NHS REVIEW

Working for Patients - More questions than answers

Many commentators o n the Government's long-awaited review o f t he NHS' have crit icised the lack o f detail - and that is wha t the Industrial Relations Committee's sub-group concluded a t its f irst meeting.

The sub-group o f four members of t he commit tee - Bridget Davis, Tom Donnelly, Fiona Jenkins and Claire Strickland, together with Phillip Gray, director o f industrial relations, and Lesley Woodward, industrial relations off icer - is drawing up comments o n the Whi te Paper t o feed in to the Society's overall response and t o advise members, I

Working for Patients: The Health Service: Caring for the 7990s. January 1989 (ISBN 0 10 105552 8) HMSO, London, €8.80.

particularly o n the industrial relations aspects. At t h e first meeting, t he sub-group drew ou t a long list o f points and questions raised about each o f w h a t the Government describes as 'key measures' in the Whi te Paper. These have been put together as a series o f questions, below, w h i c h highlight some of the main issues for physiotherapists. They may be useful t o members in any local discussions.

The sub-group a t its second meeting started looking a t the eight working papers n o w published and this contributed t o the work o f t he steering group set up by Policy and Resources Committee chaired by the chairman o f Council. This will co-ordinate the Society's strategic response t o the review, and will be reporting t o Council in March.

Seven Key Measures 1. More Delegation of Responsibility to Local Level What is the precise responsibility that is being delegated?

If the Service becomes more fragmented, where does the responsibility for planning for patients' needs lie?

If District general hospitals become self-governing and services are contracted out, what is the role of District management?

Will access to local services be guaranteed?

Where do supra-District and Regional level services fit in?

What will be the effect on smaller hospitals and less popular specialties, eg geriatrics, mental health?

What will be tKe future role of District physiotherapists?

How will physiotherapy services be bought and sold? By the District? By consultants? By physiotherapists?

What access will physiotherapists have to facilities in other units, eg hydrotherapy pools, ultraviolet, prosthetics, wheelchairs?

How will cross-boundary services be catered for, eg paediatrics, elderly?

Will there be flexibility of use of staff across boundaries? What happens to rotations? What will be the effects on less popular units?

In the only specific reference to physiotherapists, what is intended by 'scope for more cost-effective working in other professions some of which, such as physiotherapists . . . make little use of non- professional helpers'?

Community services are not mentioned. How will they be provided? Co-ordinated? Controlled?

There is no commitment to training (other than for doctors). How will NHS schools be run and funded? Which level of management is to plan and fund physiotherapy education? What provision will there be for clinical placements? Will budgets for post-registration education be maintained?

National bargaining on pay and conditions of employment appears to be eroded further. What effects will there be on recruitment and retention, if there are many local pay variations?

What will be the effects on physiotherapists' career progression?

2. Self-governing Hospitals What services will be provided? The most profitable? Will there be any requirement to provide a comprehensive range?

How will the decision to become self-governing be made? What consultation/agreement with staff will there be?

How will training and other services for the hospital itself be funded? Will the hospital be required to continue training and research?

Will the hospital be required to employ only physiotherapists who are State registered?

What protection for salary and conditions of employment will be given to staff on transfer to self-governing status?

How will staff transfer between self-governing hospitals and other NHS employment? Will there be continuity? What recognition rights will CSP have to represent its members?

How will local pay bargaining be handled? Will physiotherapists gain by being in short supply? Will services be cut to afford these salaries? Or will competitive tendering drive down salaries?

How long will the detailed data collection systems take to be installed? What will be the effect on patient-care time from more data-collection time? Who will fund the large increase in computers and administrative staff that will be needed?

3. New Funding Arrangements The review stemmed from concerns about shortage of funds for the NHS last year, but there appears to be no commitment in the White Paper to provide more funds. If there are no additional funds, where will additional money for additional work come from?

What funds will there be to redress the manpower shortage to cope with current demands?

How will the money follow the patient?

4. Additional Con su I t an t s The increase in the number of consultants is welcomed. But what provision will there be for additional physiotherapy and other patient services which will be necessary to support the work of these additional consultants?

5. GP Practice Budgets What effects will financial limits on patient treatment have on physiotherapy referrals?

GPs may wish to employ more physiotherapists directly. But how will pay and conditions be negotiated and agreed?

Will the restrictions on drugs budgets limit the availability of drugs for physiotherapy treatments?

6. Reformed Management Bodies Appointments to District Health Authorities and Regional Health Authorities will be by the Secretary of State, or by people appointed

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I Workinn for Patients? by him. How does this increased centralisation reconcile with the Government's apparent wish to distance itself from operational

What assurances are there that the costs for increased management information and accountancy will not be diverted from patient care?

v

The Prime Minister in her foreword says: 'The patients needs will always be paramount.'

matters and ena.ble patients to influence services?

What direct influence will Community Health Councils have on the

'

How realistically will patients be able their Is it an increased choice for GPsl

new management to represent interests of the local community?

views and the What are the real benefits for patients? Will services be improved I in conurbations? In rural areas?

7. Better Audit Arrangements How will patients be helped to judge 'a better service'? I Will those who cannot afford to travel to a better service be helped

What form will a review of quality and effectiveness of care take? How will 'value-for-money' be judged?

What are the criteria for a 'better service'?

to do so?

Will 'a wide range of optional extras' and choice introduce a two- I tier system based on ability to pay?

Senior Managers - Proposed New Contracts IN the January 1989 issue of Physiotherapy (page 30) we reported on the Government's proposals to extend the pay and grading arrangements for general and some senior managers to a further group of senior managers.

The Department of Health (DOH) circular was to have been published in December 1988, but, at the time of going to press, it has still not appeared. The draft proposals are all we have seen. However, the DOH leaflet from which we gave extracts in the January Journal has been widely circulated. Several physiotherapy senior managers have been approached by their general managers with offers of the new contracts.

Senior managers may be asked to choose between their existing pay and conditions and the new salary and conditions including Performance Related Pay. Since if they opt for the new conditions that decision is irrevocable, we are giving below points which members should consider carefully. We emphasise though that no one should make any final decision before the official circular is issued. When it is, we will look at the final details and advise members further.

Contracts of Employment Managers accepting the new pay and

conditions arrangements will have to accept new contracts, although these are not intended to be short-term contracts (as applied to other general managers) for most individuals currently within the NHS. The nature of the new contracts which will be signed is still unclear but (as stated in the draft circular) they 'will provide specifically for performance to be reviewed under the individual performance review arrange- ments and will specify that unsatisfactory performance may be regarded as grounds for action under the authority's disciplinary and dismissal procedures' (our italics).

Thus there is a clear threat of the possibility of dismissal for unsatisfactory performance built into the system.

Pay Flat Rate Salary

Managers will be offered a flat-rate salary (without increments) based on a 25-point

pay spine ranging from €11,790 to €30,220 a year. Within the pay spine, a 12-point pay range is proposed for each management level in Regional Health Authorities, District Health Authorities and Units. The maximum salary which could be offered to any individual represents about 75% of the maximum range point of the next higher management level. Thus, a manager who is accountable to a Unit general manager cannot be offered a salary which is more than 75% of that UGM salary. There will be local pay flexibility which will give general managers in exceptional cases the right to raise the salary for hard-to-fill posts by up to 10% of the authorised level, but it is not intended to apply this to those already in post.

The general manager will decide the pay point. Once an individual is placed on this point, there are no further annual increments. The only addition to salary will be Performance Related Pay. But PRP is equivalent to only about one increment on existing scales; slightly less at the top. Note also that PRP is not guaranteed. You could get a payment one year, then nothing for the next three.

Performance Related Pay PRP is classified in five categories. There

are maximum awards of up to 4%, 3% and 1.5% for bands 1, 2 and 3 respectively with annual quotas of not more than 20% of managers in band 1, and no more than 60% in bands 1 and 2 together. There is a cumulative ceiling over a minimum of five years which could give the most outstanding performer up to 20% additional salary. Managers in bands 4 or 5 will get no merit payment.

There are considerable problems with PRP applied to clinical grades. It is dependent on the inclusion of the individual in an Individual Performance Review (IPR) system. IPR relies on the identification of management targets, many of which are put in financial terms. The DOH has already recognised that there is some tension between managerial and clinical responsibilities. At times there will be conflict between budgetary obligations of general managers and clinical care

responsibilities of clinical managers. However, the DOH does not appear to have produced any solution to these problems.

The quota system for the maximum numb.er of managers who can get into a particular band (eg 20% in band 1) means that there is an arbitrary element about the band in which you are placed. Thus, in one year you could be in band 1 but in band 2 the following year, despite an even better performance, because of the number restriction. It is a pure cost control.

PRP is a merit pay system. The experience of many other employers is that merit pay systems, particularly where effective team work is required, can be a source of division and not incentive among members of staff. Appraisal systems, such as IPR, are already in place for many within the NHS, but many other organisations have found that IPR linked to pay is not successful.

Pay Increases Managers opting for the new contracts

will no longer be covered by the recommen- dations of the Pay Review Body. If in any year, there is a significant increase in pay through the Review Body, managers who have opted for the new contracts will not have the right to opt back again into possibly more favourable salary conditions.

The review process for salaries under the new contracts is extremely uncertain. Increases in the flat-rate salary will only come through a decision by the Secretary of State to increase salaries. There is no guarantee that this will be done on an annual basis and certainly no guarantee of what this increase would be. With no incremental payments, individuals who do not perform to a standard to be eligible for PRP, may get no annual increase at all.

Although the Government may review salaries in a reasonable way for the first year or so, subsequently there may be political pressure to limit pay, particularly to hold down inflation, with the public sector setting an example.

The Review Body process has the advantage that its reports will be published, no matter what the Government decides to do about them. In turn this puts considerable

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