Getting into shape: delivering a workforce for integrated care
A new NHS workforce policy to support integrated care and reform
The Government is rightly committed to a radical reshaping of NHS delivery, based on a shift to new care models and treatment in the community. Its management of the NHS workforce, however, has not delivered with nearly three times more doctors, and four times more nurses in the acute sector than in the community. Since 2009, the number of consultants has risen by nearly a third, whilst the number of GPs has fallen. Freedom of Information requests made for this report found that, across 61 acute trusts, only 6 per cent of consultants work in the community for at least one session per week.
As the Government and the NHS leadership have repeatedly said, the priority for the NHS is to increase its speed of innovation. To do this, the NHS is rightly seeking to devolve decision-making and to deregulate. For the workforce, however, policy remains highly centralised and tightly regulated. This paper shows how to bring the same reform ideas to the workforce as the NHS is applying to other areas.
Removing the caps
There is currently a cap on the number of medical students. The aim of the cap has been to control costs by limiting the number of doctors in training. The result, however, has been an inadequate pool of labour, difficult working conditions and a powerful staff body, many of whom choose to work for expensive agencies. By removing the cap on training places, the NHS could produce a sufficient or excess number of trained individuals that it could employ. Greater number of trainees should give managers more flexibility in shaping the workforce in accordance with population demand rather than workforce supply.
Ministers should require trained doctors to pay back the taxpayer-funded costs of medical training should they decide not to work in the NHS. This report suggests that students should pay back £11,700 per year, for a maximum of ten years, for each year spent working for a non-NHS employer or locum agency. In other professions, such as accountancy, it is normal for employers to pay for the cost for training, but for trainees to take on that cost should they leave the firm during training.
Devolved workforce planning and pay
The NHS is right to seek to devolve decisions on the future pattern of services to the local level, in the form of Sustainability and Transformation Partnerships (STPs). Local health economies are best placed to decide how to reform health and social care in their areas. Decision-making over the workforce, however, remains highly centralised, with the key actor being the Department of Health, working through the arms-length body Health Education England.
STPs should take control of the training budget in the same way as they should take responsibility for the whole health and social care budget in their areas. Different STPs have different priorities and require different workforces. An STP in an area with a large elderly population, for example, could invest in community nurses and geriatricians capable of managing multi-morbidity.
STPs should use their freedom to develop innovative ways to attract, train and retain staff. Interviewees pointed to cheaper training courses, shorter courses, guaranteed jobs on completion of medical school and flexible training opportunities. STPs should embrace new routes into health and social care employment, in particular apprenticeships.
Individual providers should not be restricted by rigid pay scales or the 1-per-cent pay cap. Instead, providers should be able to use all the tools available to design contracts that promote working across boundaries whilst suiting staff needs. These include pay, excellent performance management, progression opportunities, holidays, study leave and pensions.
Overcoming professional boundaries
The present system of workforce regulation in the NHS contributes to a siloed and disjointed system. It leads to an old-fashioned model of care in which patients are referred around the system to different regulated professionals, when care could be delivered by a smaller number of clinical staff working in one place. The aim should be to lift more low-risk tasks out of professional regulation. This would empower those staff that have the skills necessary to deliver more care but are frustrated by current regulation. It would also ease the ‘bureaucratic jungle’ that characterises the current system, allowing staff to shift time from compliance to delivering care.
Developing a universal Skills Pass for all NHS staff would enable staff to work across professional boundaries. The Skills Pass would be based on a competency-based training framework of unregulated tasks.
In the short term, it would provide much-needed progression opportunities, especially for the unregulated workforce. It would create a workforce whose skills and experience were not aligned to one particular professional group or sector, but rather a workforce of generalists which could flex its skills to the needs of the patient workers are caring for.
A deregulatory approach will be supported by improved performance management. At present NHS provision of performance management is highly variable, with evidence suggesting that it can be absent for lower paid, unregulated workers and those in social care. Meaningful appraisal should be universal amongst NHS and social care employees.
Recommendation 1: Undergraduate training should be uncapped across the health and social care system.
Recommendation 2: Doctors who choose not to work for the NHS should reimburse thecost of their training. For doctors working within the NHS, the cost should be automatically paid back by the NHS. For those choosing not to work in the NHS, they (or their employer) must pay back the cost on an annual basis. There must be a fair approach taken to arrangements such as part-time working, unemployment, sickness, maternity and paternity leave and time doing research.
Recommendation 3: All health and social care professionals should be fully registered at the point of graduation.
Recommendation 4: As STPs develop into accountable care systems, they should become responsible for workforce planning across the whole health and social care system. Training budgets should be included within their funding envelope and they must seek to deliver training that cuts across all sectors and for all staff.
Recommendation 5: STPs must take a ‘one-system, one-budget approach’ to ensure that all organisations are working towards the same outcomes. This would enable STPs to create a workforce that works across boundaries with more generalists.
Recommendation 6: Staff contracts should be designed to promote working across the acute and community sector.
Recommendation 7: STPs should develop and trial the full range of alternative and flexible routes into health and social care.
Recommendation 8: Organisations within the STP must work together to ensure high quality training is being delivered at capacity
Recommendation 9: Pay should be negotiated locally. It should be used in conjunction with other performance management strategies to attract and retain staff. Both AfC and the 1 per cent pay cap should be removed.
Recommendation 10: The Government should amend the legislation detailing the remit of the 9 regulatory bodies to include a requirement to work with health and education stakeholders to produce a database akin to the UKMED. This should include details of trainee and professional performance and should identify tasks and procedures within professions that carry risk to patients.
Recommendation 11: The Government should introduce legislation requiring each regulatory body to carry out at fixed intervals a risk audit of all the professions and roles they regulate. This should be informed by their database indicating the level of risk associated with different roles and procedures. Where evidence suggests it would not be detrimental to patient safety, bodies should deregulate tasks.
Recommendation 12: A universal Skills Pass, with non-regulated competencies, should be introduced by NHS England. All employees working in the health and social care sector will have an opportunity to gain any competency. STPs must introduce the Skills Pass in their health economy, though they will have flexibility on dictating the training structure and competencies offered.
Recommendation 13: An annual appraisal should be mandatory for all staff members.The appraisal must be useful to staff members by being outcomes focused and recognise where staff have challenged and developed themselves using the Skills Pass.