Feeling the squeeze

BMJ 2006; 333 doi: (Published 30 November 2006) Cite this as: BMJ 2006;333:1142
  1. Lisa Hitchen
  1. 1London

    The health secretary Patricia Hewitt says that NHS deficits have risen because trusts have recruited too many doctors. Lisa Hitchen says the reasons are more complex and the consequences are becoming serious

    Pressure on UK health trusts to break even by the end of the financial year, in the face of a projected NHS deficit of £1.2bn (€1.8bn; $2.3bn), is forcing managers to take tough decisions.

    A report of six month performance statistics, released last month for 2006-7, shows that 175 organisations are predicting deficits, with half of the gross deficit concentrated in 6% of organisations.

    Because hospital trusts can no longer carry their debt over from one year to the next, they have been considering laying off staff and closing departments throughout the country. And GPs in many areas have been told that they must substantially cut the number of referrals to hospital.

    This has prompted the Department of Health to start monitoring redundancies. It recently reported 903 compulsory redundancies in the first half of this year. Of these, 167 (18%) were clinical staff. “There will be further redundancies over the rest of the year,” Richard Douglas, finance director for the Department of Health, said in the report.

    Trade union officials claim that the number of job cuts is far higher than that—but not all necessarily through compulsory redundancy. Michael Walker, regional officer for the trade union Unison, said the job losses in southwest London alone have amounted to 1000 already this year, with a further 480 planned at Epsom and St Helier University Hospitals NHS Trust, Surrey.

    At the health select committee inquiry on NHS deficits last week (BMJ 2006;333:1086, 25 Nov), the health secretary Patricia Hewitt blamed trusts for taking on too many staff as the main reason for deficits. Almost everyone interviewed by the BMJ disagreed with this suggestion. Howard Catton, the head of policy at the Royal College of Nursing, called it “out of touch with reality.”

    A multitude of factors were implicated, they said, including the problems that primary care trusts were having in getting to grips with their new roles as commissioners of health care.

    “The reality for primary care trusts is that the commissioner-provider scenario is an environment that the NHS has never worked in before,” said Helen Willetts, the Royal College of Nursing's regional director for the east Midlands.

    Too much too soon was another huge factor. “If they weren't pushing us so hard to pay off our deficits, we would make logical changes which would not affect patient care,” Pauline Brimblecombe, a GP at Newham Walk surgery in Cambridge, told the BMJ.

    In the primary care sector 119 organisations are now predicting debt, compared with 67 three months ago. Reorganisation is one factor that has contributed to the rise, said Mr Douglas. In addition, compared with hospital trusts, primary care trusts are facing more stringent rules on deducting overspending from the previous year.

    Most primary care trusts in eastern England have had problems. GPs in Cambridge, for example, have been asked to cut their hospital referrals by a quarter.

    Cambridge Primary Care Trust, formed from four primary care trusts in October, is expected to have debts of £33m by March 2007. Dr Brimblecombe told the BMJ that in the face of a demand by the trust to cut referrals by a quarter, her surgery has managed to reduce them by 14% in six months.

    “GPs … are doing more work with in house triage, and we are encouraging hospitals to refer patients back to us rather than hanging on to them. In our area we know the deficits are so great that the cuts will come in our community services, and that will affect us much worse.”

    The GPs are stopping or slowing all non-priority referrals, such as for cosmetic surgery and in vitro fertilisation, but Dr Brimblecombe warned they would only be pushed so far by the trust.

    Last week staff and patients protested against a further 480 job cuts planned at Epsom and St Helier University Hospitals NHS Trust. These cuts are part of a recovery plan drawn up with management consultants KPMG. The trust must save £24m in the next 18 months.

    The trust has already restricted recruitment and cut the use of bank nurses and locums. Redundancies have not been ruled out. Other proposed measures include the closure of 170 beds, which would reduce theatre lists and outpatient activity.

    A doctor in the west Midlands who is faced with possible redundancy in the hospital sector is David Roden, a staff grade doctor at the University Hospital of North Staffordshire NHS Hospital Trust's neonatal department.

    Dr Roden has been the subject of a campaign by patients, with more than 1500 signatories calling for his post to be protected. He is one of 11-20 doctors who could be made redundant in a trust that is cutting 1000 jobs to reduce its £15m debt.

    Plans to regrade him to a job at a higher level, as an associate specialist, have been on hold for a year after the trust told him it could not afford it. A spokesman for the trust said, “We are reluctant to lose any staff, but we have no choice.”

    Education and training budgets have also been cut throughout the medical and nursing sectors. Dr Jo Hilborne, the chairwoman of the BMA Junior Doctors Committee, agreed. She has written to the secretary of state demanding an explanation for cuts to budgets for study leave, which affect doctors in training.

    “We have heard nothing back from her but we are hearing every day of another trust that is cutting study leave. Without study leave it means many juniors are not able to progress with their career as they can't attend essential courses.” she said. With money from the Multi-Professional Education and Training fund no longer ring fenced at strategic health authority level there would always be temptation to use this money to tackle debts in the future even when the NHS was more stable financially, she added.

    The 5 NHS trusts forecasting the biggest deficits in England

    • 1 Hillingdon Primary Care Trust (PCT), London—£65.6m

    • 2 Queen Elizabeth Hospital NHS Trust. London—£37.1m

    • 3 Whipps Cross University Hospital NHS Trust—£33.2m

    • 4 Hinchingbrooke Health Care NHS Trust—£29.9m

    • 5 NW London Hospitals NHS Trust—£29.7m


    • Additional reporting by Colleen Shannon. The report, NHS financial performance: quarter 2 2006-07, is available at

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