House of Commons - Health

Select Committee on Health Fourth Report

3 Assessment of the current workforce planning system

77. As we have seen in Chapter 2, the rapid period of workforce expansion between 1999 and 2005 was followed by redundancies, vacancy freezes, graduate unemployment and widespread cuts in education and training provision. Below we examine the workforce planning system itself and how far it has achieved its aims. We consider the following areas:

Capacity to do workforce planning;

The integration of different elements of the workforce planning system;

The effectiveness of the system in taking a long-term approach to workforce planning;

How well the system has done in improving workforce productivity; and

Whether enough has been done to increase the flexibility of the workforce.

Capacity to do workforce planning

78. Effective workforce planning requires organisations and individuals with appropriate experience and skills. Unfortunately, the evidence we received suggested that the health service lacks organisations and people with adequate ability and skills to undertake workforce planning effectively and has done too little to protect the resources available.[116] In particular, persistent changes to the structures and organisations involved with workforce planning, particularly the loss of separate WDCs, have undermined capacity.[117] A written submission from the Royal College of GPs summarised the problem, concluding that,

…planning has been blighted by constant changes in the mechanisms used without giving any single mechanism time to establish itself.[118]

REGIONAL CAPACITY

Workforce Development Confederations

79. A number of key workforce planning functions, including the commissioning of education and training, have been concentrated at regional level. 27 regional WDCs were created in 2001 to fulfil these responsibilities. John Sargent, former Chief Executive of Greater Manchester WDC, described the impact of the creation of WDCs:

The changes that took place in 2001 were the first time there had really been a focus on workforce development and workforce planning in a co-ordinated way.[119]

80. The evidence from NHS Employers was also positive about the contribution of WDCs, whilst acknowledging the variation in their effectiveness:

Workforce Development Confederations were a step forward compared to previous arrangements, though operational success varied.[120]

81. In 2004, WDCs were merged with the 28 SHAs which had been in created in 2002 as part of the Shifting the Balance of Power in the NHS reforms. According to John Sargent,

…just as WDCs were starting to get on their feet, there was another reorganisation…the SHA Chief Executives… felt that it would be more appropriate if the SHAs and WDCs were merged so that there could be one strategic perspective for all functions across the new SHAs areas.[121]

82. A number of witnesses expressed concern at the effects of the decision to merge WDCs with SHAs, most notably Andrew Foster, then Workforce Director at the Department of Health:

I also regretted the disappearance of the separate workforce development confederations who were tasked very specifically with being responsible for workforce planning and commissioning of education and training.[122]

83. Mr Foster explained that one of the aims of integrating SHAs and WDCs had been to improve the integration of workforce and financial planning, though as we point out later in this chapter there has been little evidence of such improvement. Instead, we heard that the loss of WDCs led to a corresponding loss of focus on workforce planning with SHAs more often focussing on financial and service issues. This point was made by the Council of Heads of Dental Schools:

A recurring problem since the merger of WDCs into SHAs has been the difficulty in maintaining expertise and retaining the focus on workforce. Service imperatives subsume all others and drive the agenda. A more long-term view would recognise the vital importance of education and training the next generation.[123]

84. The Committee also heard that the merging of SHAs and WDCs has led to less involvement for independent sector organisations and higher education bodies in workforce planning.[124]

Reduction in SHA numbers

85. In line with the Commissioning a Patient-led NHS reforms, the number of SHAs was reduced from 28 to 10 with effect from 1 July 2006. The new SHAs have broadly the same workforce planning remit as their predecessors but will oversee planning over a larger geographical area. The benefits of the new configuration were described by Lord Hunt, Minister of State for Quality:

…now that we have got the new structure of strategic health authorities down to 10, they essentially cover a region. If I think of my own West Midlands region, that is an ideal area in terms of the number of staff employed, the number of higher education institutions and the number of NHS organisations, the links with the medical schools. That seems to me to be the ideal geographical area in which to sort out most of these workforce planning issues.[125]

86. However, other witnesses expressed serious concerns about the reorganisation. Dr Judy Curson, head of the NHS Workforce Review Team, highlighted the potential loss of key workforce planning personnel as a result of the changes:

…in terms of the SHA reorganisation, there is a concern that there are very few workforce planning skills amongst SHAs and in the NHS generally…There is a very real concern that these skills might be lost as people apply for jobs, even outside the NHS, while they are waiting to see whether they do have a future in the new health authorities.[126]

87. Witnesses also pointed out that education and training is not mentioned in the strategic objectives of the new SHAs and that there is no obligation for a representative from the education sector to sit on the Boards of the new SHAs.[127] Professor Tony Butterworth of the University of Lincoln summarised the problem of lack of education sector involvement at SHA level:

If the new SHAs have a mission which is quite tight and that is to look at the delivery of service and the commissioning of service then that is fine. If education and the provision of education is an afterthought… that would be a great shame.[128]

88. In sum, we heard serious doubts about whether the new SHAs have either the will or the skill to undertake effective workforce planning. The combination of the loss of WDCs and the reduction in the number of SHAs means that there is now far less capacity for workforce planning at regional level than was envisaged in A Health Service of all the talents. Instead of 28 organisations dedicated to workforce issues, the regional tier consists of 10 newly established organisations with a much wider remit within which workforce planning is at risk of being lost.[129] It is hardly surprising, in this context, that the British Psychological Society concluded that "the prominence given to workforce planning by A Health Service of all the talents has been seriously lost and dissipated."[130]

NATIONAL CAPACITY

89. National and collective organisations perform a range of different workforce planning functions. These include strategic analysis of future workforce requirements by the NHS Workforce Review Team, collective contract negotiation by NHS Employers and national oversight and policy development by the Department of Health. Fuller details are provided in the Annex. In this section, we consider the effectiveness of some of these national organisations.

The NHS Modernisation Agency

90. The NHS Modernisation Agency (MA) was created in 2001. Its remit was to act as a national source of information about good practice and co-ordinate changes such as the introduction of new roles through the Changing Workforce Programme.[131] Mirroring the fate of WDCs, the MA was closed in 2005 though some of its functions were subsequently resumed with the creation of the NHS Institute for Innovation and Improvement (III).[132] However, the III is a much smaller organisation than the MA with a narrow, though welcome, focus on improving productivity.

91. The Government did not provide a clear rationale for the closure of the MA. However, it is evident that the decision to close the MA was not unanimous within the Department of Health. Andrew Foster, for example, commented that,

In my opinion, we set up the Modernisation Agency in order to give us really cutting edge, world best practice in terms of service and job design and it was beginning to do a fantastic job when it fell victim to the financial pressures of other priorities in the NHS. I personally feel we would have been able to do it better, if we still had the Modernisation Agency…[133]

92. Other witnesses agreed that the closure of the MA had led to gaps in national capacity for workforce planning. The RCN commented that the loss of the MA has meant that there is no organisation able to collect and share good practice in workforce planning and development.[134] Dr Sally Pidd of the Royal College of Psychiatrists described the impact of the closure of the MA on efforts to create new and amended clinical roles:

…we were disappointed with the demise of the Modernisation Agency because the Changing Workforce Programme was a big driver for looking at developing new roles and extended roles and supplementary roles to enhance the overall mental health workforce.[135]

The NHS Workforce Review Team

93. The NHS Workforce Review Team (WRT) is one of the few organisations to have maintained a relatively consistent remit in recent years. WRT produces annual recommendations for planning for all of the main clinical staff groups in the health services.[136] WRT recommendations cover future recruitment levels, training numbers and other factors including the effects of changes to skill mix.[137]

94. Some of the evidence we received was positive about the contribution of WRT. The Faculty of Public Health described WRT recommendations as "high quality, timely, and useful for planning".[138] Wyn Jones commented that WRT had contributed to the improvement in workforce planning capacity and leadership at central level.[139] However, witnesses also commented that the work of WRT had failed to have a significant impact and was undermined by poor data quality and by the fact that WRT recommendations are often ignored by SHAs.[140]

The Department of Health

95. Witnesses questioned the Department of Health's effectiveness at workforce planning. As we noted in Chapter 2, for example, the Department has consistently underestimated the costs of new staff contracts. Doubts were also expressed about the Department's ability to provide strategic oversight for the rest of the workforce planning system. Anne Rainsberry, Director of People and Organisation Development at NHS London, commented that:

…the Department of Health has a key role in setting the medium to long-term planning assumptions with which Strategic Health Authorities should plan, i.e. financial…the department could strengthen its expertise in the area of strategic workforce planning. I think that would be most welcome.[141]

LOCAL CAPACITY

Primary Care Trusts

96. Concerns were also expressed about the ability of local organisations to contribute to workforce planning. In particular, the lack of involvement of PCTs was highlighted. Anne Rainsberry told us that,

PCTs, if they are thinking about strategically shifting the direction of care, need to understand what that means for the workforce and appraise themselves of the plans of the providers so that workforce follows service, and at the moment PCTs, certainly in London, do not get involved in that dialogue, which I think is a gap that we must fill.[142]

97. The Committee heard that the impact of the Commissioning a Patient-led NHS reforms, whereby the number of PCTs was reduced to 150 with effect from 1 October 2006, had caused organisations to neglect workforce planning. Dr David McKinlay of the North Western Deanery explained that,

A key part of our strategy has been getting out of the deanery and talking to the PCTs. Four or five of those meetings have been cancelled in the last few months by the PCTs because they did not know whether they would exist, so we have got a built-in cycle of inertia while things bed in...[143]

Workforce information

98. We heard evidence of the poor quality of workforce information supplied by local organisations in support of regional and national planning. Louise Silverton of the Royal College of Midwives described difficulties in obtaining reliable information:

…we suffer quite badly from what local information is fed in. Heads of midwifery will ask what has been sent in about their need for midwives and a junior person in HR has looked at the age profile and decided that four will retire in the next two years and that is it. That takes no account of service changes and increased part-time working.[144]

99. Likewise the Institute of Healthcare Management noted that submissions to SHAs by local organisations "tend at best to be educated guesses".[145] Phil Gray of the Chartered Society of Physiotherapy was especially scathing, observing that because of a lack of reliable local data, workforce forecasting tended to be done "by the very scientific method of putting a wet finger in the wind".[146]

SKILLS AND TRAINING

100. Witnesses commented on the overall shortage of staff with workforce planning skills, including both technical and leadership skills, across the health service. The Institute of Healthcare Management was particularly damning, remarking that "Workforce planning in the NHS is a skill that has yet to be developed".[147] Other witnesses stressed that workforce planning jobs are not seen as important roles within NHS organisations.[148]

Workforce planning skills

101. The Committee received a submission from Thames Valley University which has recently finished teaching its first one-year Postgraduate Certificate in Strategic Workforce Planning. The course, commissioned by National Workforce Projects, provides students with practical workforce planning tools, an understanding of policy context and a network of workforce planning contacts. The course also concentrates on linking workforce planning with service and financial planning.[149] Courses of this type do not seem to be widely available; this is indicative of the stature of specialist workforce planning skills amongst health service staff.

102. Witnesses also commented on the importance of ensuring that general and financial managers understand and take part in workforce planning, rather than treating it as a separate, isolated activity. Norfolk, Suffolk and Cambridgeshire SHA remarked that,

Workforce planning and workforce development need to be embedded as a core skill for all managers.[150]

Leadership skills

103. Workforce planning requires leadership skills to implement changes as well as technical skills to identify the requirements for change. A number of witnesses acknowledged a lack of leadership on workforce issues, including Mike Sobanja of the NHS Alliance. Commenting on the contribution of local Human Resource Directors, he stated that:

It seems to me that the job of the HR director should be about assessing the best way in which the workforce can contribute to the service development aims of the organisation. Do they do that uniformly? No. Do they work at a strategic level? I do not believe so. Are they allowed to contribute to workforce planning sufficiently? No.[151]

104. The shortage of leadership skills was acknowledged by Lord Hunt, who commented that:

…if you are asking me what is one of my top priorities in workforce planning, it is in enhancing leadership skills of people in individual organisations so that they lead this change.[152]

Integration of planning

105. Because of the complexity of health service workforce planning, it is vitally important that different parts of the planning system work effectively together. Workforce planning cannot take place in isolation from service and financial planning, and planning for different staff groups should be joined up.[153] Improving the integration of the planning system was one of the main recommendations of the Committee's 1999 Future NHS Staffing Requirements report.[154] Unfortunately, lack of integration within the planning system still appears to be a serious problem.

MEDICAL AND NON-MEDICAL PLANNING

106. A number of submissions to the Committee highlighted the importance of planning for the whole healthcare workforce rather than treating each profession as a separate 'silo'.[155] Planning for each profession in isolation inhibits innovation, for example through the development of new and amended roles, and can mean overall workforce plans do not make sense as a whole.[156] Without an understanding of changes to the overall workforce, it is impossible to plan changes to an individual professional group accurately. In particular, the importance of joined-up planning for medical and non-medical staff groups was stressed.[157]

107. The lack of integration between medical and non-medical workforce planning was pointed out in the Committee's 1999 report:

We consider that with immediate effect there should be improved interaction between the medical and non-medical planning bodies.[158]

108. It is clear, however, that the separation of medical and non-medical workforce planning remains a serious problem. NHS London stated that,

…the planning of medical training numbers is still carried out separately from workforce planning for all other NHS staff… These two separate approaches to workforce planning has often resulted in disjointed workforce planning for the NHS.[159]

109. Wyn Jones of West Yorkshire Workforce Development Confederation underlined the difficulties experienced by local organisations as a result of the centralised approach to medical workforce planning:

Currently planning for medical and dental staff is a top-down planning model, whereas non-clinical staff planning is bottom-up…the separation of medical and dental workforce planning from the rest of the workforce remains a problem area that has not been overcome.[160]

110. Representatives from SHAs expressed particular concern to the Committee about their lack of involvement in medical workforce planning. Anne Rainsberry described the SHA role (or lack of it) in the recent implementation of Modernising Medical Careers:

The Strategic Health Authority…have had to sign off the commissions for Modernising Medical Careers…it was a very centrally driven initiative where effectively the department, with the Workforce Review Team, would say to the Strategic Health Authority, "These are the specialties that are in expansion, there are a few that are in reduction, this is the national curriculum and, therefore, please sign here."[161]

111. A number of witnesses also commented on the division of the Multi-Professional Education and Training (MPET) levy (which is described in the box below) into separate streams for medical and non-medical training. Anne Rainsberry commented that the rigid division of funding streams inhibited the flexibility of planning at SHA level:

The way in which MPET is currently managed needs to be re-looked at… the way in which MPET comes to us in the Strategic Health Authority is in predetermined packets and, therefore, we cannot actually implement the strategic plan because we are already committed to spending X on this and Y on that.[162]

Education and training funding
The majority of NHS education and training is funded through the MPET (Multi-Professional Education and Training) levy which totals around £4 billion per year. The size and make-up of MPET is determined by the Department of Health and funding is distributed to SHAs. MPET funding is currently made up of 3 separate streams:

MADEL (Medical and Dental Education Levy) which funds the direct costs of postgraduate medical and dental training
SIFT (Service Increment for Teaching) which funds the indirect, infrastructure costs of postgraduate medical and dental training and the provision of clinical placements for undergraduate medical students
NMET (Non-Medical Education and Training) which funds undergraduate and postgraduate education and training for non-medical staff

Funding for undergraduate medical education and training is administered by the Higher Education Funding Council for England (HEFCE).

PLANNING FOR NHS AND NON-NHS ORGANISATIONS

112. Effective workforce planning should take account of the needs of the entire health service, rather than just the NHS.[163] This is particularly necessary in the context of the increasing use of private and voluntary sector organisations to provide NHS-funded services.[164] The increasing size and importance of the independent sector was highlighted by Peter Stansbie of Skills for Health. When asked why he thought the independent sector should play a greater role in workforce planning, he stated that:

I think it is becoming increasingly important because the percentage of the workforce employed in the independent sector is growing… if we can do that we get some real added value in terms of the capacity that the independent sector can provide but also generally in terms of driving new roles, systems and approaches.[165]

113. However, the Committee heard that the current workforce planning system does not adequately involve independent sector organisations. The NHS Partners Network, which represents providers of Independent Sector Treatment Centres, stated that "Workforce planning would be done better if the total need of NHS patients was considered not just traditional NHS providers."[166]

114. David Highton of the NHS Partners Network explained that the merging of SHAs with WDCs in 2004 had made it more difficult for independent sector organisations to be involved in workforce planning.[167]

WORKFORCE AND FINANCIAL PLANNING

115. One of the main priorities set out in the Department of Health's 2000 consultation A Health Service of all the talents was to improve the alignment of workforce planning, financial planning and service planning in the health service. The paper stated that:

Thinking about services, workforce and resources should be done together to ensure plans and developments are consistent and co-ordinated.[168]

The paper went on to call for:

Greater integration of workforce planning and development with service and financial planning.[169]

116. We heard, however, that the integration of workforce, financial and service planning has not improved in recent years. Leicestershire, Northamptonshire and Rutland Workforce Deanery informed us that:

Alignment [of workforce planning] with financial planning both nationally and locally has been woeful…there is still not commitment from all strategic Financial and Human Resource leads to plan jointly.[170]

117. The integration of financial and workforce planning is of vital importance for the simple reason that investment in new staff or higher pay must fit within the financial resources available. Unfortunately, it is clear that many health service organisations have failed to follow this basic principle.

Local failings

118. A graphic example of the breakdown between workforce and financial planning at a local level was provided by Andrew Foster. Mr Foster described the findings of a Department of Health investigation into staff redundancies at University Hospital of North Staffordshire NHS Trust. Mr Foster told the Committee that:

…in the first quarter of last year there was this increase in workforce numbers which simply demonstrated the lack of integration in that instance between workforce planning and financial planning.[171]

119. When questioned as to why the Trust had recruited extra staff in spite of a growing financial deficit, Mr Foster commented that:

I would imagine that it is because workforce planning is done in a separate place from financial planning. The workforce planners say what work they expect to have to do, they need more staff so they start recruiting them without actually reconciling that to the budget they have available.[172]

National failings

120. The Committee also heard that the failure to integrate workforce and financial planning has affected national planning by the Department of Health.[173] As detailed in Chapter 2, the staffing growth targets set out in the NHS Plan were significantly exceeded for most staff groups and spectacularly exceeded for nursing staff. John Sargent pointed out that there was a significant mismatch between staffing growth targets and the amount of extra funding available to NHS organisations:

…in 2001, the Department of Health had issued workforce expansion targets that would have increased the size of the NHS workforce in headcount terms by almost 120,000 people by 2008. At the same time, the financial settlement arising for the Department from the Spending Review settlement was sufficient to fund workforce growth about two and a half times greater than this.[174]

121. Mr Sargent was subsequently asked why the disjunction between workforce planning targets and financial resources had occurred. His assessment of the Department of Health's failings was remarkably similar to the assessment by Department of Health officials of the failings at North Staffordshire:

I suspect, in truth, that different…sections in the Department of Health were concentrating on different aspects of the Health Service…the government policy of moving towards average OECD country levels of expenditure on health overtook some of the workforce planning targets at that time and so there was mismatch.[175]

122. As we saw in Chapter 2, the failure to integrate workforce and financial planning has had serious negative consequences for workforce planning and for the NHS in general and has been a major cause of rising financial deficits.[176]

Planning with a long-term focus

123. Workforce planning in any industry requires a combination of short-term, medium-term and long-term functions.[177] The long-term element of planning is especially important in healthcare because of the complexity of the workforce and the long training periods for some healthcare professions, notably medicine.[178] The importance of a long-term approach to healthcare workforce planning was explained by the Chartered Society of Physiotherapy:

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.[179]

124. Unfortunately, the bulk of the evidence received by the Committee argued that health service workforce planning has lacked a consistent, long-term element. Universities UK commented that workforce planning:

…tends to be short term, ad hoc interventions to redress specific shortages, rather than a wider approach that takes account of the long lead times for professional education, and the social and economic environments that concern service users and health workers.[180]

125. John Sargent pointed out that current processes for workforce planning do not encourage a long-term approach. For example, Local Delivery Plans (which bring together service plans and workforce plans for a particular organization or area) look only 3 years ahead. Mr Sargent argued that:

Local Delivery Plans cover a period of three years. To many people this may seem like a long time in to the future; and yet in strategic workforce planning terms it is almost useless.[181]

126. We also heard that the pressure to focus on short-term priorities made it impossible for the NHS to focus adequately on long-term planning. The Postgraduate Medical Education and Training Board stated that,

…education and training are long-term objectives and do not always sit easily alongside the short-term imperatives by which Chief Executives in the NHS are often judged.[182]

127. Most worryingly, the Committee heard on a number of occasions that recent changes to education and training provision by SHAs were motivated by financial incentives without any consideration of the impact on long-term workforce planning. Commenting on widespread reductions in SHA education and training spending for 2006-07, Professor Jill Macleod Clark of the Council of Deans and Heads of UK University Faculties for Nursing and Health Professions told the Committee that,

There is no doubt that the underspends [on education and training]… have been put into securing some amelioration of the basic NHS deficit. That has resulted in radical cuts in commissioned numbers for this coming year… I think the implications of that for even the short-term workforce requirements could be devastating… reduction in commissions is not related to the reduction in demand; it is a response to being able to raid a pot of money.[183]

This view was echoed by Professor David Gordon of the Council of Heads of Medical Schools who described cuts in education and training spending by SHAs as "eating the seed-corn for the future".[184]

128. Representatives from SHAs themselves expressed serious concerns about the impact of cuts to education and training funding. Trish Knight, of Leicestershire, Northamptonshire and Rutland Workforce Deanery, acknowledged that cuts made to date were severe enough to have a long-term impact on the workforce:

Dr Taylor: We did get the Secretary of State to admit that this [cutting training provision] could only be a short term policy but we could not tie her down to how long "short term" was. How long do you think this could go on without seriously affecting the future?

Ms Knight: It will affect it next year from my point of view.[185]

129. Most strikingly of all, Anne Rainsberry of NHS London agreed that long-term planning was at risk of being abandoned altogether because of short-term NHS financial problems:

Chairman: Do you think that the rapid growth in staff numbers and resultant financial difficulties have caused parts of the NHS to effectively abandon long term workforce planning, for the time being anyway?

Ms Rainsberry: I think there is a genuine danger of that.[186]

Planning for improved productivity

EXPANSION IN STAFF NUMBERS

130. As we described in Chapter 2, the main outcome of recent changes to the NHS workforce has been a major expansion in capacity. There have been some attempts to increase productivity and introduce new ways of working but these have been insignificant compared with increases in staff numbers. The Department of Health acknowledged this in its written submission,[187] and officials confirmed on 11 May that improving productivity was not amongst the aims of the NHS Plan reforms:

When we put more money into the NHS with the NHS Plan investment, we expected productivity would not actually rise. We did not anticipate that we could put all those new resources into the system and get productivity as well.[188]

131. Evidence we received was sharply critical of this approach. The Committee heard that the expansion in staff numbers should have been preceded, or at least accompanied, by attempts to improve workforce productivity.[189] Dr Karen Bloor of the University of York argued that "before planning to increase the stock of human resources it is essential to establish that the existing workforce is working effectively":[190]

Dr Naysmith: …did the NHS do this prior to this rapid growth?

Dr Bloor: No, I do not think it did do that, and it is contemplating further increases without doing that now as well. We have some evidence of that. There are huge variations in activity rates between hospitals, general practices and individual doctors… I do not think we really did address the effectiveness of the workforce enough before we expanded it.

Dr Naysmith: Why not?

Dr Bloor: …I do not know. Perhaps we should ask the Department of Health about that.[191]

132. The Committee heard a similar argument during its visit to California. Professor Kevin Grumbach, head of the Center for California Health Workforce Studies at the University of California underlined the short-sightedness of expanding workforce capacity without addressing the productivity of the existing workforce. Professor Grumbach stressed the importance of "not adding more sugar to your coffee before you've stirred what's already there."[192]

THE NEW MEDICAL CONTRACTS

133. The growth in staff numbers has been accompanied by substantial pay increases for most NHS staff, as we described in Chapter 2. Senior doctors have received the most significant pay increases through the new consultant and GP contracts. As with the increase in staff numbers, witnesses argued that bringing in new contractual arrangements for senior staff without addressing overall workforce productivity was unwise. Dame Carol Black of the Royal College of Physicians remarked that:

It would also be an enormous help if there had been some systems reform before we did all the other things like introduce a consultant contract. In fact, the system had not been reformed so consultants were paid more money but in a system which would not support more efficient working…[193]

134. Some witnesses were blunter still, arguing that the new medical contracts had led to a decline in productivity. Professor Sir Alan Craft, chair of the Academy of Medical Royal Colleges commented:

The new consultant contract is a time sensitive contract and what it did was to identify the huge amount of work that actually was being done by consultants…and I think because of that…productivity probably has gone down in some places…Because doctors are now working to a fixed contract [i.e. with set hours and pay rates], which they never did before.[194]

135. The Committee heard similar arguments with regard to the new GP contract from Professor Bonnie Sibbald of the National Primary Care Research and Development Centre:

Charlotte Atkins…their contract has meant fairly substantial pay rises for GPs. Are they doing less and getting more?

Professor Bonnie Sibbald: Yes.

Charlotte Atkins: Do you think that is justified?

Professor Bonnie Sibbald: No…We conduct national surveys of general practitioners in this country, about 1,000 GPs… On average doctors were reporting a £15,000 increase in pay and a four hour reduction in their working week.[195]

136. When questioned about the new contracts, Department of Health officials acknowledged that NHS organisations had prioritised implementation of the new contracts over improving value for money. With regard to the consultant contract, Andrew Foster remarked that:

It is fair to say that a lot of organisations put more effort into simply getting people onto the new system than generating the benefits from it… It is fair to say that many organisations, at least in the first year, did not reap the benefits that we hoped for.[196]

137. Officials also acknowledged that they did not know how well GP practices would perform against the new QOF targets, making it impossible to predict how much income would increase upon the introduction of the new contract:

There was a great deal of uncertainty about what GPs could achieve in these areas. The GPs may have known… but the centre did not know.[197]

Planning for increased flexibility

SKILL MIX CHANGES

138. Increasing the flexibility of the health service workforce is an important and well-established goal.[198] As we noted in Chapter 2, there have been significant attempts to improve the flexibility of the workforce, particularly through changes to skill mix and the development of new clinical roles at Assistant and Advanced Practitioner level. More detail on new and amended roles is provided in Chapter 4. The Committee has heard of some success stories in this area including the development of Emergency Care Practitioner (ECP) roles. ECPs work in the community and respond to emergency calls in the same way as paramedics.[199] However, ECPs have an extended range of clinical skills and are therefore more often able to treat patients in their own homes rather than taking them to hospital. Bill O'Neill of the London Ambulance Service told the Committee that ECPs are able to manage 50% of patients in their own homes, compared with 25% for a paramedic team.[200] Peter Stansbie of Skills for Health provided an estimate of the financial savings associated with using ECPs:

An estimate in the south west is that for each emergency care practitioner that they appoint it saves the health economy £56,000 a year.[201]

139. However, the Committee received other evidence which suggested that the quantifiable benefits of the introduction of ECPs represent the exception rather than the rule. It was argued that skill mix changes have often been poorly conceived and have not improved productivity.[202] Professor Bonnie Sibbald described her research into the use of nurses in primary care to perform tasks traditionally done by doctors. Professor Sibbald concluded that:

…on most occasions you will not get gains in productivity or reductions in cost… when you substitute a nurse for a doctor, nurses tend to consume more resources than physicians but generate the same high quality of care output; but as they consume more resources, that eats into the savings you get in their salaries, so the overall effect tends to be cost-neutral.[203]

140. Witnesses also argued that when staff in amended roles attempt to take on extra responsibilities, these are not always relinquished by existing staff. [204] Dr Karen Bloor commented that:

We are not always saving money or reducing the workforce but what we are doing is adding in another level of care. If that is improving patient care, that is fine, but it is important to note that certainly from research evidence they are often operating as complements and not necessarily as substitutes…[205]

141. The Committee heard that even when new and amended roles had been shown to be successful, disseminating changes across the health services remained a slow and difficult process. David Highton argued that:

In the NHS… there are always some fantastic examples of extended roles, but it is very difficult to disseminate them across the service as a whole.[206]

142. This point was acknowledged by Andrew Foster who blamed the closure of the MA for problems with disseminating new roles. Mr Foster commented that the development of new roles had become "more difficult to coordinate as an overall pattern" since the removal of the MA.[207]

EDUCATION AND TRAINING CUTS

143. Most worryingly of all, the Committee heard that even when new roles have proven to be effective, recent redundancies and cuts to education and training provision have particularly targeted such developments and therefore reduced the flexibility of the workforce.[208] Breakthrough Breast Cancer and the Joint Epilepsy Council both warned about recent cuts to specialist nursing services. The former described staff in extended roles as a "soft target".[209] Peter Stansbie commented on similar cuts to training opportunities for staff in Health Care Assistant and Assistant Practitioner roles:

It is very worrying that we heard people who are perhaps at the bottom end of the skills spectrum are going to suffer as a result of the funding cuts when what we need to do…is bring people in at that level and give them the ability to get their skills up and, indeed, move through the training. I think some of our existing systems do not help us with that.[210]

144. Representatives from SHAs confirmed that training cuts have particularly affected training for Assistant level staff and staff in new roles. Trish Knight explained:

…we had to stop all secondment of people into training, the HCAs [Health Care Assistants] or the OT [Occupational Therapy] assistant who wants to go and do their training, which is a real shame, but that is how we have managed the cut.[211]

145. Anne Rainsberry described a similar range of cuts made by NHS London.[212] Importantly, she explained that the pattern of cuts reflected the structure of education funding and contracts rather than future workforce needs:

The reason for that [pattern of cuts] is because of the way the MPET budget is made up. We have different levels of flexibility with different parts of the budget and therefore where we have the maximum flexibility is in the work around new roles. When you get into this urgent situation inevitably that is something that is going to be most vulnerable.[213]

146. It is clear that features of the workforce planning system itself make it more difficult to increase workforce flexibility, particularly in times of financial difficulty. The problem was aptly summarised by Professor Jill Macleod Clark:

…the current mechanisms unwittingly are creating a situation where we are simply maintaining the status quo. They do not allow a flexible, more imaginative and more forward-looking approach to workforce planning.[214]

FLEXIBLE TRAINING PROVISION

147. The Committee heard that in other areas where flexibility can be increased, such as the provision of flexible training and working opportunities, there have been few developments. This problem was highlighted by Karen Jennings, Head of Health at UNISON:

…the commissioners of education and training are very tunnelled in their vision about where to access education and training from. There are no universities that provide part-time registration training. Now, do you not think that is bonkers? In a time when the average age of a student nurse is 29 years of age, has children, how on earth can they last on a course that is full-time?[215]

The Medical Women's Federation likewise highlighted the declining number of flexible training opportunities for doctors since the withdrawal of central funding from the Flexible Training Scheme and Flexible Careers Scheme.[216]

Conclusions

148. There are a number of weaknesses in the current workforce planning system. Most fundamentally, there is a shortage throughout the health service of the people, organisations and skills required for workforce planning. Persistent structural changes have exacerbated this problem, particularly at regional level. The new SHAs seem to lack capacity for workforce planning even though they have a vital role to play. The removal of Workforce Development Confederations and the Modernisation Agency left gaps which remain unfilled. Local organisations have struggled even to provide accurate workforce information to support decision-making. Workforce planning appears to remain a secondary consideration for many organisations.

149. Lack of integration between different parts of the planning system remains a widespread problem. The difficulties caused by the separate planning systems for medical and non-medical staff groups were pointed out by this Committee 8 years ago but have still not been effectively addressed. Medical and non-medical planning is still done by separate organisations with separate funding streams, which inhibits the ability of SHAs to plan effectively by looking at total workforce requirements. The workforce planning system has also failed to involve the private and voluntary sectors adequately, particularly since the loss of separate Workforce Development Confederations. This is a serious failing, particularly in the context of the increasing use of the independent sector to provide NHS services.

150. Of particular concern is the continuing lack of integration between workforce planning and financial planning. There are shocking examples of failures at local level with some organisations continuing to recruit large numbers of staff in spite of rising financial deficits. But the Department of Health has made equally serious mistakes at national level, in particular by failing to ensure that targets for increasing staff numbers were consistent with the level of funding available. Both in local organisations and at the Department of Health, workforce planning and financial planning have been done by separate teams in separate places and little has been done to bring the two processes together.

151. Effective workforce planning, particularly in healthcare, must include a long-term element. This has been badly wanting in health service workforce planning, partly because there is no formal long-term planning system, but more importantly because NHS organisations tend to be too focused on short-term priorities. Recent cuts to training provision and other workforce development activities have shown an especially worrying disregard for long-term workforce priorities. The Committee is deeply concerned to hear from a key workforce leader that long-term planning is at risk of being abandoned in parts of the NHS.

152. Increasing workforce productivity is a vital goal that has been badly neglected by the workforce planning system. The Committee was dismayed to hear that improving productivity was not an explicit aim of the NHS Plan. The resultant lack of focus on increasing efficiency during the recent period of rapid growth in staff numbers was reckless and unwise. We were equally concerned by the suggestion that the new consultant and GP contracts may have reduced the productivity of these vital staff groups. Pay rates for senior doctors have increased substantially without evidence of corresponding benefits for patients. This is indicative of the lack of overall focus on improving workforce productivity.

153. Increasing workforce flexibility is an important and related goal and some progress has been made in recent years, particularly through the development of new and amended roles. However, not enough has been done to prove that all these changes are cost effective. Even when skill mix changes have proved to be effective, recent cuts in training capacity have targeted staff in new roles and hampered attempts to increase flexibility. The current structure of education funding does not support the development of a more flexible workforce and there is a shortage of flexible training opportunities.

154. A Health Service of all the talents set out a blueprint for improving workforce planning through a stable system with dedicated workforce organisations and a clear focus on improving flexibility and productivity. The health service has lost sight of this vision and marginalised workforce planning. The situation has been exacerbated by persistent structural change. The system remains poorly integrated and there is a shortage of staff with the necessary skills for effective workforce planning. In light of the need for increased activity, organisations tended to throw extra workers at the problem rather than increasing the efficiency of existing staff. Even when positive changes which might improve productivity, such as the new contracts and new clinical roles, have been introduced, benefits have not been properly realised. In particular, the current wave of education and training cuts has led to a number of backward steps for workforce development. Basic problems such as the disjunction of workforce and financial planning persist at all levels of the system. Despite great efforts in some quarters, the workforce planning system is not performing noticeably better than 8 years ago.

116 See, for example, Ev 239 (HC 171-II) Back

117 See, for example, Q 680 Back

118 Ev 168 (HC 1077-II) Back

119 Q 677 Back