The attack on the NHS takes many forms, and a lot hinges on our ability to choose fights wisely and make sure we win...

A victory in the battle for nursing education – but the attack continues

WORKERS, FEB 2013 ISSUE

For two years, despite clear and mounting evidence that the policy endangers public safety, training places for student nurses working in the general adult nursing field in London have been reduced. Since 2010 this has amounted to a 20 per cent reduction. It was due to be reduced by a further 10 per cent in September 2013 but this has now been withdrawn. There will not now be a reduction on the 2012 numbers. It is important that this small but significant victory is put in a wider context.

Nurses on the TUC’s October 2012 march against government policies.
Photo: Workers

It cannot have escaped anyone’s attention that the nursing profession in Britain is under the most sustained attack in its history. This has taken a number of forms. Firstly, a reduction in nursing posts: the NHS Information Centre has reported that 5,216 nurse, midwife and health visitor posts have been lost in England between May 2010 and July 2012. Although the Department of Health claim that support posts are being increased, 5,967 nursing support posts have been cut in the same period. A particularly underhand form of enemy attack is the reduction of nursing specialists, for example, diabetic nurse posts. As these nurses tend to be the most experienced, this strategy dissipates pools of expertise and standard setters from a locality.

Another form of attack is more insidious and involves highlighting examples of poor care, which certainly exist, attributing these to individual nurses for being “too academic”. Take one example of poor care which has been formally investigated, namely the Mid Staffordshire hospital. What were its conclusions?

Certainly patients died, and poor nursing care was a factor in many of the deaths. But the conclusion of the report highlighted managerial and financial decisions which had been catastrophic to care standards, workplace culture and organisation. (See Box below for just one example from many). There was no reference in the report’s recommendations to overly academic nurses.

So the nursing profession is under attack on many fronts but from the enemy perspective, the cleverest form of attack on the nursing profession is the one which has not hit the headlines: namely the reduction in student nurse places. If you can strangle the flow of recruits to a profession, then that profession and the service it sustains dies. There are parallels in the attack on the teaching profession in Britain.

In 2011 all the higher education institutions which provided nursing programmes for London students were obliged to bid for the ability to continue to receive their Department of Health funding. This very bureaucratic competitive tendering process resulted in the reduction in student nurse numbers in London in September last year with one institution, the University of West of London, losing its contract altogether. Many others had their student numbers reduced. As a result, very experienced nursing lecturers lost their jobs through a combination of compulsory and voluntary redundancy.

No one knows how many posts have been lost as only the compulsory redundancies are counted. Even trade unions apparently only count compulsory redundancies, but surely the equation is: compulsory redundancy + voluntary redundancy = the total loss of skill. Now that the planned reduction in student numbers for 2013 has been withdrawn, this victory for students and the service may also provide an opportunity for lecturing staff to regroup.

The attack on student nurse numbers has not been limited to London, and other NHS professions have been affected. There have been reductions to training numbers in the allied health professions, with physiotherapy and occupational therapy particularly hit. Every health region in the country except one has seen reductions in student nurse numbers in the past two years. It is not yet clear whether the ability of London to challenge this trend for the next academic year will be replicated elsewhere.

The situation in Scotland continues to be very worrying despite the frequent assertions from the Scottish Nationalist Party that they are better at looking after the health service compared to England. This year 2,430 student nurses started training in Scotland compared with 3,060 two years ago – a reduction of 20 per cent. Now a report to the Holyrood parliament health committee shows that the overall bursary budget for student nurses is dropping from £69 million to £67 million next year. So Scotland is clearly planning further reductions despite a third of its nursing workforce being over 50.

‘A concerning lack of clarity’

Extract from the executive summary of the Francis Report Inquiry into care provided by Mid Staffordshire Foundation Trust:

“The Inquiry could not trace any record of the medical floors part of the plan being considered or approved by the board. In particular, the changes of nursing skill mix, which resulted in a predominance of healthcare assistants over qualified nurses, are not recorded in any Board minute seen by the Inquiry. There were differences of account between executive directors as to who was involved in the decision and the change was disowned by the Director of Clinical Standards, and [the] only nurse on the board, in evidence to the Inquiry. There was a concerning lack of clarity about the process by which this important decision was taken.” ■

Fighting back

The tactics involved in fighting back against this attack have not involved any demonstrations but they have involved trade unionists, professional bodies and local organisations working in a variety of ways. The under-rated trade union and professional tool of “marshalling the facts” was used and needs to be taken up by workers in many different workplaces. In an age of “career politicians” (whatever that means) any worker who understands the nature of their workplace is always more knowledgeable about that workplace than the average politician.

One rough and ready tool in this fight was for nurses to constantly ask “how come we need fewer nurses when a) the population is going up, and b) the population that makes most demands on the NHS – those 85 and over – is rising sharply for at least the next couple of decades? (According to the Office for National Statistics, the 85+ population rose from 660,000 in 1984 to 1.4 million in 2009, and is projected to rise to between 3 and 5 million by 2034.)

The other part of the argument focused on detailed knowledge that all the health trade unions have about the age profile of the NHS workforce. One of the myths promoted in the NHS is that “workforce demands cannot be predicted at all” and therefore we must all go on “local knowledge”: if local employers are currently reducing posts, then students should not be trained. However the NHS, more than many other employers, has very detailed information on its workforce and certain things are entirely predictable. In fact Britain has one of Europe’s leading health workforce experts James Buchan working at Queen Margaret University, Edinburgh. He published a report in July 2011 on the nursing workforce, “The Decisive Decade”, which stated that Britain then had 352,000 qualified nurses, midwives and health visitors. As it stood even that figure was below the European average for the population served. He predicted that unless the current trends can be reversed this number will reduce to 253,000 in a decade. The full report can be read at www.rcn.org.uk/__data/assets/pdf_file/0004/394780/004158.pdf

The EU and nursing education

As well as documenting what has happened to Britain’s nursing workforce, the other aspect of James Buchan’s work has been to highlight how periodically the NHS has relied on plundering the nursing workforces of other countries to fill the politically created gaps.

After the Thatcherite period of supposed “over-provision” of nurses in the 1980s, NHS managers travelled the world recruiting from countries such as the Philippines and Zimbabwe. Even the Deputy Leader of the Scottish Conservative party was recently quoted in the Daily Record saying that the current reduction in student nurse numbers in Scotland is “severely short sighted” and “we will have to hire significant number of nurses from overseas to account for this deficit and that is something the public will not find acceptable”.

Is the current government relying on the free movement of labour in the EU to fill the predictable shortfall? For three decades EU legislation on mutual recognition of qualifications for regulated professionals has allowed EU nursing qualifications to be recognised in Britain. But the UK Nursing and Midwifery Council (NMC) as the regulator could set its own regulations. This meant that nurses with qualifications below British standards could not join the register without further training.

In 2010 the government agreed to adopt EU proposed changes to that directive making it easier for employers to employ EU nurses. But nursing trade unions and the regulator continued to highlight the risks of recognising inferior qualifications and, in particular, the fact that testing English language skills under the directive is solely the responsibility of the employer rather than the regulator. In June 2012 the University and College Union annual congress passed a motion which brought together the attack on student nurse numbers and the risks to patient safety from the directive.

Exactly why the Department of Health has changed the stance in relation to student nurse numbers in London is not clear. But the persistent questioning about workload, the ageing workforce and the dangers of relying on staff with inferior qualifications and poor language skills have all probably played their part.

Many questions remain: What is happening to student nurse numbers outside of London? What is happening to lecturing posts? Do NHS staff and the rest of the working class truly understand why the fight for student numbers in all of the professions is important for all workers now and in the future?

So yes, an important victory – but there is much work to be done. ■