The NHS post-Francis: a UNISON report
November 2013
INTRODUCTION
The report by Sir Robert Francis QC into Mid Staffordshire NHS Foundation Trust represents an opportunity to learn from and to address the issues raised in order to improve the NHS for patients and staff alike and to ensure that the mistakes that occurred must never be repeated.
UNISON is the major union in the health service, representing more than 450,000 healthcare staff employed in the NHS and by private contractors, the voluntary sector and GPs.
UNISON members include nurses, midwives, health visitors, healthcare assistants, ambulance staff, occupational therapists, cleaners, porters, catering staff and admin and clerical staff.
As an organisation whose membership encompasses almost the entire healthcare team, UNISON is in a unique position to respond to the wide-ranging implications of the Francis report and the subsequent reports by Camilla Cavendish, Sir Bruce Keogh and Professor Don Berwick that it triggered. We have put together this report to look at some of the key themes arising from these reports and to suggest areas where the NHS should be encouraged to go further than many of the recommendations propose and areas where we believe a more considered approach may be needed.
UNISON believes that there is a need for immediate action in some areas, but that the government’s response to date has been a timid one. We therefore hope to highlight the areas where we believe urgent action is needed and wish to make the case for these in this document.
Key points and recommendations
STAFFING LEVELS
· UNISON would like to see guidance on minimum staffing levels from NHS England produced as an interim measure. We believe that if interim advice is not produced patient care will suffer.
· UNISON strongly believes that the NHS needs to establish safe minimum staffing levels to reduce the potential for harm to patients in the provision of care. We believe that the government must act quickly on this matter and listen to the growing support for such a move.
· UNISON believes that a ratio that allowed for one nurse for every four patients is desirable to provide the optimum care for patients.
· While recognising that getting the right skill mix can be a complex process which must relate to patient dependency and location, UNISON believes it is essential that guidance on this is provided as a matter of urgency.
REGULATION
· UNISON believes that there needs to be a considerable strengthening of the CQC as an inspector through an increase in the number of staff to ease current problems with staff working long hours and managing excessive caseloads.
· UNISON strongly believes that the CQC must devote more time and resources to listening to staff working in health and social care as a means to identify and respond to issues and problems quickly. There should also be a requirement on the CQC to engage with trade unions as part of the inspection regime.
GOVERNANCE AND LEADERSHIP
· UNISON believes that a designated board member, preferably a non-executive member, should be accountable for staff satisfaction and staff engagement. There is now a strong body of evidence linking staff wellbeing to the patient experience of care. A designated staff engagement board member would send a strong message to staff that their voice is important and that there is a board-level channel available where their concerns will be listened to.
· UNISON welcomes the role of employee director in Scotland and believes that work should be done to develop a similar role across the UK.
· UNISON would like to highlight the need for greater training and support for board members, in terms of developing skills to examine data and information accurately and to listen effectively to patients and staff.
ANNUAL EFFICIENCY SAVINGS
· UNISON believes there needs to be a greater emphasis on long-term improvements to patient care rather than a short-term approach to achieving arbitrary cost cutting targets. The time frame within which trusts are required to meet these efficiency savings is too short and too short-sighted.
PATIENT, PUBLIC AND LOCAL SCRUTINY
· UNISON would support a move towards a majority of democratically elected members on Health and Wellbeing Boards. We also would welcome a role for local trade union representatives on the boards in order to ensure there is a proper channel for staff concerns. The boards should also be given the power of a veto over commissioning plans where they are not in the best interests of patients.
STAFF REGULATION
· UNISON would like to see multi-disciplinary inspections of quality assurance by regulators in HEIs and the placements they provide. Such an approach would ensure consistency in education standards across healthcare professional training.
· UNISON believes there is a need to listen to and increase the value placed on the views of students as part of these inspections and also to make this process uniform across the healthcare regulators.
· UNISON believes that if the NMC could launch its own investigations, it would undermine the role of the CQC in this area as well as create a confusing situation where there was too much crossover between the roles of the separate bodies, potentially meaning some issues could slip through the gaps. Therefore, we would suggest that a better system would be for the NMC to raise concerns with the CQC to allow them to consider whether to undertake an investigation and vice versa.
· UNISON does not support recommendation 227 of the Francis report. However, we believe that recommendations 35, 226 and 234 would help to enable closer working and improved information sharing.
NURSING
· UNISON believes that more emphasis needs to be given to ensuring student training and placements reflect the shift towards more community-provided care and that there is parity in access to training and development for staff working in community health.
· There needs to be more emphasis on the “soft” management skills , such as the ability to communicate well, build teams and develop staff.
· UNISON would welcome greater consistency in the recruitment of students onto training programmes and believes that all organisations should follow national guidance regarding this.
· We believe that students should be employed and salaried while studying, or at the very least receive a cost of living bursary.
· UNISON supports the need for a strong nursing voice, as suggested in recommendation 192 of the Francis report. However, we have concerns about linking this to the NMC, in part due to the cost of such a scheme and thus the impact on registration fees.
· UNISON supports recommendation 196 regarding the Knowledge and Skills Framework (KSF) and believes all NHS employers should use this as the basis for creating career and development paths for staff.
· The ‘key nurse’ approach to care, as outlined in recommendation 199, is one that UNISON supports. However, for it to be fully realised there would need to be detailed consideration given to staffing numbers and shift rotas.
· UNISON supports, in principle, Francis’s recommendations 207–212 regarding the role and registration of healthcare assistant (HCA) and believes much of this has been reiterated by the Cavendish Review.
· Based on feedback from our HCA members, UNISON was the first organisation to call for statutory regulation of HCAs. However, we do not think that the NMC should be responsible for this function given that HCAs work across both health and social care settings. We believe the Health Care Professions Council (HCPC) would be best placed to undertake this work immediately, especially as changes would need to be made to the regulatory powers of the NMC to undertake this work.
· UNISON would argue there is an urgent need for a regulatory system that delivers effective public protection, especially where staff work in isolation.
· There remains an issue of delegation of tasks and duties by registered staff to others. Many staff feel uncertain about what responsibilities should and should not be delegated. UNISON believes this is due in part to the lack of a clearly defined nursing role in many circumstances. We believe that this could be addressed by the NMC if the roles and responsibilities which should only be carried out by a nurse were clearly set out, as is currently the case for midwives.
· While recognising that this is a devolved responsibility, UNISON believes that we can learn a lot from the progress already made in Scotland, Wales and Northern Ireland in developing a code of conduct for HCAs and we would argue that public protection may be best served by a consistent approach to a code of conduct across the UK.
SOCIAL CARE
· UNISON recommends that its Ethical Care Charter should be adopted by councils commissioning homecare and so:
- ending the use of zero hour contracts and 15-minute visits for personal care;
- ensuring that travel time is paid to avoid call-cramming and rushed and inadequate care visits;
- training for care staff to be subject to standardised quality standards and with consistent qualification requirements;
- Councils’ adult social care functions including their commissioning practices to be subject to regulation across the UK. In England this means that the Care Quality Commission should have powers restored to inspect councils’ social care functions;
- Government should work with stakeholders to agree a set of national bench mark prices for social care (residential, day, domiciliary etc), which reflects the true cost of caring for the most vulnerable in our society and the true value of the work done by care workers.
· Staff who have undertaken a programme of study should have the opportunity for their learning to be credited to any certificate developed.
EXPERIENCE OF DIRECT PATIENT CARE FOR STUDENT NURSES
· UNISON is committed to working with HEE on the current pilot regarding experience of direct patient care and believes some valuable lessons could be learnt from it, but the limitations and challenges of the pilot must also be recognised. UNISON proposes an alternative approach which would be to support existing HCAs and support staff on to professional training via secondments.
STAFF ENGAGEMENT
· UNISON would support further research or a pilot project to look at the most effective means of staff engagement and to understand the benefits this can have on patient experience.
· UNISON believes that there is also a greater need for organisations to work in partnership with trade unions. Trade unions reps will often hear about staff concerns before managers and so closer partnership working will provide another mechanism to ensure that issues are not ignored.
· UNISON believes that the staff satisfaction survey should continue to play an important role in assessment of the state of services and that it should consistently be carried out by all organisations in all settings providing, commissioning or planning NHS services or care. UNISON believes that this should be included as a term of business for the NHS and that the DH should monitor the information provided.
· We believe that the NHS and other organisations should work in partnership with UNISON to roll out and deliver UNISONs Be Safe to ensure staff feel confident in raising concerns.
WHISTLEBLOWING
· UNISON wishes to see a change in the law on whistleblowing to allow for the protection of an individual or collective group, in order to encourage staff who may feel too isolated to raise their concerns alone and to protect trade union reps when they are approached by individuals over matters of concern.
DUTY OF CANDOUR
· UNISON supports the need for honesty, openness and transparency in the NHS, as well as a need for greater corporate accountability.
· UNISON believes there are already sufficient checks and balances imposed upon individuals working within the NHS, so imposing additional statutory duties upon individuals (as opposed to organisations) is not necessary.
STAFFING LEVELS
Staffing levels have come increasingly under the spotlight since the publication of the Francis report. However, many factors are adding to the strain on existing staffing levels, such as the thousands of job cuts that have taken place since 2010 or the 20% drop in the number of student nurse training places for the academic year 2011/2012.
Although the Francis report stopped short of proposing the mandatory use of minimum staffing levels, recommendation 23 called on the National Institute for Health and Care Excellence (NICE) to produce “evidence-based tools for establishing what each service is likely to require as a minimum in terms of staff numbers and skill mix”, as well as a consideration of the “benefits and value for money of possible staff: patient ratios”.
UNISON fully supports this recommendation. However, the production of advice from NICE will not be immediate and could in fact take years. Meanwhile the CQC continues to publish reports that indicate that staffing is a major issue, which indicates there is an urgent need for guidance.
UNISON would like to see guidance from NHS England produced as an interim measure. We believe that if interim advice is not produced patient care will suffer.
Alongside minimum staffing levels, other measures will need to be introduced to ensure that patient safety is paramount. Staff must be empowered and encouraged to flag up situations where staffing levels may have an impact on their ability to maintain quality services, for example where staff could be forced to breach good practice guidance and/or professional codes of conducts. Understaffing may force staff to cut corners, if, for example, staff are under pressure and do not have time to record information correctly or they are forced to delegate tasks to colleagues without proper training or supervision.