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Change in the NHS is the one constant that we have all come to rely upon. As the NHS enters perhaps the most significant series of changes since its inception, we wonder if there are lessons to be learnt from the bust, boom and bust again of the last 20 years. So, (in roughly 500 words or thereabouts) here we go...

 

A (Very) Brief History: This period of time from 1990, when the last recession was starting to bite, to the boom times for public spending under Labour in 2006, the NHS underwent landmark changes that affected how things were organised and paid for in this market. The most significant of these included those to primary care, notably the implementation of the new GP contract in 1990/91, the abolition of GP fundholding almost 10 years later in ‘98/99, and the creation of primary care groups – later primary care trusts – at the turn of the decade in 2000. Acute care did not escape financial reform as foundation trusts were introduced in 2004/05 and Payment by Results (PbR) was introduced. High level administration of the health service also underwent restructuring with the reduction of the 14 ‘health authorities’ to 8 in ‘96/97 and the removal of the NHS Executive. Even arm’s-length bodies were subject to change, e.g. the replacement in 2005/06 of the Modernisation Agency by the NHS Institute for Improvement and Innovation.

 

Some Equally Brief Stats: During this time period from 1990-2006, deficits and surpluses were identified at SHAs, PCTs and trusts. In 2005/06, of approximately 600 NHS organisations, 216 were in deficit, 11 at breakeven and 371 in surplus. If this is broken down to organisations, one SHA was in deficit, with the remaining 27 in surplus; 125 PCTs were in deficit, one at breakeven and 177 in surplus; 77 NHS trusts were in deficit, 10 at breakeven and 148 in surplus; and of the 32 trusts that were foundation trusts, 13 were in deficit and 19 in surplus. In effect, 36% of organisations were in deficit, 4% of SHAs, 38% of PCTs, 33% of NHS trusts and 40% of foundation trusts.

 

These figures give an indication as to the source of the deficits. Put simply there are deficits caused by paying for the treatment for patients and paying the people to do the treatments, i.e. the workforce.

 

A Word (or 180) on Contracts: So just how far ‘out’ was the workforce planning against the actual cost of a quality workforce? In terms of contracts:

 

The revised contracts, Agenda for Change, the 2003 consultant contract and the general medical services contract, have undoubtedly been a contributing factor to the NHS deficits. Whether this is a negative situation is questionable. The overspend on Agenda for Change was estimated at £220 million; the consultant contract £90 million and the GP contract in £250 million. This gives a total overspend of £540 million. This is remarkably similar to the net deficit in 2006 of £547 million.

 

On first consideration, the figures quoted above may imply a complete lack of ability of the contract negotiators, but ... The NHS workforce increased in terms of headcount from 1.098 million to 1.365 million during the period 1999 and 2005. At face value this may be viewed as a positive thing, as there were significant increases in all clinical staff groups. Even the headline figure of a 62% increase in senior managers, when considered further is more than reasonable, considering this represents under 39,500 people managing a workforce of 1.365 million, fewer than 3%.

 

A Target on Targets: If therefore the increases in staff salaries and staff numbers are a good thing, then how has it gone wrong? It appears that the NHS surpassed the targets set in the NHS Plan of 2000. The consultant workforce was 3% under target, with only 7,329 new consultants in post against a target of 7,500. The other main clinical staff groups were vastly above target. GPs were 105% over with 4,098 new appointments against a target of 2000; nurses an incredible 340% over target, 67,878 against a target of 20,000; and allied health professionals 69% over target with 11,039 in post against a target of 6,500.

 

An Even Briefer Conclusion: So is it revised contracts? Over-recruitment of clinical or managerial staff? Targets? Or is the cost of a quality health care system just more expensive than was envisaged? What is clear is that clinical workforce planning is like a Rubik cube... hard to get completely right, easier to line up one group at the expense of the others; nevertheless it remains defiantly the future.

 

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