Political and Parliamentary Monitoring
Week Commencing 31^st December 2018

The new year has provided many news outlets, think tanks, and analytical platforms with the opportunity to reflect on 2018, in doing so highlighting the main health news which grabbed the nation’s attention and reviewing and assessing how much has changed in terms of health policy. The Digital Health publication focused its attention on the growing technological challenges facing the NHS. In November, the Health & Social Care Secretary, Matt Hancock, confirmed that 500 NHS Digital staff would be made redundant as part of the organisation’s restructure, with the announcement coming just months after the Department of Health & Social Care committed to investing nearly half a billion pounds in to new technology.

The theme of restructuring was also prominent in the Health Service Journal’s review of 2018. The outlet’s most read stories included the plans from NHS England and NHS Improvement to create seven new “single integrated regional teams” to improve co-working, and calls for NHS Directors to stand down after an investigation by the NHS Counter Fraud Authority.

The year ahead will undoubtedly be dominated by the NHS spending review. The 10-Year Forward Plan outlining the health service’s priorities for the next decade was meant to be published at the end of 2018, but has since been delayed. It has already been announced that the Plan will include a new cancer strategy, but there is speculation that the Government is angling for a commitment from leaders at the Department of Health and Social Care that the extra money will also help reduce waiting-times, which have risen in recent years.

As ever, in the short term the new year will pose challenges for hospital admissions, with the number of emergency calls expected to rise in the event of a cold weather snap. Should demand on NHS services rise, and staff are diverted to work on the frontline, this will inevitably have an effect on day-to-day and planned services. The Secretariat will continue to monitor any developments.

The Secretariat wishes the PCF a prosperous 2019.

Overview

• NHS will still be short of nurses in five years
• First ever drop in teaching assistant numbers “concerning”
• Act now to reduce health inequalities

New funding pledged to support children with SEND

The Education Secretary, Damian Hinds, has announced that an additional £350 million is to be allocated to supporting children with complex needs and disabilities. In an announcement published during the Christmas recess by the Department for Education, the Education Secretary announced that local councils will receive an additional £250 million over the next two years to provide “much needed support for children and young people with complex SEND.” This is in addition to £6 billion which the Department has already allocated for SEND support over the same time period.

The Secretary of State also announced that families will benefit from more choice over their child’s education through an extra £100 million investment to create more specialist places in mainstream schools, colleges and special schools. Additionally, more special free school meals will get the green light, as the Education Secretary confirmed that he will approve all high-quality bids in the current round of special and alternative provision free schools.

Speaking about the announcement, Mr Hinds said that “every school or college should be one for a young person with special educational needs.” The announcement comes just two months after a petition against special needs funding cuts was delivered to the Prime Minister by head teachers. Indeed, there remains speculation that despite the pledged extra funding, many local authorities and schools face growing deficits this year which require difficult funding decisions and the reduction in some services.

There is evidence that, in some cases, paediatric continence issues can be linked to physical, psychological or emotional development in children. With this in mind, any new money for children with SEND will impact on the work of paediatric continence experts, nurses, and those who assist in managing continence conditions.

Extra funding for social care makes NHS better prepared for winter crisis

The National Health Service has said it is “better equipped” to deal with the surge in demand for health services during the winter thanks to a multi-million-pound funding boost. Some £240 million of extra funding made available to local authorities over the last year means that older patients have been able to be discharged from hospitals at a quicker rate, thus freeing up hospital beds.

Councils in England also plan to deliver an additional 30,000 packages of care to older people over the next few months, meaning those at risk of being hospitalised can receive high-quality care in the safety and comfort of their own home.

The Department of Health and Social Care will be eager to avoid a situation like last year, when official figures showed ambulance queues and bed shortages hit their worst levels on record. Ambulance Trusts across England were provided with an additional £36 million in 2018 for 250 new ambulance vehicles. 100 had been delivered by Christmas Eve, with the expectation that more will be made available by Winter.

The news regarding extra funding to avert a winter crisis will be welcomed by PCF. Whilst it is unclear where the funds are coming from, and whether they are being diverted from other NHS services, the additional money is likely to ensure that staff who work in outpatient and non-A&E services will not be diverted, subsequently reducing the possibility of delays for patients needing treatment.

Children ‘second class citizens’ as staff redeployed

Seriously ill children are being treated like “second class citizens” by the NHS as scarce paediatric staff are pulled from emergency rooms to cope with winter pressures in adult service. Around 850 paediatric consultants are needed across the NHS to provide safe and sustainable care, according to the Royal College of Paediatrics and Child Health.

However, many nurses and consultants are now being diverted to other duties in adult services, meaning that entire wards are being closed because there are not the staff numbers in place to run them safely. Dr Simon Clark, workforce officer at the Royal College of Paediatrics and Child Health said that “if we do not have the beds, we cannot treat the patients and that means children are missing out on important care.”

The shortage of paediatric consultants is compounded by the staff recruitment crisis in the sector. There has been a 58 per cent drop in the number of European doctors applying to paediatric training in the last year, whilst those consultants working in paediatrics on average only work around 77 per cent of full-time hours. Professor Russel Viner, President of the Royal College of Paediatrics and Child Health, has said the NHS “urgently needs hundreds more” doctors.

The Paediatric Continence Forum will be concerned about this news. Given the growing demand for paediatric continence care services, as well as the delays in accessing care at ‘early’ stages from a GP or school nurse, further disruption to planned treatment could result in the quality of life of young people with continence issues falling.

Political and Parliamentary Monitoring
Week Commencing 17^th December 2018

This week, the Government revealed its eagerly anticipated immigration white paper, setting out how the UK’s border system will operate post-Brexit. The white paper, aspects of which will continue to be consulted on over the coming months, will prove influential as the National Health Service plans its services moving forward. The incoming Chief Executive of the King’s Fund, Richard Murray, called on the Government to “grasp the nettle of migration policy and allow in [to the country] many more health and social care staff from abroad.”

It is unclear whether the white paper lives up to Mr Murray’s demands, with many concerned that a £30,000 minimum wage cap, which sets the threshold for what is defined as a ‘skilled migrant’, could prove detrimental to the social care sector. Those earning under the £30,000 cap may find it difficult to secure long-term visas.  Although the Cabinet is still divided over what the exact cap should be, and further consultation is likely, the £30,000-figure has been touted as the preferred cap by the Home Office based on recommendations by the Migration Advisory Committee.

Given the average salary of a care worker is in the region of £20,000, and the starting salary of a nurse is in the region of £22,000, it is unsurprising that many in the health sector have raised their concerns over whether desperately needed staff from abroad will be able to gain access in to the UK. The Cavendish Council of health and care organisations said it was “extremely concerned” that visa proposals would prevent the health service and businesses accessing the number of care staff needed to sustain services.

For those health workers earning more than £30,000 (predominantly doctors, consultants and other specialists) the removal of the cap on number in the existing tier 2 visa route made the sponsorship system less bureaucratic for employers. This has since benefitted non-EU doctors attempting to gain entry in to the UK.

This is the last monitoring document of 2018. Monitoring will resume on Friday 4^th January 2019. The Secretariat wishes the PCF a Merry Christmas, and a prosperous and peaceful New Year.

Overview

• NHS will still be short of nurses in five years
• First ever drop in teaching assistant numbers “concerning”
• Act now to reduce health inequalities

NHS will still be short of nurses in five years

Ian Dalton, Chief Executive of NHS Improvement, has said it will be more than five years before the number of nurses the NHS needs are available. Speaking ahead of an anticipated long term plan on workforce strategy, Mr Dalton said that the shortfall in nurses was proving hard to solve and that he expected reaching breakeven would take at least five years.

Recent figures from NHS Improvement show that the number of vacant posts in the health service has risen by almost 10 per cent in the first quarter of the year, with more than 42,000 nursing posts being advertised across England and Wales. Mr Dalton, along with Simon Stevens, the Chief Executive of NHS England, have previously indicated that increases in staffing will be closely linked with additional resources provided to the NHS. Dame Donna Kinnair, the Acting Chief Executive of the Royal College of Nursing, said that “swift action” was required to avoid a recruitment crisis.

NHS Improvement has said that it will be working with those Trusts with the lowest retention rates to improve the training and opportunities available to staff. At the same time, NHS England said that it hoped that the recent recruitment campaign for the NHS would continue to be funded as part of the NHS’s long-term plan.

The news regarding the number of nursing vacancies will be of concern to the PCF. Delays in treatment can negatively affect the standard of living for those with bladder and bowel complaints, and can often create the ‘stop-go’ style of care which damages trusts in clinicians. The Secretariat  will continue to monitor recruitment and retention figures.

NHS’s long-term plan delayed until January

The HSJ has learnt that the NHS’s long-term plan has been delayed until at least January, with the political fallout over Brexit preventing the document from getting approval from all cabinet ministers. The plan commissioned by the Prime Minister when she announced the NHS’s £20 billion funding settlement in the summer – was initially expected to be published in November. Simon Stevens, the Chief Executive of NHS England, then said the plan would be delayed until early December. It is now understood that the document will not be revealed until 2019.

The plan is expected to set out the priorities for the NHS over the next five years – which are covered by the £20 billion funding settlement – and some targets for improvements over the next decade. A planning timetable sent to NHS Chief Executives suggests that the financial documents associated with the long-term plan will continue to take place over 2019. Responding to the news about the delay, Jonathan Ashworth, the Shadow Secretary of State for Health, said that patients “deserved better”.

Niall Dickson, Chief Executive of the NHS Confederation, which represents organisations across the healthcare sector, said the new plan must be “radical” but needed to avoid being “unrealistic”, adding that the current situation facing the NHS was “very serious”, with overstretched services. NHS England declined to comment on the delay, except to say that it was important to get the long-term plan right.

The Secretariat is prepared for the launch of the report early in 2019, and will inform the PCF of the exact date when it is released. The Secretariat will also provide expert insight and analysis in the announcement and the possible implications for paediatric continence care.

‘Catastrophic’ funding gap could pause district nurse supply for a year

The supply of district nurses coming into the NHS could drop to zero in 2021 unless the government provides additional funding, it has emerged. Health Education England’s national funding for the one-year postgraduate course is due to finish in 2019-20, with the government planning for the apprenticeship levy to provide funding for a part-time two-year course from 2020-21. However, nurses training through the apprenticeship route would only qualify in 2022, meaning no new recruits in 2021.

The Chief Executive of Queens Nursing Institute, Crystal Oldman, has said that this would be “catastrophic”, whilst NHS Providers said this would have a “severe” impact on the nursing workforce. As the PCF will be aware, district and community nursing is essential for supporting vulnerable people, including children and young people with bladder and bowel issues which may effect mobility or their ability to access treatments. At the same time, district and community nurses play a crucial role for those remote communities who may have little or no direct contact with major centres of healthcare.

In response to the news, a Department of Health and Social Care spokeswomen said, “we are working with HEE on funding for the specialist qualification for district nursing”, whilst earlier this year the Care Minister, Caroline Dinenage, said that the Government would offer “golden hellos” worth £10,000 to new post-graduates who wish to train as a district nurse.

The Paediatric Continence Forum will be concerned about this news. Given the growing demand for paediatric continence care services, the prospect of no district nurses entering the Health Service in 2021 risks exacerbating the challenges the Service faces in recruiting new staff.

Political and Parliamentary Monitoring
Week Commencing 10^th December 2018

In a tumultuous week in Westminster, Theresa May has won the backing of her party to stay on as Prime Minister. At nine o’clock on Wednesday evening, Sir Graham Brady, Chair of the 1922 Committee of backbench MPs, announced the result. In a blow to pro-Brexit Conservative MPs who had hoped to remove the Prime Minister, the result – 200 votes in her favour, 117 against – means she cannot be challenged in a similar vein for another year.

Emerging from 10 Downing Street late on Wednesday evening, the Prime Minister said she and her party had a “renewed mission” to deliver Brexit and unite the country. May flew to Brussels on Thursday to appeal to her fellow EU leaders to offer Britain a legally binding commitment that the backstop on the island of Ireland, which would be introduced in the event of a no-deal scenario in which new trade arrangements have not been completed, would be legally binding.

In private, it is believed that May confirmed to colleagues that although she would like to fight the next general election, she would step down before 2022. James Cleverly MP, a loyalist to the Prime Minister, said that May “recognises a lot of people are not comfortable with her leading us into a future general election.” In response to the vote, the Leader of the Labour Party, Jeremy Corbyn, urged the Prime Minister to “bring her dismal deal back to the House of Commons.”

Plus ça change, plus c’est la même chose. The more things change, the more they stay the same. At the end of a week of politicking, the Prime Minister remains secure in her position, and a vote in Parliament on a Brexit deal remains some weeks off.

Overview

• NHS waiting lists for lung and bowel treatments double in eight years
• Scottish GP workforce increases
• Act now to reduce health inequalities

NHS waiting lists for lung and bowel treatments double in eight years

NHS waiting lists for patients in “excruciating pain” or with life-threatening conditions including lung cancers and bowel diseases have doubled since 2010, and the overall waiting list now stands at more than 4 million. Specialist treatments have been worse-affected by the ‘double whammy’ of tighter controls on health spending and the increase in the number of NHS staff vacancies.

Despite the commitment to another £20.5 billion of funding for the NHS from 2019, the investment rate is still just a quarter of the amount the Health Service relied on for decades. Rachel Power, Chief Executive of the Patients’ Association, said that the mixture of budget cuts and loss of staff meant “we risk returning to the days of unacceptably long wait for elective surgery”, adding that for some “those days are clearly here again already”.

Since its inception the NHS relied on average annual growth of around four per cent, but since 2010 spending on the Health Service has risen by just one per cent a year. Waiting lists fell to a low of 2.4 million in 2009-10, but have since climbed. Jonathan Ashworth, the Shadow Health and Social Care Secretary, said that the “staggering increases in waiting lists” had resulted in “patients waiting longer and longer in pain, distress and anxiety”.

In response to the news, a Department of Health and Social Care spokesperson said that “nearly 15,000 fewer people are waiting over a year for non-urgent operation compared to eight years ago.”

This news will be of great concern to the PCF. Without the expert staff and investment, many patients with bladder and bowel issues can go for long periods without the offer for suitable treatment. This can impact quality of life, and in the meantime may mean that some are not using the devices or short-term treatments best suited for them.

Scottish GP workforce increases for first time in a decade

Figures published by the Scottish Information Services Division show that there were 4,994 GPs working in Scotland at the end of September 2018 compared to 4,919 in 2017, representing a small but significant increase in the number of GPs working in the country. This is the first real increase in GP number Scotland has seen for a decade, and is part of a wider trend which has seen some surgeries close and ‘super surgeries’ expand.

Chair of the General Practitioners Council of Scotland, Dr Andrew Buist, welcomed the figures, but added that in the short-term it is “essential that we do everything possible to retain the GPs currently working”. A new GP contract introduced by the Scottish Government, has aimed to increase the retention rate by addressing working conditions.

The increase in Scotland has not been mirrored in other parts of the country. In England, GP numbers have only just stabilised after months of rapid decline, November figures show. At the time, Professor Helen Stokes-Lampard, Chair of the Royal College of General Practitioners, said that “the trajectory is on the up” and recommitted the organisation to work with the NHS to increase numbers.

As the PCF will be aware, having well-trained doctors available to diagnose and treat young people and children is essential for good care. With this in mind, the organisation will welcome the rise in the number of GPs, and the Secretariat will continue to monitor whether the increased number of staff will have an impact on delays to treatment.

Act now to reduce health inequalities, public health experts said

A group of thirty senior public health experts from England have written an open letter highlighting their concerns over the cuts to central government public health grants. Quoting the Northern Health Science Alliance’s Health for Wealth report, the experts, which include the Chief Executive Officers of multiple NHS Trusts, warn that more must be done if the country is to avoid exacerbating a postcode lottery of services.

The letter says “the government has future opportunities to halt the widening gap between rich and poor in the country”, adding that health inequalities can be tackled by “using next year’s spending review to reverse cuts to public health grants.” The letter comes in the same week that local authorities in Sunderland, Shropshire, South Shields and Durham have all announced that they are slashing the public health budgets for their areas.

The Paediatric Continence Forum will be concerned about this news. Given that school nurses are now funded by local authorities, to see that central government grants are continuing to fall in this area could negatively affect services.

Political and Parliamentary Monitoring
Week Commencing 3^rd December 2018

The number of people accepted onto nursing courses in England continued to fall in 2018, despite the fact UK-wide acceptance rates hit a record high, the latest university application figures show. A new report by the Universities and College Admissions Service (UCAS) shows that number of applicants from England being accepted on nursing courses fell by 1.4% over the last year. This is the first time ever that acceptance rates have fallen two years in a row.

At the same time, the number of applicants to nursing courses across the UK declined for the second year running, with a 7.6 per cent decrease in 2018 on the back of 17.6 per cent drop the year before. Despite this fall in the overall number of applicants, places on nursing courses continued to be over-subscribed. In contrast to England, the number of acceptances in Scotland and Wales, two countries which unlike the Department of Health & Social Care in England, decided to retain bursaries for nursing students.

The Council of Deans of Health, which represents universities providing nursing, midwifery and allied health professional courses, said it was concerned about the decline, with its Executive Director, Katerina Kolyva, saying it showed the need for “urgent” steps to boost student numbers. Last month, Health Minister, Stephen Hammond MP, indicated that the Government may be wiling to consider reintroducing bursaries or a new system of grants in England.

Overview

• NHS funding hike must bring permanent end to GP crisis, says Chair
• Cuts to public-health short-sighted, according to BMJ study
• Secretary of State to consider safe staffing law in England

Secretary of State to consider safe staffing law in England

Matt Hancock, the Health and Social Care Secretary, has said he will look at the possibility of introducing safe nurse staffing legislation, it has been revealed. It is believed the first time a minister in England has openly said they are willing to look into the idea of enshrining safe staffing in law, with the Government have previously opposed such a move. The comments by the Secretary of State also come after a similar was introduced in Wales.

Speaking to members of the Royal College of Nursing (RCN), Mr Hancock said he would be “very happy” to look at proposals to introduce safe staffing laws. The admission comes after the RCN ran a high-profile campaign to call for legal minimum safeguards in the face of rising demand for services, falling numbers of staff, and rising vacancies. The law, as envisioned by the RCN, would make it mandatory for healthcare providers to have sufficient nurses on shift or available on projects to ensure patient safety.

Dame Donna Kinnair, acting Chief Executive and General Secretary of the RCN, welcomed the comments from Mr Hancock, saying that Mr Hancock was “right to make the workforce a top priority for a sustainable NHS”. Mr Hancock had attended the RCN summit to launch a new Government strategy to reduce violence against NHS workers.

Whilst the Secretary of State’s comments will be welcomed by the PCF, it raises several questions. It is unclear about whether it would apply to all nurses, or just those in A&E, and how the NHS would operate should it fail to meet the ‘safe standard’. As more details are released, the Secretariat will engage with inform the PCF of developments.

NHS spending on public health creating a postcode lottery of support

A new report published in the BMJ has highlighted that cuts to preventive health budget have affected some local authority activities more than others. Looking at the history of public health spending, the report examines the impact of reductions in spending by the Heath Service centrally, as well as local authorities, comparing spending in the decade 2000-2010 with 2010-2018.

Less emphasis is being put on public health now than at any point since Derek Wanless released his report in 2002, which placed the spotlight firmly on changing behaviours and improving public health with the aim averting more costly interventions at a later date. Since then, public health spending by central government has been scaled back greatly, with local authorities having bigger control over public health measures.

This, the BMJ article notes, has resulted in a postcode lottery with some councils allocating more funding to public health than others, and with the Local Government Association (LGA), which represents local authorities to central government, warning that some authorities are “salami slicing” services or digging into case reserves to make ends meet. “Some local authorities [are] showing they can cope better with austerity [than others]” the LGA says, adding that changing demographics and rising demand for services is increasing costs.

This report by the BMJ will further support the PCF’s calls for a review of how public health funding is allocated. Local authorities oversee school nurse funding, a health sector which has seen reductions in funding and provision over the last eight years.

Ofsted condemns ‘disjointed’ disability provision

Ofsted, the schools’ watchdog, has delivered a damning indictment of the education of children with special educational needs and disabilities. In her second annual report, the Chief Inspector of England’s schools, Amanda Spielman, warned that provision for pupils with SEND was often “disjointed and inconsistent”, with thousands missing out on vital support.

Her report, which captures the state of education in England, criticised the fact it took too long for many young people with special educational needs diagnoses, thus preventing them and their families accessing vital support. Her report highlights concerns around the step rise in the number of Education and Health Care Plans being delayed or refused. In 2017, there were 14,600 refusals by local authorities to carry out assessments, a third more than two years earlier.

The report also flagged the growing postcode lottery and disparity in the amount of provision and care offered by different local authorities, with a widening gap in performance and outcomes between the best and the worst local areas. Of the 68 inspections of SEND sites, there were serious failings in 30. Addressing an audience of education professional and policy experts in Westminster at the launch of her report, Spielman said that “there are still children who lag behind. Children for whom it seems the die is cast, even before entering nursery, and who never catch up in 12 years of schooling.”

Commenting on the report, a spokesperson for the Department for Education, said that the report also recognised that England has a “robust education system” where “parents can feel assured that the vast majority of schools, early years providers, children’s homes and local authorities provide a high level of education and care for young people, regardless of their circumstances.”

The Paediatric Continence Forum will be concerned about the findings of Ofsted’s annual report. Children with bladder and bowel issues and recognised disabilities linked to urology and continence issues are evidently not getting the support needed. If the PCF agrees, the Secretariat will engage with the schools’ regulator about the need to provide adequate support and facilities for those with disabilities.