcelona, Spain, July 3-6 (ESHRE Secretariat, c/o Bruno Vanden Eede, A7--VUB, Laarbeeklaan 101, 1090 Brussels, Belgium). International symposium on Recent Advances in Male Reproduction: Hyderabad, India, July 12--14 (Prof P. R. K. Reddy, School of Life Sciences, University of Hyderabad, Hyderabad 500 134, India). 8th international congress of Endocrinology: Kyoto, Japan, July 17-23 (Society for Endocrinology, 23 Richmond Hill, Bristol BS8 1EN, UK). 20th international meeting of Organisation Gestosis: Cork, Ireland, July 27-29 (Convention & Incentive Services, CIE Tours International, 35 Lower Abbey Street, Dublin 1, Ireland). 8th world congress on Medical Law: Prague, Czechoslovakia, Aug 21-25 (Czechoslovak Medical Society J. E. Purkyne, 8th World Congress on Medical Law, P 0 Box 88, CS-120 26 Praha 2).
Commentary from Westminster Crisis in the NHS: Downing Street on the Counterattack after the Presidents’ Statement have circumstantial evidence that the Prime Minister was really jolted by last week’s statement from the presidents of the Royal Colleges that acute hospital services in the NHS have "almost reached breaking point".1 It did not come on the floor of the House of Commons, where Mrs Thatcher responded to their criticism by using her welltried (but increasingly ineffective) trick of reciting NHS growth statistics. Instead her attitude was revealed in an unattributable briefing by her press secretary, Mr Bernard Ingham, to the political correspondents of the Sunday newspapers. She and he were concerned enough about the political impact of what the presidents had been saying to launch a blistering attack on "top hospital consultants", accusing them of standing in the way of a better NHS by
WE
now
"restrictive practices and deeply entrenched attitudes". They were blamed for running hospitals on a "collegiate" basis and of spending too much time away from the NHS work doing lucrative private practice. It was the old, old story. She did not like the message, so she shot the
clinging
to
messenger.
There is
element of surmise in this observation. Proceedings Ingham’s collective lobby briefings are confidential and can be deduced only from what the journalists write afterwards. In this case the footprints of Mr Ingham were unmistakable. There was a tell-tale uniformity about reports in last Sunday’s papers that "senior Government sources" had attacked the doctors and had sarcastically observed that "trade unionism has moved up the social scale". It can now be concluded that the presidents of the Royal Colleges are to be regarded in the Downing Street bunker as enemies. Whatever power they and their institutions previously had, they now have rather less. There will be vengeance. This pattern of behaviour has become Downing Street’s customary response to a really effective attack. The spokesman quickly moves in to discredit the attacker. Perhaps the most celebrated recent example was the fate which befell Mr John Biffen, a Cabinet member and Leader of the House of Commons, before the last election. In a television interview he implicitly criticised Mrs Thatcher by arguing that the Conservatives’ fortunes would be better served by a "balanced ticket", with greater emphasis given to selective increases in public spending. He was immediately denounced (unattributably) by Mr Ingham, who described him on the Prime Minister’s behalf as a "semi-detached" member of the Cabinet. He was sacked in the post-election reshuffle. Mrs Thatcher cannot sack the presidents of the Royal Colleges. They should realise, however, that nothing they do can now reverse their fall from grace. They can only press on with their cause and take comfort in the company they keep. It is not obvious that Sir George Godber, the former chief medical officer, who wrote forcefully in their support in The Lancet last week (p 1400), has yet been rubbished by Mr Ingham, although all the faults of the NHS will no doubt shortly also be laid at his door. When the Prime Minister said that the NHS was safe in her hands, she did not add that she thought it was being corrupted by the restrictive some
at Mr
1 See: Lancet Dec
12, 1987, p
1411.
practices of the consultants. When she smiled on the development of private hospitals, she did not cavil at NHS doctors playing their part in them. Whatever the force of some of these arguments, methinks the lady doth protest a little too late. The unattributable briefings began after Mrs Thatcher’s least successful question-time appearance at the dispatch box for some while. Neil Kinnock began by asking if she agreed with the presidents’ remarks. When she answered with further data on NHS expenditure, he responded by accusing her of "incurable complacency" and "untreatable arrogance". Patient care was deteriorating, acute services were almost at breaking point, and morale was depressingly low. Was that not a crisis? he asked. In the exchanges which followed, the Prime Minister remained stuck in her statistical rut. The Tory backbenchers behind her looked glum. They seem to know that the recitation of figures is no
longer good enough. All this suggests that the Government is still uncertain what to do. The Social Services Secretary, Mr John Moore, returned to his desk at the DHSS last week still weakened after his illness. He is not expected to take a full workload until the New Year. There is concern among some officials at the Department that policy is being made up on the hoof by the Parliamentary Under-Secretary, Mrs Edwina Currie. On a radio phone-in she suggested that more people should seek private health care. "If people have got the money-and many people have done rather well out of this Government-then I would encourage them to seek their health care elsewhere." But in the Commons on Thursday Mrs Thatcher rejected a proposal for tax relief on insurance premiums for private health care. The one concrete development is that Ministers have decided on an initiative to relieve the shortage of specialist trained nurses. They announced that they had reached agreement on new grading arrangements for nurses and had submitted them to the nurses’ review body, which will report next spring. But the Health Minister, Mr Tony Newton, subsequently warned that there could be no short-term solution to the shortages of nursing skill. He said the Government could not guarantee to accept everything the review body recommends, because that would be like signing an open cheque. On a visit to Birmingham for talks with regional health officials, he acknowledged: "I can’t pretend there’s an immediate short-term answer that will suddenly produce nurses that are not there." A clue to the Government’s more fundamental thinking about how it should respond to the NHS crisis emerged from a report in The Guardiaii. It said that Mrs Thatcher had ordered Sir Roy Griffiths, deputy chairman of the NHS Management Board, to halt closures of hospital beds to take the NHS out of the political limelight. According to this report, the Prime Minister had ruled out extra funds and had commanded that health authorities should find money to keep beds open by delaying payment for supplies, refusing to accept price rises, and negotiating price cuts. The DHSS responded by denying any directive about late payment, but acknowledging that health managers were being given extra time to find ways of reducing spending without cutting services to patients. Amid all this uncertainty, there was one piece of good news last week. The Commons Select Committee on Social Services has been reconvened and is to carry out an inquiry into the resources of the NHS. The committee immediately identified the key paradox which we are all trying to understand. How can the Government’s legitimate claim to
1477
have increased NHS resources be reconciled with a perceived failure to fulfil long-held expectations about the level of NHS services? The committee, which is inviting interested parties to submit written evidence as soon as possible, is well placed to reach some valuable conclusions. Its two senior Tory members, Mr Nicholas Winterton and Sir David Price, have both demonstrated that they are more interested in securing a decent NHS than in pleasing their party whips. The committee’s new chairman, Mr Frank Field, former director of the Child Poverty Action Group, lost his Labour front-bench post and many of his political allies because of a tendency to speak his mind rather than mouth the party line. Between them they have the potential to produce a cracker of a report. DHSS Ministers and officials will not relish the prospect of being grilled before this cross-party combination. We may see some interim findings around Easter.
JOHN CARVEL
The survey showed that in the short term nurses are bearing the burden of understaffing and inadequate pay levels. NHS management did not emerge as "an enlightened or forwardthinking employer". It appeared all too ready "... to exploit the professional commitment of nurses and disregard the best interests of patients".
A New A
Grading
new
clinical
grading
structure
would enable clinical nurses,
midwives, and health visitors possessing advanced knowledge and skills and carrying particularly onerous responsibilities to have this
recognised increases
in pay
Existing scales must be given sufficient that staff started in their new scales at an
terms.
to ensure
appropriate level. The College asked for a common percentage increase for grades from enrolled nurses to senior nurse 7. It encouraged the Review Body to recognise that the introduction of the new structure represented a one-off opportunity to correct the combination of inadequate differentials and grossly overlapping scales which had plagued the profession for so many years.
Students
National Health Service The Nurses’ Case PUBLISHED this week, the Royal College of Nursing’s evidence to the Review Body for Nursing Staff, Midwives, Health Visitors and Professions Allied to Medicine includes the following points: .
Shortages of Staff College’s survey of 152 RCN branches showed that staff shortages were now affecting most areas in nursing and hitting both hospital and community services equally. Of the 17 NHS Regions (14 English regions, Scotland, Wales, and Northern Ireland), 13 had problems in recruitment of staff, 14 believed that their staff establishment was too low to meet increased workload, 12 had underfunding of posts and resources, 7 had insufficient specialist trained nurses, and 7 had recruitment/vacancy frozen in specific areas to stay within budget. The
Overtime and
Secondlobs
Almost 60% of nurses had worked some overtime in the week survey conducted by the Institute of Manpower Studies. "The exent of overtime worked represents a ’hidden shortage’ of nursing staff, as working nurses feel obliged to cover for shortages by undertaking overtime. It also represents a hidden saving to the NHS in terms of the paybill, because nurses are working additional hours for inadequate compensation, or no compensation at all". Overtime was rarely paid; and time off in lieu could rarely be taken. "Management is only too willing to exploit the commitment of nursing staff by maintaining a situation in which excessive under-compensated overtime is required to sustain adequate levels of staffing and patient care." 20 % who responded to the survey had one or more additional jobs. This percentage was higher for younger nurses, male nurses, and nurses in the south-east. 71 % said their reason for having two jobs was purely financial. The majority worked in agency or bank nursing. Over 60% worked for an agency or bank in their own health authority.
preceding the
Job Dissatisfaction 31 % said they were fairly or very dissatisfied with the level of responsibility they had to bear. 36% related this dissatisfaction to staffing levels that were too low. 34 % said they were fairly or very dissatisfied with the standard of psychological and social aspects of care provision. The majority felt they had insufficient time to communicate with patients or to spend on counselling.
The low level of pay received during training was a major source of discontent among student nurses, acting as a significant disincentive to would-be students and a major reason why those in training might consider leaving. One student said: "The learner bears the brunt of the work but gets the crumbs of the salaries". Student contribution to the workforce often exceeded 60%. Many did other jobs such as agency auxiliaries in the NHS and in private nursing homes, work in bars, restaurants, and fast-food chains, distributing leaflets, and childminding. Students had consistently been awarded lower percentages than all other groups of nursing staff. Their financial plight would be increased if they had to pay the
poll tax. The review body should recognise the contribution of students to the NHS and "redress the use of students as cheap labour by
management".
International
Diary
1988
Aids and Sexual Diseases: Egypt, March International conference 3-5 (Medical Scientific Society, 5 Saray el-Manial Street, Cairo, Egypt). Symposium on Stress, Vulnerability, and Child Health: San Francisco, USA, March 12 (Extended Programs in Medical Education, Registration Office, Room 575-U, University of California, San Francisco, California 94143, USA). on
Course on Sampling and Evaluating Airborne Asbestos Dust: Utah, 11-15 (Rocky Mountain Centre for Occupational and Environmental Health, Continuing Education, Registration Coordinator, University of Utah, Building 512, Salt Lake City, Utah 84112, USA). Annual meeting of the American Lung Association and the American Thoracic Society: Las Vegas, Nevada, May 8-11 (Annual Meeting, American Lung Association, 1740 Broadway, New York, NY 10019, USA). Course in Magnetic Resonance Imaging: Trondheim, Norway, May 30-June 3 (Ingrid Susann Gribbestad, The MR Center, N-7034
USA, April
Trondheim, Norway). 4th annual meeting of the European Society of Human Reproduction and Embryology: Barcelona, Spain, July 3-6 (ESHRE Secretariat, c/o Bruno Vanden Eede, A7--VUB, Laarbeeklaan 101, 1090 Brussels, Belgium). International symposium on Recent Advances in Male Reproduction: Hyderabad, India, July 12--14 (Prof P. R. K. Reddy, School of Life Sciences, University of Hyderabad, Hyderabad 500 134, India). 8th international congress of Endocrinology: Kyoto, Japan, July 17-23 (Society for Endocrinology, 23 Richmond Hill, Bristol BS8 1EN, UK). 20th international meeting of Organisation Gestosis: Cork, Ireland, July 27-29 (Convention & Incentive Services, CIE Tours International, 35 Lower Abbey Street, Dublin 1, Ireland). 8th world congress on Medical Law: Prague, Czechoslovakia, Aug 21-25 (Czechoslovak Medical Society J. E. Purkyne, 8th World Congress on Medical Law, P 0 Box 88, CS-120 26 Praha 2).