This time of year we are required to finalise and submit our workforce plans. If I’m honest, I haven’t paid much attention to these in the past, because they never felt real enough to describe the future, or use as a working plan.
But I was wrong, and I am interested now, for two reasons.
Firstly, most hospital Trusts struggle with cost improvement programmes – on average we achieve maybe 75% of the planned savings. I’m now thinking we would do better to monitor achievement against a matched workforce plan – get this right and the costs would surely follow?
But secondly, and crucially, they should provide a narrative for the transformation we must implement in the coming years. They should describe the contraction of the acute sector, the growth in community services, and the training we must start in order to create the new roles that will underpin this such as advanced practitioners, physicians assistants, reablement specialists, and experts in home care delivery.
A good plan will show a smaller administrative workforce, with remaining staff being multi-skilled in all aspects of a new digital infrastructure that will allow immediate advice, guidance and booking of all steps in the patient pathway. Behind this will be an electronic patient record that is accessible to patients and shared between hospitals, general practice, and community carers, and without referral letters, discharge summaries, or clinic letters in paper form.
Forward-looking workforce plans should show that smaller A&E services will transform into urgent care facilities combining roles currently carried out by hospital doctors, GPs, extended role and specialist nurses, and paramedics. They will describe too how hospital, primary care and community sectors will jointly staff merged services to support the frail elderly or those with long term illness, with corresponding adjustments in traditional GP or specialist numbers.
Acute Trust plans should detail a reducing headcount, commensurate with bed base reductions. They may describe how staff will move into community-based reablement teams that focus on early discharge and prevention of readmission? If so, corresponding changes should be evident in plans from more traditional community service providers.
Staff numbers will increase in our Informatics and IT services, alongside a reduction in administrative functions. Support services will also show reducing numbers as outsourcing and cross-system rationalisation plans are implemented.
Overall, credible workforce plans must show at least 3% less staff each year, given that we need a 5% cost reduction each year across the system and 60% of costs are in staff?
So does the workforce plan for my Trust show all of these things? Er no, it doesn’t. We followed a good process, with wide involvement from all areas, but our amalgamated plan projects a reduction in staff of 96 over 5 years. With a workforce of circa 11,000 that is a drop of just 0.17% per year!
This tells me that many of our clinical leads feel their area is set to grow. Understandable, given their past and current experience of remorselessly increasing activity levels, but completely unaffordable. Whether we work in the acute sector, primary care, community and social care, or commissioning – somehow, together, we have to turn this demand downwards. Not by rationing care, but by putting aside our narrow interests and working differently in order to maintain health and reduce the need for expensive interventions.
I have submitted our workforce plan, but I’m embarrassed because I know it isn’t realistic. It can’t be. I did send an accompanying letter, describing our planned transformation programme and promising it would look very different when updated next year. It must, because if it does not we will most definitely not be an organisation that is fit for the future.
Derek Williams
Hi Mark
A fascinating dilemma indeed. Looking at it from the Commissioner’s perspective and it doesnt look much clearer! Should we start by teasing out the differences behind workforce planning for education commissions and workforce planning for service development. Appreciate there is an overlap but maybe not as much as we think – most of the people who will be providing care in 10 years time are currently already employed in the NHS. At the risk of sounding flippant ?? perhaps we should extend our education commissions to include marketing and comms professionals who could help us manage the ‘demand’ that currently locks us into traditional service models
MarkN
Thanks Derek, it is a complex dilemma I agree. Much of the training may need to be for existing staff that is true, as there may be some substantial changes of role. For instance, physicians may need to spend part of their working week in ‘community’ settings, assessing people with long term conditions and planning to maintain their health, rather than (as currently) reacting when they fall ill enough to be admitted to hospital. Or admin staff may need to be multi-skilled to avoid the current ‘hand offs’, particularly if the hospital business systems are digitalised. Why cannot one member of staff make or amend appointments, respond to queries, update on progress, provide information, and so on, simply by entering the information systems and actioning?
But fundamentally, it is impossible to accurately plan the workforce in the absence of a clear transformation plan that will keep us viable through the coming straitened times. That feels like the first challenge to me!
Derek Williams
Hi Mark. It would seem that uncertainty about new models of care is the biggest barrier to effective workforce planning. I understand that the CfWI is investing in ‘horizon scanning’ and have designed a hub (october launch) to provide access to information that will help us clarify the workforce implications of the new service models. Help is at hand!
Gbenga
Hi Mark
The answer has to be yes, problem is how to get everyone on the same page. To ensure a shared understanding of the problem, the benefits of solving the problem are equally shared. For example is population health an acute problem ? How is it commissioned ? Etc… I think this one of those big change problems that no one wants to own. I do think the answer may be in Intergation of primary ,secondary, and possibly commissioning. To become a bit like Kiaser ? Needs a lot more thought and discussion. Yes needs a lot more attention
MarkN
Hi Gbenga, I agree it’s a huge challenge. Essentially it is necessary to plan the future before a realistic workforce plan can be created, and that is a broad and complex issue!
Bessfort
Note the date for comments has pasesd but having looked at these comments and from the webchat yesterday.I still think it important to underline the need for education and training ( and CPD) for the wider workforce (bands 1 of 4) as well as health care professionals. I will comment about how new roles at band 4 assistant practitioners- can contribute to delivery of more seamless and improved healthcare outcomes by November 18th but just to note the critical contribuion these new roles also make to productivity, improving team capability and of course the bottom line. For Band 4 roles to be successfully introduced they need to be part of an established and funded education and career progression route to enable appropriate staff with qualifications at academic level 2 and 3 and at pay bands 2/3 to develop and have the confidence to become trainee assistant practitioners typically studying at academic levels 4 and 5.And yes ! I haven’t met anybody in my work in the service around APs who does not think that registration of at least assistant practitioners would allow this group to expand on a firm basis, with transferability and recognition assured, and the delegation and public safety issues resolved to the satisfaction of professionals, patients and the assistant practitioners themselves.This is so important.Much progress has been made in recent years around the learning of support staff but there is a very real danger that with the end of Joint Investment Framework and the current reforms to MPET and the SHAs that Bands 1 to 4 will slip off the radar yet again.Can they be included in Health Education England(and Skills Networks) remits please?ThanksTony
Patrick Keady
Hi Mark, a report from the LSH&TM this week suggests that errors of ommission in UK Hospitals are more frequent than active mistakes and that together, they contribute to 13% of hospital deaths. While your FT followed a good proocess, I am not so sure about Workforce Plans elsewhere in the NHS. And at the same time, there seems to be an out-moded understanding of how to reduce demand. My guess is that demand on Acute services continues to be high because Acutes continue to over-emphasise the benefits of surgery and other care, while underplaying the downsides. At the same time, more surgery and other care results in more income for Trusts. At the moment, risks are probably highlighted to patients in general (and sometimes medical) language. However true consent is about explaining to elective patients in their own terms, what it is that they could loose if they go ahead with the proposed care. Once Hospitals start to fully quantify how the downsides can affect individual patients, it is likely that more and more patients will decide not to go ahead with surgery. Therefore we are likely to see reductions in the numbers of staff needed and the numbers of errors. Workforce plans need to take into account, improvements in the consent process as well as how future healthcare workers will prevent 13% of hospital deaths being caused by errors of ommission and active failures.
MarkN
Hi Patrick, You may be right. I’m not sure that it’s hospitals that over-emphasise the benefits, but patients do have great faith in what surgery and other treatments can offer. Isn’t this part of the ‘gatekeeper’ role of the GP? It is just the sort of expert advice that they would be well placed to provide, and indeed knowledgeable about?
Joyce
I think Mike makes a significant point here. Having wokred at a number of NHS trusts there are several ways of accomplishing training, some of which is less than cost effective.If we take the example of annual update training which is a requirment in place at all trusts, a universal standard, applied through a distance learning package would suffice for the majority of training, it would also take significantly less time than the 1-2 days usually spent on it. This would set a bench mark standard, and be significantly cheaper for the trusts to undertake. After all the COSH, HASAW etc have not changed significantly since i started employment.The other area that should be looked at with urgency is that of advanced practice and the training that is undertaken to perform this. There has been an explosion of roles in professions allied to medicine where more advanced assessment and patient management is carried out, normally to a high standard. However the training that supports these advanced roles is very often locally arranged by trusts, either in house or at a university. There is often no universally accepted standard, which should be laid down by the NMC, HPC as appropriate.
Lucien
What aspects of edtnauicg and training the health workforce needs improving? In particular, what are the skills and behaviour that need more development?Since implementation of MTAS the training of specialty doctors, particularly surgeons, appears to have significantly declined in quality. To become a competent surgeon what trainees need most is cutting time, not soft skills’ class room training, endless clinics and paper pushing. Having lived and worked in Australia for the last 3.5 years a friend of mine who has since successfully obtained a surgical training post in the UK has observed is the significant reduction in cutting time/hands on training time now available as apposed to 5 years ago within the NHS. This friend is viewed as a top performer’ in the training programme but this is only because of their significant experience accumulated in Australia not the UK. Had they not acquired this abroad they believe that they would not be satisfactorily experienced enough at the end of their training to operate independently to a high standard, and has observed that many surgeons at the end of their specialty training now are not confident and less able to perform relatively simple surgical procedures let alone complex ones as a result of being trained under the UK system as it currently is structured this is very concerning.How should these improvements be made?Redress the balance of soft skills training versus practical cutting time/training. Increase cutting time for trainees (EU working time Directive is a significant blocker’ in this regard as a re local hospital policies(I have heard of a Trust that has now proposed that one day every 5 weeks registrars must spend a whole day on the ward’, this has a massive impact in reducing yet more cutting time and is a waste of expertise and training time, pushing paper and twiddling their thumbs ludicrous!! Why are the SHOs and HOs not competent enough to administer the ward tasks as they once were??)). Free up the experienced Consultants away from the mountain of managerial/paper work tasks they now have to undertake, make more time to train/cut as apposed to pushing paper.