New institutions for pay and skills development in the NHS: improving internal labour market structures for low wage workers? Paper for 4th Performance and Rewards Conference, Manchester Metropolitan University, 29 March, 2007
Annette Cox, Damian Grimshaw, Marilyn Carroll and Anne McBride Manchester Business School, University of Manchester, MANCHESTER, M60 1QD. Email addresses:
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Abstract This paper considers the contribution that the NHS new pay system - ‘Agenda for Change’- and skills development initiative – the ‘Skills Escalator’ – are making to strengthen the internal labour market (ILM) for workers at the lower end of the occupational hierarchy. Financial pressures on public healthcare and organisational restructuring are shown to have exploited HCAs and cleaners in the recent past through limiting increased pay and development opportunities. Drawing on data from 13 NHS Trusts, we scrutinise the impact of the new pay system on bolstering earnings for low paid workers and find substantial improvements in pay for these groups. Opportunities for progression are more variable and dependent on management choices and strategies at the organisational level rather than national wage-setting institutions. The renewal of ILMs is overall contingent upon the distribution of and demand for a supply of skills which will pull lower grade employees up through a career trajectory.
1. Introduction In the UK and the US, the question of how to improve prospects for low wage workers has attracted a good deal of attention among researchers in recent years in response to the unenviable position of having a relatively high and persistent incidence of low pay among OECD economies (Salverda 2005). Many studies suggest this is largely a consequence of ‘skill-biased technological change’, whereby new technologies increase the wage premium of enhanced education and training and reduce demand for low skill workers (see Levy and Murnane 1992 for a review). However, the economists’ toolkit of supply and demand does not explain everything. Detailed investigation of low wage work in the US points to a range of factors including deregulation of product markets, the increasing power of institutional investors in financial markets, the weakening of trade unions and the falling real value of the minimum wage (Appelbaum et al. 2003a). And in the UK, where the relative wage of the lowest paid dropped during the 1990s despite rising demand for low skill jobs, two labour economists recently concluded that institutions, not supply/demand factors, provide a better explanation for changes in pay at the bottom end of the labour market (Goos and Manning 2003). Alongside labour market institutions, research also shows that employer strategy matters in explaining the persistence of low pay in the US and the UK. In their study of wages among care assistants in the UK, Machin and Manning conclude that employers exercise ‘considerable discretion’ in the setting of wages (2004: 384). Also, Card and Krueger (1995) identified alternative competitive strategies among firms in the low wage fast food industry in the US, distinguishing between those that opted for low pay and high staff turnover and those opting for better pay and lower staff turnover. More generally, employer innovation with respect to enhanced job design, improved opportunities for pay advancement and lengthened job ladders are found to have improved prospects for workers in a variety of low wage sectors (Appelbaum et al. 2003b; Autor et al. 2003). This renewed attention to institutions and employer strategy in shaping workers’ prospects and the appreciation of heterogeneity of outcomes across firms, despite similarities in business conditions and worker skills, recalls the central arguments of internal labour market theory. The classic text argues that
formal and informal institutional processes within the firm (especially customary norms, on the job training for firm-specific skills and incremental job ladders) play an independent role in shaping the level of pay and job advancement (Doeringer and Piore 1971). For low skill workers looking for a job, internal labour markets provide opportunities for skill development, career advancement and relatively good pay that is largely sheltered from external rates (op. cit.). In the UK and US context, where there is an absence of either well developed and reputable systems of vocational training (as in Austria and Germany) or a legal obligation on firms to provide training (such as the levy system in France), internal labour markets would appear to be an especially vital instrument to improve the position of low wage workers. An explanation of the increase in the incidence of low wage work over the last 20 years might therefore seek to investigate its interconnection with a possible weakening of employers’ commitment to internal labour market structures. This is a difficult task, however, because there is not a consensus in the research data about trends in internal labour markets. Case studies in both the US and the UK tend to depict considerable erosion of internal labour markets, while large-scale surveys suggest only marginal change. For example, in their review of statistics on employment stability for the US, Osterman and Burton state that ILMs ‘seem to be in mild retreat’ (2005:432-3). For the UK, data from the large-scale Change in Employer Practices Survey 2002 actually suggests there has been a modest reinforcement of many of the principles of internal labour markets, including the provision of career ladders, internal recruitment for high level posts and an increased number of job layers (White et al. 2004). Moreover, their results indicate that both employees and employers believe more opportunities for progression are available in 2002 than ten years previously, especially in expanding sectors and growing medium-sized organisations. By contrast, the evidence from case studies suggests considerable erosion of employers’ commitment to providing internal labour market structures and, as a result, reduced opportunities for low skill workers to be hired into ‘good jobs’. In the US, case studies reveal employer practices of downsizing, delayering and withdrawal from training provision, leading to a shift from internal labour markets to what Cappelli and colleagues (1997) call ‘market-mediated employment relationships’. And in the UK, case-study research similarly identifies growing use of employment practices by large organisations that do not conform with the traditional principles of an internal labour market, including delayering of job ladders, greater use of temporary agency labour, a dilution of skill content of entry level jobs, a shift away from transparent and integrated pay and job grading hierarchies and policies of downsizing and outsourcing (eg. Grimshaw et al. 2001). It is not clear why there is such a strong contradiction in results. Of course, the case study findings may reflect a biased selection of organisations, while the survey results more accurately reflect change at the aggregate across a variety of organisations that either strengthen or weaken their commitment to internal labour markets. However, case studies do usefully illuminate the nature of change in ways not possible using survey data. For example, increased training provision may involve a switch from technical skills to generic skills that are less valuable for internal promotion, and increased numbers of job layers may disguise a hollowing out of mid-level posts in favour of developing separate career paths at the bottom and the top end of previously vertically integrated job hierarchies. More importantly, case study research is perhaps better suited to investigate the research question, how have changing internal labour market structures impacted upon low wage workers? In her wide-ranging review of evidence of fragmentation of traditional pay structures, job ladders and training routes, Rubery (1999) has emphasised the negative consequences especially for low paid, working class employees right across different parts of the economy, including public sector organisations which have traditionally sought to maintain reputations as ‘good employers’. Indeed, Morris argues that it is
precisely these organisations which are ‘at the forefront of change’ (2003:265). Case studies also reveal how a coalescence of factors, including privatisation, outsourcing and internal business restructuring, further damage job prospects for low skilled workers entering today’s ILM structures. Those who do strive for progression may complete training and take on extra tasks but in downsized organisations with financial constraints, there may be no guarantee of additional pay or promotion unless openings become available (Grimshaw et al., 2001). However, some critics argue for the need to view practices of delayering, outsourcing and downsizing as one stage in a continually adapting, evolutionary process. Rather than ILM dissolution being a static end state, employer practices to rebuild, consolidate and reform internal labour markets are also possible, given the right institutional support and favourable market conditions (Salzman et al., 1998; Moss et al., 2000). This suggests a need to investigate trends in large organisations, utilising a research method that can identify evidence of a reinvigoration of employers’ commitment to internal labour market structures and the impact on job prospects for low wage workers. In this paper, we respond to this argument by considering new employer policies and practices in the public hospitals sector of the UK (the National Health Service, NHS). We choose to investigate the position of low skilled employees in the NHS, because, despite promotion of new skilled paraprofessional and intermediate roles, there is some doubt about the relative demand for these skills, compared to less skilled work. Rainbird et al. (2004) give the example of vital but relatively monotonous, low-skilled work in surgical instrument sterilisation which is difficult to automate, thus sustaining the need for people to do lowskilled jobs. In 2005, 39% of the NHS workforce were in ‘non-qualified’ roles including healthcare support, estates and facilities, a figure which has reduced only marginally from 41% in 2005, despite a large expansion in the nursing workforce (figures calculated from Department of Health, 2005). Skills for Health (the relevant Sector Skills Council) also assesses the current greatest proportion of skills shortages in the sector as lying in lower skilled ‘personal services’ occupations at 42% (2006:61). Future predictions are much harder to make, but evidence suggests that the largest absolute number of new jobs created between 2004 and 2014 in the healthcare sector will be in personal service occupations, rather than higher skilled work, with a combined total of over 300,000 recruits required to replace leavers and fill new roles (Dickerson et al., 2006, p.199). We therefore address two research questions designed to illuminate the extent to which strengthened internal labour market structures in the NHS have benefited low wage workers: i) is there evidence of improved pay rates, sheltered from external market competition?; and ii) do low wage workers benefit from opportunities for skill development that facilitate career progression? The findings contribute to those of other recent studies that explore the impact of internal labour market structures in selected sectors for different workforce groups (eg. Lane et al. 2003 on the US food service sector; Jago and Deery 2004 on the Australian hotel sector). The paper is organised as follows. Section 2 describes the pay and employment conditions of two low wage occupations - hospital cleaners and healthcare assistants (HCAs). Section 3 outlines the recent policy and management interventions of two major national policy initiatives for the NHS, Agenda for Change and the Skills Escalator, which sought to improve pay and career progression, especially for workers at the bottom of the jobs hierarchy. Section 4 describes the two research projects that generated the data reported in this paper. Sections 5 and 6 present the results, organised around the two central research questions regarding pay prospects and training and promotion prospects, respectively. Finally, section 7 discusses the results in light of both their contributions to existing literature on internal labour markets and the policy issues they raise concerning how best to support managers’ development of internal labour markets. 2. Pay and employment conditions for hospital cleaners and healthcare assistants
Greater use of voluntary and private sector provision under Private Finance Initiatives and outsourcing arrangements, strict financial controls and a plethora of productivity and performance targets leading to experiments with ‘skill mix’ has created pressures to fragment ILMs in NHS organisations. Increased financial autonomy through the creation of Foundation Trusts with increased possibilities for varying terms and conditions from those agreed nationally raise a further threat. Concerning pay and employment conditions for hospital cleaners, the market-based principles of outsourcing have considerably weakened traditional internal labour market norms, replacing transparent pay and promotions structures with discretionary individual remuneration (Hebson et al. 2003). Unlike other business sectors where firms are to a large extent in control of a decision to outsource activities or retain them in-house, until late 2005 all public sector hospitals undertaking new private sector financed hospital building programmes were required to outsource ancillary services. Transferring cleaners have their terms and conditions (except pensions) protected through adapted European legislation (the Transfer of Undertakings Protection of Employment, TUPE). However, protection is patchy and provides no defence against subsequent changes to terms and conditions following transfer, or against the setting of worse terms and conditions for new recruits with fewer training opportunities, restricted access to promotion and potential inequitable terms and conditions between employees of the same organisation (see Kessler et al., 1999; Marchington et al., 2005 for further discussion). Figure 1. Distribution of hourly pay for hospital cleaners and HCAs £20.00 £18.00
Gross hourly pay
£16.00 £14.00 £12.00 £10.00 £8.00 £6.00
All occupations
£4.00
Hospital cleaners
£2.00
Assistant nurses Qualified nurses
9 D
8 D
7 D
6 D
IA N
4
M ED
D
3 D
2 D
D
1
£0.00
Note: Sample sizes are 517 (HCAs), 1,316 (qualified nurses) and 116 (hospital cleaners); decile pay figures for cleaners are therefore not reliable. Source: Labour Force Survey (2005), kindly provided by Matt Osborne and Geoff Mason at NIESR.
Earnings data for this occupation show the vulnerability of these workers. In July 2005, the median gross hourly pay for hospital cleaners £5.60 (LFS data). This rate is only slightly higher than the National Minimum Wage of £4.85 that applied during October 2004-September 2005, but compares favourably to cleaners in all sectors for whom the median was £5.34, although significantly less than the median gross hourly pay for all employees of £8.65. Compared to the low wage threshold of £5.77
(two thirds of the median for all employees) 60% of hospital cleaners are low paid. The pay distribution is especially flat with the first and ninth deciles compressed between pay of £4.66 and £7.43 (see Figure 1). There is no statutory requirement for particular levels of educational or other qualifications to do the job, but hospitals do provide mandatory training in areas such as moving and handling, fire safety and hygiene. Additionally, the government’s NHS Plan (Department of Health, 2000) made a commitment to all staff without a professional qualification that they would have access to a Learning Account of £150 per year, or dedicated training to National Vocational Qualification (NVQ) Level 2/3. This NHS Learning Account Scheme was introduced in April 2001. The role of Health Care Assistant was created by the government in 1990. While originally intended to augment the stock of qualified nurses, in practice, Trusts used HCAs as a means of cost reduction (Lloyd and Seifert, 1995), a motivation which has endured, as shown in the work of Grimshaw (1999) and Beynon et al. (2002). The practice of leaving nursing vacancies unfilled and vertically substituting (Nancarrow and Borthwick, 1995) qualified nursing staff with Health Care Assistants attracted particular attention in the late 1990s (Thornley 1996, 1997, 1998). Outcomes for staff in these roles are mixed as are interpretations. Grimshaw (1999) found pay of unqualified nursing auxiliaries rose more slowly than that of professionally qualified nurses in 1990s and Thornley’s work reported that 40% of HCAs had no access to nurse training (1998). Grimshaw (1999) found widening pay dispersion between qualified nurses and unqualified HCAs, with cuts especially noticeable at the bottom end of pay scales, and evidence of substitution of qualified with unqualified staff where external labour market conditions would permit it. Development rates attached to the achievement of qualifications offered some opportunities for pay progression but had strings attached in the forms of performance appraisal processes and the numbers likely to benefit were doubtful. Reception of such ‘skills mix’ strategies has varied. The Royal College of Nursing has sought to protect professional interests, while Beynon et al (2002:198) found evidence that HCAs themselves have welcomed upgrading of skills and greater job variety. More recently, the extent to which HCAs gain or lose under the new NHS pay system and initiatives to provide career development has not been addressed, so this paper intends to contribute to our understanding of their impacts for staff in this role. Prior to Agenda for Change, wages were relatively low. In July 2005, the median gross hourly pay for HCAs was £7.28 (LFS data). They earn significantly less than the median gross hourly pay for all employees of £8.65. Compared to the low wage threshold of £5.77 (two thirds of the median for all employees) 21% of HCAs are low paid. Like cleaners, HCAs require no formal qualifications, but share the training opportunities available. In addition, under the NHS Plan, hospitals are required to offer NVQ Level 2 for HCAs without equivalent qualifications. More recently, the role of Ward Housekeeper was introduced in 2001 to assist with keeping wards clean, supplies of basic equipment and dealing with non-clinical patient needs (May and Smith, 2003). This role bridges the work of a cleaner and an HCA and could be interpreted as the reinsertion of a rung on a job ladder and, for contracted out staff, the opportunity to re-gain employment in public sector healthcare organisations on preferable terms and conditions. Where cleaning is outsourced, the private contractor may also employ the equivalent of Ward Housekeeper with job titles such as Patient Services Assistant and Ward Steward. 3. New institutions to bolster ILMs? Against this backdrop, concerns over recruitment to key occupations and the quality of care provided to patients are two of the stimuli which prompted the creation of a new pay system and a national skills
development initiative. The purpose of Agenda for Change, which came into effect in October 2005 with the agreement of the key social partners – trade unions and employers - was to harmonise terms and conditions across occupational groups and simplify a complicated pay system. It also responded to a need to protect against equal pay claims, union demands to improve the pay of low wage workers in the NHS and to optimise earnings progression for staff within existing jobs. The successful agreement of this new national pay structure for the NHS was subsequently extended to private sector firms that provided services to NHS organisations. The Department of Health stipulated that the new national terms and conditions should apply to all workers in private sector subcontracting firms. Furthermore, there was an ending of the compulsory transfer of staff as part of PFI outsourcing deals, such that only supervisory staff were obliged to transfer under the Retention of Employment Model. The Skills Escalator was launched in 2002. Described variously by the Department of Health as a ‘concept, metaphor, strategy’, it has a fourfold purpose encompassing principles of widening participation in learning and employment in the NHS, meeting skills shortages, expanding career development opportunities, and improving productivity through role redesign and task delegation. Skills Escalator aims are supported through the Knowledge and Skills Framework which outlines competencies required for each role and provides a framework for personal development planning. Pay increments within bands under Agenda for Change are based on assessment of competence using the KSF. However, unlike AFC, the Skills Escalator is not compulsory and not performance-managed; rather it was expected to be attractive to Trusts by helping them to meet service priorities. 4. Research method In analysing the impact of the chosen initiatives on low paid workers we have selected the examples of cleaners and Health Care Assistant roles as the focus of our analysis as these occupational groups have historically suffered relatively low wages and could be regarded as an underutilised talent pool, from which staff shortages in nursing and AHP roles could be filled. This paper draws on interviews from 13 case studies across two research projects. The first project was funded by the Russell Sage Foundation as part of a wider international and cross-sectoral study of low wage work and examined the impact of Agenda for Change on cleaners and health care assistants. It took place from 2005-2006 and included 7 case studies of NHS Acute Trusts, consisting of interviews with finance and HR staff, supervisory managers, employees in the selected roles and outside contractors. The second project was funded by the Department of Health and examined the take up and impact of the Skills Escalator idea. We draw upon data from six case studies including a Mental Health Trust, 2 Primary Care Trusts and 3 Acute Trusts. While the scope of this project included a wider range of staff, skills development initiatives focussed heavily upon the two target occupations. It thus provides a complement to the first research project because it allows us to examine the provision of career development opportunities in relatively advanced Trusts which have actively chosen to engage with the Skills Escalator concept. Interviews took place with HR and training staff, external contract managers and training providers, line managers and the target staff groups. Table 1 provides background information on all the case sites. [insert Table 1 here] 5. Pay improvement and protection from external markets With the negotiation and implementation of a new national pay structure for the NHS workforce, our argument in this section is that the new institutional regulations have been, in the main, relatively
effective in improving pay rates for cleaners and assistant nurses. They appear to have boosted basic rates of pay and established a degree of protection from rates of pay for comparable jobs in the external labour market. In hospitals which had outsourced ancillary services, there were problems of fragmentation of pay structures between NHS employees, outsourced employees and newly recruited workers in the private subcontracting firms. However, the agreement by government of a new ‘Two Tier Code’ on employment conditions in October 2005 largely remedied this situation. The implementation of the new pay structure was decentralized to the hospital level, allowing for adaptation of idiosyncratic job descriptions to appropriate pay banding through local job evaluation. This was a costly exercise, involving a great deal of managerial time reviewing jobs and negotiating individual appeals. Indeed, some managers would have preferred a national matching of all jobs to the national pay scale to avoid repetition of administrative work across hospitals and to prevent hospitals placing similar jobs in different bands. Nevertheless, HR managers welcomed the general spirit of the new national agreement, especially its capacity to improve partnership relations with unions and to improve the position of low wage workers. The following quotes are illustrative: Agenda for Change has been an absolute God-send as far as partnership working goes (Assistant HR Director, Trust 4). I think it’s an opportunity to grasp and pay people or reward people for developing and taking on additional duties (Assistant Director of HR, Trust 2).
Data in table 2 support the argument of the positive impact of AFC for cleaners and HCAs in terms of basic pay. For example, a grade B cleaner with a basic hourly rate of £4.92 on the old Whitley pay scale would expect to transfer to a new Band 1 rate of £5.89, an increase of 20%. Similarly, new recruits to the post of assistant nurse would experience a rise from £5.69 to a Band 2 rate of £6.09, an increase of 7%. The rise is greater for cleaners since, like all ancillary workers, they also benefit from a reduction in the working week from 39 to 37.5 hours which raises the hourly rate; the change in hours accounted for approximately 25% of the increase in the basic rate. Table 2. Comparison of basic hourly pay rates between old and new national pay scales (April 2005) a) Cleaners Old payscale for ancillary staff (Whitley)* Grade B
£5.09 £5.00 £4.92
Grade C
Grade D
£5.13
£5.31 £5.13
New harmonized payscale (Agenda for Change) Band 1 £6.43 £6.26 £6.09 £5.89
£5.00
b) HCAs Old payscale for nursing staff (Whitley) Grade A Grade B
New harmonized payscale (Agenda for Change) Band 2 Band 3 £8.40 £8.21 £7.95 £7.73
£6.89* £6.68 £6.46 £6.27 £6.07 £5.88 £5.69
£7.61* £7.36 £7.12 £6.89 £6.68
£7.56 £7.28 £7.02 £6.83 £6.63 £6.43 £6.26 £6.09 £5.89**
£7.56 £7.28 £7.02 £6.74** £6.43** £6.18**
Notes: * Additional increment for staff with CARE NVQ level 2 (grade A) and level 3 (grade B); ** special transitional pay rate.
Only one case in Trust 9 threw up tensions between an existing pay structure and Agenda for Change. One directorate was trying to develop its own pay and career structure for housekeepers. This differentiated them into two grades with two different rates of pay depending upon their level of skills and responsibility. However, under Agenda for Change, both roles were graded as a Band 2 so managers were grappling with the implications for work organisation and staff morale and had not resolved the problem when fieldwork was completed. While entry pay rates increased, the potential impact on outcomes such as recruitment and retention depends on subjective perceptions of internal and external pay equity. We therefore asked cleaners and HCAs to reflect on whether they thought their new rate of pay was fair, both in relation to their level of education, skill, experience and age and in relation to alternative jobs they could apply for in other organizations. Responses were only available in nine cases, as fieldwork in some of the Skills Escalator project sites concluded before Agenda for Change bandings were known. The responses suggest less widespread satisfaction with the fairness of the new pay agreement than we had perhaps anticipated, contingent upon level of skill, age and experience. The following response typifies those dissatisfied: A lot of people have gained from [the new pay agreement], but I don’t feel that we have, for what we’re expected to know and expected to do in this job (Assistant nurse 2, Trust 1).
At Trust 9, a group of cleaners had completed NVQs 1 and 2 and a British Institute of Cleaning Science Qualification and were under the impression that this should benefit them with some kind of financial reward under Agenda for Change. When they discovered they had been placed on Band 1 alongside others without these qualifications, they were disappointed. It’s like this Agenda for Change, right. With all the housekeepers, I’d say the team cleaning staff have had more NVQs and that than they have, but they’re on a lot more money… We’re based at the very bottom…So really for our NVQs and BICs and that, we may as well not have taken them, because we’re no better off at the moment… So we are going to appeal’.
Similarly at Trust 5: Now we’ve got our NVQ …we don’t get any more money…We get more qualifications but we don’t get any extra pay (Cleaner 2, Trust 5).
However, most believed the pay was fair compared to other job opportunities. One of the cleaners had previously worked part-time in the evenings after working days as a fully qualified nursery nurse, but then quit her job as a nursery nurse and started as a full-time cleaner because the pay was better. Others compared their pay favourably with similarly skilled workers in the care sector. Yes, because I could go and do care work but it’s less. It’s like £4.85 an hour. I’m not going to do that for that. I used to do it before I came here (Cleaner 1, Trust 3).
I think that [public sector hospitals] pay a lot more than like domestics in other jobs, definitely. And I mean, you’ve got sickness pay as well. I was off for fourteen months and still got paid, which was wonderful (Cleaner 2, Trust 2). If I’m having a bad day I think, ‘Oh, I’m going back to work in residential [care]’. And then I reflect back to the pay on that and I think, ‘No, you’re alright where you are. Leave that newspaper alone!’ (HCA, Trust 2).
Thus, while pay rates do appear to be positively sheltered from external ‘market rates’, the complex job evaluation associated with the matching of jobs to new pay rates appears to be less than ideal. Some of the frustration and dissatisfaction with the new pay rates reflected particular problems caused by the fact that higher basic rates of pay did not always amount to higher total pay. Under the previous national pay structure hospitals had included performance supplements for ancillary workers including attendance allowances and special premia for working in Accident and Emergency which were all abolished under Agenda for Change. Furthermore, enhancements for overtime and unsocial hours working were reduced. New overtime rates cut the double time premium for Sundays to time and a half. Unsocial hours premia were less generous, paying a maximum of 25% of the basic weekly wage, in contrast to minimum hourly enhancements of 33% for night hours to 100% for Sunday working. Despite the reduced premium rates, because these are applied as a supplement to all hours worked, most workers were expected to gain under the new pay structure.1 However, those working a large share of unsocial hours would lose. For example, an experienced grade A HCA on night shifts (three nights, 9pm-7.30am, per week including weekends) earned £8.35 per hour on Whitley rates, but just £7.96 on the new rates despite receiving the maximum 25% enhancement (Unison 2004). Our interviews suggest that the problem was less the overall impact on total pay than the fact that the proposed system abolished a longstanding custom and practice, concerning time and a half and double time, which clearly specified the enhanced hourly rate of unsocial hours working. This generated confusion among some workers we talked with: ‘But the thing that is bothering me at present … When I do my weekends I get time and a half for Saturday and double time for Sunday, which helps to boost up our low pay an enormous amount. Now, under Agenda for Change … they want us to work weekends for the same rate of pay as we do in the week. And it will not work.’ (Domestic 1, Trust 1). ‘I am worse off for the fact that obviously I used to get double time for a Sunday. I now get time and a half, I suppose in the end you’ve got to accept Agenda for Change, it wasn’t done to make us better off. I can’t be that naïve really like…you’ve got to sort of grin and bear it…I did climb I think was it really by about 90 pence an hour, which was obviously a considerable rise…but obviously we’d like to receive, still like to receive double time on a Sunday’ (Domestic, Trust 10).
While it appears that only a minority of workers suffered a loss of total earnings under the new pay agreement, the level of concern among unions was such that there was a national agreement to retain the old national terms and conditions regarding unsocial hours payments until a revised set of conditions is agreed (draft proposals for comment issued February 2007). Consequently, during the first year of implementation workers’ enhanced pay was protected. Any cleaners who were working weekends only as a second job to make ends meet would clearly be disadvantaged under the new scheme. For the majority of staff, it seems that managers have more work to do in communicating the impact of the new pay system so that staff misgivings about adverse impact can be allayed where possible. 1
For example, a part-time grade B domestic assistant working a 5pm-9pm shift, five days each week, including rotating weekends, earns a total hourly wage (basic plus enhancements) of £5.92 on the old Whitley structure, but this rises to £6.46 on Agenda for Change conditions (2004 wage rates). Similarly, a part-time domestic working three 8-hour shifts, 6am-2pm, including Saturday, would expect a pay rise from £4.81 to £5.62 (all calculations cited in Unison 2004).
A final issue in our assessment of pay prospects concerns how new institutional arrangements shaped conditions for cleaners in the seven hospitals where they were employed by a private firm. With the new ‘Two-Tier Code’, cleaners with protected terms and conditions following staff transfer experienced the same change to pay as other cleaners employed in-house. However, cleaners who had been newly recruited by the private sector firm enjoyed an enormous improvement, not only in the basic rate of pay, but also in other conditions such as holiday entitlement, unsocial hours premia and sick pay. For example cleaners employed by Contractor 2 at Trust 7 were all paid a flat rate of £5.09 and were looking forward to an increase to rates varying from £5.89 to £6.43, reflecting the nature of their job. At Trust 8, the cleaners were employed by Contractor 3. Managers reported that prior to the introduction of Agenda for Change all were highly conscious of the better pension, sick pay and holiday entitlement offered by the Trust. Cleaners interviewed were very keen to gain direct employment as HCAs or housekeepers for the Trust with the attraction of enhanced conditions. At Trust 2, where a ‘retention of employment’ model had been agreed, we discovered that cleaners employed by the hospital were paid higher rates than their supervisors who were employed by the private cleaning firm, Contractor 1. Supervisors were paid an annual salary of £11,000-12,000 compared to a range of £11,486-£12,539 for cleaners on the new public sector pay scale. In the words of the Associate HR Director, ‘The supervisors have been saying, ‘Get on with it. What are you going to do about it [Contractor 1]. Come on, pull your finger out’’. The HR manager at Contractor 1 recognized this was a problem but argued that the issue was ‘Who’s going to pay for the five days’ extra holiday? Who’s going to pay for the increase in rates of pay?’ Since our fieldwork, the government agreed to fund the bulk of the costs associated with raising terms and conditions of private sector cleaners to the level of the public hospital pay agreement. 6. Development and progression opportunities The second characteristic of the type of internal labour market that Doeringer and Piore (1971) described is the capacity for skill development and pay advancement along carefully designed vertical job ladders within the organization. Within roles, pay progression is facilitated by extended pay scales. As we saw above, the new national pay structure extends the possible pay scale for HCAs from a minimum-maximum range of 134% to 138% (from £5.69-£7.61 to £6.09-£8.40, see table 2). For cleaners, however, the pay scale was not significantly lengthened; the previous pay scale of £4.92£5.31 represented a pay range of 100-108% and the new pay scale of £5.89-£6.43 a range of 100109%. Alternative mechanisms for progression are therefore dependent on possibilities for skills acquisition to enable promotion, sometimes into newly created roles. We consider opportunities and obstacles for each group separately. Progression opportunities for cleaners Cleaners at some of the Trusts (1-7) from the RSF project were required to undertake formal qualifications, but there was evidence of considerably slightly more training and development opportunities open to them at Trusts 8-13 which were committed to Skills Escalator principles. All of these organisations required domestics to complete a minimum of NVQ Level 1 (and reported that all were completing it successfully) and some offered Level 2. Trusts 9 and 12 supplemented this with additional infection control training and courses from the British Institute of Cleaning Science. This reflected different approaches to managing expectations about personal development opportunities. Managers at trusts 8-13 stressed an inclusive approach to training and development, extending across the whole workforce. In interpreting the Skills Escalator concept, the majority of managers laid
particular emphasis on offering opportunities for staff whose learning needs had been neglected in the past. Three were running specialist programmes aimed at domestic and other ancillary staff. Trust 8 ran an innovative programme called ‘Archway’ in partnership with the outsourced cleaning provider, aiming to put around a third of the domestics through training designed to build up skills to place cleaners in a better position to apply for and gain roles as housekeepers and HCAs. Trust 9 was piloting NVQ 2 in Support Services and Trust 11 ran an Employee Development Programme, offering nonwork-related courses to tempt staff with few or no formal qualifications back into learning. Managers pointed to the increase in confidence that domestic staff had gained through validation of existing skills and that this inspired some domestics to gain faith in their own abilities and pursue customer care and health care qualifications. Of the 11 cleaners we spoke to in Trusts 8-13, five had further career ambitions stimulated by the learning opportunities in which they had participated; those without desires to progress were almost all within a couple of years of retirement. Managers in Trust 8 reported that around 12 out of 100 cleaners each year moved onto housekeeping and HCA work and in Trust 12 the Domestic Supervisor reported that out of around 160 domestics, she lost over 30 each year to housekeeping and HCA roles. Trust 6 included a career structure for the domestics as part of the inhouse bid for the cleaning services. The route for progression enabled domestic assistants to progress to team leader then supervisor, and domestic staff were also encouraged to take the nursing pathway and go on to become HCAs. The Facilities Director at Trust 5 described their service as ‘a bit of a recruiting ground for the rest of the organisation’ and acknowledged that turnover could cause problems in managing the service. Cleaners in Trusts 1-7 were able to progress into supervisor and facilities management roles or move into catering, staff services, pharmacy or healthcare assistant roles. However, we found evidence that at Trust 5, training resources for the NVQ programme were directed at HCAs where there was a clearer developmental path. The HR Director believed managers had to consider, ‘What will be the return for the Trust?’ Consequently, while cleaners at Trust 5 could complete NVQ Level 1, this was not compulsory, nor was it actively encouraged by managers in view of limited resources. Most of the activity across all the case sites focussed on developing cleaners and housekeepers for HCA roles or at pre-employment levels to help socially excluded groups into work. There was particular emphasis on this in Trusts located in inner cities with skills shortages, plenty of alternative employment opportunities and latent talent pools among disadvantaged communities. Six of the thirteen Trusts had introduced the new role of Ward Housekeeper, and the private firms at Trusts 4, 6 and 7 had introduced a similar new role, the Patient Services Assistant or Ward Steward. Views were mixed as to how far this represented a real career opportunity. In Trust 9, cleaners in one directorate were given the choice of whether to remain in their current roles or to train as housekeepers. Most of the cleaners had chosen to transfer; one estimated that only six cleaners remained to cover several wards. Some interviewees were extremely enthusiastic about the housekeeper role, and saw it as a step on a career ladder: ‘You can’t just say I’m being housekeeper for the rest of my life. You can branch into a different department if you want to do level 3 and do administration. Iif you’ve got the head to go for it, you go for it’ (Housekeeper, Trust 8).
However, while cleaners welcomed the potential to earn higher pay, not all believed the housekeeper role was of a higher value in terms of the duties required. She makes tea for them. She will change the flowers, generally tidy up round where they are. She will assist to feed the patients. So it’s sort of a step up from a cleaner. … I feel we’re worth more than what we get. And I feel … we’re doing the heavy slogging stuff for less. She may end up coming out with
maybe 20p an hour more than I do, which might not sound a lot to people, but over a month … (Cleaner 1, Trust 1).
Across all the case sites, some managers and staff were conscious that career progress for cleaners and housekeepers within ancillary work were likely to be very limited and questioned where they could move to, given relatively limited numbers of supervisory and management positions. Cleaners said: We have to have all these training things, right, but it doesn’t do anything at all for our job, because we’re still staying in Band 1. You know, if we go, take all this training and we could sort of, go higher up the scale, but there’s nowhere else for us to go. The nurses and things like that, when they do all these training things they go higher up (Cleaner 1, Trust 2). ‘I sometimes feel that we are probably kept in the position that we’re in instead of being offered Progression. Seems to me that we’re short of cleaners… The opportunities for us to move on are very limited’ (Cleaner, Trust 10).
A final issue concerning career paths for cleaners revolved around the various complications introduced by outsourcing of cleaning activities. One complication was the potential for outsourcing to rupture the job ladder connecting skilled cleaners to the post of HCA. Managers at Trusts 4 and 7 expressed concern that fewer cleaners were applying for HCA posts than previously when cleaning was managed in-house. Part of the problem was a lack of information sharing between the hospital and private firm, as well as a potential unwillingness of the private cleaning firm to lose its more able staff. At Trust 4, HR managers were wary of undermining partnership relations with the private cleaning firm by ‘poaching’ cleaners: When we go over to the [contractor’s] induction programme we quite often get asked, ‘What are the opportunities to come and work in the NHS?’ And you feel a little bit – you’re sitting there with their manager saying, ‘We’re not here to poach you!’ But clearly we would welcome them if they take an interest in a particular area. So it’s a little bit sensitive really because clearly [Contractor 2] want to keep their best workers (HR Director, Trust 2).
A second complication was introduced by the new ‘retention of employment’ model implemented at Trust 2. This model ruptured the job ladder between cleaner and supervisor because progression to supervisor required a change of employer from the public hospital sector to the private firm, Contractor 1. And, while the new Two-Tier code means that pay rates are as favourable, transferring staff still lose the generous public sector pension scheme. Trusts 6 and 12 had successfully bid to bring cleaning services back in-house. Trust 6 hoped that this will provide a clearer job ladder for domestic assistants, with the creation of more team leader and supervisor posts and the manager of domestic services at Trust 12 was already benefiting from being able to access more training for staff. Only Trust 8 had successfully made use of local regeneration monies to fund backfill costs enabling outsourced domestic staff to undertake training to access NHS jobs under its Archway Programme.
Progression opportunities for HCAs At all 13 Trusts, the majority of HCAs were paid at the Band 2 level and were expected, or at least encouraged, to take the NVQ Level 2 qualification in Care. There were several examples of new Band 3 posts, which required NVQ level 3 skills, and these were offered as possible paths of progression for Band 2 HCAs. For example, two Trusts had introduced the new role of Junior Doctor’s Assistant. These are HCAs who are on-call and trained to take some of the workload from junior doctors by carrying out routine procedures such as cannulation and phlebotomy. Seven Trusts had introduced the
new post of Assistant Practitioner for HCAs who wished to further their career. This post involved completing an NVQ3 plus a two year foundation degree. Assistant practitioners are trained to provide a higher level of support and to carry out procedures such as venepuncture, and ECG recording. Some may be able to progress into therapy roles. Moreover, once fully qualified, assistant practitioners are paid Band 4 rates. Trust 9 had developed a ‘mini’ Skills Escalator for rehabilitation assistants working with elderly inpatients to help them regain independence. This involved a mixture of NVQs 1-3, inhouse competency based training and specialist modules. This then opened up career routes into professional training in occupational, physiotherapy and speech therapy. All 13 Trusts also offered secondments to nurse training on 80% of salary for HCAs who wished to become qualified nurses. These were funded by the government through SHAs. Despite these opportunities for HCAs, there were also obstacles to progression. First, several of our interviewees had completed the NVQ Level 3 qualification but had not been promoted to a Band 3 post. This was because promotion only occurred where a post became available, rather than following skill acquisition per se. As the Assistant Director of Nursing at Trust 4 put it, ‘What wasn’t explained to people is that qualifications don’t necessarily match role progression’. Unsurprisingly, therefore, we found evidence of dissatisfaction among those HCAs who had been funded, and encouraged, to complete a level 3 qualification but were still paid at the same rate as those with a level 2, or no qualification. Managers recognized this was an issue: Maybe [HCAs] have undertaken their NVQ3, for example, but what has happened is, we have said the role needs to change. The fact that you’ve got an NVQ3 doesn’t mean that you’re better, or you’re doing a different role. So it’s about how that has impacted on the duties that they undertake. [The new pay structure] is about what the role is and what the responsibilities of that role are. … The fact that you’ve got an NVQ3 doesn’t mean that you’re automatically a Band 3 (HR Director, Trust 4).
A response to this potential problem of oversupply of skills and labour, combined with cost pressures on the funding for training provision and on the pay bill formed a second obstacle to progression. In some Trusts, even those which were committed to Skills Escalator projects, we discovered that managers had changed their strategy toward skill development and during 2005 did not offer the chance to complete a level 3 qualification simply on the basis that an HCA wanted it. Instead, the opportunity was restricted to those who were either defined as occupying a role that required level 3 skills, or earmarked for a forthcoming Band 3 post vacancy. We don’t automatically go, ‘Oh that’s it, you can have this now then’. Otherwise you’d have no control over your pay and it also may be that actually whilst it’s nice for the individual to go and do their NVQ3 you don’t actually require that level of skills and knowledge on your ward. But you’re quite happy to support them to go and get the qualification so they can apply for other jobs (Deputy Chief Nurse, Trust 3). ‘Somebody who has achieved their Level 2 can access Level 3 but it’s not automatic progression here. They have to be a role above and beyond what they’re doing now in order for them to do a Level 3; they can’t just do it because they want to do it basically’ (NVQ Co-ordinator, Trust 12).
At Trust 6 a distinction was made between support workers and HCAs, the latter qualified to NVQ Level 3. One of the support workers was currently working towards the NVQ3 qualification, and when asked whether she would become healthcare assistant, and receive a pay rise on completion of the qualification she explained, ‘No. I’d have to probably apply for a new job to become a healthcare assistant, because it’s a different band’ (Support Worker, Trust 6).
A third potential obstacle was that in some situations, even where a Level 3 post had been created there was a mismatch with the pay rate. For example in the Renal Unit at Trust 3, two HCAs who were training as Assistant Practitioners were still paid a Band 2 salary despite working in a post requiring extra qualifications. I’ve got NVQ Level 2 and Level 3 in Care, NVQ Level 3 in Haemodialysis and, as I say, I’m now working for this Foundation Degree … We’ve been told that we are going to be a Band 2 as we currently are, which we are going to object to. Because we think that, as an ordinary [HCA] is a Band 2 we should be slightly higher because of our extra involvement (HCA1, Trust 3).
An HCA in the day surgery unit at Trust 12 had undertaken extra training and gained agreement that she would gain a Level 3 banding, but reported that no money was available to pay her and the impact this had on her: ‘I do feel sometimes that you could be more than just a HCA and with the skills that you have achieved you do feel like a trained nurse, and I feel it’s unfair sometimes… it’s hard work and especially if you’re taking on extra skills as well, like bloods and ECGs, and if you’re not recognised for them too and not paid, it does sort of make you feel a bit demoralised’ (HCA, Trust 12).
The last obstacle was that while the secondment route was open to experienced HCAs who wished to become qualified nurses, the number of places offered was variable. One directorate of Trust 9 had particular success in gaining unspent monies from the SHA and provided up to 20 places per year. In other Trusts secondment places were more limited (around 10 to 16 annually) and ‘always oversubscribed’ (Deputy Chief Nurse, Trust 3). Only three secondment places a year were available at Trust 5. In Trust 12, the numbers of secondment places were being reduced from 15 to 10 each year as Foundation Trust status was making the organisation link individual development tightly to organisational goals and the NVQ Co-ordinator reported that 35 people had applied in the last round. One manager in Trust 13 had recently seconded 4 HCAs onto nursing training. Some secondees noted that progression into professional training was dependent on how hard individuals and their line managers pushed for access, suggesting assertiveness and confidence as pre-requisites.
7. Discussion and conclusions Following a period in which the fragmentation and dissolution of ILMs has been debated, it seems that within the NHS, their characteristics are experiencing something of a rebirth. Our evidence suggests that the implementation of Agenda for Change has improved pay levels for low paid health service workers and increased opportunities for progression within pay bands. Innovations were taking place in skills development for workers within and outside NHS organisations and labour market circumstances had prompted particular innovations in the form of pre-employment schemes for Trusts in inner city locations. Progression for cleaners to career opportunities in higher skilled jobs were available in the form of HCA roles (though accompanying reward was less certain) and entry to professional and new paraprofessional roles through secondment opportunities for HCAs was possible, but dependent on funding availability. There are three key aspects to consider in evaluating the significance and sustainability of these innovations. Agenda for Change has mostly been well received but some confusion was found among workers over the impact on total wages, as well as doubt over the equity of local job evaluation processes so that pay may not always be consistent for the same role across different Trusts. Government intervention to equalise wages for ancillary workers employed in private and public sector
organisations is indicative of continuing problems in managing the employment relationship across organisational boundaries (Marchington et al., 2005) and is a rare case in the UK of regulation of unfettered market forces on pay. But sustainability of the impact is doubtful. Employee perceptions of equitable pay will only continue if pay rises keep pace with those of alternative employers, which may be questionable given the policy of below inflation public sector pay rises being pursued by the Chancellor of the Exchequer in 2007. In this respect, the formation and protection of key dimensions of ILMs in the public sector is not wholly within the control of the employer, but heavily dependent on state co-ordinated wage-setting mechanisms and state perceptions of inflationary and other economic pressures on the public purse. The second key issue affecting the overall impact of AFC and the Skills Escalator on career progression for low paid staff are their links to the NHS Knowledge and Skills Framework and how the acquisition of skills will be treated under the accompanying review system. Tensions emerged between what Marsden (1999: 32-36) refers to as a training versus a production approach to the allocation of jobs and individuals to jobs. On the one hand, managers sought to match jobs with worker skills and to provide training so as to achieve high levels of skill utilisation and to support the development of workers’ skills (‘training approach’). On the hand, however, managers also aimed to define jobs to meet the functional service needs of the hospital ward or directorate and to develop the necessary skills accordingly (‘production approach’). Over two thirds of managers interviewed in case sites running Skills Escalator projects interpreted (and supported) its purpose as solely for the benefit of individuals rather than the organisation. However, across both projects we saw examples illustrating the dilemma of whether employees could be regraded to gain higher pay for undertaking training which makes them more competent in a role they currently do. Under the KSF system, skills acquisition deemed necessary for full competence in a role will result in incremental pay progression through ‘gateways’ on the payscale but not regrading into a higher pay band. This may raise some sensitive issues about pay system equity if staff compare the new and previous pay systems. Careful attention may therefore be needed in addressing any remaining staff expectations of automatic incremental progression and managing perceptions of pay equity in relation to requirements to train. In this respect, we found worryingly little evidence of any attempts by managers to think through the implications of how the KSF, AFC and the Skills Escalator connect with each other. Members of the implementation teams we spoke to for KSF and AFC were treating the schemes as a technical exercise in profiling and valuing jobs, driven by tight timescales from the Department of Health. We found few examples of cross-team membership for the two systems and none where learning and development or other managers leading Skills Escalator projects were party to AFC or KSF implementation projects. It therefore remains to be seen whether skills development for future as well as current job needs will mutually reinforce the provision of career ladders and satisfy worker expectations of future reward, as well as organisational capacity to pay. This attempted re-integration of ILM practices and structures is therefore perhaps more shaky than it first appears. A further complication is that under the KSF prescription, any organisation which identifies a training need that requires satisfying before staff can progress through a ‘gateway’ will not be permitted to hold the employee back from passing through the gateway and gaining extra pay if the training need cannot be met due to inability to fund or release employees for training. The employee may gain an increment in the short-term but in the long-term may be left without skills which are vital to progression into a higher pay band. The third issue affecting the progress of HCAs and cleaners up through ILMs is the availability of progression opportunities. In contrast to centralised pay determination mechanisms, where the impact of the national institutional framework is felt directly, progression opportunities were more amenable to management choice and control and there was greater variety of practice. For cleaners, the routes were very traditional and employer boundaries and strategies with respect to outsourcing were found to be
key to enabling access to progression. HCAs had a somewhat wider range of specialist clinical opportunities available to them but the major constraints on this were availability of funding for nursing training secondment places and demand for new roles. Trusts gave little attention to the possibility and desirability of creating non-clinical career routes out of auxiliary and ancillary work, although some case sites reported staff shortages in management and support roles. Job ladders and opportunities for career progression were therefore concentrated in organisational and occupational niches. Staff numbers benefiting from the opportunities presented were often, but not exclusively, relatively small in proportion to the size of each Trust’s workforce. While significant amounts of public funds, policy emphasis and expansion of a professionalised management function have provided supportive conditions for the renewal of internal labour markets, this must be balanced against whether there is sufficient management capacity and capability to innovate and create new roles. Planned expansion of Assistant and Advanced Practitioner roles enabling staff to take on delegated tasks from professional staff offers some potential for pulling employees up the organisational hierarchy. Further stimulus to the adoption of these roles comes from widely reported financial constraints on NHS trusts. This could lead to a drive to remodel the profile of the healthcare workforce so that clinical tasks are carried out by the cheapest (i.e. lowest graded) possible employee while maintaining safety standards. Institutional support for the development of career ladders comes from the Sector Skills Council. Plans in Skills for Health’s Sector Skills Agreement (SSA) also include building ‘natural progression’ into entry level roles and research into provision of a guaranteed minimum quantity of protected learning time (Skills for Health, 2006), placing the healthcare sector some way in advance of other parts of the economy. But fundamentally, the difficulty of (re)designing roles within organisations is unappreciated and underestimated. Hyde et al. (2004) have shown the difficulties of the process of role and service redesign in the NHS Changing Workforce Programme. The process requires high levels of management skills in both reconceptualising work processes and managing change processes, which is a significant challenge to both the leadership skills and resources of operational managers and HR staff. Parker et al. (2001) review work in the area and provide a helpful but huge contingency model of influences, processes and outcomes. However, they largely equate work redesign to introducing teamworking, rather than how individual jobs are constructed, concluding that managers currently attempting to redesign work will feel ‘inadequately prepared’ (p.433) by current theory. Further renewal of internal labour markets for low skilled workers in the health sector will therefore require support at an organisational as well as institutional level to reconcile ‘training’ with ‘production’ approaches to work organisation.
Table 1. Case study summaries 1 (Small Town 2 (Large PFI 3 (City 4 (City Hospital) Hospital) Hospital) Hospital) Greater Manchester Local rate of 4.6% unemployment* Location
PFI 5 (One Star 6 (City Suburb 7 (Rural PFI Hospital) Hospital) Hospital)
West Midlands 5.1%
Greater Manchester 4.5%
Greater Manchester 4.5%
North West Greater Midlands Manchester 2.6% 4.5%
South West Midlands 3.8%
Number of sites
4
3
6
2
1
2
1
Number of staff
4,339
6,663
5,400
5,500
2,227
4,281
1,600
Number of beds
831
1,417
Performance rating
3-star
3-star
Management of In-house domestic services
PFI
No
Private cleaning n.a. firm Deficit Financial balance £743,000 (2004/05)
855 1-star
3-star
Outsourced In-house (4 Outsourced (supervisory) sites) In-house (non- Outsourced (2 supervisory) sites).
In-house
Yes
Yes
No
Outsourced at Outsourced time of interviews. In house since April 2006. No (future PFI Yes planned)
Contractor 2
n.a.
Contractor 1
2-star
No (Yes 2008) n.a.
3-star
800
from
Contractor 1
Forecast Deficit £7.7m Surplus £59,000 Deficit £2.5m Surplus deficit £6.4m (2004/05) (2004/05) (2004/05) £450,000 (2005/06) (2005)
Notes: * rate of unemployment refers to local travel to work area.
2-star
Contractor 2 Surplus £20,000 (2005)
Location Local rate unemployment Employees No. of sites
8 Inner City Acute South East City of 7.5%
9 Midlands 10 Rural PCT PCT Midlands East Midlands City 5.2% 4.6%
11 Mental Health
12 Suburban Acute
13 Outer City Acute
East Midlands
North West
South East City
4.7%
2.6%
6.5%
2000 4 reducing to 3 in 2006.
3800 4 main hospital sites and 33 small residential units
5000 3200 4 main sites and a 1 main site number of smaller ones
4500 2 main sites, 1 smaller one, a walk-in unit and an urgent treatment centre
424
608 main hospitals 2-star
810 in main hospitals, 946 in total
1340 3 community hospitals; a minor injuries unit; an NHS Walk-in Centre; 6 health centres in 200
2-star Performance rating Management of Outsourced In-house domestic services
2-star
340 on sites 625 operated by the Trust 3-star 3-star
Outsourced
In-house
Yes, to open Summer 2006 Private cleaning Contractor 3 firm Financial balance Surplus £13,000 (2005/6_
No
No
n/a
Contractor 2
Surplus £320,000 (2005/6)
Deficit £2.5m Surplus (2005/6) (2005/6)
No. of beds
PFI
1-star
Formerly Outsourced outsourced, but brought back inhouse in April 2005 Yes, in process of Planned Two, one completed, one construction in progress
n/a
N/a £2m
Contractor 2 Deficit £24 m (2005/6)
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