During times of financial famine, when the big guns come looking for easy prey, training budgets should run for cover. And post-registration training should run even faster, since its camouflage kit appears to be covered in bells and flashing lights.
‘If you want to make a quick cut, then you have a quick cut on post-registration. It is more exposed,’ says Paul Turner, executive officer at the Council of Deans of Health.
This vulnerability stems from the fact that post-registration training involves short courses, which are an easy target when much of the other funding is tied into three-year courses.
Mr Turner argues that returning to ringfenced education budgets would help.
Training for nurses in England is provided through education contracts between strategic health authorities and universities. SHAs receive funding for education and training from the Department of Health through the multiprofessional education and training (MPET) funding system. The nursing education component includes pre-registration, post-registration and CPD.
The MPET budget was ringfenced until 2005–2006, after which the DH allowed SHAs to use the money as they saw fit. MPET budgets were raided by SHAs of £135m in 2005–2006 and £340m in 2006–2007 to offset deficits in overall budgets.
‘There was a determination by the secretary of state for health to bring the NHS back into balance in 2006–2007,’ explains Mr Turner. The fallout included reductions in post-registration and CPD commissions of at least 10% but with wide variations. SHAs also withdrew funding for acute trusts and PCTs for backfill.
For 2007–2008 the DH negotiated a service level agreement with SHAs to supposedly ensure the adequate provision of training. However, the agreement does not ringfence MPET money.
The Council of Deans of Health estimates that five out of the 10 SHAs plan to divert funds in 2007–2008. East of England, South East Coast, South Central, South West and East Midlands will use some of their MPET allocations towards contingency funds or strategic reserves.
The plundering continues, even though SHAs, with the exception of East of England, project an overall surplus for 2007–2008.
Service level agreement
And what of the service level agreement? This says the DH ‘expects investment decisions and plans to be based on long-term workforce planning’. On post-registration training, particular requirements are that a target number of nurses should take prescribing training, and that training should support new roles.
‘The question is whether the service level agreement has got any teeth,’ says Mr Turner. While it is too early to say whether it will deter raiding, the council and Universities UK want transparent monitoring on whether the service level agreement is being upheld.
But regardless of whether courses are being funded, are nurses being released to go on them? ‘That is a continuing problem,’ says Mr Turner. ‘Previously, when people released staff, they could get a payment back from the SHA for a certain portion of their salary, so that they could employ agency staff to cover. The SHAs stopped doing that last year in 2006–2007.’
Gordon Evans, programme leader and CPD lead in the department of health sciences at the University of York, says that while SHAs may pay course fees, they will not pay trusts for backfill. ‘Often the word out there in practice is there is no study leave,’ he says. ‘Managers are saying: “We’re not sending people on study leave because we haven’t got money for travel expenses or replacing the staff.” In some areas there are even ‘study leave embargoes’.
The upshot of all of this, says Mr Evans, is that more nurses are attending courses in their own time. ‘They’re accessing courses that are paid for by the health authority but they’re not claiming travel expenses or paid study leave – they’re coming in their own time.’
Dawn Dowding, senior lecturer in clinical decision-making at the Hull York Medical School, has been a personal tutor to nurses on its master’s programme. She says: ‘I certainly know that nurses have had great difficulty getting study leave.’
Staff shortages and the costs of paying for cover are just some of the reasons nurses are given for not being released.
Ms Dowding adds that these are ‘motivated, bright individuals’, who are ‘the future leaders’. She says they are ‘the ones who have been able to do their master’s normally, in spite of rather than because of their work situation’.
Lorrae Allford, senior sister in the emergency department of Royal United Hospital in Bath and an RCN convenor at the hospital, agrees there is funding available for nurses at most trusts to go to local universities for post-registration training courses but the problem lies in whether or not ward managers have the ability to release staff.
‘I think it’s ward managers trying to balance between clinical need and allowing staff time off to do it,’ she says. ‘It’s just staff shortages. A lot of hospitals are working inside the recommended establishment levels but it is always taken down to the bare minimum. So, when sickness comes into play, people then have to cancel their study days.’
The result? ‘I think a lot of nurses are using their annual leave to attend courses,’ Ms Allford says.
Be more flexible
Mr Evans says universities could deliver education in more flexible ways, such as ‘open learning and blended learning’, which would make it easier for staff to attend courses.
‘It’s moving towards ways in which staff don’t have to be in educational premises on rigid, set days of the week,’ he says.
Michelle Gallifent, head of education and development at East of England SHA, agrees that blended learning is the way forward. Providing different ways of delivering education ‘so not all of it is talk and chalk’, is a requirement that has been written into the five-year rolling contracts the SHA has with universities from 2007–2008 to deliver education for all non-medical professional groups.
‘They’re multimillion pound contracts and the idea there is to protect that money going forward to ensure that it is spent on the continuing professional development of those clinical workers,’ says Ms Gallifent.
She disagrees that training budgets have been seen as an easy way to plug deficits.
‘While the official line is that we had to put this money forward against the deficit, the reality in the past financial climate was there was absolutely no way that staff would have been released to undertake CPD, in particular, anyway.’
An end to cuts?
Going forward into 2007–2008, the SHA has taken £34.6m (10.4%) of the MPET budget for a strategic reserve to support its financial position. But Ms Gallifent says that in 2008–2009 the SHA will not plug deficits or contingencies with any
of the funds it receives from central government for education and training.
And she is adamant that the service level agreement will not affect how the SHA allocates funding for CPD. Instead, it is there to provide accountability to the DH and to that end, the SHA is providing equal funding for training across the workforce.
‘We’ve taken the 2007 workforce census from each of the trusts and we give them a financial per capita allocation against their qualified workforce. So it’s equitable, it’s comparable and it’s transparent.’ The days of backfilling are ‘long, long gone’, says
Ms Gallifent, who sees partnership as the way forward. ‘The SHA pays for the tuition and the trusts decides to whether this education for the individual is priority for the service or purely priority for the individual. And each of the trusts have a different amount of study leave that they allocate according to their policies and procedures.’
Realistically, will trusts be able to release staff? Ms Gallifent does not think it will be a concern, since the uptake of courses from trusts is on target so far. ‘Because there’s been some starving of the staff at trust level, they’re flocking in their dozens to take up each and every course that’s on offer,’ she says.
‘I sincerely hope that, as we move into the next financial year, we will be in the position where we can give the staff at the sharp end what they need with regard to CPD,’ she adds.
Kate Guyon, dean of the School of Nursing and Midwifery at the University of East Anglia, which comes under the East of England SHA, says the SHA has ‘given signals’ that it is aware that CPD is important, particularly for band 7 nurses.
However, she fears that trusts will continue to be unable to release staff for training, despite the stability of the five-year rolling contract between the university and the SHA. ‘I think it is still difficult for people to release staff for education and training and I can’t really see that changing too quickly.’
Trusts in the region have had difficulties meeting their budgets, which has led to leaner staffing structures than might otherwise have been the case. Trusts therefore have fewer people to cover for a nurse attending training. To add to the problem, the region – and the University of East Anglia in particular – has seen a cut in pre-registration programmes. This means that in the next three years fewer trained nurses will be coming into the system.
Ms Guyon says: ‘My concern is, are there going to be enough people coming off the line at the time when demographic changes are happening and when there is growth in primary care services and care becomes more intensive? And therefore does that then have a knock-on effect in that those trusts will not be able to release their staff?’
Marketing nursing as a good career option is becoming a hard task, says Ms Guyon, not just in terms of student employment, but also with respect to career progression after qualifying.
‘Stuck on a treadmill?’
And what of patient care? ‘How do you ensure that the staff are delivering care that is evidence-based?’ asks Mr Evans. ‘How do you have the confidence that patients are getting the most up-to-date practices for their care?
‘And, if trusts are not releasing staff, how are they setting systems in place so that care in the future can be advanced – or are we stuck on a treadmill?’
Case Study: Ros Carlile, senior sister A&E
‘In all honesty, if I didn’t do things in my own time, I would not have had the courses that I was given,’ says Ros Carlile, senior sister in A&E at the Royal United Hospital in Bath and nurse practitioner for Wiltshire Medical Services, a GP out-of-hours cooperative.
In 2004 Ms Carlile took a nurse practitioner course. She was fully funded by the hospital and given one study day a week for nine months, plus three months of full-time leave to spend with a mentor.
In 2005 she did a one-year advanced nurse practitioner course but was told the trust would either pay for the course or give her the time. ‘I decided they would pay for the course because I couldn’t afford those fees straight up. I used some of my own time to do the practice requirements. But I did have some study days given to me for my exams.’
Next came a nurse prescribing course, which she needed for the respiratory clinic she was running in a general practice. West Wiltshire PCT agreed to fund the course but the GPs refused to mentor her or give her time to do the course, so she left.
She bumped up her days in A&E and the hospital paid for the course but she had to do it in her own time although she was given some study days for exams. She has since added on work at the out-of-hours cooperative, where the GPs are very supportive on training.
Ms Carlile is worried about the effect on patient care if nurses continue to have to use their own time for training. ‘I don’t think the youngsters will do it,’ she says, ‘I don’t think they think they should have to.’
Time out for training- the campaign aims
• To persuade trusts to guarantee sufficient training time is set aside for both career progression and patient safety
• To compel the government to bring back ringfencing of training budgetsTo persuade SHAs to guarantee that education funds are spent only on training
• To raise awareness of the importance to the profession, those in the NHS and the wider public of post-registration training for nurses
• To secure guarantees for sufficient backfill to cover the training requirements of nurses
• To support nurses in lobbying trusts and government on their training needs