Select Committee on Public Accounts Twentieth Report


TWENTIETH REPORT


The Committee of Public Accounts has agreed to the following Report:

EDUCATING AND TRAINING THE FUTURE HEALTH PROFESSIONAL WORKFORCE IN ENGLAND

INTRODUCTION AND LIST OF CONCLUSIONS AND RECOMMENDATIONS

1.     Ensuring that the NHS trains the right number and type of staff and that these staff are fit for practice requires good workforce planning and effective commissioning and delivery of education and training. It depends on close co-operation between NHS organisations, education and training providers and the statutory and professional bodies.[1]

2.     In 1999-2000, the NHS spent £705 million on pre-registration training places and student bursaries for some 50,000 nursing and midwifery, and 14,000 health professional, students. This training is provided under some 100 or so NHS pre-registration contracts by 73 higher education institutions, and leads to degree, and in the case of nursing and midwifery students, degree or diploma level qualifications.[2]

3.     The NHS Plan published in July 2000 acknowledged that the biggest constraint facing the NHS was staff shortages. The plan stated that by 2004 there would be a further 5,500 nurses and midwives and 4,450 therapists and other health professional staff entering training programmes each year to help, over time, address staff shortages and raise the quality of services.[3]

4.     On the basis of a Report by the Comptroller and Auditor General,[4] our predecessor Committee examined the Department of Health (Department) and the Higher Education Funding Council for England (Funding Council) about the steps needed to meet the demand for nurses and other health professionals, and to improve the value for money from the education and training arrangements. The Audit Commission had also published a parallel report — Hidden Talents: Education, Training and Development for Healthcare staff in NHS Trusts.[5]

5.     In the light of our predecessors' examination, the Committee draws three overall conclusions.

  Delivering the NHS Plan depends on an increase in the number of nurses and other health professionals. Providing an extra 20,000 nurses by 2004 will not be easy. The Department have made a promising start by increasing the number being trained and by encouraging qualified people to return to work though modern, flexible human resource initiatives, such as Improving Working Lives and Return to Practice.

  The key to success is partnership working, between the NHS and the higher education sector, and through membership of the new Workforce Development Confederations. This means jointly tackling barriers to the expansion of training, reducing student attrition, and developing new contracting arrangements with greater transparency over pricing and an increased focus on quality.

  Constant developments and improvements in clinical practice and treatment require nurses and other healthcare professionals to keep up to date and remain fit to practice. The Audit Commission's finding of variations in access to, and delivery of, continuing professional development in NHS Trusts is worrying, and suggests that patients may be put at risk. The Department should ensure that Health Improvement Programmes address the training needs of staff, and with the statutory and professional bodies review continuing professional development requirements.

6.   Our more specific conclusions and recommendations are as follows.

On Meeting the Demand for Nurses and Other Health Professionals Envisaged in the NHS Plan

(i)    Workforce planning in an organisation as complex as the NHS is not easy. It involves making judgements about changes in the way healthcare is delivered, for example the balance between inpatient and day case treatment. It depends on where healthcare is delivered, for example in hospitals or in the community. It needs to anticipate changes in the way conditions are treated, for example the need for more specialist staff. It involves forecasts of staff turnover and has to take into account the lead-time to train new staff, which is considerable (paragraph 22);

(i)    The new workforce planning system balances all of these requirements. The new Workforce Development Confederations should ensure that they, and their members, have the right information systems and skills to cope with these complexities successfully (paragraph 23);

(i)    Since the mid-1990s, the Department have taken a wide range of initiatives to increase the recruitment and training of staff, to improve staff retention and to encourage trained staff to return to work. These are showing encouraging signs of success. But to sustain and build on these improvements, and meet the commitments set out in the NHS Plan, the Department should:

ensure that all Trusts promote family friendly and flexible packages through achieving re-accreditation under the Improving Working Lives initiative and active support of the Return to Practice campaign;

ensure that Workforce Development Confederations work closely with higher education institutions to achieve the planned increase in the number of students on NHS funded courses through a joint approach to recruitment, selection and retention, and that there are specific action plans to tackle particular problems areas such as radiotherapy and midwifery;

work with the Funding Council to tackle barriers that might prevent the higher education sector from providing the necessary training capacity by identifying sufficient good quality practice placements, providing resources to invest in teaching accommodation and finding ways of ensuring that salaries of lecturing staff are competitive (paragraph 24).

On Improving the Value for Money from the Training Arrangements

(i)    Although attrition from courses compares well with rates from higher education generally, it represents a significant waste of resources and loss of opportunity for the people involved. There are significant variations in achievement rates between colleges, for example in nursing and midwifery. Some of these may be caused by differences in starting qualifications and age, but neither the Department nor the Funding Council have information to explain them at institution or course level. The Department and the Funding Council should undertake research into the causes of attrition and variations between colleges to reinforce the work they are already doing to disseminate good practice (paragraph 33);

(i)    The Department has set targets to reduce attrition to 13 per cent for nursing and midwifery students and 10 per cent for those studying for allied health professions. These look particularly challenging for those institutions where attrition rates are far higher. In the light of their research into the factors behind variations in attrition, the Department should look at introducing more refined targets, reflecting local circumstances (paragraph 34);

(i)    The prices paid by the NHS for training vary considerably. While there may be rational explanations for some variations, such as local costs and the inclusion of capital charges, the Department and the Funding Council do not have the data to assure themselves that prices are reasonable and offer best value. They should complete as quickly as possible their review of alternative pricing methods, including the use of benchmark prices and open book accounting (paragraph 35);

(i)    Ensuring that new health professionals receive appropriate education and training and are fit for practice in the NHS is only the first step. Continuing education, training and development is crucial to maintaining and enhancing skills, so that staff are able to keep pace with developments in clinical practice and treatment. However, the Audit Commission found weaknesses and variations in continuing professional development in Trusts. The Department should issue further guidance, building on the Commission's work, to disseminate good practice and monitor progress (paragraph 36).

MEETING THE DEMAND FOR NURSES AND OTHER HEALTH PROFESSIONALS ENVISAGED IN THE NHS PLAN

7.   The Comptroller and Auditor General noted that past underestimates by Trusts had led to insufficient numbers of training places being commissioned, which had contributed to staff shortages.[6]

8. The Department of Health told our predecessor Committee that a number of factors had affected decisions on the volume of training commissions in the early 1990s. Because of very significant changes in expectations about future requirements, the NHS ended up with staff shortages and too few nurses coming into training.[7] Some of the more significant factors were:

  In the early 1990s there was lower wastage from the nursing workforce than in previous years. At the same time many hospitals sought to cut costs and either to reduce staff numbers or change skill mix. This often led to slowing down or stopping nurse recruitment.[8]

  Significant changes in nurse training with the introduction, from 1989, of Project 2000, which promised a range of benefits including:

skill-mix changes which included better use of health care assistants to undertake work previously carried out by enrolled nurses;

lower attrition from training and better retention of qualified staff, together with increased productivity;

rationalisation of pre and post registration education programmes.[9]

Planned changes in the delivery of healthcare, for example a move from in-patient to day patient activity and a considerable drive towards care in the community, pointed in the direction of lower workforce numbers.[10]

The transfer of responsibility for commissioning non-medical education and training to Regional Health Authorities. The aim was to ensure that workforce planning was responsive to employer needs. Regions, in consultation with local employers, were responsible for identifying the demand for qualified nurses and for deciding the number of students to be recruited and trained. In order to co-ordinate their decision making, they developed their own "Regional Balance Sheet" in 1991 to ensure each region met local demand as well as making a fair contribution to the national training picture. The Department maintained a national overview in relation to supply. Concerns that training levels were too low began to be raised by the Department in1994 and led to increased commissions for nurse training.[11]

9. Since 1994-95, there had been annual increases in the number of students. For example, in England, the numbers of new student nurse and midwifery entrants each year grew by 50 per cent (from 12,480 in 1994-95 to 18,707 in 1999-2000). Nevertheless, the vacancy survey for March 2000 showed that there were 10,000 nursing posts vacant for 3 months or more (some 3.8 per cent of nurses). Shortages were particularly severe in London and the South East, and in specialist areas such as radiography where staff were essential in delivering the NHS Cancer Plan.[12]

10. Between 1996 and 1998 the Department devolved responsibility for planning and commissioning student places from its Regional Offices to local Education and Training Consortia (geographically based groups of NHS and other employers). The Comptroller and Auditor General found weaknesses in the revised workforce planning arrangements, including the information base used and differences in the level and expertise of input to local plans. The Department launched a review of workforce planning in 1999. Their consultation document "A Health Service of all the talents: Developing the NHS workforce", published in April 2000, noted in particular the need for a multi professional approach to education and training, better links with NHS service developments, and the need to build on and develop partnership working.[13]

11.   The Department responded to these issues in the NHS Plan, and gave a commitment to increase the nursing workforce by 20,000, by 2004. The Plan proposed a number of initiatives to increase supply, including a further 5,500 nurses and midwives and 4,450 therapists and other health professional staff entering training courses each year. In parallel, the Department are taking steps to improve workforce planning, including the establishment of 24 Workforce Development Confederations from April 2001. These actions place responsibilities on Chief Executives of Trusts and health authorities to ensure that their Health Improvement Programmes address workforce planning and education and training requirements.[14]

12.   The Department of Health told our predecessor Committee that they were reasonably confident about meeting the increased demand by 2004. They were meeting their targets for additional training places, and the number of nurses working in the NHS had increased by 6,300 in the year to September 2000. They were also moving to get a better balance between centralised and decentralised planning of staffing requirements and provision.[15]

13. The Department placed great emphasis on improving Trust's management of their employees, including implementation of more flexible family friendly policies. They had introduced a programme called Improving Working Lives and within it were accrediting Trusts for the way they worked with their employees including whether or not they had day care facilities, facilities for part-time working, arrangements for career breaks and so on. As a result, there had been a big expansion in childcare facilities and part-time working and evidence that this was attracting people back to the NHS. Indeed by March 2001, they had successfully encouraged 4,181 nurses, midwives and health visitors to return to practice, partly as a result of a more family-friendly and flexible approach, and another 2,000 were preparing to join them. Over 60 per cent of those who had returned had taken up part-time posts.[16]

14.   The Funding Council were also confident that institutions could deliver the planned increases in places. But this meant meeting some capital needs, to increase teaching accommodation, and making sure that the salaries of lecturers were competitive.[17] The Department acknowledged that finding sufficient clinical placements was also a bottleneck, but that they were now giving this priority, including securing placements in the private sector and in a wider range of fields than before.[18]

15.   Progress was, however, less good for certain health professionals and our predecessors explored two in more detail: midwives and radiotherapy.

(a) Midwives

16. The Department saw their biggest challenge as attracting more people into midwifery. Over the period 1995-96 to 2000-01, the number of midwives had remained at around 22,500. But under the NHS plan, numbers were expected to grow to 26,783 as a result of investment in recruitment and retention initiatives. At the same time, the age profile of existing midwives posed a risk that more would leave than could be recruited.[19]

17. One issue was pay, and the NHS Plan had announced new arrangements that would allow midwives faster progression up the salary scales. In addition, increasing investment in midwives and midwifery services was expected to have a positive impact on retention of existing staff. Consultation showed that what staff wanted most, alongside fairer rewards, were more staff and investment in services. Application of Improving Working Lives standards to midwives would also help, but would require long-term changes in working practices.[20]

18. Getting people back into midwifery was seen as the best option for a quick increase in numbers. Of about 90,000 people on the register with relevant qualifications, only 33,000 were practising midwives. Recent surveys suggested that about 1 in 5 of those not practising would return, and the Department was working with the Royal College of Midwifery to encourage them. Over the past 12 months, 209 had returned and a further 156 were on their way back. Recruitment and retention initiatives had been improved from April 2001, so that returning midwives will now receive: free refresher training, a minimum of £1,000 in income whilst retraining, help with childcare, and assistance with travel, subsistence, books etc.[21]

19. As regards recruitment, the number of training commissions for NHS funded pre-registration midwifery was planned to rise from 1772 in 1999-00 to 2,176 in 2002-03. The Department had widened the entry gates, making it easier for people to get into the profession, and supporting staff and people from wider educational backgrounds.[22]

(b) Radiography

20.   There is an increased demand for radiographers as a result of the NHS Cancer Plan, yet the Comptroller and Auditor General reported significant staff shortages, insufficient recruitment to fill training places and high rates of attrition from training. The Department agreed that this was an area they were worried about. Places commissioned were rising by about 10 per cent a year, but further progress was constrained because most hospitals were close to or had reached their capacity for supervising students. The Department had taken initiatives with the Society of Radiographers, including a big awareness campaign and, in February 2001, contacting all lapsed members on the register to encourage them to return to work: there were some 14,000 radiographers across the United Kingdom not in practice. They were also taking action more generally to increase the number of placements. However, the Department were not confident these measures would be enough.[23]

21. A big concern was that attrition during training was high - for therapeutic radiographers it was 27 per cent. The major reason given by people leaving was that they had made the wrong career choice, which could be partly about not recognising the stressful nature of the occupation. The second highest reason was poor academic performance. Some universities had taken steps to reduce wastage by introducing continuous assessment to target learning support more effectively, in the belief that some students might find smaller components easier to handle. The Higher Education Funding Council had not focussed its studies on radiography so far, but recognised that one consequence of the Comptroller and Auditor General's Report might be to look rather more closely at this particular issue.[24]

Conclusions

22.   Workforce planning in an organisation as complex as the NHS is not easy. It involves making judgements about changes in the way healthcare is delivered, for example the balance between inpatient and day case treatment. It depends on where healthcare is delivered, for example in hospitals or in the community. It needs to anticipate changes in the way conditions are treated, for example the need for more specialist staff. It involves forecasts of staff turnover and has to take into account the lead-time to train new staff, which is considerable.

23.   The new workforce planning system balances all of these requirements. And the new Workforce Development Confederations should ensure that they, and their members, have the right information systems and skills to cope with these complexities successfully.

24. Since the mid 1990s, the Department have taken a wide range of initiatives to increase the recruitment and training of staff, to improve staff retention and to encourage trained staff to return to work. These are showing encouraging signs of success. But to sustain and build on these improvements, and meet the commitments set out in the NHS Plan, the Department should:

  ensure that all Trusts promote family friendly and flexible packages through achieving re-accreditation under the Improving Working Lives initiative and active support of the "Return to Practice" campaign;

  ensure that Workforce Development Confederations work closely with higher education institutions to achieve the planned increase in the number of students on NHS funded courses through a joint approach to recruitment, selection and retention, and that there are specific action plans to tackle particular problems areas such as radiotherapy and midwifery;

  work with the Funding Council to tackle barriers that might prevent the higher education sector from providing the necessary training capacity by identifying sufficient good quality practice placements, providing resources to invest in teaching accommodation and finding ways of ensuring that salaries of lecturing staff are competitive.

IMPROVING THE VALUE FOR MONEY FROM THE TRAINING ARRANGEMENTS

25.   The Comptroller and Auditor General found that although a great deal of effort had been put into improving the quality and efficiency of education and training, more could be done to take forward the cost and quality agenda.[25]

(a) Student attrition

26.   He drew attention to wide variations in student attrition (non-completion rates) between higher education institutions and limited understanding as to the reasons. On average, 20 per cent of nursing students (but ranging from 9.3 to 37.6 per cent) and up to 28 per cent of other health professional students failed to complete their course. Whilst these average rates were comparable to attrition from other higher education courses they represented wasted resources. The Department had set attrition targets of 13 per cent target for nurses and 10 per cent for allied health professions starting with the September 2000 intake, but these presented a challenge for many institutions.[26]

27.   Our predecessor Committee asked how realistic these targets were, and what the Funding Council and institutions were doing to achieve them, and reduce variations. The Funding Council noted that in general in Britain completion rates in higher education were higher than any other country except Japan, and attrition rates in nursing and related topics compared well with other University courses. Taking into account the average level of qualifications of nurses and their age, the record was very good. That said, variations in the qualifications students started with, their age, and the subjects they studied made it difficult to compare the performance of specific institutions and courses, and the Funding Council did not have the data to go into that level of detail. They had, however, set up a task group to look for good practice in those institutions with better completion rates, which they would publish and disseminate more widely.[27]

28.   One of the specific initiatives the Department had taken to reduce attrition was to allow people to step on and off courses. This was likely to be particularly attractive to mature students and should help keep more of them on training and in the system. They were also starting to establish a better relationship between the NHS and students very early on. Many students now have a host Trust, which is tasked with developing the relationship alongside the relevant institution, and the emerging evidence was that a high number of students went on to work in their host Trusts.[28]

(b) The value for money provided by education and training contracts

29.   The Comptroller and Auditor General reported that the NHS did not have the information to understand or compare institutions' costing policies. There were no common contract and standard benchmark prices, wide variations in the price per student for the same qualification and a lack of consistent application of benchmark standards in assuring quality. The NHS had reduced its costs through agreed reductions in the average price paid per student in real terms, and expected to save £7.1 million in 2000-01 compared with 1998-99. However, the scope for further gains needed to be offset against the fact that in higher education institutions the contribution to overheads in NHS funded contracts was much less for than for other contracts. He also suggested that variations in the relationship between price and cost may not have led to the best allocation of resources.[29]

30.   Our predecessors asked the Department what they were doing to ensure they got value for money from the prices they paid. The Department pointed out that a large number of prices were now within a very tight band, and were legitimately explained by variations in costs in different parts of the country. They had looked at courses outside these bands and there were valid reasons for cost variations, for example, cases including capital set up costs, cases where prices had been agreed some time ago where students had been added on at marginal cost, and variations in pension arrangements. There was also an element of commercial judgement by institutions. However, they had set up a group, including higher education institutions, to look at the length of the contracts; the current customer contractor relationship; and alternative ways of costing or pricing contracts, such as benchmarking and an open book examination of costs.[30]

(c) Retaining staff and keeping their skills up to date

31.   As with all graduates, there is no guarantee that nurses and other healthcare professionals trained under these arrangements go on to work in the NHS, and many move to the private sector, including agencies. However, the Department assured our predecessors that they recognised the challenge, and were working to improve retention, for example through the new arrangement linking students to a host Trust, which aimed to build up a relationship that would lead to their employment in that Trust.[31]

32.   In parallel with the Comptroller and Auditor's Report, the Audit Commission had published a report Hidden Talents: Education, Training and Development for Healthcare staff in NHS Trusts. This highlighted disparities in the extent to which Trusts invested in and gave access to continuing professional education, for example, as far as registered nurses and midwives were concerned the best were spending ten times more than the worst. The Department accepted that this was an area that had not been given sufficient priority.[32]

Conclusions

33.   Although attrition from courses compares well with rates from higher education generally, it represents a significant waste of resources and loss of opportunity for the people involved. There are significant variations in achievement rates between colleges, for example in nursing and midwifery. Some of these may be caused by differences in starting qualifications and age, but neither the Department nor the Funding Council have information to explain them at institution or course level. The Department and the Funding Council should undertake research into the causes of attrition and variations between colleges to reinforce the work they are already doing to disseminate good practice.

34.   The Department has set targets to reduce attrition to 13 per cent for nursing and midwifery students and 10 per cent for those studying for allied health professions. These look particularly challenging for those institutions where attrition rates are far higher. In the light of their research into the factors behind variations in attrition, the Department should look at introducing more refined targets, reflecting local circumstances.

35.   The prices paid by the NHS for training vary considerably. While there may be rational explanations for some variations, such as local costs and the inclusion of capital charges, the Department and the Funding Council do not have the data to assure themselves that prices are reasonable and offer best value. They should complete as quickly as possible their review of alternative pricing methods, including the use of benchmark prices and open book accounting.

36.   Ensuring that new health professionals receive appropriate education and training and are fit for practice in the NHS is only the first step. Continuing education, training and development is crucial to maintaining and enhancing skills, so that staff are able to keep pace with developments in clinical practice and treatment. However, the Audit Commission found weaknesses and variations in continuing professional development in Trusts. The Department should issue further guidance, building on the Commission's work, to disseminate good practice and monitor progress.


1  C&AG's Report, Educating and Training the Future Health Professional Workforce for England (HC 277, Session 2000-2001), para 3 Back

2  ibid, p2, Box A Back

3  ibid, para 4 Back

4  Report, Educating and Training the Future Health Professional Workforce for England Back

5  Audit Commission Report (2001), paras 55-63, 64-75 Back

6   C&AG's Report, para 7 and p3, Box B Back

7  Qs 63-64, 67-69, 99-102, 197-203 Back

8  Q203; Ev, Appendix 2, pp 21-24 Back

9  Q203; Ev, Appendix 2, pp 21-24 Back

10  Qs 64, 68, 99, 202 Back

11  Qs 127, 203; Ev, Appendix 2, pp 21-24 Back

12  C&AG's Report, para 3, and p2, Box A and paras 1.5, 2.16, 2.25; Qs 75, 78-79, 106, 119-124  Back

13  C&AG's Report, paras 4, 1.4, 2.2, 2.6-2.7 Back

14  ibid, para 4, 1.5, 2.27 and Box B; Qs 91-98, 106, 128, 197-199 Back

15  Qs 1, 68, 71-72, 105-106, 119, 138, 156-166 Back

16  Qs 73-75, 138-139, 145-147, 151-153  Back

17  C&AG's Report, para 8; Q5 Back

18  Qs 136-137  Back

19  Qs 3-4, 42-46; Ev, Appendix 2, pp 21-24 (Tables 1 and 2, p22) Back

20  Qs 45-48; Ev, Appendix 2, pp 21-24 Back

21  Qs 45-56; Ev, Appendix 2, pp 21-24 Back

22  Q47; Ev, Appendix 2, pp 21-24 (Table 3, p23) Back

23  C&AG's Report, paras 2.17-2.18, and case example 2, p20; Qs 2, 131-134 Back

24  C&AG's Report, paras 2.17-2.18, and case example 2, p20; Qs 134-135 Back

25  C&AG's Report, paras 10-11  Back

26  ibid, paras 2.38-2.52 and p25, Figure 5 Back

27  Qs 7-9, 142-144, 172-182, 184-189, 204-213 Back

28  Qs 145, 183-184 Back

29  C&AG's Report, paras 7, 3.4-3.10 Back

30  Qs 10-11, 13-16, 56, 214-217; Ev, Appendix 1, p21 Back

31  Qs 17, 111-118 Back

32  C&AG's Report, paras 2, 1.22-123; Audit Commission Report (2001) "Hidden Talents: Education, Training and Development for Healthcare Staff in NHS Trusts", paras 55-75; Qs 190-196 Back


 
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