Exclusive: RCN agrees more strike exemptions after CNO pressure

Previously the only “national derogations” agreed were in acute services (critical care, chemotherapy and dialysis), while paediatric accident and emergency has been added over the past 24 hours following concern about Strep A pressures.

However, HSJ has seen a letter from the Royal College of Nursing leaders tonight agreeing further national derogations – essentially exemptions from strike action – for aspects of mental healthcare and community services.

The RCN’s letter to the four UK CNOs reveals it has agreed “specific derogations” nationally for mental health, learning disability and autism services across children and adolescent mental health services, adults and older adults “as part of an emergency crisis response”. Discussions are ongoing about how to staff high-security inpatient units such as Rampton and Ashworth at Nottinghamshire Healthcare Foundation Trust and Mersey Care Foundation Trust respectively.

Meanwhile, the letter says community physical health services will be “explicitly derogated to a Christmas Day service, and this will enable NHS community teams to provide palliative care and clinically urgent interventions (for example, insulin)”. It is thought this will also cover urgent paediatric services and clexane injections. 

However, some of the latest requests from the UK CNOs are rejected by the RCN.

Its letter appears to say that inpatient units and wards will have only “night duty” staffing, unless further local agreements are made for more – despite the CNOs saying a night staffing approach could ”significantly impact on the safety of patient care (for example, by impacting delivery of intravenous antibiotics on time, patient observations and medication rounds)”.

On cancer, the RCN last night said it had agreed that “emergency cancer services” will be covered, although its letter earlier that day said there would be no further derogations on cancer beyond chemotherapy as previously agreed, despite new requests from NHS England for cover for high-priority cancer surgery. It is unclear what the latest position means for urgent “priority one” and “priority two” cancer operations, with hospital managers understood to be seeking local derogations for these, but still unconfirmed a day before the first strike date.

It also remains unclear how far inpatient mental health, and community mental health services for severe mental illness will be protected.

The strikes are set for Thursday 15 December and Tuesday 20 December.

Discussions took place today following pressure from the UK’s four CNOs. In a strongly worded letter to the RCN sent yesterday, leaked to The Times today, they said there should be parity of esteem between mental and physical health services and recognition of the potential safety consequences of having insufficient nursing staff in services managing the highest levels of risk.

Mental health and community services leaders have raised concerns in recent days that national derogations only cover acute services, reflecting an apparent bias, and that there were also serious risks of harm in some non-acute services.

The letter said the RCN had in recent days agreed to national derogations for dedicated, stand-alone paediatric accident and emergency departments, given recent Strep A pressures, and staffing adult A&E on “a Christmas Day staffing model”.

However, it laid out concerns in relation to general acute care about an “assumption, implied by the RCN, that night duty staffing on day duty is safe”.

It went on to highlight specific concerns about community health services including palliative care, and to request derogations for services including inpatient mental health, learning disability and autism services across CAMHS, adults and older adults; all-age crisis care provision including crisis lines, home treatment teams, psychiatric liaision in acute emergency departments, and section 136 health-based places of safety; and community mental health services supporting people with severe mental illness, including practitioners who may need to be called on to support Mental Health Act assessments.

The CNOs added that within inpatient services it will also be important to address need for staffing increases in response to levels of patient risk, for instance: escalation from general observation to 1:1 nursing, and maintaining the ability to respond to changes impacting patient safety or clinical risk in real time.

They wrote: “The current absence of derogation for these mental health services leaves us very concerned that people with the highest level of MH need and staff teams managing the highest levels of risk will be kept safe.

”We are also concerned as to the message this gives the public regarding parity. We would, of course, be willing to work with you to consider further.”

Outside of national derogations, trusts can make local agreements with their nurses – but they have reported that this is proving difficult, with local leaders uncertain what to do, and sometimes under pressure from regional or national union leaders not to sign up to more.

A number of nurses across mental health, including some of the largest such as Mersey Care FT and Cambridgeshire and Peterborough FT, are striking while dozens of acute trusts are set to walk out on Thursday. Community trusts striking include Leeds, Cambridgeshire and Gloucestershire. 

The RCN said in a statement: ”Nurse leaders are working closely with us as part of our commitment to make this strike safe and effective.”

We also asked NHSE for an update on the agreement.

Updated through evening of 13 December and morning of 14 December with new information.