Evidence submitted by the Chartered Society
of Physiotherapy (WP 36)
INTRODUCTION
1. The Chartered Society of Physiotherapy
(CSP) is the professional, educational and trade union body for
the 47,000 chartered physiotherapists, physiotherapy assistants
and students in the UK. The CSP is pleased to give written evidence
to the Health Committee on this important issue and would wish
to provide oral evidence if called upon. The CSP's recent experience
of problems in NHS workforce planning (at both local and national
levels), forecasting and the well-known issue of the lack of sufficient
jobs for new physiotherapy graduates (while there exist over 1,500
unfilled vacancies for senior physiotherapists) would make our
oral evidence very relevant to the Committee's investigation.
2. Planning which aligns workforce with
service needs is essential to the delivery of high quality patient
centred care and value for money for tax payers. Fifty-nine per
cent of all NHS costs in England are staff related and £4
billion is invested in NHS staff training each year (A National
Framework to Support Local Workforce Strategy Development,
DH, December 2005). The CSP believes that there is substantial
scope for improving workforce planning in the NHS. Inadequate
workforce planning has led to unprecedented numbers of newly qualified
physiotherapy graduates being unable to find employment as junior
physiotherapists in the NHS. The background to this situation
is set out in some detail in this introduction because the CSP
believes that this is a prime example of the effects of poor workforce
planning in the NHS.
3. The CSP first became aware that newly
qualified physiotherapy graduates were finding it increasingly
difficult to obtain employment as junior physiotherapists in the
NHS in 2004. Until then there had been no difficulties in finding
sufficient posts to accommodate all graduates seeking jobs. Research
undertaken by the CSP in the past has shown that over 95% of graduates
take up employment in the NHS on qualifying in order to be able
to undertake a range of rotational placements in various clinical
areas to allow them to consolidate their undergraduate education.
4. Since 2004 the CSP has been tracking
the employment status of all physiotherapy graduates in the UK.
Our latest survey (undertaken in January 2006) has shown that
of the 2,172 students who graduated in 2005 approximately one
third have been unable to find work within the NHS. Each of these
graduates has cost the taxpayer an average of £28,500 to
train. The majority graduated during summer 2005 and have now
been unable to find work within the profession for at least six
months. Financial pressures mean that these graduates are increasingly
likely to seek alternative careers. The NHS is in danger of losing
them altogether from the profession which would result in an enormous
waste of public money and talent which the NHS will need in the
future.
5. A planned expansion of the physiotherapy
workforce was generated by the NHS Plan 2000. Investment and
Reform for NHS staff—taking forward the NHS Plan (DH,
February 2001) stated that "physiotherapists are very much
in demand for implementation of the NHS Plan . . ." (page
13). This document also projected an increase in the number of
physiotherapists working in the NHS by 59% from 15,600 in 2000
to 24,800 in 2009. This projection was confirmed by John Hutton,
then Health Minister, in a response to a Parliamentary Question
on 28 January 2002.
6. Significant efforts have been made to
expand the number of students to meet future workforce needs.
However, very little effort has been made at local level to stimulate
the creation of sufficient junior jobs to absorb the increased
output of graduates. The number of physiotherapy jobs is continuing
to expand rapidly but many of these new jobs have been senior
and specialist posts which new graduates cannot fill on qualifying.
Expansion of the physiotherapy workforce is also necessary to
help meet increasing patient demand and achieve the 18-week target
on waiting times. At the same time a survey of NHS physiotherapy
managers undertaken by the CSP in summer 2005 revealed that 1,500
senior posts in physiotherapy were vacant. This is a reflection
of a long standing problem with substantial numbers of vacancies
in physiotherapy.
7. The short term impact of NHS financial
deficits (despite a large growth in total NHS funding) should
not be under-estimated in considering the problems for graduates.
Financial freezes have led to vacancy freezes in 2004, 2005 and
2006. Junior posts are more vulnerable to being frozen than senior
posts which have powerful medical consultant backing in dealing
with shorter waiting lists. One illustration of this is that in
our survey of physiotherapists graduating in 2005, carried out
in October of that year, we identified 850 graduates who did not
have a job at that point. Yet there was only an increase in the
number of UK graduates from 2004 to 2005 of 208. The gap between
the two is a clear example of the impact of short term financial
vacancy freezes. It is not evidence that too many physiotherapists
are being trained nor is it a reason to cut student in-takes.
8. Health care trends such as the ageing
population, an increasing number of people with long term conditions
along with government targets such as orthopaedic waiting times
mean that demand for physiotherapy services will continue to grow
over the medium and long term. Unemployed physiotherapy graduates
are not then a symptom of over supply but of a failure in NHS
workforce planning which has been unable to ensure sufficient
posts for newly qualified staff, particularly in the primary care
sector. Unless newly qualified physiotherapists can consolidate
their education in a junior post, they cannot progress on to fill
the more senior jobs. Junior physiotherapists make a major contribution
to patient services and undertake work of real value to the NHS.
9. In our view, critical to more effective
workforce planning is the need for planning and development to:
— Involve all stakeholders in a meaningful
way, including trade unions and professional bodies.
— Be informed at all levels by expert
information such as on disease trends and technological developments.
— Take a long term perspective so,
for example, the NHS is able to respond to tightening labour markets,
particularly for skilled staff, and to the future requirements
of service modernisation.
— Embrace the whole NHS Career Framework
(registered and unregistered staff, clinical and non clinical
staff) ensuring appropriate access to training and learning resources.
— Be better joined up so, for example,
NHS providers are able to respond to the workforce challenges
of national policy developments.
In considering future demand, how should the effects
of the following be taken into account: recent policy announcements,
including Commissioning a patient-led NHS (CPLNHS), technological
change, an ageing population and the increasing use of private
providers of services?
10. Workforce planning means, therefore,
ensuring that there are the right numbers of staff, with the right
skills at the right time to meet service (patient) need. Workforce
planning must comprise more than just a focus on staff numbers:
"head content" as well as "head count" (Workforce
Planning—The wider context, Employers Organisation for
Local Government and Institute of Employment Studies, July 2003).
In the NHS it should embrace access to learning, career development,
diversity, continual professional development, recruitment, retention,
pre registration commissioning, learning resources (such as libraries
and e-learning), competency frameworks and more.
11. Through policy announcements such as
CPLNHS (2005), Our health, our care, our say: a new direction
for community services (2006) and The NHS in England:
operating framework 2006/07(2006), the Department of Health
(DH) sets out the strategic framework and policy priorities against
which workforce planning takes place. The CSP is not, however,
convinced that workforce is always sufficiently central to policy
development and believes that there needs to be greater integration,
consideration and planning of the often significant and complex
workforce consequences of policy developments. As explained above,
the decision nationally to increase the number of physiotherapists
(and others) being trained did not lead to sufficient expansion
of junior posts locally. Trusts on the whole did not plan for
the expansion in complement despite rising demand for physiotherapy
services. At a macro policy level it is not clear how the proposal
in Our health, our care, our say to integrate service and
workforce planning between the NHS and local authorities will
work in practice and how this will relate to pre registration
commissioning. Nor is it clear how effective, national workforce
planning will be undertaken in light of the planned fragmentation
and expansion of service providers into private, voluntary and
social enterprise organisations. Given the need to begin now to
plan the future community workforce this is a major omission.
12. Effective workforce planning has been
challenged nationally and locally by almost continual changes
to health care structures and delivery models—what NHS historian
Charles Webster in his book The National Health Service: A
Political History (2002) has described as "constant revolution".
While needing to be flexible to fit in with changing priorities,
workforce planning in health care crucially requires taking a
longer term perspective. This is partly because of the time it
takes to train and develop staff but also because of the time
frame of emerging health trends and policy developments such as
the shift of resources from the acute to the community sector.
The DH agrees with this—"Long-term workforce planning
is important to provide a strategic view of supply and demand
and to reflect the changes in the wider context of technology,
resourcing patterns and demographics", (A National
Framework to Support Local Workforce Strategy Development,
January 2006).
13. Far too often though decisions are based
on short term factors. Proposals were made by the DH Workforce
Review Team to cut physiotherapy pre registration commissions
by 10% in 2006-07. This is despite evidence that demand for physiotherapy
will continue to grow in the future (for example because of the
rising incidence of musculoskeletal disorders). Indeed the recent
White Paper Our health, our care, our say: a new direction
for community services (January 2006) clearly sets
out the factors that will increase demand for physiotherapy such
as self referral, the importance of intermediate care, care provided
nearer home and an ageing population. Cuts now will result in
insufficient capacity in the future.
14. Workforce planning of professionals
cannot be turned on and off like a tap. It is not a short term
fix. Universities usually receive at least 12 months notice of
changes to in-take numbers. The majority of training courses last
for three years. The short term problems facing 2005 and 2006
graduates will not be solved by cuts in commissions which will
not have an impact for a further three years.
15. The CSP in its evidence to the Healthcare
out of Hospitals consultation said:
We are concerned that the impact of
CPLNHS will result in a reduction in staff morale, retention and
recruitment difficulties and limited opportunities for continuing
professional development.
The CSP is concerned that the drive to increase
the number of alternative providers of NHS services (and associated
infrastructure changes such as practice based commissioning and
payment by results) will increase financial instability within
the NHS with some trusts "failing" in the new market
(How should we deal with hospital failure? Kings Fund,
December 2005). Financial instability will undermine sensible
and integrated long term workforce planning.
16. Significant advances in medical technology
such as genetics and remote monitoring of patients are likely
in the near future. Technological advances increase the health
service's ability to treat people, especially the old. They do
not result in a decline in demand for staff, in fact they imply
a need for increased capacity and the development of new skills.
17. The number of people aged 85 years and
over is projected to rise by 75% by 2025. Older people are major
users of physiotherapy services with over half of new patient
contacts made by physiotherapists in 2004-05 with people over
55. In 2003 the DH's Care Group Workforce Team Recommendations
(Older People) supported the need to increase the current
(physiotherapy) workforce by up to 50% noting that "falls
intervention and osteoporosis are significantly under funded".
Incidences of osteoarthritis are expected to increase as the age
of population rises and because of rising rates of obesity (Burden
of major musculoskeletal conditions, Wolf and Pfleger, Bulletin
of World Health Organisation: 2003).
18. Physiotherapists are playing a major
role in reducing substantially the problems of delayed discharge
from hospitals by increasing rehabilitation and enabling older
people to return to independence in their own homes as well as
decreasing the numbers of emergency admissions. This also provides
a much cheaper alternative to nursing homes. In both ways physiotherapists
have saved the NHS and Social Services substantial costs they
would otherwise have incurred and have increased efficiency in
service provision.
19. The CSP supports the government's objective
of promoting health and well-being in old age. To achieve this
though will require greater staffing capacity (including more
staff) and capability in the community sector. There will be a
particular need to develop staff with specialist skills able to
work in multi disciplinary teams and networks across health, local
authority and other settings able to deal with patients with complex
conditions. There is little evidence of planning being undertaken
to develop this workforce or support available from the DH or
SHAs to assist trusts.
20. The increasing number of private and
voluntary providers of health care will in the CSP's view create
further significant challenges in planning a fit for purpose workforce.
It is vital that the Knowledge and Skills Framework, NHS Career
Framework and career and competency frameworks developed by Skills
for Health and Skills for Care apply to all providers of health
care so that there is a common structure for developing staff
and developing competencies around patient pathways. Thought will
also need to be given to how new providers can appropriately support
the training of students through clinical placements. Plurality
will increase the need to ensure a strong central overview of
training and development and support for local employers to achieve
this.
21. Smaller and medium sized professional
groups such as AHPs have found it difficult to effectively influence
decision making locally around workforce—ensuring an effective
voice for all stakeholders is essential. The CSP believes that
each SHA should have a senior post responsible for AHP workforce
issues to help coordinate and support local activity as well as
providing strategic leadership and engaging with education providers.
This has worked more effectively recently and should not be lost
in the SHA re-organisation.
How will the ability to meet demands be affected
by: financial constraints, the European Working Time Directive
(EWTD), increasing international competition for staff and early
retirement?
22. The NHS spends £4 billion on pre
and post registration education for its employees. It is a major
concern of the CSP that current NHS financial problems in England
will result in short term decisions locally and nationally to
cut workforce spends through further vacancy freezes, cuts in
NVQ funding, reductions in post registration education expenditure
and support for Foundation Degree courses for Assistant Practitioners
and cuts in the MPET allocation and consequently pre registration
commissioning numbers. Given the time it takes to train an undergraduate
clinician or a support worker studying a NVQ cuts now will have
a long term impact on capacity, the operation of the Knowledge
and Skills Framework and the ability of the service to meet access
targets and rising demand.
23. Financial constraints are also likely
to stifle innovation such as new ways of working. There is emerging
evidence of the impact that physiotherapists can have in emergency
care reducing waiting times by rehabilitating injuries more quickly
and facilitating early discharge. Developing the role of physiotherapists
in A&E departments, as Derby Hospitals NHS Foundation Trust
has, could have a major impact on waiting times and reduce unnecessary
referrals. However it is less likely that trusts will undertake
the necessary initial investment in role redesign (for example
developing appropriate competencies and support) if they are required
to cut back on education and training expenditure.
24. The need to ensure that medical staff
comply with the European Working Time Directive, the age profile
of the workforce and additionally a desire by staff to have a
better work-life balance will all impact on capacity. The DH NHS
Workforce Census for 2004 revealed that out of a total headcount
of 19,139 qualified physiotherapists in England 8.8% (1,687) were
aged over 55 years and a further 7.9% (1,511) were aged 50-54
years. Many physiotherapists still retain the right to retire
from age 55 without any actuarial reduction to their NHS pension.
Although not all these staff will chose to retire at this age,
there will still be significant numbers of physiotherapists retiring
in the next few years who must be replaced.
25. "Being a good employer is more
than simply meeting legal requirements: supporting a good work-life
balance, flexible working, childcare provision and healthy workplace
policies are all important" (Our health, our care, our
say, DH, January 2006:189). While the DH has signalled
the importance of addressing demographic factors such as measure
to retain over 50s and 60s there is little sign that such strategies
are being pursued (A National Framework to Support Local Workforce
Strategy Development, DH, 2006, page 12). An ageing workforce
will mean a disproportionate rise in retirements in the future.
These workers will need to be replaced.
26. An ageing population and declining birth
rate means that competition for skilled labour such as physiotherapists
will tighten in the future. National and international competition
for labour will increase particularly from America (Workforce
Crisis—How to Beat the Coming Shortage of Skills and Talent,
Dychtwald, Erickson, Morison, Harvard Business School Press,
2006).
27. This view is shared by the DH who in
A National Framework to Support Local Workforce Strategy Development
rightly argues "demographic trends mean that for many health
and social care employers maintaining an `edge' in recruitment
and retention of the best staff will be important" (DH,
January 2006:14), while the Institute of Employment Studies
notes "the future is expected to bring a shift to higher
skilled `knowledge worker' jobs, increased competition"
(2003: 7). The CSP is concerned that the NHS is not planning sufficiently
for the impact of demographic changes such as the retirement of
the "baby boomer" generation on labour supply.
28. Attention must also be paid to the effects
on the NHS workforce of changes in other countries. In London
the vacancy rates for senior physiotherapists and high turnover
among staff has led to a growing dependence on short-term physiotherapists
from countries such as Australia and New Zealand. However, impending
reductions in the numbers of physiotherapists being trained in
Australia means that there is likely to be a dramatic decrease
in the numbers of Australian physiotherapists able to bolster
the London workforce in this way. This in turn will have a detrimental
impact on waiting lists and the service provided.
29. The CSP believes that short term cuts
in investment in training and development will have long term
consequences and inhibit the NHS's ability to recruit staff in
the future and meet rising demand for health care.
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, better retention,
the recruitment of new staff in England and international recruitment?
30. While there is scope to redesign and
enhance roles it is the CSP's view that this will result in a
changed workforce profile with, for example, more specialist and
highly specialist physiotherapists (levels 7 and 8 of the NHS
model Career Framework) and more Assistant Practitioners (level
4). There is no evidence that changing roles will reduce demand
for existing staff overall. The CSP believes that the Knowledge
and Skills Framework offers the opportunity to improve the skills
of existing staff but that it is vital that all staff whether
registered or not have fair access to training. This is not
the case at present with AHPs frequently struggling to access
learning resources locally.
31. The CSP supports the government's commitment
to increase widening participation in learning and welcomes the
establishment of the Widening Participation in Learning Strategy
Unit headed by Professor Bob Fryer. For too long staff in bands
1-4, including physiotherapy assistants and administration staff
working in physiotherapy departments, have struggled to gain access
to NVQs and other means of learning. Fair access to education
supported by appropriate learning environments for all staff is
essential to ensure the effective delivery of services. It is
particularly important that spending on NVQs and Learning Accounts
is ring fenced. The CSP would be concerned about any move away
from this.
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?
32. At present the following stakeholders
are involved to a greater or lesser extent in NHS workforce planning:
Department of Health, Skills for Health, service providers, education
providers, professional groups and networks, trade unions and
professional bodies and SHAs. In the future local authorities
and private and voluntary organisations will join this list. Given
the size of the NHS workforce the CSP firmly believes it is vital
that there is strong central leadership and strategic overview
of NHS workforce planning which takes account of expert information
and advice, as well as the long term perspective. Partnership
working with professional bodies and trade unions must form part
of this approach. The CSP regretted the demise of the National
Workforce Development Board as this was the only body that allowed
high level discussion with external stakeholders around workforce
issues. Unemployed physiotherapy graduates illustrate the consequence
of not joining up thinking around workforce planning. There is
a real danger that plurality of provision will result in greater
confusion.
33. The CSP is also concerned at the tendency
to group all Allied Health Professions (and increasingly Health
Care Scientists) into one group ignoring the different issues
affecting each profession. Local Delivery Plans being developed
by Strategic Health Authorities, which include their proposals
to increase their local workforce numbers, only provide information
for this group as a whole. This makes it extremely difficult for
trade unions and professional bodies such as the CSP to comment
on these plans in a constructive manner. For example, physiotherapy
has one of the highest ratios of applications for each undergraduate
training place and an extremely low attrition rate from the courses.
In radiography the main problem is in finding sufficient applicants
to fill the available training places. In physiotherapy there
is a great deal of competition to attract staff into the private
sector working in a range of settings such as sports clinics,
occupational health, charities, private hospitals, private clinics
etc. In radiography such opportunities do not exist outside the
NHS to any great extent. If workforce planning does not take proper
account of such differences, it becomes less and less meaningful.
34. The CSP's view is that far more detailed
workforce information is needed before effective national workforce
planning can be instigated. A survey of our members undertaken
in 1999 allowed us to obtain information about physiotherapists
working in the NHS in greater depth than DH surveys have done.
One example of the benefits of this level of information were
shown when we examined the age profile of members working in the
NHS by clinical specialty. Although it is well known that the
NHS workforce is ageing, our research revealed that a disproportionately
high number of physiotherapists working in care of the elderly
(69%) fell within the 40+ age bracket compared to 50% of all those
working in the NHS. Only 4% of those working in care of the elderly
were aged 20-29 years compared with 17% of all those working in
the NHS. This highlighted the need to ensure that student placements
and junior posts are developed in this specialty to ensure that
those retiring could be replaced in the future.
35. For some years the CSP has expressed
its concern that the DH in England only collects vacancy statistics
for posts which have been vacant for at least three months and
which organisations are actively trying to fill. This presents
a distorted picture of the true situation because posts which
have been frozen or which are not currently being recruited to,
often due to financial constraints, are not included. Although
there is value in gathering information about posts which have
been vacant for this length of time since this is the average
time taken to fill a post, we also believe that it is essential
that data is collected on all frozen posts and "on the day"
vacant posts to obtain a clearer picture of the extent of the
problem. This data used to be collected in the 1990s for the Pay
Review Body. The CSP's workforce survey revealed that the "on
the day" vacancy rate was, on average, around twice as high
as the three month vacancy rate. Vacant posts reflect the inability
of the NHS to provide the level of service needed to meet patient
need and without accurate information about the vacancy situation
it becomes very difficult to plan action to address the full extent
of the problem.
36. In conclusion, the CSP would wish to
see:
— Involvement of all stakeholders in
a meaningful way, including trade unions and professional bodies,
and better sharing of information used to support long term planning
and ensure partnership working in this complex area.
— Recognition that the short term impact
of financial deficits in the NHS should not lead to "boom
and bust" variations in university intakes which have serious
long term impact on the future of healthcare.
— Action is taken to plan and create
more junior physiotherapy posts to ensure that current graduates
are fully employed recognising that there remain over 1,500 senior
physiotherapy posts in the UK and that the juniors of today are
the senior physiotherapists of tomorrow. Lack of effective NHS
workforce planning could deprive the UK public and the NHS of
the skilled professional workforce it has already paid to provide.
— More detailed workforce data collection
including information by profession which examines age profile,
clinical specialties, ethnicity, disability, and so on.
— Collection of "on the day"
vacancy data for each profession in addition to three month vacancy
data.
— Enhanced collaboration between national
and local levels so that NHS providers are better able to respond
to the workforce challenges of national policy developments.
— Establishment of a senior post responsible
for AHP workforce issues within each SHA to help coordinate and
support local activity as well as providing strategic leadership
and engaging with education providers.
— Direct involvement of local service
managers in collection of data to ensure that the information
submitted for each profession is as accurate as possible.
— Strong central over view and monitoring
of steps being taken at local and regional level to tackle problems
which arise such as shortages in particular professions and clinical
areas within those professions. This will become increasingly
important with increasing plurality of providers.
— A longer term and wider perspective
which takes account of demographic trends; developments in other
countries which are likely to have a significant impact on the
NHS; and the impact of the various strands of the NHS modernisation
programme.
— Account being taken of the whole
NHS Career Framework (registered and unregistered staff, clinical
and non clinical staff) ensuring appropriate access to training
and learning resources.
Phil Gray
Chief Executive, Chartered Society of Physiotherapy
March 2006
| 
