Evidence submitted by Amicus (WP 05)
1.1 Amicus is the third largest trade union
in the National Health Service with a membership working in primary
care, mental health and acute NHS Trusts.
1.2 Amicus believes that workforce planning
is one of the missing ingredients from a "joined up"
approach to health service reform. In a people based service like
the NHS we cannot allow effective workforce planning to be the
sum total of decisions on this issue by NHS trusts. However at
the same time we should avoid grand plans and instead provide
strategic and indicative planning, assessing trusts on how well
they improve the health and well being needs of the population
that they serve in line with the government's set health priorities.
2. How Effectively Workforce Planning, Including
Clinical and Managerial Staff, Has Been Undertaken, and How It
Should Be Done In The Future
2.1 This inquiry is timely and is welcome.
For sometime there has been an apparent mismatch between the Department
of Health's (DoH) policy objectives and the need to properly undertake
workforce planning in order that these are met. For example Amicus
has previously observed in evidence submitted to the National
Pay Review Body for Nurses Midwives and Health Visitors that despite
many welcome new policy initiatives placing additional responsibilities
on community practitioners, which our members are more than willing
and competent to undertake, the Whole Time Equivalent (WTE) numbers
involved in undertaking this work has remained virtually static.
For example the latest figures for health visitor numbers reveals
an increase from 10,046 to 10,137 WTE over the period 2000-04
or less than 1%. Survey evidence from Amicus reveal that this
small advance has been reversed by recent cuts in numbers will
not appear in DOH statistics until 2007.
2.2 Workforce Development Confederations
are responsible for workforce planning at a Strategic Health Authority
level. There appears to be little dynamic to this process in responding
to changing health priorities as determined by the DoH. Where
numbers are expanded in response to increasing government investment
this takes place across broad occupational groupings and often
at the expense of relatively small specialities. For example health
visitors form approximately 4% of registered nursing workforce.
One would expect in an era of expanded resources that numbers
of staff employed will increase but in some occupations expand
at a faster rate in response to the government's health priorities.
There is evidence that this has not happened which reflects a
weakness in current workforce planning.
2.3 Likewise strategic planning has been
broad brush in its approach. For example the Wanless report called
for expanded numbers in very broad categories doctors, nurses,
therapists and ignoring groups like healthcare scientists. We
accept that this report was intended for another purpose, namely,
making the case for expanding capacity in the NHS. So the report
can be seen as an undoubted success, however its publication highlights
the absence of any subsequent strategic planning.
3. In Considering Future Demand, How Should
the Effects of the Following Be Taken Into Account
— recent policy announcements, including
Commissioning a patient-led NHS;
— an ageing population; and
— the increasing use of private providers
of services.
3.1 Demand for healthcare is relatively
"elastic". Many of these issues point to an increasing
demand for clinical and other staff. Yet it may also point to
different kinds of staff differently educated and trained. Whether
this "demand" is identified and met depends on the health
priorities of the day and the levels of investment involved. There
are many drivers for demand in health services and not all demand
is met.
3.2 The most tangible driver on demand is
the recent White Paper: Our health, our care, our say: a new
direction for community services as this represents a statement
of government intent.
3.3 While welcoming the broad thrust of
the White Paper, we are keen to ensure that the interpretation
and implementation of this document recognises the work of our
members who have a proven track record of success in many preventative
interventions.
3.4 Amicus welcomes the comment that general
practice was wider than general practitioners alone; however some
of discussions related to surgeries rather than health centres,
implying a medical focus. There is a need to highlight that primary
care is delivered by a wide range of health workers.
3.5 Community healthcare professionals are
vital in every aspect of health promotion and service delivery,
helping and protecting some of the most vulnerable children and
adults in our community, yet they are being treated as "soft
targets" by Primary Care Trusts attempting to make cost savings.
Cuts in frontline staff are short-sighted as they will inevitably
impact on the nation's health and will hamper government targets
to deliver public health improvements.
3.6 There is a credibility gap for many
of our members based on their own experience.
3.7 This is not the first White Paper produced
by the DoH which has placed the emphasis on primary care, public
health and health promotion but it does contain the clearest vision
of this kind of approach. We simply ask that if we are going to
effect change of this kind have the lessons about the delivery
failures previous White Papers been learnt?
3.8 The NHS is subject to undue political
pressure. This more often than not arises out of issues concerned
with acute services as primary care services are seen as less
measurable in terms of output or outcomes. This is despite clear
clinical evidence and public acceptance that public health and
health promotion in the medium to long term provides better health
outcomes. But it is a fact that concern is expressed, rightly,
if patients are on trolleys in corridors awaiting a hospital bed,
but no such similar concern is expressed if school children do
not receive health and well being advice from a school nurse because
her caseload is over 5,000. Relative to acute services public
concern about Community Mental Health Services does not feature
on the political radar except for the most conspicuous failures
that grab press attention.
3.9 This Inquiry is a once in a lifetime
opportunity for the NHS to effect many of the changes contained
within the White Paper. A transition of this kind would always
be easier to achieve in an era of expanded investment. It means
that on a like for like basis a greater emphasis can be placed
on the goals of the White Paper by expanding resources in these
areas at a faster rate. Combined with a stated intention to deliver
more services closer to service users then real change can be
achieved. Yet if the NHS waits to the next spending round, which
may be less generous, then it would be doubtful if such change
can be effected.
3.10 As for demand we expect to witness
greater numbers of community healthcare professionals both in
absolute numerical terms but also as a proportion of the overall
workforce.
3.11 Likewise an ageing population is driver
for demand. Whether this is recognised and met also depends on
the health priorities of the day. The White Paper in a number
of sections makes specific mention of this issue and how these
health needs can be addressed. This is a statement of government
intent so we would expect to see over time a greater number of
community health and social care professionals involved in addressing
the health and well being needs of this section of the population
ie demand will increase.
3.12 Technological change is demand neutral
in our view. Health is not a production "process" where
productivity can be greatly improved by more intense deployment
of technology. In some areas (eg diagnostics) technological development
may improve productivity but most developments in this area are
focused on how these services may be delivered closer to service
users. In other areas technological development may help better
address particular health needs which in turn increases demand
for this service. Combined with the desire to deliver more clinical
technical services closer to patient (eg Ear, Nose and Throat)
we would hope that some workforce modelling would take place based
on quality of service envisaged and numbers of staff and skill
required to deliver it.
3.13 A key concern remains in relation to
the government's arguments in the White Paper in favour of the
increasing use of private providers of services leading to fragmentation.
The arguments in favour of contestability are not evidence based.
We welcome the admission by government that the requirement that
PCTs divest themselves of provision by 2008 was wrong, however
we believe this remains the direction of policy and would prefer
new resources to encourage entrepreneurial enterprises to be invested
in developing the spread of best practice between PCT providers
where evidence based evaluations show the highest standards of
primary care outcomes.
3.14 More importantly for the focus of this
inquiry we believe that it will make the strategic planning of
the workforce more complex and private providers do not help meet
any subsequent demand. On the contrary they are often "free-riders"
on the backs of publicly funded initiatives to improve the number
of skilled and professional staff required to meet the government's
health targets.
3.15 Whilst we accept that tackling health
inequalities includes a need to shift resources it is essential
that staff currently employed in the acute services are retained
and that their skills and experience are deployed to meet the
increased demands with delivery of primary care.
4. How Will the Ability To Meet Demands Be
Affected By
— The European Working Time Directive.
— Increasing international competition
for staff.
4.1 Amicus recognises that not all health
demands will be met. Health spending constitutes a social contract
between the electorate and the government of the day. We have
outlined what we believe the government needs to undertake to
meet its health priorities. We hope these priorities have popular
consent through informed consultation.
4.2 The European Working Time Directive
(EWTD) is a "red herring". Firstly strict compliance
with no opt outs will improve public health as the EWTD is a health
not an employment directive. Amicus revealed in research "lost"
by the last government that the incidence of coronary heart disease
and other conditions increased significantly amongst those who
worked over 48 hours per week.
4.3 Long hours in the NHS is a function
of two factors. Poor work organisation and an unwritten contract
for some low paid workers that this could be "made up"
through excessive overtime hours. This will be tackled for staff
by Agenda for Change. The investment in the new pay system will
make the NHS a more attractive organisation for skilled and professional
staff to work for, thereby aiding recruitment and retention, and
helping to reduce the need for excessive overtime. In addition,
a degree of harmonisation will be achieved on overtime premia
which may help "disincentivise" excessive overtime.
4.4 The long hours culture is an issue which
all NHS employers in England have been required to address in
reaching practice plus standard for Improving Working Lives (IWL)
accreditation. The "model employer" next stage in this
process to make the NHS a world class employer must continue to
prioritise this issue.
4.5 There is a tendency for some professions
to argue that long hours are required for appropriate training
of clinical staff. We prefer to look at how many workforce questions
can be addressed through appropriate skill mix through delegating
roles, functions and tasks to properly trained and competent health
professions. The professions who argue the case for long hours
are very often the same who are opposing developments in this
direction.
4.6 Likewise early retirement is another
"red herring". Firstly, public sector workers draw their
state pension the same age as everyone else. Under the terms of
their occupational scheme some health service staff can draw their
pension without reduction aged 60, whilst a declining number can
draw this at 55 as this facility was closed in 1995. In reality
the actual age of retirement from the health service is closer
to 60 for those who draw this without reduction at 55 and 63 for
those who can draw this without reduction at 60. Besides recruitment
and retention will be not be addressed by forcing people to work
for the NHS against their will but by making it an attractive
employer. Current negotiations with the DoH on pensions are intended
to give incentives for health service staff to work longer. These
negotiations have not concluded, let alone determine whether any
agreement meets this objective.
5. To What Extent Can and Should the Demand
Be Met, for Both Clinical and Managerial Staff, By
— Changing the roles and improving
skills of existing staff.
— The recruitment of new staff in England.
— International recruitment.
5.1 Amicus not only has aspirations for
our members on terms and conditions but also for their career
development. Changing the roles and improving the skills of existing
staff is very much line with the government's ethos of creating
opportunities and life chances. If the country's largest employer
was to pursue a path in this direction it would have a significant
effect on life chance for the disadvantaged and those who have
previously been failed by the formal education system. Social
class is also a major determinant of health needs.
5.2 It is also economically desirable to
pursue this path. If the government is to meet its workforce targets
for health professions it is going to have to take a disproportionate
number of university graduates year-on-year for at least the next
five years and possibly decade. If it was successful in this objective
it can only have the effect of denuding the wealth creating part
of the economy of graduate employees. This is not sustainable.
5.3 Many health roles are highly regulated
which is appropriate and protects patients. Clearly protection
of the patient is paramount and regulation provides for protection
of title so that patients can understand what kind of clinical
services they are receiving. However, in some cases this is out
dated or designed to protect work areas based on a "craft"
mentality.
5.4 Some of this is based on practitioners'
experience that "skill mix" has been used by some employers
to dilute the quality of services and cut employment costs. At
the root of this problem is clinical services being driven by
an "accountants" mentality rather than based on health
needs. The White Paper typifies this confusion particularly in
relation to "talking therapies" and at best identifies
the nature of the problems without suggesting any clear solutions.
This is a workforce issue because unless the nature of the appropriate
skill mix for any service is informed by health needs, any moves
in this direction are likely to be resisted by health professions.
5.5 At the same time we need to provide
vocational routes into the professions. The "one size"
approach may prevent some health staff from fulfilling their potential.
Some professions (eg Biomedical Scientists) have opened up routes
for support staff to attain qualifications but across the NHS
there are few such examples and therefore the pace of change is
slow and piecemeal.
5.6 This is unlikely to change if training
budgets continue to be reduced in real terms. In this respect
there is a strange parallel with British industry with training
being hit first when expenditure restraint is required when exactly
the reverse should take place.
5.7 Other changes are easier to introduce
but held back by attitudes from Commissioners who do not fully
appreciate the types of services that can be provided by these
groups and effectively deny them to fulfil their potential. School
Nurses are potentially able could to deliver many of the health
needs of the school age population and their families provided
they were given appropriate recognition through status and grading,
and sufficient numbers were trained. Previous commitments to have
a school nurse for every school have been watered down to access
to a school nurse for every school resulting in many holding unmanageable
caseloads.
5.8 Better retention is obviously also key.
Amicus is very hopeful that the knowledge and skills competency
framework which was negotiated as part of Agenda for Change will
help in this process providing rewarding careers but also careers
that reward.
5.9 New staff should obviously be recruited
from England as long as this does detract from freedom of movement
for labour amongst nations in the UK and our European Union partners.
Amicus has a long tradition of international solidarity and are
concerned at reports from our sister trade union in South Africa
that their health services are being denuded of skilled and professional
staff by the NHS. Besides, as we have stated, we believe that
the public sector can help maintain socially acceptable levels
of employment and provide opportunities for social mobility.
5.10 On international recruitment we would
very much promote a co-operative approach between individual nations
rather than a "beggar thy neighbour" approach. The NHS
has a good track record in this respect. However, such co-operative
agreements are being undermined by independent providers who are
envisaged as providing more health services in the "Our health,
our care, our say" white paper. Contestability as well as
leading to fragmentation of services may lead to the NHS no longer
being able to enter into meaningful agreements on workforce issues
with developing nations.
6. How Should Planning Be Undertaken
— To what extent should it be centralised
or decentralised?
— How is flexibility to be ensured?
— What examples of good practice can
be found in England and elsewhere?
6.1 Amicus believes that the workforce needs
and planning should be decentralised with strategic direction
from the "centre". We certainly would wish to avoid
a NHS workforce version of Gosplan. We are not confident that
such a plan could be reached and if so it would be undoubtedly
over influenced by traditionally stronger voices at the expenses
of those groups or services who may be in a better position to
address the government's health priorities.
6.2 So what are these health priorities?
What quality of service is envisaged? What staff are in the best
position to provide this service? Where should they be deployed?
What support should they provided with so that they meet their
objectives?
6.3 The White Paper sees the need for the
stronger participation of the public in determining this. But
this must be informed participation. Many community health professionals
have analytical tools for assessing the health needs of their
client groups. Health needs assessments could form the basic building
block for informing this choice. It also provides for greater
flexibility because health needs differ across the country.
6.4 In commissioning these services to meet
agreed needs we have concerns on the emphasis of Practice Based
Commissioning (PBC) as this may lead to exclusion of professions
who are in a better position to determine how these health needs
can be addressed or a bias to one kind of service over another
which may be more clinically effective. There certainly should
be greater "democracy" amongst health professions if
PBC is introduced.
6.5 In turn workforce planning needs to
take on board what are the health needs of the local population?
What are the priorities in this respect? How can they be met?
What are the obstacles to these being met? How can these obstacles
be overcome?
6.6 The Select Committee Inquiry is welcome.
We hope that its findings will contribute to a "joined up"
approach to health service reform.
Gail Cartmail
Head of Health, Amicus
March 2006
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