Carter bows out with his head held high

RCN chief executive and general secretary Peter Carter leaves the college this month after eight-and-a-half years. He can be credited with turning around the college’s finances and reversing a decline in the membership, rebuilding a working relationship with government, and increasing its influence on health issues beyond nursing. He warns that the NHS will continue to struggle unless funding is improved.

In 2012 I interviewed Peter Carter to mark his first five years in the top job at the RCN. Then, I was struck by his energy and confidence. Some people in high-profile roles view media interviews as a chore or a minefield, others relish the opportunity to get their message across. Dr Carter was clearly in the latter category.

Picture credit: Justine Desmond

Today, three years on, I am back in the college’s elegant London HQ to quiz the outgoing general secretary and chief executive about his record in office over eight-and-a-half years. And what years they have been. Dr Carter’s time in the spotlight has coincided with seismic events in nursing, in the health service and in the country: the economy on the brink of collapse and the clampdown on public sector funding, the NHS convulsed by a bitterly contested reorganisation, and nursing – indeed the RCN – scrutinised and found wanting by Robert Francis’s inquiry into the Mid Staffs care scandal.

If the rigours of the past near decade have taken their toll on Dr Carter, he manages not to show it. Sitting in his office, surrounded by well-wishers’ cards, he is noticeably relaxed, more so, possibly, than at our last meeting.

At 65, he has no plans to retire and instead will be working as a consultant, focusing on policy and culture change. He says he is considering offers from a number of organisations. The only thing he has ruled out is running another organisation.

We are no longer seen as an organisation that can simply be disregarded or ignored

When I ask if burnout has played a part in his decision to leave, he laughs. ‘I feel really good, physically and mentally,’ he says. ‘I love life – I have a lot of fun. I want a bit more fun.’ The RCN was ‘a dream job’, he says, but now he wants ‘more personal space’.

But if Dr Carter is in a good place personally, he is far from relaxed about the state of nursing and the health service. He is scathing about politicians’ failures to support NHS staff to implement health policies.

Peter Carter pictured with Russell Brand at a fair pay rally in London last year; arriving in Basra to visit nurses in 2007

Picture credit: Mark Hakansson

He is unembarrassed about highlighting his achievements for the college, and frank about the times when things did not go his way.

When he arrived at Cavendish Square, the RCN was in debt and membership was falling. Dr Carter brought nearly 12 years’ experience as chief executive of a large London mental health trust. He says he balanced the books by managing the college like the business it is, ensuring ‘every penny was spent wisely’, and introducing ‘highly professional, slick’ recruitment of new members. Membership today stands at 435,000, up from 390,000 in 2007.

But he found it easier to turn around the college’s finances than to change ministers’ minds on key policy areas. The pragmatism he brought to the college in 2007 appears now to be streaked with pessimism.

Dr Carter hands over to his ‘brilliant colleague’ and successor Janet Davies an organisation in better shape than it was when he arrived. But he also leaves with stark warnings about the scale of the problems facing the health service, the profession and, ultimately, the health of the nation.

Thelma Agnew (TA): Three years ago you said 2012 was shaping up to be the NHS’s toughest year. So how do you rate 2015?

Peter Carter (PC): Sadly, it is even tougher – and I didn’t think it could get any tougher.

Arriving in Basra to visit nurses in 2007

Picture credit: Mark Hakansson

The majority of NHS trusts are now in deficit. The government plays with the figures but if you flatline the NHS’s funding it is effectively a cut because the costs go up all the time. We pay less as a percentage of GDP than Ireland, France, Spain and Germany. It is not a profligate healthcare system.

If you look at many of the trusts in deep financial trouble, they are starting each year finding millions to service PFI (private finance initiative) debt. PFI has been an unmitigated disaster. Those companies have taken the NHS to the cleaners. It’s a rip-off.

We have the lowest level of access to CT and MRI scanners of all western European countries. It’s no good naming and shaming GPs if they don’t get it right on cancer diagnosis. Give GPs access to scanners and MRI and they will get it right.

TA: How big a problem is nursing shortages?

PC: If there are more nurses than ever before, then why is every trust recruiting overseas and why is the agency bill at record levels? It doesn’t square.

There has been progress in the acute sector but in 2003 we had 12,000 district nurses, today there are 6,500. We have lost 5,500 of the very nurses who prevent people coming into hospital and also facilitate appropriate hospital discharge.

Visiting staff and patients at Hemel Hempstead Hospital on Christmas day 2008

Picture credit: Tim George

Nursing training places are still not up to 2010 levels – we are playing catch-up now. The NHS is going to be dependent on overseas recruitment for many years to come.

TA: Pay increases for nurses have been frozen at 1% until 2020. Do you have regrets about steering RCN members away from industrial action?

PC: For industrial action to work someone has to be seriously affected. People talk about the late Bob Crow having got the tube drivers £50,000 a year. But Bob Crow could say ‘next Tuesday the trains will stop running’ and it happened. Ultimately, nurses will not walk off wards.

TA: Some unions who had never gone on strike before, such as the Royal College of Midwives, did take action.

PC: People were demonstrating in their lunch break. For the average trust chief executive, the industrial action passed them by.

Andrew Lansley at the ‘2010 Health Debate’ ahead of the general election

Picture credit: John Behets

I thought there was a more sophisticated way of going about it, but nurses didn’t believe that our letter-writing campaign would make a difference. A number of people said to me ‘what the hell will that do, writing to my MP?’ But a lot of MPs had tiny majorities and lost their seats by a few hundred votes.

TA: Is there a problem that nurses, as a group, are not particularly politically engaged?

PC: Part of the challenge is that more than 90% of nurses are women and a high proportion of them have family responsibilities. They work hard and when they get home the idea of lobbying their MP does not appeal. They don’t realise the strength in that.

TA: Are you proud of the impact the RCN had under your leadership in resisting former health secretary Andrew Lansley’s reorganisation of the NHS?

PC: We were one of the key organisations that challenged the Lansley reforms. Obviously we didn’t succeed. You don’t win all your battles, it is a democracy. We took the argument out there for two years and won some concessions.

TA: In 2007 you set about rebuilding the college’s relationship with the Labour government after the nadir of 2006, when the then health secretary Patricia Hewitt was booed at congress. How is the college’s standing now with health secretary Jeremy Hunt and NHS England chief executive Simon Stevens?

PC: Our relationship with Simon Stevens is extremely good. He has been a breath of fresh air – if he is allowed to get on with the job, he will make a major impact on the direction of travel of the NHS, as long as the politicians can keep their fingers out of his pies.

With Jeremy Hunt, it is very mixed. It is not a cosy relationship, not by any stretch of the imagination. But we are no longer seen as an organisation that can simply be disregarded and ignored.

TA: How important was it to increase the college’s influence and media profile?

Promoting RCN’s Frontline First campaign

Picture credit: Nathan Clarke

PC: It was one of the key objectives I set myself and the team. In terms of the media we are now one of the ‘go-to’ organisations when a health story is breaking, as opposed to just popping our head up once a year to talk about nurses’ pay. We want to contribute to the wider message on health.

The UK has the highest levels of obesity among children in all developed countries and we now have record levels of lower limb amputations because of type 2 diabetes. Yet two months ago the public health budget was cut by £200 million – the last thing we should cut is public health.

Right across the age range people are drinking too much but in his last three budgets George Osborne has taken a penny off spirits and beer. He should be doing what Nicola Sturgeon is doing in Scotland on minimum pricing. There is a disconnect between government rhetoric on public health and what is actually happening,

TA: Hasn’t there has always been a gap between government policy on what the NHS should be doing, and the resources required by staff to achieve it?

PC: It’s got worse. Everyone says ‘keep people out of hospital’ but you need the workforce to do that. The workload is rising year on year.

Delivering a seven-day service is not about changing the consultants’ contract or finding a few medical staff to work weekends – that’s far too simplistic. It’s about porters, domestics, catering staff, receptionists, outpatients’ clerks before you even get to nurses, radiographers and path lab staff. To go from a five-day system to a seven-day system is a paradigm shift. The NHS is struggling to meet current demand, let alone address these issues.

I predict that if you interview my successor in four to five years’ time, unless resources are put in, it will not change.

We could not have prevented Mid Staffs

In 2008 Peter Carter visited Mid Staffordshire NHS Foundation Trust. Afterwards he wrote to the local press, praising the hospital.

The Francis report into failures of care at the hospital between 2005 and 2008, published in 2013, criticised the RCN for being ‘ineffective’ and called on it to consider splitting its trade union and college functions. The college rejected such a change. Dr Carter withstood calls for his resignation.

‘I visited Mid Staffs a year before any of the problems were known,’ he says. ‘I was there for a couple of hours and everyone I spoke to spoke very highly of the hospital.

‘I don’t want to downplay what happened at Mid Staffs, it was appalling. But the idea that the RCN somehow caused it or could have prevented it, I don’t accept. I think we could have done a lot better locally at getting the issues raised by staff up the line. We now have a hotline and have said to members that if you don’t feel confident about doing something locally, let us know.

‘We also have been clear that we won’t defend the indefensible. If a nurse has done something and there are no mitigating circumstances, that individual has to be held accountable. It would be ridiculous to have a mindset of “our members, right or wrong”.’

Dr Carter says people who knew his record, knew he would never ignore poor care. ‘I didn’t feel that much personal pressure. I was overwhelmed by letters and cards of support and people saying “this is ridiculous”.’

He believes the public did not lose faith in nursing. ‘At Mid Staffs there was too much emphasis on junior nurses and not enough on the people at the top of the organisation who were ultimately responsible. I think the public gets that.’

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