NHS pay has been the source of a bitter dispute between the government and NHS staff over the past few years. The NHS Pay Review Body (NHS PRB), which makes recommendations to the government on pay for NHS staff, has been at the centre.1 Now proposals on seven-day NHS services submitted to the NHS PRB by the Department of Health (DH) threaten to reignite nurses' anger.
In August 2014, Danny Alexander, the chief secretary of the treasury, wrote to the NHS PRB asking it to review the NHS pay review structure and how seven-day services could be achieved without an increase in the staff pay bill.4 In December 2014, the DH submitted evidence2 to the NHS PRB on reconfiguring the NHS to provide 24-hour, seven-day-a-week care for patients. In the evidence, the DH argued that there were unacceptable variations in care at night and on weekends, saying 'accidents do not cease to happen because it is the weekend, and people do not stop being ill at 8pm on a Friday.'2
The evidence submitted by the DH contained the caveat that the changes to services must be set in the context of the government's current policy of public sector pay restraint. The DH emphasised the need for efficient use and restructuring of current resources to provide seven-day services. It claimed this could reduce costs in the long-term by increasing access to primary care services and reducing patient need for expensive secondary care services.
However, unions representing NHS staff such as the RCN and Unison have said that moving to seven-day services without an increase in the staff pay bill could mean reductions in Agenda for Change's system of unsocial hours payments, which provides community and other nurses employed by the NHS with extra payments if they work after-hours or on the weekend (see box). The majority of practice nurses are not covered by Agenda for Change, although many are already required to work overtime for no extra payment. A survey by Independent Nurse in August 2014 found that 83% of primary care nurses regularly worked overtime.
The Conservative party has pledged to extend GP opening hours from 8am to 8pm, seven days a week. However, NHS staff have voiced concerns that these proposals could be unmanageable, due to a lack of staff and an already overstretched workforce.
In the evidence to the NHS PRB, the DH said that 'reformed, fairer and more affordable unsocial hours and progression pay could act as enablers for the delivery of more services in the evenings and weekends to help ensure patients receive the care they need whenever that need may arise.'
This has not been popular. The RCN said in a statement to the NHS PRB that: 'The NHS trade unions and their members clearly see this review as an attempt to weaken the Agenda for Change agreement and reduce current unsocial hours pay provisions.'
Tom Sandford, director of RCN England, believes that: 'By asking the review body to ensure its recommendations on seven-day services do not cost any extra money, the government is interfering with a supposedly independent body and attempting to force the dismantling of Agenda for Change and unsocial hours payments.'
Christina McAnea, head of health at Unison, concurred: 'The government should be doing everything it can to ensure the continuity of the service, not saving money by yet again cutting staff pay.'
Unite has previously said that without additional funding, the only way for the NHS to maintain cost efficiency while providing seven-day services will be to cut unsocial hours pay. Barrie Brown, Unite's national officer for health, says: 'This is an issue that our members feel very strongly about. Over the last five years, they have already seen pay cut in real terms, and our members will certainly be up for a big fight if there are cuts to unsocial hours payments.'
Josie Irwin, RCN's head of employment relations, says: 'For our members, the impact of taking away something on top of dealing with staffing pressures, workload, all the issues related to the gaps in staffing, would be a hammer blow to nurses who are already under pressure.'
Opposition to the proposals has not been confined to NHS workers. An online petition demanding the protection of unsocial hours pay in the public sector had 134,308 signatures as of 13 April.
If unsocial hours payments under Agenda for Change are eroded, it will likely have a knock-on effect for nurses on individual GP contracts.
The pledge to introduce seven-day services in general practice settings has raised concerns that the practice nurse workforce is not staffed well enough to handle the extension of GP opening hours, and that nurses will not be fairly rewarded for their contribution. Louise Brady, a practice nurse in Manchester, says: 'I think that extended opening hours presents an opportunity for us to reach patients who work during the week. However, I just don't think that we have the staff to provide consistent care if seven-day services comes in.'
Jenny Aston, the chair of the RCGP's practice nurse forum, says: 'In terms of pay you would certainly expect staff to be compensated if they were working out-of-hours or at weekends.'
However, practice nurses are already working outside regular hours for no extra pay. Ms Brady says: 'At the moment, GPs are individual contractors and each individual practice will set the rate for seven-day services. Many practices will not pay unsocial hours or remunerate for that and that's what we've seen with Saturday morning flu clinics at the moment.'
Practice nurses might have more power to negotiate if practices in a locality pooled resources and became a consortium. 'If practices federate, there may be more opportunity for practice nurses to have more leverage for out-of-hours remuneration. But that would depend on two or three practices and their contract. Nobody really knows at the moment how practice nurses will fare but as it stands currently, it is going to be quite challenging to get remuneration for seven-day services.'
Claire O'Connor, a practice nurse in Greenwich agrees: 'We have to fight for funding for education and courses which we need for our job. So do I think we will get extra money? No. Most people work as a practice nurse so they can work a normal week and have a social life. If my GP turned around and said I had to work nights and weekends for no extra pay, I would go back to an acute setting. At least there, you are protected by Agenda for Change.'
A report by Keele University into the possible effects of the changes to Agenda for Change, Under pressure and 'the whole umbrella's going to have to grow': Capturing the voice of NHS workers3 published in December 2014, highlighted that the pressure on the NHS workforce means it is already struggling, without the addition of seven-day services.
In the report, an NHS worker summarised the atmosphere in the workforce, saying: 'Saturday, Sunday is precious time when you're already a full-time worker, to give up more time with your family, to come to work, to provide a service for people that really need it, to have it go unnoticed by just being paid a flat rate of pay, I think it would be quite selfish of them if that were the case. So I definitely wouldn't be doing it. I'd definitely put my name down for a change back to Monday to Friday, which I think most people would.'
Mr Sandford has said that the government is 'in danger of making working for the NHS unaffordable for many nurses and healthcare assistants. When the NHS is facing a recruitment crisis, this is an utterly reckless course of action.'
Ms McAnea agreed, saying: 'Not paying [NHS staff] fairly when they are working over the weekends could be the final straw. Many staff have already left the NHS and others are considering it.'
Will it happen?
The DH's proposals for seven-day services have not yet been accepted as policy, but it is likely that the Coalition government will go ahead with the plans if it is returned to government. At the RCN's pre-election hustings on 23 March, the issue of unsocial hours was raised. Andy Burnham, Labour's shadow health secretary, committed unequivocally not to cut the payments. In contrast, Dan Poulter, Conservative undersecretary of state for health, pledged only to protect overall pay for nurses, while stating that the DH was currently exploring the options to incentivise nurses to work extra hours in their own time. Norman Lamb, Liberal Democrat health minister, said that it was important for nurses to be paid fairly, but did not commit to protecting unsocial hours payments.
When the RCN accepted the government's offer of a pay increase in March, chair of council Michael Brown suggested that the seven day-service proposals could lead to further dispute between the government and NHS unions. 'The RCN's fight for fair pay for all nursing staff is [not over]. We know the government is looking at how to get seven-day services on the cheap, and we will do everything we can to defend the terms and conditions of our members.'
On 14 April, Unison members voted to conduct a ballot on strike action if unsocial hours payments were reduced as a result of seven-day working.
Josie Irwin, the RCN's head of employment relations isn't suprised. 'This issue has more potential for deep industrial relations problems. I think members are angrier about this issue than they were during the NHS pay dispute,' she says.
It remains to be seen whether proposals for seven-day services will go ahead. If they do, the government could have another fight on its hands. IN
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2. DH evidence to the NHS PRB. www.gov.uk/government/publications/evidence-for-pay-review-bodies-of-healthcare-professionals
3.Under pressure and the whole umbrella's going to have to grow. www.unison.org.uk/upload/sharepoint/Toweb/NHS%20UNISON%20Research%20Paper%20Final%20Version%20%28appendix%201%29.pdf
4.Treasury letter to the NHS PRB. www.gov.uk/government/uploads/system/uploads/attachment_data/file/340541/20140731_CST_to_DDRB_final__2_.pdf