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