1. Director, RCN in Northern Ireland Royal College of Nursing
Janice Smyth
Director, RCN in Northern Ireland
Royal College of Nursing

2. Devolution One RCN in Four Countries
Northern Ireland Assembly
Scottish Government
Welsh Assembly Government

3. The Scottish Context Scottish National Party minority Gov since 2007
Next elections May 2011
Block grant decided by Westminster (Barnett Formula) but allocated to priorities by Scotland
Policy and legislative authority in Scotland for almost all health and social care issues
Scottish health service delivered by 14 unified geographic health boards, 7 special health boards to:
*5 million people - inhabiting 40% of the UK landmass - 90 inhabited islands.
Political difference in cross-border Governments likely to cause increasing tension as financial screws tighten.  Also, only 12 of 59 Westminster seats held by Con / Lib Dem coalition.  Labour increased it's share of the vote at this year's UK election.
Budget cuts will start to really bite in the middle of Scottish election campaigns - impact on outcome of our election?
Changes to spending in England directly affect the level of block grant coming to Scotland under current Barnett arrangements.  Coalition gov proposal to bring in a Scotland Act would radically change how Scotland is funded in the future - depending on detail, possibly further financial pressure north of the border?
So far, Scottish Gov has protected health spending
Different political and policy priorities for spending in Scotland possible under devolution - although benefits remain under the jurisdication of Westminster.
Particular issues to meet in Scotland, including its geography 3

4. The Welsh Context Labour/Plaid Cymru Coalition since 2007
Next Assembly Election May 2011
Block grant decided by Westminster (Barnett Formula) but allocated to priorities by Welsh Assembly Government
Policy and legislative authority with Welsh Assembly Government for almost all health and social care issues
NHS delivered by 7 Local Health Boards

5. Northern Ireland Context
Power-sharing Executive since 2007, dominated by Democratic Unionist Party and Sinn Féin
Health Minister - Ulster Unionist Party
Block grant determined by Westminster (Barnett Formula) allocated to priorities by N I Executive
Policy and legislative authority in N Ireland for almost all health and social care issues
Service delivered through five integrated Trusts, a Health and Social Care Commissioning Board, Public Health Agency and Patient and Client Council

6. Scotland in the UK
Different politics, different priorities, different health structures BUT many of the same problems as the rest of the UK

7. Wales in the UK
Different politics, different priorities, different health structures BUT many of the same nursing issues as the rest of the UK (e.g. shift to community)
Significantly poorer economically with higher levels of ill health. This links to lower levels of public funding for services (Holtham’s £300m underspend is not when calculated on need but when calculated on same funding formula as England spend.)

8. Northern Ireland in the UK
Different politics, different priorities, different health and social care structures, different political parties
All-Ireland and cross-border health and social care agenda
BUT: many of the same problems as the rest of the UK and some far worse (historic under-funding, particularly in mental health, estimated to equate to £600 million by 2011)

9. Scottish health spending 2010-11
Health and wellbeing dept received 1/3 of Scotland's £30bn+ budget
roughly 70% of NHS Scotland budget on staffing costs
Nurses make up around 40% of the workforce
So nurses becoming the easy target for saving money
WILL CHECK FIGURES ON MONDAY 9

10. Challenges to public spending in Wales
There will be cuts (£2 bill over next few years)
Public sector employment bedrock of economy – not enough private wealth created
22 local authorities – recognised as too many
Higher Education sector will shrink substantively.

11. Northern Ireland Health and Social Care Budget
Health and social care budget of £3.6 b, more than 40% of total N Ireland Executive budget
£700 m in “efficiency savings” to be secured
Additional £126 m cut for announced by Executive, Further cuts widely anticipated
Continuing rising demand estimated to add a further £50 m to these pressures
Greater part of the budget allocated to salaries: little room for manoeuvre ... debate about local pay

12. Pressures on nursing
Nursing comprises around 40% of the HSC workforce, the largest staff group
RCN has already successfully challenged previous plans to axe 722 nursing posts
2% payroll reduction announced for : DHSSPS estimates this equates to 1300 posts
Pro-rata, this could entail the loss of around 500 nursing posts
Vacancy freezes (BBC estimates up to 16% in some areas) and curtailment of overtime, bank and agency staffing

13. NHS Scotland's challenge 2010-11
Core revenue funding for 14 geographic boards: £7.5bn
Estimate of savings need to break even: £260m (c.3.5%)
WTE nursing posts predicted to be lost this year:  1,523
NB: These pressures on money and jobs are coming whilst still (technically) in time of plenty
Core revenue funding is the basic allocation given to the 14 geographic health boards, excluding special funds (e.g. for waiting times targets) and capital funding
This efficiency figure is based on evidence given to the Scottish Parliament health and sport committee - but it is worth noting how difficult it is to clarify these figures from documents available in the public domain
All NHSS boards must meet a 2% efficiency target, which then can keep to reinvest. However, Individual board efficiencies just to break even are being forecast as between 1.9% and 7.6% this year.
To help make the books balance 2.6% of WTE nursing posts (across all bands: 1+) will go this year – but we don’t yet know the detail of how these cuts will be made across bands
Whilst public rhetoric is about cuts, NHS in Scotland still got a small rise this year....  Yet crisis is still hitting hard 13

14. Key issues in Scotland 1
Slight rise in NHS Scotland budget, BUT: Boards forecasting cost pressures (e.g. drug costs) will outstrip this increase
Boards focusing on making significant cuts in workforce, BUT: still inefficiencies, waste, duplication in other areas (but harder to tackle quickly than workforce cuts...)
Scottish policy of no compulsory redundancies, BUT: emerging pattern of non-strategic decisions to cut numbers (e.g. vacancy freezes; using specialist nurses to fill gaps on wards)
Scottish health budget went up by just over 2% - but some boards presuming increases of up to 10% in drug costs for example
Audit Scotland reported this month that medics could the lessons learnt by nursing in reducing bank and agency spend to save money, and that by £12 million could be saved by getting the biggest spenders on medical locum costs to match the average spend
Nicola Sturgeon apparently wrote to all NHS staff this month emphasising the Scottish Government policy of no compulsory redundancies – but this is not the only way for boards to reduce staffing costs! 14

15. Key issues in Scotland 2
Comprehensive workforce planning system for nursing supported by Gov and unions, BUT:
anecdotal evidence of workforce plans bypassed to cut wage bill and not all workforce plans agreed and published for this year
Opportunities to re-examine skill mix in some areas, BUT: Some boards using skill mix to replace not enhance registered nursing workforce without evidence of risk assessment (e.g. Greater Glasgow & Clyde)
Successful formal Scottish partnership process has delivered through consensus, BUT: can this survive the economic downturn?
Scottish workforce planning tools are comprehensive, but we are hearing reports of the outputs of these workforce tools, as submitted by nurses, being adapted to meet financial envelopes available
Glasgow are the largest board and are attempting to make significant skill mix changes (a little detail to add here?) - but despite repeated requests have still not supplied us with a copy of their risk analysis for the proposed changes.
Under pressure on the issues of workforce cuts, the cabinet secretary has invited the unions to join a new workforce scrutiny board – however, the remit of this group is still not clear and plans are still not available. RCN has agreed to an initial meeting. Issue over whether all unions (with different membership bases) can find consensus on workforce cuts given pressures faced. 15

16. Key issues for Welsh NHS
There will be cuts (£1.9 bill to NHS alone over next 5 years)
3% cut at Band 5 and above every year for 3 years?
650 nursing jobs to be cut every year for 3 years?
Shift to community
Skill mix or risk of downgrading of posts (especially risk of registered nurses being replaced by HCSWs).

17. Key issues in Northern Ireland (1)
Ensuring that service realignments are conducted appropriately, proportionately and with consideration of the impact on nursing and consultation with RCN
Identifying local impact of cuts, particularly on nursing posts
Challenging loss of nursing posts
Resisting calls for local pay agreements
Use of skill mix to enhance care, not to cut costs
? Sustainability of current HSC structures?

18. Key issues in Northern Ireland (2)
Sustainability of Trade Union Partnership and Regional Partnership Forum
Need for strong nursing role in commissioning process
Development of nurse-led services as a template for the future
Efficiency, safety and patient outcomes
Workforce planning