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The Ward Round: The RCN makes (another) break for it

Published on: 22 Mar 2023

Staffing is the issue keeping NHS leaders awake at night – and which consumes two-thirds of trusts’ spending. The fortnightly The Ward Round newsletter, by HSJ workforce correspondent Annabelle Collins, ensures you are tuned in to the daily pressures on staff, and the wider trends and policies shaping the workforce.

Could this be the beginning of the end for Agenda for Change? The pay deal finally reached by the healthcare unions and the government – and how it might be funded, which is still unclear – grabbed the headlines last week. But the non-pay commitments that emerged alongside it have put the cat among the pigeons.

In a letter to the Royal College of Nursing’s chief executive and general secretary Pat Cullen, Steve Barclay committed to work to tackle “specific challenges faced by nursing staff in terms of recruitment, retention and professional development”. He said this could potentially involve a separate “pay spine” for nurses – meaning, in practical terms, a pay scale outside AfC.

Having irritated other unions in February by entering “intensive talks” with government alone, the RCN had then sought to present a united front in negotiations over the last few weeks.

But it can be assumed other unions are again not best pleased with the RCN over this “pay spine” discussion.

The latest breakaway move was described by one insider as perplexing, with another adding: “I don’t know what they [the RCN] are doing… it’s going nowhere.”

Another argued it wouldn’t make anything better for the RCN’s members, and pointed to an evaluation of nursing and midwifery job profiles already being done by the NHS Staff Council.

So why is the RCN pushing for a separate pay spine? The simple answer is to get a better pay deal for their members, as it will be more likely that more money may be directed at one staff group over others.

However, Billy Palmer, senior workforce policy fellow at the Nuffield Trust, said this would have “lots of challenging consequences” that cannot be overlooked.

There was a risk that disaggregating Agenda for Change by profession would bring a return of the pay inequalities the framework was introduced to address in the first place in the 2000s, he said. Other concerns include how a nurse-specific framework would fairly capture either registered nurses working in non-nurse-specific roles or where registered nurses and other professions do the same or similar roles.

Mr Palmer said the concern that AfC is now outdated was a “salient point”, as graduates’ expectations of pay and progression had changed a lot, but he argued this should be looked at “more broadly”.

There are other ways to navigate AfC’s limitations, he pointed out, like shifting a greater proportion of nurses to higher bands compared to other groups; and promoting advanced practice for nurses. Funding has to be available to give everyone these opportunities, however.

In an HSJ article this week, the Health Foundation’s Anita Charlesworth and James Buchan argue that the “founding aspiration” of the AfC framework must not get lost in any new proposals from the RCN, concluding that a “divide and rule [approach] would be disastrous for the NHS”.

In another non-pay offer to the RCN – less controversial with other staff groups – the Department of Health and Social Care said it would look at “introduc[ing] measures to ensure safer staffing levels in hospitals”, and “work with unions and employers to identify more way to tackle and reduce violence against NHS staff”.

There has long been a campaign to legislate for “safe staffing” – and back in 2015 we came close to getting official clinical guidelines, until the National Institute for Health and Care Excellence had to suspend its work.

There are laws in Scotland, Wales and elsewhere which, it is argued, improve safety and reduce deaths. But the Westminster government has so far resisted, and the chances of it relenting now are slim.

Downskilled doctors

The chair of NHS England stirred interest around the forthcoming (we hope) long-term workforce plan this week with some comments on medical training at an event held by the Social Market Foundation.

Richard Meddings appeared to agree with former health minister Lord Warner that medical training could be made shorter, in order to get more docs for less cash.

Mr Meddings did not quite utter those words himself but, as reported by the Daily Telegraph, he did say: “We train [doctors] to full skills and the way we work in the system most of the doctors don’t get to work to their full skills. So actually there is a need to change that.”

The former banker segued quickly to citing an expansion of physicians associates as part of the answer, and general commentary about clinical reform and skill mix.

Academy of Medical Royal Colleges chair Dame Helen Stokes-Lampard, a GP, argued on the BBC’s World at One that Mr Meddings’ comments had been taken out of context. There was “a lot of misunderstanding about doctor training in the UK… you don’t have to be a fully qualified GP or consultant to give massive service”, she explained.

Dame Helen added: “There are many things that can be done before looking at the length of training… there is no way we will compromise on the standards and quality of that. It does take a long time to train a doctor to do their jobs well, but that is right and proper.” If you like you can judge for yourself what Mr Meddings’ meant, as the video is online.

Undoubtedly the long-term workforce plan will lay it on thick around reforming roles and staffing models, the importance of generalism, and skill-mix flexibility. The Treasury will, as we speak, be trying to ramp up estimates of the productivity improvements these can bring.

But diluting the training of medical students, and even trying to replace doctors with unregistered staff, is not the answer to the workforce crisis. Nor is the red-herring of increasing medical school places.

Instead, look at higher training. Perhaps this could be condensed, made more efficient, and more training numbers funded to ease up the specialty training bottleneck. And then there is the whole other subject of improving doctors’ working lives to retain more talent in the NHS. One for another Ward Round altogether. 

Tributes paid to Andrew Foster

Like so many others I was shocked to hear of the death of well-known and liked former NHS chief Andrew Foster this week. A true workforce expert and advocate, and an extremely kind man who was always generous with his insight, and the odd tip.

He made an enormous impact in the DHSC in the 2000s, including implementing the momentous Agenda for Change, discussed above.

And he really cared about making the NHS a better place to work – last year he spoke to the Ward Round about his campaign for the Nursing and Midwifery Council to urgently review the English language test for overseas nurses, frustrated by its lack of urgency to speed up employment of this valuable group.

Readers’ comments below HSJ’s piece on his passing are really moving and his loss will clearly be felt in all corners of the service.