Examination of Witnesses (Questions 180
MONDAY 29 OCTOBER 2001
180. I just wanted to ask Robin or Stephen if
they wanted to comment on the question. It is very complicated,
you hare bed numbers and PFI, the same things applies, it is flies
pressure on clinical, stress on workers. Is that anything to do
with PFI in your opinion?
(Mr Moss) You asked earlier about turnover in the
hospital, there is a huge turnover problem and a huge staffing
problem within this hospital at the moment. I will take one ward,
ward 10, there are ten beds closed on ward 10 because of staff
shortages, five trained staff have disappeared out of that wards
in recent weeks.
181. What we are really trying to do in this
inquiry, you blamed a lot of this on PFI, I want to see what evidence
you can adduce for that?
(Mr Moss) It goes back to the affordability question
with regard to the staffing levels. In 1996-97 there was an acute
affordability crisis. Various figures came out of that but the
figure that was quoted at the time there was an affordability
gap of £3.8 million. That was subsequently added to and in
the last three years it became a £5 million acute affordability
gap. The way in which that translated itself into staffing numbers
was that the clinical staffing budget, i.e. doctors and nurses
were cut by 22 per cent. In the year 2000 as a result of cut upon
cut upon cut to make this affordability gap 13 per cent fewer
trained nurses were employed.
182. We are trying to identify this to PFI.
We have already been told you were going through a major reappraisal
to deal with financial problems; how much of these affordibility
problems can you really say is due to the PFI option against the
public option? I accept it was different in 1994. We want to identify
the difference due to the private sector involvement.
(Mr Weeks) It is difficult to isolate the PFI set
because there is no comparable to compare it with. The number
of public sector hospitals publicly financed has been reduced
to such a small proportion. We believe we have given circumstantial
evidence on repeated effects that we believe are directly linked
to PFI. The government is changing assumptions about bed numbers
and we welcome that, and we welcome the National Beds Inquiry
change the overall direction on bed numbers and to some extent
they change the assumptions about staffing and about absolute
numbers of nurses, and again we work on that. What that means
is the schemes are having to go back and revise upwards their
bed numbers and revise upwards in some cases their staffing levels,
that has a cost implication because the original schemes were
based on different assumptions.
183. It would on both sides.
(Mr Weeks) We cannot test that because there are no
publicly funded hospitals, with a handful of exceptions, to test
it against. We believe there is a direct PFI link.
184. Whether or not the pressure is on beds
as a result PFI I would like your view, we now have a PFI scheme,
if there was a decision to increase beds the PFI existence would
make it more difficult for that to be proceeded with?
(Mr Weeks) We believe it makes it more costly for
that to be proceeded with because the assumption is built into
the costing of PFI. Some extra money would have to be found from
somewhere, and the Trust are looking at providing extra beds,
albeit by buying them in the private sector.
185. If the Trust was looking to provide extra
beds, whether there was a PFI scheme or no PFI scheme, there would
be extra resources essentially. In terms of achieving and increasing
the beds and staffing levels increase do you believe there are
more problems because the hospital is a PFI one?
(Mr Weeks) We believe that a contractual relation
with a private sector consortium and a guaranteed income stream
does create additional problems.
186. Can I go back to nurse staffing and nurse
morale. I was delighted when we went to the medical admissions
wards because to my absolute amazement they said they were well
staffed. Going back to that article in the Guardian, that
I am sure you all remember, we had impassioned pleas from nurses,
"I keep having to say I am sorry, you are just going to have
to wait. We do not have time to watch people. It is every day
basic care. The pressure of beds is intense and as a result normal,
good practice is often compromised." Was that so at the beginning,
and you have got over it, or is it still so? Did we see the one
well staffed ward in the place?
(Mrs Lemmon) I think you will find the staffing levels
vary from ward to ward?
187. You do have tremendous pressures in some?
(Mrs Lemmon) One of the surgical wards I can think
of particularly because they took all of the inpatients with them
when the moved happened, they took patients with them that could
not be discharged or could not be put else where, so they hit
the ground running, if you like, and they set up their wards and
they made it work from day one with the patients, with all of
the pressures. I think it was just last week, when they had an
unforeseen lull in patient admissions, maybe due to consultants
being on holidays, they actually had some empty beds, and last
week and, this is now towards the end of October, was the first
time those girls had a chance to go round and make the ward as
they wanted it. They got a chance to sort out cupboards, they
got a chance to reorganise things, they got a chance to sit back
and take stock and actually set the ward up as they wanted to
run it. That is six months it has taken them to have the time
to do that. Up until then they ran on a system of organised chaos,
things had been put in cupboards but they were not quite sure
where they were because nobody had the time to do that because
they too busy looking after the patients. They have had, I think,
four or five staff leave since the new hospital opened.
188. From that one ward?
(Mrs Lemmon) One, because some of them were specificically
urology trained nurses and were led to believe from years ago
that we would have a urology unit within the hospital, this did
not happen, it was combined with surgery. When they moved the
combined urology and surgical unit they decided this was not what
they wanted to do but also because the pressures were intense.
The work load was intense.
189. In some areas those comments would still
(Mrs Lemmon) Some areas, yes, yes. I have to say some
areas are still very badly staffed.
190. Is that because there has been an overall
reduction in staff?
(Mrs Lemmon) I think it has just happened, we have
lost some staff. I do not think it is deliberate.
191. It is not related to the PFI and the reduction
in money for salaries?
(Mrs Lemmon) I do not think so because when we moved
up we did not have enough staff. You share out what you have to
where you can put them. If people still feel pressured then they
leave or they get on with it.
192. One of the complaints we received about
PFI schemes generally is a decline in the standards of some of
the services, cleaning, food, et cetera, et cetera. Would you
say there has been a decline in cleaning standards? Could you
also comment, I have always thought that it was the manager's
responsibility to ensure the cleanliness of the ward, do you think
there is a particular problems for nurse manager's enforcing cleaning
standards when the staff are not employed by and large by the
NHS and work for another employer?
(Mrs Lemmon) In this situation the staff who are responsible
for cleaning on the wards are employed by the Trust, they are
team assistants, support level staff. These used to be ladiesmostly
ladies, I beg your pardon for being sexistwho are the domestics
on the wards mostly. They now do the domestic duties, the cleaning,
et cetera. They are responsible for heating up the meals and serving
the meals. They are responsible for portering patients from the
ward to different areas, unless they are going on a bed or to
theatre, they take the patients.
193. They are not part of the PFI?
(Mrs Lemmon) The services are led from the ward. The
only time we have contact with cleaning services, the PFI people
clean the main corridors and the public access areas. The ward
cleanliness is solely the responsibility of the ward staff. We
do not have any cleaners, other than, I think, the other week
we had some Hayden people come in to clean the air vents and things
like that. The general day-to-day cleanliness of the wards is
totally the responsibility of the ward manager, who allocates
her team assistant support to do the ward cleaning. It is slightly
different from the old system where the domestic services cleaned
the whole hospital and could be found wherever the need was. If
you have group of six team assistant supports who work on your
ward and you have a couple people off with sicknessI think
there may be a bank now of team assistant supportsyour
responsibility is to keep the ward clean. I have known in one
situation where there was a sudden fall, people left or whatever,
in the team assistant supports I know one weekend the nursing
staff were cleaning the wards because they did not have anywhere
else to get the service from.
194. From UNISON's and RCN's point of view generally
is this a unique or unusual situation?
(Mrs Lemmon) It is certainly new to us, it is a whole
new system to us. Whether it happens elsewhere I really do not
know. I think this is where we had problems when it comes to the
boundaries, say something goes wrong, I have a problem on the
ward with the doors. I will give you an example, our main access
doors to the ward are fire doors, they have a little blue plaque
to say "fire door keep shut". A couple of months ago
on the other side of the door a little blue plaque arrived "open
both doors in the event of fire". We could not comprehend
that one side of the door was a "fire door keep shut"
and the other was "open both doors in the event of a fire".
In fact it was Hayden who had come and put these little black
plaques on. When I asked the fire officer for the hospital he
had had no input into this and he did not know who had given this
order. To this day I have not found out why that happened. It
is a lack of communication, whereas before I would have picked
up the phone and spoke to somebody in the estates office and said,
"what is going on", I was diverted and I could not find
the route of why that had happened. That concerns me, that I do
not have a direct line of communication. I can get day-to-day
jobs done but when something like that happens I cannot find out
who is responsible.
(Mrs Bottrill) You used the term "modern matron"
and also the term "senior nurse" which has been a very
vital part in ensuring teamwork and co-operation. It is our belief
if you had a group of senior nurses working on a PFI project they
would have given you all of the early warning signals and said,
X amount of feet between the beds, swing doors going to theatre.
Somebody with a broad clinical view if they had been involved
at the design stage would have saved people an awful lot of heartache
and, similarly if you are talking about team workers, everyone
revolves round the patient, and that is where you have to have
seamless care. If you have people responding to different masters
they do not then come under the authority of either the ward manager
or the senior nurse or the modern matron, use whatever title you
like. That is what it should be all about, having somebody with
senior clinical experience to actually advise people right from
the start before you even put the plans down.
(Mr Weeks) In terms of the overall record obviously
this Trust pioneered an approach to keep cleaning a part of the
ward team, and we warmly welcome that and worked with that to
try and make it work, notwithstanding our other differences of
view with the Trust. In terms of overall rapport with the private
sector in terms of cleaning servicesobviously the Committee
will be looking at that later onrecent evidence from the
Government's Cleaning Order is that private sector contractors
accounted for 20 out of 23 of those Trusts that failed cleaning
standards. As far as the PFI is concerned, in terms of functioning
PFI schemes, five out of the ten regarded as fully functioning
failed. They are obviously all cleaned by private contractors.
We accept there may be some marginal improvements compared to
traditional market testing but it certainly has not solved the
problem. We were promised, again it is one of the arguments for
PFI, the integration of cleaning with design and operation would
lead to a higher standard of cleaning standards. We think you
can say from the evidence so far that is not proven.
195. I want to ask the RCN about some of the
concerns you raised, things like staff facilities perhaps not
being there initially, being charged more for car parking and
meals, and so on. I wondered if that is something directly related
to PFI hospital or are there new build hospitals where you have
the same problems with accommodation and changes. Can you link
that directly to the private sector involvement?
(Mrs Lemmon) I would think almost certainly the car
parking services are related to PFI, that was part of the contract
with PFI that they got the money for the car parking.
196. You do think that would happen in the public
(Mrs Lemmon) When car parking charges were introduced
we were told it was in line with the government initiative to
try and get people back on to public transport and then we were
told, no, it was part and parcel of the contract for the PFI and
that it was built into that contract and there was no room for
negotiation, the costs was as it appeared and there was nothing
that we could do about it. We were never involved in those negotiations.
If you are looking for a sore point in this Trust then that is
197. I would just like to explore your feelings
about the transfer of staff. We are all very pleased that the
retention of the cleaning staff has worked well, but there is
a feeling there might be a move in future PFI projects transferring
clinical staff. Although that was hotly denied in April now we
think there is one or two happening, so watch this space on that
one. We talked to UNISON in particular and you stated your concerns
about the creation of a two-tier work force, in which the NHS
transferred staff for newly recruited staff but they are going
to carry out exactly the same job with different terms and conditions.
Has that been resolved, because the further down the route we
go the bigger that gap is.
(Mr Weeks) We believe that the best way of resolving
that is by not transferring the staff. There may be other ways
of resolving it and obviously we will pursue those if we not able
to pursue the nontransfer of staff. We are exploring with the
Department of Health a model known as the Potential Employment
Model, which would allow the majority of staff to remain NHS employees.
Examples of places like North Durham, where some sections of the
staff have been retained, shows that is very successful and we
are hopeful that the discussions round that will prove productive
and the pilot scheme that is being proposed will be implemented
and extended throughout. Obviously there is a whole issue round
the duty of work and Robin Moss can highlight some examples of
that. Obviously the most glaring one is the NHS pension scheme
we have secured with the government, and we pay credit to the
government on that, protections for transfer staff allow a broadly
comparable pension scheme. It has to be said that new employees
in most contractors do not access to a pension scheme of anything
like the same level as NHS staff, and transfer staff in particular.
We will put on record that Hayden is better than a number of contractors
in that it does actually have a pension scheme for its staff but
I do not think they claim it can be or is as good as the NHS pension
198. You are basically saying that over a period
of 30 years it is impossible to keep the staff in line because
of that. I use 30 years because that is the length of the average
(Mr Weeks) I am a trade union negotiator so I would
never say impossible. I think it would be very, very difficult
to find a mechanism to do that if the staff become employees of
another organisation. I know business service associations have
touted quite widely in the papers its proposal, they may have
some way to do that but we remain convinced that the best approach
and the one that deals with the issue of retaining the NHS staff
team, as well as the questions of the condition of service, because
conditions of service are only one issue, the key issue is to
remain part of the clinical team, working side by side with the
nursing staff to pursue the retention of employment model so that
staff remain NHS employees.
(Mr Moss) Our solution within the Trust to avoid the
two-tier work force was to ask Hayden to agree to NHS terms. For
some strange reasons they declined that offer repeatedly. It was
not such a big problem within Durham because of patient focused
care. Had patient focused care not been there something like 400
or 500 staff would have transferred. As it was 250 were supposed
to transfer but in the end, because of our work with the Trust,
a significant number of staff were redeployed before transfer
so only 100 staff went over. However, there are still problems.
You have a portering work force employed by Hayden where three
quarters of the staff are ex NHS, the other quarter are Hayden
staff, and the NHS staff are paid £35 a week more, because
the NHS staff get paid bonus, they get shift premiums, the get
shift enhancements, there are differences in sick pay, there are
differences in holiday, there are differences in bank holidays,
there are differences in the length of the working week, Hayden
staff work 40 hours and our members work 39. What you have within
the areas where there are these crossovers domestic, porters,
catering staff you have a lot of resentment and it does cause
friction and it does cause problems. It also causes problems to
Hayden, their problems in terms of running two sets of conditions
of service, two payrolls are enormous. It is only in the last
few weeks that we have not had enormous problems with getting
pay wrong as a result of the complexities of Hayden absorbing
NHS terms and conditions, the way in which protection is interpreted,
et cetera. Things are very difficult, they do cause industrial
relation problems, they do cause friction on the ground amongst
the work forces concerned. It is a nonsense that you have two
sets of people working side by side, doing the same job paid entirely
different pay rates and different conditions of service.
199. You would be in favour, presumably, of
the government's proposal to retain staff within the NHS whilst
working for the private sector, do you think that is a viable
(Mr Weeks) Absolutely, if it can be made to work.
Despite our objections to the private sector managing services
we are willing to work with that proposal.
Dr Naysmith: How did the concept of patient
focus care come about in Durham?