The Royal College of Nursing's general secretary, Peter Carter,.has altered its stance on reconfiguration, plurality and the wisdom of heckling Hewitt. But he promises fierce opposition to poor management and short-term cuts

Signalling a change in policy for the Royal College of Nursing, new general secretary Peter Carter says nurses' blanket opposition to cuts must be revised, but he argues that if any nurses lose their jobs bad management will be to blame

The RCN is to take on more trusts over cuts to services, Mr Carter tells HSJ in the run-up to the RCN's annual congress this week. But it will support changes it believes are in the best interests of patient care.

Mr Carter also promises that the union is to 'get more sophisticated' to fight 'slash and burn' reconfigurations that seek only to balance the books.

And the former mental health trust chief executive says the RCN will not tolerate a minority of bad managers 'distorting' the NHS's overall financial position.

About one in five managers are 'not up to the mark' and job losses can be avoided by good workforce planning, he argues.

But the union would support reconfigurations as long as the result improves health outcomes and managers involve staff from the outset, Mr Carter insists.

The RCN's track record of opposing all service cuts throughout the country has been 'disparate' and now must improve.

Mr Carter, who took over from Beverly Malone in January, explains: 'It's one thing having some high-level overarching views on things but, to be honest, the way forward is locally; for branches to be looking at the local performance, particularly of primary care trusts, and being prepared to take them to task.

'Our performance is disparate on that. Some branches of the RCN and some local activists regularly attend overview and scrutiny committees and contribute. In other areas that is not so, and we want it to be much more uniform.'

Improving accountability

Getting local branches involved in the work of local authority overview and scrutiny committees is a vital part of improving accountability, he argues, especially as the effectiveness of councillors and public and patient involvement forums was also 'disparate' around the UK.

Mr Carter says questions and papers will be submitted to committees and members will monitor board papers to 'see where the money is going'.

But he adds: 'Where it is properly thought through and has good health outcomes, we will support hospital closures.

'That's very different to what's been going on over the last two years where we have had a series of short-term slash and burn approaches that have nothing to do with a strategic plan and are just trying to get PCTs through the next few months in order to balance their books.'

He claims there are 'copious examples of closures for the wrong reasons' but it is 'not realistic to assume every hospital can do every intervention'.

However, good engagement and consultation with members is essential: 'What PCTs particularly have to do is get in planning and consultative mechanisms that involve people, not just responding to the plan but being part of it.'

Mr Carter, who was chief executive of Central and North West London Mental Health trust for 12 years, has 'absolutely no doubt' nurses will adapt to retraining and redeployment if there was management engagement.

'This caricature of health workers generally and nurses specifically as being luddites and resistant to change is simply an urban myth.

'You will find that with proper training and proper consultation nurses will adapt to change.'

Job losses will only be a result of bad management, he argues, considering the need for more nurses ahead of the coming wave of retirements and the 15,000 shortfall predicted by the Department of Health (news, pages 5-9, 4 January).

'If you know you are going to change the service and those changes have a lead-in of at least a year - and often several years - with proper workforce planning you can ringfence posts and redeploy people into existing vacancies,' he explains.

'So, to be honest, the need for redundancies or job losses for people in clinical posts shouldn't really be on the agenda.'

The RCN would 'be able to demonstrate in most places where that is happening that it's because people haven't planned properly'.

Too often cuts lay with poor management, he says: 'Overall the quality of NHS managers is extremely good and I was very proud to be an NHS manager.

'Unfortunately about 20 per cent are not up to the mark and that 20 per cent significantly distorts the performance of the 80 per cent.'

A key area where management needs to improve is in commissioning, says Mr Carter. 'The quality of commissioning is incredibly varied, there is a large disparity in expertise.

'You can have neighbouring PCTs with similar populations, demography, morbidity and investment but a differential in operational and financial performance.'

Same place, different problems

He believes the vast number of PCTs set up in 2001 meant there were too many managers who lacked the necessary 'talent' and 'could not properly manage the money, which is one of the root causes of the mess we are in now'.

But apart from in London - where he reckons the 32 PCTs could be reduced to eight - the government has now 'got it right', and it is essential to focus more on improving the quality of commissioning.

He says: 'There is no proper career planning for commissioning. People tend to learn on the hoof; there is a lack of training, a lack of investment and far too often commissioning teams can be very junior, inexperienced people.'

More senior people prepared for 'the long haul' are needed for teams, he adds. Only then can the pitfalls of inappropriate investment, lack of evidence base and poor engagement with clinicians be avoided.

The key to making PCTs 'highly sophisticated, well-developed commissioning agencies' is the dissolution of their provider arm. 'All the evidence suggests that PCTs, by and large, have really struggled with their directly managed services,' he explains.

The need for community nurses to then provide NHS care by working for the private or voluntary sector remains a difficult issue.

'I know people initially have fears about this but you increasingly find people don't have a problem. Although it's fair to say the critical mass of our NHS members would like to stay in the NHS.'

A plurality of providers for NHS care is 'not something I have a problem with' considering a quarter of the RCN's members work outside the NHS, mostly for the independent sector. 'There are copious examples of the private sector coalescing quite neatly with the public sector and that is not something we fear.'

However, he is keen to stress that this must not run the risk of damaging NHS services: 'If you go down to a service which is increasingly at a critical mass, there is a danger that private companies could find many aspects of the NHS unattractive because they have to make money.

'The bottom line is they have to balance their books and will go out of business, unlike some PCTs that have been bailed out.'

It will be 'unacceptable' for services to be denied in parts of the country because of this, he insists.

Foundation fears

There were also fears among RCN members about foundation trusts. 'What we don't want to get into, and this is a real worry, is foundation trusts planning in private and having aspirations for service development when an adjoining trust may be doing the same thing,' he says.

A 'natural bringing together' could see neighbouring foundation trusts merge, he adds.

Considering his views on the scaling down of PCTs, it is no surprise that Mr Carter supports mergers such as that of St Mary's and Hammersmith Hospitals trusts with Imperial College London to create an academic centre for health sciences, which he calls 'the most welcome development in years'.

Mr Carter has a busy agenda for the year ahead. His appointment came ahead of nurses' below-inflation pay award and just months short of the health secretary getting a new boss when Tony Blair steps down.

He says nurses are 'very despondent' over the 1.9 per cent pay offer: 'Many of them don't believe the investment has been made. They ask why 0.6 per cent of their pay is being withheld if investment has more than doubled.'

The massive overspend on the national IT programme presented a 'double standard' to them and is 'the kind of area we intend to go on and on about until people start to listen'.

Yet Mr Carter remains more optimistic than some. He says the NHS today is better than its 'desperate state' 10 years ago, but patient care is still 'mixed'.

'If the government had listened more to trusts and frontline people the problems we have seen over the last two years could have been avoided and Tony Blair would be going out now with the sense of a job well done.'

And the RCN's future with health secretary Patricia Hewitt? Work undoubtedly must be done to improve the relationship after the heckles and slow hand-clapping which followed her infamous 'best year ever' claim, he says.

'If you end up with a health secretary being put into that position you can't expect to have people saying they want to work with the RCN.

'Relationships were not good, and we have been rebuilding them over the last few months. We are working very closely with the government on trying to find solutions to these very complex problems.'