Evidence submitted by the Cambridge Institute
for Research Education and Management (WP 19)
I am pleased to submit this self contained memorandum
of evidence (by Email) to the Health Select Committee. Cambridge
Institute for Research Education and Management (CiREM) consider
that the Inquiry is critical in the light of significant changes
to service provision and the resultant impact on the skills of
the workforce.
CiREM has undertaken research and evaluation
programmes in the health sector over a number of years and provides
evidence and analyses which supports improved workforce planning,
skills development and workforce productivity in the short, medium
and longer term.
We would be happy to provide further information
and data should this be required by the committee.
1. INTRODUCTION
1.1 This memorandum primarily addresses
one aspect of the Health Committee's terms of reference namely:
How should planning be undertaken?
— To what extent should it centralised
or decentralised?
— How is flexibility to be ensured?
— What examples of good practice can
be found in England and elsewhere
Labour market intelligence (LMI) refers to the
characteristics (data, information and analysis) of the workforce
and their skills, potential workforce (labour pool) and to the
future needs of the service (replacement and new demand). Cambridge
Institute for Research, Education and Management `s spectrum of
analysis spans LMI leadership, strategy, infrastructure, operational
functioning and promotion with respect to the health care workforce
and related skill demands.
In order to better understand the LMI needs
of the future, a secondary objective is extract the LMI implications
from likely changes in the workforce. Thus CiREM will review and
comment on:
To what extent can and should the demand be met,
for both clinical and managerial staff, by:
— changing the roles and improving
the skills of existing staff;
— the recruitment of new staff in England;
and
— international recruitment.
Thus whilst the former question looks at the
how of workforce planning, inclusion of some aspects of the latter
question encompasses the what of workforce data and information.
1.2 In doing so, it will make reference
to what forms of data, information and intelligence (eg the shape
and nature of the workforce) it should have in order to support
a health service which continues to provide high quality provision
as is able to continuously improve. Rather than reference sources
in the text, a bibliography has been provided.[22]
1.3 In presenting a clear, concise and coherent
case, this memorandum will also make reference to examples of
LMI practice across the sector and beyond England.
1.4 Cambridge Institute for Research, Education
and Management was founded in 2000-01 and is an independent organisation
specialising in research and evaluation services to the health
sector in general and to the NHS in particular.
1.5 The company's strengths are in the following
key areas:
Skills
CIREM undertakes primary and secondary
research on skills shortages, skill gaps and latent skill shortages
We have experience in skills strategy development, particularly
at sector skill council levels. Our clients are at regional and
national levels.
Labour Market Intelligence
We undertake assessment and summary
reports of UK wide labour market intelligence data in the health
care fields. We have experience in future "scenario planning"
in health care related workforce development.
Learning Needs Analysis
We have considerable expertise and
experience in devising and analysing an organisation's learning
needs. Our work encompasses writing peer reviewed papers, scoping
a field of study, analysis and synthesis of data to produce executive
summary and full reports. Our client base is at national, regional
and SME levels.
Evaluation
CIREM specialises in evaluations that
are innovative in their methodology or subject matter.
— We design evaluation frameworks
for organisations and particular programmes.
— We conduct meta-evaluations
across employment sectors and professional disciplines.
— We advise on evaluation
practice and policy.
Research based projects
CiREM specialises in short term research
based project work. We participate and contribute to the project
planning components of the research.
2. BACKGROUND
2.1 The health sector (ie NHS, independent
and voluntary & community) employs nearly two million employees
in the UK. It is important to view the health sector as a whole
as:
(i) policy implications in England are resulting
in an expansion of service provider; and
(ii) the NHS draws from the same labour pool
and thus the sector's interdependence in workforce terms is reinforced.
The sector is recognised as having a highly skilled workforce,
a diversity of staffing professions and occupations, and high
investment in education and training.
Prior to 1999 workforce planning had relied
on a highly centralised structure which reviewed a series on year
x year training numbers in the professions (medical and nursing).
These numbers were increased or decreased according to central
returns of staffing numbers.
In March 1999 the Health Select Committee recommended
a review of how workforce planning was undertaken in the health
service. Later, the publication of A health service of all
the talents provided recommendations around four key areas:
— Greater integration and more flexibility
of workforce planning.
— Better management ownership, clearer
roles and responsibilities within planning.
— Improved training, education and
regulation.
— Better planning for overall staff
numbers and career pathways.
2.2 Workforce Development Confederations
(WDCs) were created to plan effectively for all staff groups on
a locality basis and to work collaboratively with other organisations
so that data and workforce plans could be accrued nationally.
In April 2004 WDCs were integrated with Strategic Health Authorities
(SHAs) to bring together capacity for service and workforce planning
within one body.
SHAs are undergoing review in relation to both
scale (the numbers of SHAs in England) and scope (core strategic
functions).
2.3 The NHS Improvement Plan, published
in June 2004, set out the way in which the NHS needs to change
in order to become truly patient led. These changes are fundamental,
they affect the whole system and the way individuals and organisations
behave.
In 2005 Creating a patient led NHS outlined
how the improvements in capacity, with increased numbers of staff
and reductions in waiting times and improvements in mortality
rates, would be matched by changes in the structures of the NHS.
2.4 Skills gaps and shortages have been
met as more staff have joined the NHS year on year. Since 1999
until September 2005 the NHS workforce has grown by approximately
23,000 more doctors, 68,000 more nursing staff and 11,000 Allied
Health Professionals. Vacancy rates have fallen steadily as these
staff have entered service. Staff are also working shorter hours
as the successful implementation of the European Working Time
Directive (EWTD) in 2004 limited a majority of staff hours to
48 and doctors' hours to a maximum of 58.
International recruitment
2.5 International recruitment was viewed
as a short to medium-term strategy. Since 2005 there has been
a steady decrease in volume of international recruitment in all
sectors. Increasingly as the year-on-year increases in training
emerge, the health service will be more self-reliant on UK trained
professionals.
International recruitment however will be used
to target specific strategic areas for example dentists (from
Poland) and GPs (from Germany and Spain) into priority locations.
2.6 The sector does not collect reliable
data on inward migration. The Labour Force Survey can do this
by proxy using "Organisational institution where qualified"
but to date there is no coordinated method or plans for collating
this data.
There is evidence to suggest that this facility
would be needed at national at regional levels (especially in
London which has seen the majority influx of workers).
2.7 Department of Health recently published
A national framework to support local workforce strategy development.
This document supported HR Directors in the NHS and Social
Care to integrate their strategy for local staff development.
The document covered six main areas:
The objective of the document is to help organisations
devise simple strategies to create a workforce that is flexible,
productive and affordable.
There is recognition that local organisations
need to devise local solutions based upon their service and financial
development. However it is clear that the solutions fall short
of the more medium and long term workforce planning issues—it
assumes that "more of the same" will be required in
workforce development.
2.8 The objective of workforce planning
is straightforward: match supply to demand. Workforce planning
(in the NHS) has had a somewhat chequered history. There is an
oversupply of physiotherapists, a severe shortage of dentists
and growing realisation from rapid changing technology in the
service, an oversupply of cardiothoracic surgeons.
Workforce planning (NHS) has tended to overlook
the financial implications of simply following a demand model.
2.9 A wide range of organisations in England
share between them various roles and responsibilities. The main
ones are listed below.
Department of Health (DH)—who have a key
role in assimilating this information and advice; and taking key
decisions. In particular, at a macro level DH seeks to ensure
that in aggregate, NHS workforce plans are coherent alongside
its financial and service plans. DH also has a central role to
play in "steering" the investment of (approximately)
£4 billion contained in the "MPET Levy" and issuing
guidance and targets to individual SHA's to inform their commissioning/investment
plans. In practice this means that a large proportion of SHA resources
are already pre-committed, firstly because there are many students
who are on programmes which started two or more years ago. Secondly,
DH comes to a view as to how many new pre-registration commissions
are needed nationally each year for each of the healthcare professions;
requiring each SHA to commission their "share" of the
overall total.
Skills for Health—(SfH) was established
in April 2002 and licensed as the Sector Skills Council (SSC)
for health in May of 2004, a sector that employs some two million
people with a mix of highly qualified and unqualified staff over
a wide range of work roles and setting. The organisation is funded
through the four UK health departments, DFES, the Education Act
Regulatory Bodies and the sector, which as a whole spends over
£3 billion pounds each year on direct training and development.
Skills for Health is licensed as the SSC for health through the
Sector Skills Development Agency (SSDA), under the Department
for Education and Skills (DFES) Sector Skills Councils has four
key goals:
— addressing skills gaps and shortages;
— improving productivity and performance;
— increasing opportunities to boost
skills; and
— improving learning supply, including
apprenticeships, higher education and National Occupational Standards
(NOS).
Strategic Health Authorities—have a co-ordinating
role for producing coherent workforce plans (linked to service
and financial plans) for all the employers in their area—for
commissioning the education and training in support of those plans;
and submitting overall workforce and commissioning plans to the
Department of Health for approval.
Individual NHS organisations—required
to prepare their own workforce plans.
Other employers in the sector—(eg Nursing
Homes, independent hospitals, voluntary sector organisations)
who have the option of working closely with NHS organisations
in a particular Strategic Health Authority (SHA) area.
The Workforce Review Team—who advise the
Department of Health as to future workforce number requirements.
National Workforce Projects (NWP) who are taking forward a number
of innovations in workforce development to support service change.
Royal Colleges—who offer their own advice
to the Department of Health, especially in respect of future requirements
for doctors in training and Consultants/GP's that come within
the remit of each of the Colleges.
Other "Advisory Committees" and bodies
such as NHS Employers and external organisations.
2.10 Skills for Health are responsible for
the production and implementation of a sector skills agreement
for the sector. Stages 1 and 2 of the research process noted that
simply planning for "more of the same" will be insufficient
to meet the challenges of the next 10 years and beyond.
There is a recognised need to produce a more
flexible workforce rather than to continue to commission workforce
education and training along traditional lines. A stage three
report Case for Change highlighted the fact that strategic
drivers converge in two specific areas namely: the need for a
more flexible workforce (a more effective mix of people undertaking
wider and different roles) and the role of competences as a currency
and framework for addressing skills gaps and their workforce development
implications through future planning and commissioning.
2.11 The need for a more systematic structure
for workforce planning is now more widely recognised within the
NHS.
Good (ie up to date, comprehensive, robust)
LMI makes a vital contribution by providing the evidence base
on numbers and skills, and informing future policy on what intelligence
on the future workforce will be required to continue to provide
high quality patient care.
We believe that in the current climate of financial
instability, there has never been a greater time at which the
tensions between "wants" (more doctors, more nurses)
and "needs" (what is required in good clinical care
by the patient at the right time) have had to be resolved.
2.12 The current systems of intelligence
and planning has produced sufficient staff with appropriate skills
to deliver the volume and service of healthcare, within budget.
However, an analysis of the implications of the current policy
implications suggests heavily that these systems will not be robust
enough to be effective in changing healthcare contexts.
3. WORKFORCE:
KEY CHARACTERISTICS
3.1 Employment composition by gender
and status
— Health care is one of the largest
sectors, and covers more than two million workers, or around 7%
of total employment the UK. Employment growth is expected to be
positive over the next 10 years, and employment is anticipated
to expand by another 10% over the period 2004 to 2014, representing
more than 200,000 extra jobs.
— Women dominate the health care workforce:
80% are female, which is second only to care sector.
— The high proportion of women in health
care is reflected in the high proportion of part-time employment,
with almost 45% of workers employed part-time, almost all of which
are women.
3.2 Occupational composition of employment
— As would be expected, Associate Professional
& Technical Occupations, and Personal Service Occupations
dominate the employment structure of health care.
— Together these two occupational groups
comprise 56% of total employment in the sector in 2004.
— Almost 600,000 workers are classified
in Associate Professional & Technical Occupations and almost
560,000 in Personal Service Occupations.
3.3 Expansion demand, replacement demand
and total requirement 2004-14
— The health sector has a comparatively
high replacement demand ratio, and coupled with the forecast expansion
in employment, these give the sector a total recruitment requirement
for the next 10 years of almost 50% of current employment.
— Total requirement is in excess of
60% of current employment levels for Managers & Senior Officials
and in Professional Occupations, since these two occupational
groups are forecast to grow strongly over the next decade in both
levels and shares of total employment in the sector.
— In terms of the level of recruitment,
total requirement for the sector is forecast to be in excess of
one million new workers over the period to 2014.
3.4 Workforce planning data is currently
based on numbers required in each of the already established healthcare
professions and workforce groups Very little data on the large
proportion of the workforce not qualified as registered
healthcare professionals.
3.5 Growth in knowledge and technology means
that existing, new and changing job roles do not conveniently
fit into the workforce group "profession typology" designed
many years ago.
Workforce planning returns and other workforce
information submissions to DH contain little reference to new
roles particularly at Assistant and Advanced practice levels,
therefore the scope and flexibility for investing in them is severely
limited.
4. RECOMMENDATIONS
The key recommendations have been grouped into
five categories: leadership, strategy, infrastructure, operational
functions and promotion.
4.1 The practice of LMI workforce planning
has suffered in part from:
(b) an inability to engage employers with
the more strategic dimensions;
(c) poor coordination of resources and functions;
and
(d) lack of strategic vision.
There needs to be clear leadership in this area.
The health sector would be best served by UK/national LMI bodies
which represent the whole sector or by sub sector organisations
which have a firm grasp of the strategic direction of health care
as a whole.
4.2 A UK strategy for the health care sector
would necessarily span the sections here (leadership, infrastructure
and operational functions).
A future workforce: undertake strategic analyses
of the characteristics of the workforce required and thus the
types of LMI data which will be required in the future.
Appraise the possibility of converging DH Census
data with other UK national minimum data sets.
Progress plans for harmonisation of UK skill
surveys (4) in relation to:
(iii) latent skill shortages for health care
sector.
Need to explore potential with:
— Skills Monitoring Survey (NI).
Determine the critical mass of capacity and
capability required at regional level for effective use and application
of national and regional LMI.
Explore ways of linking short to medium and
long term objectives in LMI planning: phasing of development programmes
will be critical.
Assess demand for a UK web based portal for
information and advice on health sector LMI.
4.3 Undertake an assessment and appraisal
of a UK IT infrastructure which supports the integration of LMI
national data sets (ie facilitate read across). There is significant
work carried out in Scotland in this respect (SWISS).
4.4 There should be better utilisation of
existing data and intelligence across the whole sector in terms
of existing workforce and the labour pool.
Invest in the capture and collation of LMI data
on staff relating to international recruitment and inward migration.
Undertake assessment of future LMI needs in
relation to the future workforce (the development of a flexible,
competent staff).
4.5 Promote greater understanding of:
— Better ways to disseminate findings.
— Improved approach to determining
skills needs (current and future).
Production and dissemination of research bulletins
of reports from LMI research.
Demonstrate link to productivity (via information
to achieve greater effectiveness and efficiency) and indirectly
to improved patient care.
Dr C Loughlan
Chief Executive, CIREM
14 March 2006
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