A flagship London hospital trust is reducing the proportion of qualified nurses on its wards as part of two-year cuts programme – confirming the worst fears of campaigners that NHS management would resort to cutting highly-trained staff to make ends meet.
Details of a package drawn up at the Barts and London NHS trust reveal there will be a minimum of one qualified nurse to seven patients on general wards although higher ratios will be kept in some areas including critical care.
In documents leaked to the Guardian the trust outlines a plan to save money by cutting more than 10% of qualified frontline nursing staff from its wards, , raising concerns among nurses, a major cancer charity and a national patient group. It runs Barts, the Royal London and London Chest hospitals, and is to cut more than 250 nursing posts among 630 jobs being axed. About 100 beds for patients, equivalent to four wards, are also going, including 22 cancer beds which have already gone.
Barts says the present 80% to 20% mix of qualified nurses to unqualified support staff is higher than comparable trusts and should be reduced to 70 to 30, as already exists in its cancer centre, opened by health secretary Andrew Lansley last month.
But it also says there are too few senior nurses on wards so will cut “non-ward-based” posts. Posts linked to Macmillan Cancer Support are among those at risk. Its chief said trusts nationally should not reduce specialist nursing staff who help keep patients out of hospital, a warning echoed by the Royal College of Nursing (RCN), which also raised questions over the trust’s patient to nurse ratio.
The Barts details emerged as a King’s Fund report revealed NHS finance directors’ predictions of job cuts and ward closures. They coincided with Macmillan claiming that experience of cancer patients at Barts was among the worst in England. The trust comes fourth from bottom in its analysis of Department of Health figures. It included factors such as the number of nurses on duty and whether patients got enough support after leaving hospital.
Barts already has about 500 unfilled posts – its overall staffing establishment is about 7,400 – and hopes to save £56m, a fifth of that, on nurses’ job cuts. In a statement, it said a 70-30 skills mix had been the norm until three years ago. “Within this ratio, we will see more senior nurses and fewer junior nurses on our wards. This skill mix and experience is in line with many other leading centres and is better for patients who benefit from well-run wards, led by more senior nurses who oversee patient care and support junior staff … From the start of our workforce consultation process we have been very clear that we are not cutting frontline clinical service.”
The trust would increase day treatment and reduce hospital admissions. Posts of lead cancer nurse and consultant nurse for chemotherapy were “primarily training and managerial positions” and could be “absorbed” without harming patient care. A decision on a third, unfilled, post for a neuro-oncology clinical nursing specialist had yet to made.
The RCN’s head of policy Howard Catton welcomed involvement of nurses in drawing up Barts’ proposals, but added: “Just because you may be above a benchmark, that is not a good enough reason to say ‘we have to go down to the level of the benchmark’. Barts is in one of the world’s major cities, is a teaching centre and has a more complex mix of patients, sometimes with rare conditions and diseases. There may be very good reasons why they have a higher skill mix because of the patients they have and their teaching and research responsibilities.”
The number of patients per nurse was critical in terms of safety, said Catton. “Seven (patients) is a bit at the high end for me. I would prefer to see five or six.” Ratios might change during a shift – with patients being discharged and others being admitted to wards – so there could at times be one nurse to 10 patients. “That takes one into territory where risks increase.” He also raised concerns over cutting non-ward based and specialist nurses. “Things can change very significantly very quickly. There can be some quick but very important clinical decisions about moving staff around that need experts. A minimum (staffing ratio) can quickly become a maximum.”
Katherine Murphy, chief executive of the Patients Association, said: “With pressures on budgets there is a real danger trusts will replace highly skilled nurses, with cheaper unregulated healthcare assistants and leave people being cared for by staff who do not have any national safeguards or accountability.”
Macmillan, whose name is linked to more than 5,300 specialist nurses, doctors and other clinicians across the UK, is in discussions with the hospital. It still “badges” the lead cancer nurse at Bart’s and funds the vacant post. Its chief executive Ciarán Devane, said: “We know that the NHS is under a lot of pressure to cut costs, but NHS managers need to make good choices on how they respond to this. Instead of asking some specialist nurses to do routine work, they should ensure specialist nurses are using their skills to make patients happier and healthier so they spend less time in hospital – therefore saving the NHS money …”
The charity pays the costs of posts for the first two or three years before the NHS funds them. It currently supports 1,000 posts. The NHS supports more than 2,900 posts, funding for 300 new posts has to be finalised and about 1,000 others carry the name because they are in Macmillan teams.