Evidence submitted by Shared Solutions
Consulting (WP 03)
A. INTRODUCTION
1. This response is from George Blair who
had lead responsibility for the Education Training workforce planning
at the Department of Health, 1992 to 1995 and has spent 20 years
in this field in the NHS.
2. This paper is divided into three main
sections:
B. Issues to take into account—this
explains some of the assumptions and underlying principles that
are behind our answers.
C. Answers—this responds to the Committee's
questions.
B. ISSUES TO
TAKE INTO
ACCOUNT
What is workforce planning?
3. Workforce planning is often defined in
a way that ignores crucial issues such as productivity. This is
because a definition such as the following is used: the "right
number of staff, with the right skills, in the right place, at
the right time." This then focuses on supply issues, such
as training needs analyses, commissioning education at training
and improving recruitment and retention.
4. However, recently there have been serious
concerns about the declining productivity in the NHS. There are
a many of examples of this, such as buying expensive equipment
to treatment more patients, when existing equipment is only used
on a nine to five basis, Mondays to Fridays or using expensive
on-call arrangements instead of extending the shift system.
5. One of the interesting aspects of this
issue is the lack of useful data on changes in productivity. This
is because there has been historically a lack of management focus
on the topic. There has been a complete lack of clarity regarding
who is responsible for trying to improve productivity, due to
a silo culture where the data on staff, costs and patient activity
sit in three different departments, without much consideration
being given how best to integrate it.
6. In the few areas with excellent productivity
data, this tends to be only in the possession of service managers
who have many other concerns and little or no incentive to do
anything about it. However, this will change with the implementation
of payment by results.
7. It is proposed that organisations should
be encouraged to have productivity leads. They could be workforce
planners working with clinical leads and finance staff or management
accounts staff who have some training in workforce planning, working
with their other colleagues.
The long-term nature of workforce planning
8. The timescale of workforce planning for
most professions is at least five years. This is because negotiations
need to take place with education providers about the future size
of their intakes, which can take a couple of years to implement
in addition to the usual three years duration of degree or diploma
courses. This process is even longer in the case of medicine,
due to the seven year duration of their education programmes.
Thus at least five years need to elapse before the adequacy or
otherwise of a workforce plan can be established. Therefore, in
2006 we can only evaluate with any certainty workforce decisions
made before 2002!
What is successful workforce planning?
9. How accurate can such plans be, given
the need to plan so far ahead? Many events or policy changes could
take place after the plans have been made that will have a substantial
impact on them. This could take the form of a large increase in
staff, as in the case of the NHS Plan, or changes in the location
of care with the shift to primary care, or between the NHS and
the independent sector, with 15% of certain types of services
to be provided by the latter. Therefore, the best that can be
hoped for is that workforce plans are a close approximation of
demand. Given the impossibility of accuracy, a decision needs
to be made whether it is better to under or over train? Under-training
saves training costs, but leads to staff shortages, increased
waiting times and the use of more, high cost agency staff. In
the case of over-training, the advantages and disadvantages are
reversed. The established wisdom is that slight overtraining is
the preferred option.
Geographical differences
10. There are very pronounced regional differences
in terms of levels of education, rates of employment and pay that
need to be taken into account.
Clinical placements
11. Before newly qualified staff can become
effective members of the workforce, they need a considerable investment
in terms of on-the-job training and close supervision. Providing
clinical placements has proved difficult in the past and is likely
to be more so in the future, unless healthcare providers are financially
compensated for their loss of throughput. Therefore, mechanisms
that support the provision of clinical placements should be a
success criterion for any proposed workforce planning system.
C. ANSWERS TO
THE COMMITTEE'S
QUESTIONS
How should the effects of recent policy announcements,
including Commissioning a patient-led NHS be taken into account?
12. This would entail unravelling their
many facets that have workforce implications. For instance Commissioning
A Patient Led NHS would mean: fewer management staff with
the mergers of SHAs and PCTs; training GPs in commissioning skills;
anticipating the workforce impact of changes in commissioning.
13. There would be value in a central group
of people from different levels of the NHS with workforce planning
skills reviewing such documents and producing a workforce implications
grid that would spell out: possible changes in workforce numbers;
roles; locations; patterns of working; education and training;
and finally, where responsibilities for meeting these changes
falls.
How should the effects of technology be taken
into account?
14. The impact of technology and new drugs
can be huge. For instance, if a vaccine against cervical cancer
were developed, a great deal of time would be released, as practice
nurses and laboratories would cease screening. There are a growing
number of tests that patients can carry out themselves, meaning
patients will be able to monitor and manage their conditions with
less intervention from healthcare staff. However, there would
need to be substantial up-front investment in patient training.
15. Given the wide ranging nature of the
above, drug and equipment manufacturers should be invited to write
papers on this topic. They could be allowed to have their name
on the documents, so that they would gain kudos from the exercise.
The papers could then be put on a workforce planning website,
eg that of the National Workforce Projects.
How should the effects an ageing population be
taken into account?
16. This has several facets, such as the
impact on the demand for healthcare on the one hand and on the
other NHS's own workforce, namely what types of jobs are most
suited to the older worker?
17. One approach is to study how societies
with a higher percentage of old people manage, eg Japan and China[135]
and then apply the lessons to England.
18. When it comes to planning to replace
retirements, this is best done centrally, with reference to national
age profiles from professional registers or the NHS electronic
staff record. The reason is that it is easy for employers to lose
sight of this problem. For instance, many acute trusts would not
plan to replace nurses coming up to retirement because they only
have a few of them. However, community and practice nurses tend
to not to plan to replace their many nurses coming up for retirement
either, as they can readily recruit experienced nurses from the
local acute trust, rather than directly from university.
How should the effects of private providers of
services be taken into account?
19. The number of staff employed in the
private sector could be obtained from registration bodies, if
they were to extend the mandatory information required of their
members.
20. However, this would not provide information
on future demand and therefore an important piece of information
would be missing. Unfortunately, private sector providers are
likely to be unwilling to provide this information, as this would
reveal too much of their confidential marketing strategy.
How will the ability to meet demand be affected
by financial constraints?
21. Financial constraints are likely to
result in a reduction in the use of agency staff and possibly,
redundancies. This might mean that some newly qualified staff
will not get jobs, as these might be taken by more experienced,
unemployed staff.
How will the ability to meet demands be affected
by the European Working Time Directive (EWTD)?
22. This will affect parts of the NHS where
staff work substantially more hours in excess of EWTD regulations,
such as medical staff, radiography and pathology staff. This can
be addressed by new ways of working, such as teams of staff working
across specialties in the Hospital at Night programme or by changing
skill mix to make better use of more expensive professional staff,
eg introducing assistant practitioners who would release professional
staff from undertaking many chest x-rays.
How will the ability to meet demands be affected
by increasing international competition for staff
23. This is likely to have a serious impact
on England's capacity to recruit and retain nurses. Many Filipino
nurses only work in Britain because they were barred from applying
for jobs in the USA, their first preference, until recently. In
addition, some expensively trained UK trained nurses in hard to
recruit specialties, eg intensive care, are likely to be attracted
by better America rates of pay.
How will the ability to meet demands be affected
by early retirement
24. This is presumed to refer to medical
staff being encouraged to retire early due to the unintended consequences
of pension changes. This will clearly have an adverse impact on
the whole of the service.
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
25. This would be attractive option in terms
of developing existing staff and improving efficiency. However,
it should be noted that past achievements have been limited and
excellent examples of innovation have not been copied widely.
It is hoped that Payment by Results and the Knowledge and Skills
Framework will encourage more innovation of this type.
26. In addition, benefits can be gained
from improving working processes, eg simplifying workflow in pathology.
To what extent can and should the demand be met,
for both clinical andmanagerial staff, by better retention
27. All things being equal retention rates
may well decline, due to the greater choice of employers with
the growth in the number of independent providers. In addition,
there would be losses due to more retirements, even with the development
of post-retirement careers. A further consideration is that there
are marked regional variations in retention due to the very distinct
labour markets, such as London and the South East attracting younger
and more mobile workers. Indeed, Capital Health? Creative solutions
to London's NHS workforce challenges[136]
suggests rather than try to stem this tide, London organisations
should design career opportunities to make the most of recruits
wanting a brief career in London, before moving on.
To what extent can and should the demand be met,
for both clinical and managerial staff by the recruitment of new
staff in England or by international recruitment?
28. The objective should be that England
is self-sufficient in the supply of health staff. This is because
there are benefits to patients in having staff who understand
their culture and can more effectively communicate with them.
Therefore, reliance on foreign trained staff for anything other
than a sudden and unforeseeable increase in demand should be regarded
as a failure in workforce planning.
29. This goes beyond planning around nationality
to include ethnic origin. It means that ethnic populations are
better served if more staff with whom they have face-to-face contact
are recruited from amongst them. Urban regeneration can be fostered
by investing in the education and training of disadvantaged populations.
30. There are ethical issues to consider
when overseas recruitment is at the expense of poor, sub-Saharan
Africa countries where such staff are in short supply. For instance,
of the 600 Zambian doctors trained since independence, only 50
are said to have remained in the country. [137]It
is said that there are now more Zambian doctors in Birmingham
than in their country of birth.
To what extent should planning be centralised
or decentralised?
31. Planning for whom? There are some small,
but important staff groups with just 50 staff and clearly they
can only be planned for centrally. Usually, the best way to do
that is in conjunction with their professional body that would
have membership lists, age profiles, etc.
32. The NHS has a tendency to alternate
been centralised and decentralised approaches every three to four
years, as each approach has its own set of advantages and disadvantages.
33. More important issues are, what are
the checks and balances in the system? For instance, when education
monies can be diverted to funding health care provision deficits,
this has been too great a temptation for trusts to resist.
34. The advantage of central planning is
that it is likely to take into account the need to replace a large
number of staff coming up for retirement. However, it is difficult
for a central system to respond to the needs for very different
local labour markets. The advantages and disadvantages are summarised
below in tables 1 and 2.
Table 1
CENTRALISED PLANNING—ADVANTAGES AND
DISADVANTAGES
Advantages
| Disadvantages |
Can readily address the needs to maintain the workforce, eg retirements, by commissioning more education
| Has difficulty in identifying new sources of demand, as this is dependent on the plans of local healthcare providers.
|
| Local organisations feel disempowered, as key decisions are made above their heads. This can lead to a lack of cooperation when plans are implemented locally.
|
| Can lead to central targets being divided into local targets that are at odds with local needs.
|
| |
Table 2
LOCAL PLANNING—ADVANTAGES AND DISADVANTAGES
Advantages | Disadvantages
|
Local changes in demand are more likely to be met
| Can lead to short-term policies. The serious shortage of nurses was driven by the massive and unsustainable reductions in education in the early 1990s.
|
| Local organisations are more likely to take planning seriously, as they are making the decisions themselves
| |
| |
35. As there are quite marked advantages and disadvantages
to both approaches, can elements of centralisation and decentralisation
be combined, as part of the same model? For instance, national
work could set floors and ceilings for education supply and then
local organisations decide how they are going to contribute to
meeting the targets. This would also need a mechanism to force
local organisations to increase training, when it is below the
level of the centrally set floor.
How is flexibility to be ensured?
36. This is difficult to achieve. One approach is to
use scenario planning so that if the preferred scenario were to
prove unattractive because of unforeseen events, another scenario
can be adopted.
D. RECOMMENDATIONS
37. This section includes recommendations on:
— criteria for evaluating a workforce planning system;
— a structure for workforce planning;
— a means of distilling the workforce impacts of
healthcare policy;
— a means of contribution to long-term thinking
on the impact of technology and drugs; and
— the need to focus on productivity improvement.
(i) Criteria for evaluating a workforce planning system
38. These should be:
(1) To respond effectively to the needs of small groups,
ie with 50 members as well as large ones.
(2) To prevent education and training monies from being
diverted to fund financial deficits in the provision of healthcare,
where this is to the detriment of the future workforce.
(3) To enable enough clinical placements to be provided
to support the required volume of education and training.
(4) To involve all relevant stakeholders, ie including
education providers and professional bodies.
(3) To avoid serious staff shortages as indicated by:
the number of unfilled vacancies; the number of agency staff and
the number of overseas recruits.
(ii) Recommended system of workforce planning
39. The following are recommended:
(1) Membership: to be employer driven, while engaging
legitimate stakeholders, eg education, professional bodies and
patient groups.
(2) Roles of different bodies:
(a) The Department of Health or The Employers Organisation
should set national ceilings and floors, based on commissioned
research that would have some professional body input. Department
of Health clinical strategies should spell out the likely workforce
implications. In addition, the national lead organisation is to
commission papers on long-term issues. All this information should
be available to all on the web.
(b) Regions or whatever amalgamated Strategic Health Authorities
will be called, would conduct workforce planning exercises with
Trusts and other healthcare providers to negotiate with the national
body regarding what its target should be for each staff group.
Any disputes on the level of commissions should err on the side
of slightly over-training than under-training. SHA/Regions would
also engage education providers about the design of courses and
commission education, in the way currently undertaken by SHAs.
(c) Healthcare providers should provide plans to their SHA/Region.
(iii) Government policy documents and their workforce
implications
40. It is recommended that a workforce group with representation
from different levels of healthcare produce a workforce implications
paper for each policy document for which this might be useful.
This would include the likely impact on staff numbers, roles,
ways of working and education and training.
(iv) Assessing the impact of technological change
41. Given the wide ranging nature of the above, drug
and equipment manufacturers should be invited to write papers
on this topic. They could be allowed to have their name on the
documents, so that they would gain kudos from the exercise. The
papers could then be put on a workforce planning website, eg that
of the National Workforce Projects.
(v) Recommendation on productivity
42. It is recommended that consideration is given to
how information on productivity is produced and reported to the
different layers of management. This should include how action
is taken to improve productivity that goes beyond reducing budgets
to high cost services and covers benchmarking top performers and
sharing information on process improvements. NHS organisations
tend to suffer from too much data and too little information.
Information should be presented in an integrated manner, with
clear options regarding areas where action should be taken.
43. One option would be to give an award of £50,000
to the organisation that handles the efficiency agenda across
the whole organisation most effectively. This could be written
up and shared on the web. Therefore, the approach would be of
demonstration and not prescription.
George Blair
Managing Consultant, Shared Solutions Consulting
20 February 2006
Source: http://www.chinadaily.com.cn/english/doc/2006-02/13/content—519515.htm
accessed 13 February 2006.
135
Shanghai has become the Chinese city with the highest proportion
of residents over the age of 60 one in five, or 2.6 million. The
situation facing the whole country is equally worrying. By 2035,
a quarter of Chinese will be above the age of 60 more than the
total projected populations of Britain, France, Germany, Italy
and Japan combined. Back
136
In Capital Health? Creative solutions to London's NHS workforce
challenges (2003) London: The King's Fund. Back
137
Roach J, Stealing Doctors, Triple Helix 2002: Autumn
14-16. Back
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