“Don’t tell me what your priorities are. Show me where you spend your money and I’ll tell you what they are.” – James. W. Frick

How much are you worth? Five thousand pounds? A million dollars? Ten quid and a KitKat Chunky? There’s no doubt that the subject of money brings out a squirming discomfort in many people, especially Brits, which is difficult to replicate in any other circumstance. To illustrate this, in 2016 researchers from UCL discovered that British people are seven times more likely to tell a total stranger how many sexual partners they have had than to reveal their income. 

On top of this, healthcare professionals have traditionally been afforded a certain amount of immunity against the raging sea of capitalism. As public “do-gooders”, we have sometimes been permitted to fly under the radar where other professions have been required to justify their income. But our immunity has been weakened after decades of public cuts and we now have to face an uncomfortable truth; everyone and everything has a price.

President Donald Trump, no stranger to controversy, further aggravated the British populous during his recent visit to the UK by stating that “everything was on the table” during future trade talks between the UK and the US “including the NHS”. He has since retracted that statement, presumably because one of his long suffering advisers gently explained over his evening hamburger and fries that you can’t take other people’s stuff without asking first. However, it put the quibblers in many an avid Twitter user and posed an interesting thought experiment; how much is the NHS worth? Or more interestingly; how much are we worth individually?

It’s about now that I would like to unveil the main thrust of this piece; the F word. The F word that people cry in exasperation, the F word that never fails to provide appropriate emphasis when driving home a pertinent point in conversation, the F word that many dislike hearing in their day to day work. Funding. 

The government’s strategic priorities focus on the development and transformation of the NHS workforce in their Five Year Forward View. This includes upskilling the workforce to enable them to respond more effectively to the changing needs of the population. This makes sense. However, in 2015/16 the Higher Education England (HEE) budget for workforce development, which is predominantly used for Continuing Professional Development (CPD), was £205m. In 2018/19 the budget is now £83.49m. That’s a reduction of 60%. These cuts were brought in with very little warning and very little evidence of strategic planning at national level as well as almost no policy discussion regarding the potential consequences, either for the NHS or the higher education sector. In one area of the UK, all CPD provision for AHP’s has been effectively wiped out by the cuts. 

It gets worse. In the Council of Deans 2016 paper “A False Economy”, leading institutions who provide CPD for NHS trusts across the UK have come up against another barrier. Time. Time is money and the NHS is woefully short of both. This means that even if the CPD budget is reinstated to a useful value, there is a large chance that staff will still be missing out because Chief Execs up and down the UK are refusing to release staff for training. 

So, if the government says they want a skilled and reflexive workforce, and NHS Chief Execs say that they want the same, why is no one making it happen? If I were a cynical beast, I would posit that some may have a vested interest in ensuring that the nursing workforce doesn’t become too powerful. Goodness, imagine if we knew what we were worth! The fragile ecosystem upon which our entire NHS hierarchy is built would come tumbling down in a thunder of bedpans and bandages. However, the more likely explanation is as I have already stated. Everything has a price. And if we are to have protection for CPD funding and the time needed to undertake it, we need to prove that the investment is a worthwhile one. Herein lies the problem. Educational interventions are notoriously tricky to evaluate. Every time you think you’ve isolated a variable, it slips away and is masked by another one that you hadn’t even considered. 

But what’s that glistening on the horizon? A glimmer of hope, the faintest whisper of opportunity? No, they are ‘proxy measures’ and they are here to sort of save the day in a round about kind of way. Literally. Proxy measures are something used in research to enable us to determine whether an intervention has been effective when there are just too many variables to consider. Possibly the most well known use of a proxy measure is GDP. Measuring and evaluating quality of life is hugely challenging and therefore GDP is used as a proxy measure. If GDP is high, we can reasonably assume that a population has access to education, opportunity and wealth as well as other things that can increase quality of life. Proxy measures have their limitations though. Another classic example of a limiting proxy measure is BMI. What we really want to know is how much body fat someone is carrying, but this is difficult to do without a number of pieces of equipment and calculations, so BMI is a crude proxy measure to give us an idea. The problem is that it doesn’t account for very muscly people who often weigh heavy, but have little body fat. But it helps to highlight any potential issues with body weight in the majority of the population so it’s OK if we use it with caution. 

So, what proxy measures can we use to highlight the importance of CPD in our workforce? We could consider staff retention. It is well established that career development is an important driver for NHS workers. But we are doing pretty badly right now with 42’000 unfilled posts. OK, so we could consider morale and work satisfaction. People who are being developed are more likely to feel valued and happy at work. We are sadly failing here too with an estimated 12.6 percent of all sick days in the NHS attributable to stress and burnout and over 300 nurse suicides in the last seven years.

But even conducting the research to prove the value of CPD is a challenge because research isn’t even eligible for CPD funding. We can look to outside agencies, but many of them are geared towards medical conditions and don’t readily lend themselves to professions outside of medicine. The NMC doesn’t help our cause by only mentioning “using evidence” twice in the entire Code of Conduct. And two of our biggest British run nursing journals, Journal of Clinical Nursing and Journal of Advanced Practice, take the majority of their submissions from overseas.

So now there’s very little money to undertake CPD because it is not deemed a worthwhile investment, but there is also very little money to undertake the kind of evaluation that would prove that this isn’t the case. There’s no doubt that funding cuts have wreaked havoc on the NHS for decades. The areas hit hardest will always be the ones that have yet to prove their worth. So, I ask again; how much are you worth? If you don’t know, you need to figure it out. Your ignorance could end up costing you far more.


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