House of Commons - Health

Select Committee on Health Fourth Report

4 The future health service workforce

155. In Chapters 2 and 3, we examined past developments in the health service workforce and the workforce planning system. In this chapter, we consider the type of workforce that the health service will require in order to meet future challenges. The evidence we received consistently agreed on the need for changes to the structure of the workforce and to the way in which staff work. Skills for Health argued that in light of expected policy, demographic and technological developments, future workforce requirements are likely to change radically. The organisation concluded that:

Simply planning for "more of the same" will be insufficient to meet the challenges of the next 10 years and beyond.[217]

156. The Department of Health provided a similar analysis, stressing in particular the impact of the impending retirement of the "baby boom" generation on the health service and its workforce.[218] The Department concluded that:

The NHS has seen a period of growth in both financial support to the NHS and the size of the workforce…The past five years has been about staff growth and the next five years will be about transformation into a flexible affordable staff mix to deliver patient centred care.[219]

157. In this chapter we focus on what the 'transformation' of the workforce envisaged by the Department of Health should consist of. We consider the following areas:

The need for a more productive workforce;
The need for a more flexible workforce;
The importance of shifting the balance of the workforce towards primary care; and
The need for improved management skills throughout the workforce.

A more productive workforce

158. In Chapter 3 we concluded that the health service has paid too little attention to improving workforce productivity. We expressed serious misgivings about the Government's argument that increasing staff numbers and staff pay were rightly regarded as more important goals than improving efficiency. The unprecedented recent growth in health service funding has led to some significant improvements in service, most notably in shorter waiting times. However, the potential benefits of much of this increased investment remain unrealised because the availability of so much extra money has made it easier to increase capacity and activity rather than improving productivity and efficiency.[220] As Dame Carol Black put it:

It is always easier to do what you normally do. It is easier to put another doctor or another nurse into a clinic than to take the much more difficult, both mental and cultural, things that are needed to really sit down all together and say how on earth do we change this for patient benefit. That requires much more planning. It requires that you put much more intellectual effort into this.[221]

159. More recently, as it has become clear that future funding levels are highly unlikely to keep pace with recent growth,[222] putting an extra doctor or nurse into a struggling clinic will no longer be possible. As a result, increasing workforce productivity will be fundamental to ensuring that the health service continues to improve.

160. There is some evidence that workforce productivity is now being taken more seriously by the Government. This is clear from the ambitious 'Productive Time' initiative, which aims to save £2.7 billion per year, and from the creation of the NHS Institute for Innovation and Improvement which will concentrate specifically on improving productivity.[223] In this section we look at how workforce productivity can be increased, particularly by making better use of the new staff contracts.

MEASURING PRODUCTIVITY

161. Better information is essential to improving productivity. Defining and measuring health service productivity is a complex task and we outline some of the main difficulties in the box below. However, if productivity cannot be reliably measured, then it cannot be demonstrably increased. Witnesses stressed that there is a shortage of information about productivity and that the little information that exists is rarely put to good use. George Blair of Shared Solutions Consulting commented that "the NHS drowns in data but has very little information" on productivity.[224] Dr Karen Bloor made a similar point, arguing that:

You asked earlier about whether the NHS is an organisation prone to measuring activity rather than productivity. I would argue that until quite recently they tended to ignore both…Until we share information, until we use information, there is not the incentive to make it [productivity] better.[225]

Improving information

162. A number of different solutions were suggested to increase the amount and quality of information available to local organisations about productivity. George Blair proposed the development of a "clinician's dashboard" of key indicators such as patient throughput, quality of care and quality of patient experience.[226] Dr Karen Bloor suggested making wider use of Hospital Episode Statistics to compare activity levels between organisations and individuals.[227] Witnesses also consistently emphasised the importance of making productivity information meaningful to, and usable by, clinicians.[228] There was strong criticism of the lack of investment in people and systems for improving productivity information. George Blair memorably commented that,

The information side is not well resourced…Some analytical staff could…be easily those people first for the chop because they are not hands-on. Giving you a metaphor, in the Battle of Britain radar was crucial so that the scarce resources were most effectively deployed. There was no clamouring for scrapping the radar and having more pilots.[229]

The Better Care, Better Value Indicators

163. The Committee received more positive evidence about the quarterly Better Care, Better Value indictors published by the NHS Institute for Innovation and Improvement (III) since October 2006. The comparative indicators underpin the 'Productive Time' initiative and measure organisational performance in 15 different areas. These include direct measures of workforce productivity, such as levels of sickness absence, and of clinical productivity, such as the number of day surgery operations and the average length of hospital stay. The III provides an estimate of the money each organisations could save by improving performance in each area.[230]

164. Witnesses generally supported the use of the Better Care, Better Value information although some expressed reservations about the quality of data. The need for widespread dissemination of the information, particularly amongst clinical staff, was also emphasised. Sir Jonathan Michael, Chief Executive of Guy's and St Thomas's NHS Foundation Trust, commented that,

It is very helpful information. One of the problems with the data we are currently seeing is that they are not properly case-mixed adjusted which therefore makes it quite difficult to compare one organisation with another, but all foundation trusts are looking at …productivity—the efficiency of the organisation and the way it is organised, for example the utilisation of theatres, beds and so on. That is a sensible discipline for any organisation to manage costs.[231]

Defining and measuring productivity
Some measures of productivity compare activity levels (outputs) with the amount of money spent (inputs). However, in healthcare particularly, this approach can be problematic. As Dr Jonathan Fielden of the BMA pointed out,
If I am a cardiologist, the more patients that I put on beta-blockers, ACE inhibitors and otherwise, the fewer should be coming back to my clinic, so my productivity [activity relative to cost] is going down but my health outcomes are going up.[232]
Thus an alternative approach to measuring productivity compares changes in patient or population health (outcomes) with the amount of money spent (inputs). Some witnesses argued that productivity information should focus on 'outcomes' rather than 'outputs'.[233] However, other argued that in some cases 'outputs' could be used as a reasonable proxy for assessing productivity.[234]
In reality, both types of measure are likely to be used in different contexts. For example, the new consultant contract links payment with the number of units of time worked, thereby linking pay with activity. Under the new GP contract, practice income is determined partly by clinical results and patient satisfaction, thereby linking pay more directly with outcomes.
Some of these problems are evident in the most recent attempt by the Office for National Statistics (ONS) to measure the overall productivity of the health service. In February 2006, the ONS published Public Service Productivity: Health which contained six different assessments of NHS productivity between 1995 and 2004. Depending on the definition of productivity used, health service productivity was shown to have decreased by an average of up to 1.3% per year or to have an increased by an average of up to 1.6% per year. The six different results produced by the ONS were based on three different measures of output/outcome:

Unweighted output (which shows a drop in NHS productivity of between 0.6% and 1.3% per year between 1995 and 2004);
Output weighted for improvements in the quality of healthcare and health services (which shows change of between -0.5% and +0.2% per year); and
Output weighted for improvements in quality and the increase in the value of healthcare over time (which shows an increase of between 0.9% and 1.6% per year).[235]

The 2005 Atkinson Review recommended that productivity measurements should be adjusted for changes in quality. However, there is continuing debate about whether the adjustment for the value of healthcare should be used. The ONS recommended that their results taking account of value should be used "cautiously, pending further debate".[236]
The Government has made inconsistent use of the ONS results. In its response to the Committee's Public Expenditure Questionnaire 2006-07, the Department of Health wrote that NHS productivity had risen by 1.6% per year (using the results adjusted for quality and value).[237] However, at the evidence session on 25 January, Lord Hunt described NHS productivity as "probably level rather than plus or minus anything dramatic" (apparently using the results adjusted for quality but not value).[238]

THE KNOWLEDGE AND SKILLS FRAMEWORK

165. In Chapter 2, we described the introduction of new contracts and pay systems for the majority of health service staff, focussing particularly on Agenda for Change, the consultant contract and the GP contract. In Chapter 3, we examined some of the problems with the implementation of the new pay deals; including the suggestion that the new medical contracts may have reduced short-term productivity. However, witnesses also highlighted the potential of the new contracts to be used as a lever for improving productivity in the future.[239] In this section we examine how each of the new pay schemes can be used to improve productivity.

166. The Agenda for Change agreement contains a number of mechanisms for increasing productivity, notably through the annual appraisal cycle.[240] The appraisal process is supported by the new Knowledge and Skills Framework (KSF), a vast atlas of pre-defined skills and competences which can be linked to responsibilities and pay levels for each post. The KSF covers a wider range of clinical, technical, managerial and personal competences; staff can progress in each area from level 1 to level 4.[241] Individual annual appraisals should identify which of the necessary skills are lacking or need to be improved. This information can be used to define training requirements and to set personal objectives for staff members. More detail on the KSF is provided in the box on competence frameworks below.

Productivity benefits

167. Witnesses were enthusiastic about the potential of the KSF to improve access to training and to improve the links between training and service requirements.[242] Improving access to relevant training is vital to enable staff to take on a wider range of responsibilities and increase their efficiency and value to employers. Karen Jennings of UNISON stated that,

The Knowledge and Skills Framework is like the jewel in the crown of Agenda for Change. It is inspirational, in the sense that, for the first time, all staff in the NHS—from porter right through to consultant and chief executive—have the right to access education and training.[243]

168. Professor Bob Fryer, National Director for Widening Participation in Learning at the Department of Health, described the potential benefits of improving access to training for lower grade staff. He cited a close link with workforce productivity:

The KSF, with this built-in entitlement [to annual appraisal] is a tremendous opportunity for building and growing our own workforce and that has huge advantages. There is evidence that it actually reduces labour turnover and absenteeism and raises the morale of staff, in particular what this does is actually hold out the prospect to somebody who comes in at a relatively modest level to improve their professional skills and competences and indeed their life expectancy.[244]

It is notable that these are some of the very areas targeted by the 'Productive Time' initiative, specific aims of which include decreasing staff turnover and sickness absence rates.

Current limitations

169. Regrettably, given the apparent link with improved workforce productivity, the Committee heard serious doubts about how well the benefits of the KSF have been realised to date. Karen Jennings highlighted the decline in the number of staff with professional development plans (PDPs), which detail future training requirements. She described this development as "alarming" as it suggests that the annual appraisal process which supports KSF implementation is receding precisely when it should be expanding.[245] More worryingly, Ms Jennings emphasised the impact of recent cuts in education and training funding on the ability of organisations to actually provide the training identified by appraisals and PDPs. She concluded that,

We have one third of trusts which are in debt… when you make cuts and announce redundancies, that is the last measure. There will have been a whole raft of other measures put in place to save money. Under education budgets—we know from hearing that from our members—KSF is becoming an almost impossibility.[246]

170. Ms Jennings commented particularly on cuts to opportunities for Health Care Assistants, a staff group she described as "key to the modernisation of the NHS".[247] Representatives from SHAs confirmed that cuts in education spending have particularly affected lower grades of staff, precisely the group for whom the KSF should offer the greatest benefits.[248]

THE QUALITY AND OUTCOMES FRAMEWORK

171. As part of the new GP contract, a proportion of each practice's income is based on performance against the Quality and Outcomes Framework (QOF). The practice is awarded a score based on a number of indicators covering areas including disease management, practice organisation and access to care. In 2004-05, for example, up to 1,050 QOF points were available to each practice, with up to 19 points available for regularly checking the blood pressure of patient with heart disease and 40 points for undertaking a patient satisfaction survey. In total, practices were assessed against 146 separate indicators in 2004-05. On average, practices received £75 for each QOF point in 2004-5; this rose to £120 per point in 2005-06.[249] The QOF is updated annually and changes to indicators are negotiated by GPs and NHS Employers.[250]

The impact of the QOF

172. There is clear potential for the QOF to increase the productivity of the GP workforce by linking income directly with the achievement of specific objectives, many of which relate to clinical outcomes. It also seems that GP practices have responded to the objectives set out in the QOF: practices achieved an average of 91% of QOF points in 2004-5.[251] However, as we observed in Chapter 3, Department of Health officials admitted that managers did not know how well GPs were performing against the QOF indicators prior to the introduction of the new contract.[252] It is therefore impossible to judge the level of improvement in GP performance in return for the substantial increases in income which accompanied the contract.

173. As we have seen in Chapter 3, some witnesses argued that the new contract has decreased GP productivity in the short term.[253] Other witness presented a somewhat different picture, arguing that QOF targets in particular had been challenging to meet and that practices had invested in additional staff in order to improve their QOF performance. Dr Graham Archard of the Royal College of GPs commented:

I do rather take exception to your words that [QOF] targets were met so easily. Like most practices in my area, we scored extremely highly; the reason we scored extremely highly is because we worked extremely hard. We employed two full-time nurses as well to try to move this agenda forward.[254]

Using the QOF to increase productivity

174. It is clear that the QOF provides effective incentives for GP practices, in spite of the understandable doubts about whether it has provided value for money to date. The Committee questioned witnesses about improving the auditing of QOF submissions by PCTs but witnesses generally defended the effectiveness of the existing system.[255] Witnesses did stress, however, that PCTs need to make better use of the QOF by making targets more challenging in future. Dr David Colin-Thome, National Clinical Director for Primary Care at the Department of Health, argued that QOF requirements should be made "a bit tougher" in order to get more value from the contract.[256] Paul Holmes, Chief Executive of Kingston PCT, told the Committee that after consistent improvements in QOF performance, requirements had been made more challenging:

For the forthcoming year…the bar has been set a little bit higher and it will be interesting to see whether we maintain the rate of improvement.[257]

CONSULTANT JOB PLANNING

175. Like Agenda for Change, the new consultant contract is based on an annual cycle of appraisal and objective setting. Under the terms of their new contracts, consultants' pay is directly linked to the number of Programmed Activities (PAs) worked. A PA comprises half a day's worth of activity: for example, an operating list, outpatient clinic or period of administrative work. Consultants agree the number of PAs they will work each week and what they will do in each PA in annual negotiations with their employers. This process is known as 'job planning'. As part of the annual job planning cycle, employers can also agree performance objectives with consultants. Performance against job plans and performance objectives can be used by employers to determine whether consultants receive increased pay the following year.[258]

Doubts about job planning

176. Unfortunately, as we discussed in Chapter 2, there are significant doubts about the success of the consultant contract to date. Many of these doubts have focussed on the effectiveness of the job planning process. A Kings Fund report on the new contract, published in May 2006, concluded that,

There has been considerable variation in approach and outcome between and within trusts. Job planning for consultants has been process-driven, with cost pressures driving negotiations in some trusts…The link between job planning and appraisal of consultants is also often blurred or unclear, compounded by the fact that objective setting has so far often been weak.[259]

Witnesses from NHS Employers and the Department of Health acknowledged the variation in the quality of job planning but insisted that the standard is continuing to improve.[260]

Improving job planning

177. The Committee heard that, if effectively used, job planning and objective setting provide vital mechanisms for NHS organisations to increase the productivity of consultants. Department of Health officials commented on the importance of effective job planning and of linking consultant performance against agreed objectives with pay increases. Andrew Foster stated that,

The other piece of leverage inside the consultant contract…is the ability to agree annual personal objectives with each consultant, for those objectives to be reviewed at the end of the year because pay progression through the scale…is dependent on meeting the job plan and delivering the agreed personal objectives.[261]

178. Other witnesses pointed out that the job planning cycle allowed employers to have a meaningful influence on consultants' clinical activities for the first time.[262] The importance of this dialogue, and the inflexibility of the previous system, were highlighted by Sian Thomas of NHS Employers:

Before the contract if you wanted to switch the way a consultant worked between their emergency work, their planned work and their weekend work it was really an impossible thing to try to do. The contract is a framework which enables employers to do that.[263]

Dr Karen Bloor commented on the importance of the Medical Director's role in negotiating effective objectives with consultants.[264]

Measuring performance

179. Witnesses argued that performance objectives should be underpinned where possible by measurable targets. Dr Karen Bloor recommended using Hospital Episode Statistics, which measure levels of consultant activity, as a basis for agreeing job planning targets.[265] Dr Jonathan Fielden argued that objectives should be based on data relevant to the particular specialty and on measures of patient outcomes rather than simply on consultant activity rates.[266] This difference of opinion demonstrates the lack of agreed standards for local organisations to use in developing meaningful measures of clinical performance. There is a clear need for improved guidance for developing clinical productivity measures, which could be provided by NHS Employers or the NHS Institute for Innovation and Improvement. Different measures would be required for each clinical specialty, some relating to activity levels and others to clinical outcomes. NHS Employers could work with the relevant Royal Colleges and other organisations to agree the best measures to use in each case. Standard productivity measures for each specialty, many of which can be based on existing data sources, would make it much easier for local managers and Medical Directors to negotiate consultant performance objectives across a range of specialties.[267]

A more flexible workforce

180. Closely linked to increasing productivity is the need to develop a more flexible workforce. Increasing the flexibility of the health service workforce has been a long-standing objective and was clearly outlined as a priority in A Health Service of all the talents in 2000.[268] We consider some of the definitions of 'increasing flexibility' in the box below. The importance of improving flexibility was described by Skills for Health which concluded that:

The strategic drivers we highlight converge in two specific areas namely the need for a more flexible workforce (a more effective mix of people undertaking wider and different roles) and the role of competences as a currency and framework for addressing skills gaps…[269]

181. The Committee heard some specific examples which underline the importance of increasing workforce flexibility. The Royal College of Pathologists pointed out that lack of workforce flexibility often prevents new technologies from being introduced as staff are not able to learn new skills quickly.[270] Professor Sir Alan Craft commented that the use of nurses in amended roles was vitally important to meeting the 2004 European Working Time Directive requirements, concluding that "…if we had not had nurses taking on extended roles, we would have fallen flat on our faces."[271] Several witnesses commented on the large number of cardio-thoracic surgeons rendered obsolete by unanticipated technological changes, pointing out that problems of this type can be mitigated by developing a more flexible medical training system.[272] We consider some of the ways of increasing workforce flexibility below.

SKILL MIX CHANGES AND NEW AND AMENDED ROLES

182. The most concerted recent attempts to increase flexibility have involved changes to skill mix and the introduction of new and amended clinical roles.[273] The use of new and amended roles allows changes to be made to the overall structure of the workforce, as we describe in the box below. The majority of new roles have been introduced at Assistant Practitioner level (for example, rehabilitation assistants or clinician's assistants) and at Advanced Practitioner level (for example, specialist nurses or Surgical Care Practitioners). Changes to existing roles have taken place across a range of staff groups, notably Health Care Assistants, who have developed new skills in nursing, physiotherapy and other areas.[274]

Ingredients for successful skill mix change

183. New and amended roles can have clear and measurable benefits. As Andrew Foster put it:

It is cheaper for nurses to prescribe than doctors, and if you train a nurse to take on a significant amount of extra responsibility and pay them for taking on that extra responsibility, you have a win-win.[275]

However, as we discussed in Chapter 3, a number doubts were expressed about the effectiveness, and particularly the cost effectiveness, of work of this type. Professor Bonnie Sibbald stated that the introduction of new roles can result in "doubling the volume of service but not enhancing the efficiency of the service."[276]

184. We heard from a range of witnesses about what factors determine whether skill mix changes, such as the development of new and amended roles, are likely to be successful. The following points were most often highlighted:

Skill mix changes are not ends in themselves and should have clear and measurable goals e.g. increasing productivity (for example by having specially trained workers to take blood from patients in order to allow doctors to concentrate on more complex tasks), addressing workforce shortages or improving quality;[277]
Changes should either be justified by an existing evidence base or be fully evaluated (preferably quantitatively) to assess their effectiveness (for example, an evaluation of Emergency Care Practitioner (ECP) roles showed that £56,000 could be saved with the introduction of each ECP);[278] evaluation should not take place too early as skill mix changes can take some time to take full effect;[279]
Clinical involvement in designing and implementing new and amended roles, rather than imposing them from the centre, improves the likelihood of success;[280]
The impact of introducing new roles and extending roles on existing staff should be planned for; in particular, it is important that staff in new roles act as substitutes not complements and do not overlap with existing staff (as, for example, in the case of specialist nurses in primary care providing some similar services to GPs);[281]
Planning for new and amended roles should involve all interested parties at an early stage, including employers, education providers and regulators where necessary;[282] and
When new or amended roles have proven to be effective, there should be greater efforts to disseminate them across the health service.[283]

Department of Health review

185. Department of Health officials told the Committee that they plan to review the "100 or more" new and amended roles that have been introduced in recent years. Nic Greenfield, Director of Education, Regulation and Pay, explained that the review would aim,

…to actually evaluate the business case to see, from the perspective of value for money, whether the patient experience and whether the benefit to the service overall has improved.[284]

What is meant by "increasing flexibility"?
One way of defining 'flexibility' is by looking at the overall 'shape' of the workforce. For example, the diagram below (produced by the Department of Health and the NHS Workforce Review Team) shows the overall 'shape' of the health service workforce, defined by staff group and by nine different levels of seniority, which reflect the nine pay bands of the Agenda for Change agreement.

There are very large number of staff at levels 5 and 6 (around the level of a staff nurse or junior doctor) but many fewer at levels 4 (the level of a rehabilitation assistant) and 7 (the level of a specialist nurse). Thus tasks which might be performed by a specialist nurse (level 7) will often be performed by a consultant or GP (level 9) because of the shortage of staff at levels 7 and 8. Similarly, a task which could be performed by a Health Care Assistants (levels 2-3) or an Assistant Practitioner (level 4) will often be performed by a staff nurse (level 5). It is because of these inefficiencies that the workforce can be described as 'inflexible'. It is also for this reason that many of the new roles which have been developed in recent years will fit in at levels 4 and 7 of the above diagram, thus filling current gaps and increasing workforce flexibility.

ACHIEVING A MORE FLEXIBLE WORKFORCE

186. Increasing the flexibility of the workforce is a complex task. This will require flexible funding and an education system geared to achieving the task. The use of competence frameworks is seen as an essential part of improving the education system.

Competence frameworks

187. One of the apparent success stories of recent years has been the development of 'competence frameworks' (which we describe in more detail in the box below); such frameworks support the development of new roles and allow workforce planners to look at total workforce requirements rather than at the needs of each profession in isolation. The importance of competences in supporting the move away from planning in professional 'silos' was emphasised by Peter Stansbie:

… what we should use as the building blocks are the competences that people need to deliver the service that is required by the patient or the population…they are very powerful building blocks that will allow you to get a change to the way that you plan your workforce and then…a change to the way you deliver that workforce.[285]

188. John Sargent pointed out that the use of competences to define workforce requirements will make it easier to introduce new technologies, as in future "not all the work will be neatly parcelled up" within professional boundaries.[286] A more tangible example was provided by Nic Greenfield who argued that the use of competences would make it easier for staff to re-train in response to changes in workforce requirements.[287] Introducing flexibility of this type to the medical training system, for example, would help to prevent problems such as the current over-supply of cardio-thoracic surgeons.[288] There has been clear progress in the development of competences as the main currency for measuring workforce requirements through the Knowledge and Skills Framework, Modernising Medical Careers and the production of a range of national competence frameworks by Skills for Health.[289]

What is a "competence framework"?
"Competences" are descriptions of skills or qualities against which a staff member's performance can be assessed. They can be used to define the requirements for fulfilling a specific job (e.g. registered nurse) or for performing a specific task (e.g. managing a hospital ward). Because they perform both of these functions, competences can be used to translate the requirements for a particular service (e.g. a Minor Injuries Unit) into specific workforce requirements (e.g. three doctors and six nurses or one doctor, five nurses, three Health Care Assistants and one physiotherapist). As this example demonstrates, if service requirements are defined by competence, it may be possible to find several different workforce combinations which fulfil the requirements.
"Competence frameworks" list and categorise all of the different competences that may be required by a particular industry or organisation. For example, the new NHS Knowledge and Skills Framework (first published in October 2004) defines all of the competences that may be required by NHS staff (excluding doctors). There are 30 different competences ranging from 'Communication' to 'Assessment and Treatment Planning', all of which have four different levels. Each specific job in the NHS is defined by a particular combination of the 30 competences and four levels. Staff performance can be assessed against the competences relevant to their job and training needs identified. If information from individual appraisals is collated, training requirements across an organisation (or the entire NHS) can be identified. The use of a single competence framework means that there is a common language and currency for identifying and defining training requirements.
Other competence frameworks define the range of skills required to deliver a particular service, irrespective of the professional groups traditionally involved. For example, Skills for Health has produced frameworks for Children's Services and Mental Health.

Education and training provision

189. Competence frameworks do not represent an end in themselves and one of their main uses is to define future education and training requirements.[290] Unfortunately, the evidence we received suggested that the education system itself often represents a barrier to increasing workforce flexibility.[291] As we pointed out in Chapter 3, cuts to education and training funding have particularly targeted staff in new roles, specialist nurses for example, and groups such as Health Care Assistants seeking to upgrade their skills. Such cuts are worrying in themselves but also serve to highlight wider, systemic problems.

190. Witnesses suggested a number of changes which would allow the education system to support a more flexible workforce:

Undergraduates should be more easily able to transfer between different training courses and the penalties for education providers who allow staff to transfer should be removed (a similar point was made with regard to postgraduate doctors);[292]
More opportunities are needed for existing staff to upgrade, e.g. from Health Care Assistant to Assistant Practitioner or registered nurse, rather than all staff being trained from scratch;[293]
Increased access to part-time training is required; particularly in nursing, for example, where the average age of a student is 29;[294]
Closer links between service requirements and education commissioning are required so that the need for changes in training provision are recognised earlier, for example, so that the need to shift activity into primary care is quickly followed by increases in community nurse training places;[295] and
Funding for education and training should be made more flexible so that innovative training opportunities are not automatically targeted by cuts (we discuss this in more detail in Chapter 5).

191. The Committee also heard that education and training requirements for some staff groups have become more academic and less vocational in recent years. Bill O'Neill described changes to training for paramedics:

We traditionally provide our training in-house so it has not been associated with higher education…now with the standards of education that are set by the Health Professions Counsel, with the curriculum guidance published by the British Paramedic Association, we see ourselves in a far more higher education direction, which is right.[296]

Similarly, the number of nurses educated to degree rather than diploma level has increased in recent years.[297]

192. While they may be appropriate in particular cases, it is notable that the shift from vocational to academic training tends to reduce the flexibility of education and training provision and therefore of the workforce itself. Evidence from the Nursing and Midwifery Council highlighted the importance of maintaining a flexible approach to defining minimum professional standards.[298]

An increased focus on primary care

193. The Committee heard a good deal of evidence about the importance of improving the primary care workforce. Current health reform aims to increase the role of the primary and community care sector in the provision of services and to move towards a more preventative model of care. This approach is clearly outlined in the Choosing Health (2004) and Our health, our care, our say (2006) White Papers.[299] The latter, which includes a target to shift 5% of activity from acute to primary care, has particular implications for the distribution of health service staff. This was underlined by NHS Employers:

"Our health, our care, our say"…sets out a new direction for NHS services which will require a shift of the NHS workforce into community settings as well as a range of other workforce changes such as an expansion of numbers of staff working in public health and new roles such as personal health trainers and care navigators… Most importantly it will require an increased focus on planning of the primary care workforce.[300]

194. A number of witnesses commented on the traditional lack of focus on the primary care workforce, relative in particular to the acute sector. Dr David Colin-Thome commented that "there basically has not been enough investment in primary care"[301] while Dr Graham Archard stated that "there is a very dramatic increase in workload in primary care, which is not being reflected in the increased workforce". The disparity between the acute and primary care sectors is also evident in changes in staff numbers: the number of hospital consultants rose by 37% between 1999 and 2005, while the number of GPs rose by only 17% over the same period.[302]

Improving the primary care workforce

195. The Committee heard a number of different proposals for increasing the capacity and effectiveness of the primary care workforce. NHS Employers identified GPs and primary care specialist nurses as staff groups in need of immediate expansion.[303] Witnesses also underlined the need for staff to move between secondary and primary care and for the boundaries between the two settings to be blurred. Dr David Colin-Thome explained that:

The other issue about more care out of hospital is that it will not all be done by primary care workers. What we are arguing about is that we need our hospital-trained staff, but working in different ways nearer the community…[304]

Professor Bonnie Sibbald predicted an increase in the number of GPs with specialist interests and specialist nurses working in primary care.[305]

196. The Committee heard that redundancies affecting clinical staff, the majority of which have occurred in the acute sector, could be mitigated by transferring staff to primary care. Josie Irwin of the RCN, commented that,

We certainly welcome, for example, looking at ways in which we can encourage those who may be losing their jobs in the acute sector to re-train and for there to be a proper programme of transition to allow them to work in the community…[306]

197. In addition, we heard that new roles should increasingly be developed in 'intermediate care' working between hospital and community services, what one witness called the "primary care/secondary care interface".[307] An example of this was provided by Paul Holmes, who described the impact of community matrons, senior nurses who intensively manage the care of patients in the community with complex, long-term conditions:

…one of our community matrons has 36 patients…on her caseload, and over the previous year those 36 patients accounted for 85 admissions. The average length of stay for each of those patients is ten days and that equates to 852 bed days. Over the period since they have been caring for that cohort of patients we have had no emergency admissions.[308]

The Department of Health subsequently stated that the work of community matrons in Kingston had saved £127,000 over six months.[309]

Barriers and limitations

198. Unfortunately, the Committee also heard evidence of a number of barriers to the development of a more primary-care orientated workforce. Witnesses emphasised the lack of time spent in primary care by clinical staff during training.[310] Sian Thomas pointed out that the majority of staff continue to be trained in a hospital setting, even though the direction of policy will require an increasing proportion of staff to work in the community.[311]

199. Lack of exposure to primary care during training not only means that staff may lack the skills to work in primary care, but also that they may not wish to. As Dr David McKinlay, who has a long experience of educating GPs, pointed out, this represents a particular problem in the case of medicine:

…there is still what has become known as the "hidden curriculum". Young doctors …are prejudiced against general practice…about a quarter of undergraduates think of general practice as a career, but the country needs half of them to be GPs.[312]

Dr McKinlay also stressed that there is a shortage of "learning environments" in primary care, such as classrooms, seminar rooms and other teaching facilities.[313] However, he acknowledged that recent pay increases had made it easier to recruit GPs to traditionally understaffed areas.[314]

200. More worryingly, the Committee heard clear evidence of a shortage of training opportunities for specialist nursing staff in primary care and that capacity has been further reduced as a result of recent cuts to education and training funding. The lack of infrastructure for training primary care nurses was described by Professor Jill Macleod Clark:

Professor Macleod Clark: We know we need more nurse practitioners in general practice…There is no money… there is no career framework, there are no training posts.

Charlotte Atkins: So the government's plans to move the focus from the acute sector into primary care…is completely undermined by this lack of funding of posts and career pathways within the primary care sector?

Professor Macleod Clark: Absolutely, that is spot on…We had examples of SHAs…where there has been 100% reduction in the community nursing commissions this year at post-qualification level.[315]

201. The Committee subsequently asked Lord Hunt for his comments on the shortage of opportunities for nurses in primary care. He described reports of reductions in training capacity as "disappointing".[316]

The public health workforce

202. We received alarming evidence of recent cuts to the public health workforce, another staff group with a crucial role in helping the health service move towards a more preventative model of care. A 2005 workforce survey by the Faculty of Public Health found that the number of public health consultants had fallen by 17% since 2003. The Faculty described the problem as "particularly acute in England" with only 36% of PCTs believing they have enough capacity for public health work.[317] Professor Selena Gray commented that the recent reduction in the number of PCTs and SHAs had led to a further loss of public health capacity as a number of senior staff have taken early retirement.[318]

203. As commissioners and providers of primary care services, PCTs have particular responsibility for leading the changes and addressing the concerns set out in this section. The new, larger PCTs, created as a result of the Commissioning a patient led NHS reforms, should have more capacity for workforce development. We discuss the role of the new PCTs in more detail in Chapter 5.

Management and leadership

204. The Committee received a considerable body of evidence about the importance of improving management skills across the health service workforce.[319] This will require both better managers and better management skills amongst clinicians. Witnesses stressed that "management" is not the exclusive responsibility of managers themselves, but should also be amongst the responsibilities of a range of other staff. As Sir Jonathan Michael pointed out,

A ward sister is a manager because she runs a ward; a consultant is a manager because he manages his practice; and a general practitioner is a manager. Therefore, you are still separating out the definition of management in general and general management. I argue that we need to put them back together again.[320]

THE MANAGEMENT WORKFORCE

Number of managers

205. Much of the evidence we received focussed on the number of managers in the health service. As we observed in Chapter 2, the number of NHS managers increased by 62% between 1999 and 2005. However, this figure may give a misleading impression since the majority of additional managers were employed in PCTs following their creation in 2001.[321] Department of Health officials told the Committee that the rapid rise in the number of managers in PCTs is now being reversed as a result of the Commissioning a patient-led NHS reforms. Andrew Foster explained that £250 million per year would be saved by reducing the number of managers in PCTs and SHAs.[322] He commented that such change was necessary because "the size of unit which is typically commissioning care in primary care, the PCT, has been too small".[323] Sian Thomas of NHS Employers commented with regard to recent redundancies and post reductions that "Many of the posts are managerial posts, and that is only right."[324]

206. Other witnesses presented a different view, arguing that managers tend to be soft targets when cuts are required. Mike Sobanja, for example, described the growth in the number of managers in PCTs as "desirable and laudable".[325] A written submission from Leicestershire, Northamptonshire and Rutland Healthcare Deanery argued that:

With managerial staff it is clear they are often seen as an expendable group as each new change hits the NHS. This loss of expertise is devastating and should be halted.[326]

As well as disrupting and reducing the management workforce, recent reorganisations have affected workforce planning itself, as we observed in Chapter 3.

Effectiveness of managers

207. More important than the number of managers, however, is their quality. We heard serious concerns about variability in the quality of managers, although a number of witnesses argued that it is difficult to assess their effectiveness, particularly because there are no formal training, assessment or development requirements for managers.[327] Mike Sobanja summarised this view, stating that:

I think that your diagnosis…is absolutely right: we do not know how well management in the NHS is doing.[328]

208. Witnesses did suggest, however, that the effectiveness of managers could be assessed in part by looking at the overall success of organisations in meeting targets and complying with Healthcare Commission standards.[329] Lord Hunt agreed that assessing the quality of the management workforce is a difficult task and acknowledged the variation in standards:

I think that there is clearly a capability issue about whether all our managers have the capability and the skills needed…It is very easy to knock managers in the Health Service but they have a hell of a difficult job to do. Many of them are absolutely brilliant…but there is clearly a variation in quality.[330]

209. The Committee heard a number of different suggestions for improving the quality of managers. The following points were amongst those raised:

The NHS is under-managed but over-administered; there is a need for managers to focus more on strategic problem-solving rather than bureaucracy and chasing government targets;[331]
NHS organisations should do more to recruit high calibre managers, recruiting from the private sector if necessary;[332]
The "ad hoc" systems for continuous professional development for managers is a major source of variation in quality and should be addressed;[333]
Managers need to develop improved quantitative and commercial skills such as contracting, negotiating, risk management and project management;[334]
Managers should make better use of data and information such as Hospital Episode Statistics; many managers do not have the skills to use information effectively;[335]
The high turnover rate amongst managers, particularly Chief Executives (who stay in post for an average of only 2.5 years), should be addressed as this causes disruption and damages relationships between managers and clinicians;[336] and
Managers need improved skills in workforce planning itself and need to give greater priority to education and training requirements.[337]

That witnesses put such emphasis on the need for wide-ranging improvements is indicative of the current shortage of managers with adequate skills.

CLINICIANS AND MANAGEMENT

210. Witnesses consistently highlighted the importance of increasing the involvement of clinicians in management, both by encouraging more clinicians to move into general management roles and by improving the skills of clinicians who have management responsibilities within their existing roles. Sir Jonathan Michael, one of the few health service Chief Executives from a medical background, stressed that increased clinical involvement in management would help to break down existing barriers between managers and clinicians:

My solution…is to involve clinicians in management much more thoroughly and move towards an integrated unitary management structure where clinicians have not only clinical responsibility but responsibility for the management of the service within a defined resource.[338]

211. The Committee heard that increasing clinical involvement in the management of services would help attempts to improve productivity and to introduce skill mix changes. Lord Hunt agreed that more clinicians should move into senior management roles, stating that:

I am convinced that alongside the excellent lay managers we have got to encourage more clinicians into senior leadership and managerial positions, and I am sure that that is the way to get greater ownership amongst clinicians for changes.[339]

Supporting clinicians in management roles

212. Importantly, the Council of Heads of Dental Schools warned against assuming that clinicians are automatically suitable to take on management responsibility. The Council concluded that:

Clinicians are best at clinical work. A few may have the flair for management but it is wasteful to put too many clinicians into management roles.[340]

213. This point was partially supported by Sir Jonathan Michael, who warned that clinicians moving into senior management positions required effective training and support. He described his own early experiences as a Chief Executive as "like learning to swim by being thrown into the deep end".[341] A number of witnesses pointed out the role of the NHS Institute for Innovation and Improvement's Enhancing Engagement in Medical Leadership scheme in developing management skills amongst doctors and preparing them for leadership roles.[342]

214. The need for a larger management component within clinical training was also raised on several occasions. Dame Carol Black argued that management training should play a bigger role in medical training.[343] Mr Bernard Ribeiro, President of the Royal College of Surgeons, also commented that consultants will need to take on more specialist roles in future and argued that some should specialise in management.[344] Paul Streets of the Postgraduate Medical Education and Training Board described current work to develop consultant roles with specific management expertise:

…there needs to be the opportunity for people to pursue medical management as a speciality…and also potentially the opportunity for doctors to take time out to do, for example, an MBA.[345]

Conclusions

215. Future workforce requirements are very difficult to predict; for this reason, increasing the flexibility of the workforce is an important priority. In spite of the difficulties in predicting future requirements, it is clear that the workforce must become more productive, particularly since there is likely to be less extra funding available in future. There is also a clear need to increase the size and quality of the primary care workforce and to improve the standard of management across the whole workforce.

216. Increasing workforce productivity is a difficult goal and reliable information is vital to achieving it. In the past, although a great deal of data has been collected by the NHS, information directly relevant to productivity has been either lacking or not used sufficiently. The recently introduced Better Care, Better Value indicators are a good source of information about comparative productivity, although they should be improved, for example by adjusting for case mix.

217. Effective use of the Knowledge and Skills Framework (KSF) has great potential to improve staff productivity. The KSF can improve access to relevant education and training, and support amended roles which will allow staff to develop the skills required to increase flexibility and efficiency. However, there is little evidence that these opportunities are yet being taken. NHS organisations must make wider use of the KSF to prioritise training requirements and to offer training to staff groups, such as Health Care Assistants, that have too often been denied it in the past. In particular, the health service must do everything possible to ensure that such training opportunities are protected from short-term budget cuts. Human Resources department should ensure that the KSF becomes a fundamental tool for staff management and development.

218. Despite its high, and arguably excessive, cost to the health service, the new GP contract has potential to improve future productivity. The Quality and Outcomes Framework (QOF) should be used to negotiate more exacting targets for improving standards. The government should consider allowing some QOF targets to be negotiated at a local level in order to address specific local priorities. PCTs should maintain or improve the standard of the auditing of QOF returns wherever possible.

219. The new consultant contract has been expensive and time-consuming to implement and its impact so far on productivity has been minimal. Yet this is largely because implementation was rushed and most employers have therefore struggled to get to grips with the job planning and objective setting processes. Employers must use these processes to challenge traditional working patterns and practices, and to negotiate and monitor demanding performance objectives with consultants. Medical Directors should play a central role in negotiating objectives and the effectiveness of objective setting should be scrutinised by Trust Boards. Failure to meet agreed objectives must constrain or limit pay progression not only for medical staff but also for the responsible Medical Director. It is only through agreeing rigorous and detailed objectives that employers will derive benefits from the consultant contract which correspond with the significant pay increases it has brought.

220. There is a clear need to develop consistent criteria for measuring clinical productivity which would make it much easier for local organisations to negotiate meaningful performance objectives for consultants. Different specialties and disease areas will require different measures: in some cases, activity measures are a good reflection of productivity; in others, measuring outcomes is more appropriate. To this end, we recommend that NHS Employers and the NHS Institute for Innovation and Improvement work with the relevant Royal Colleges to agree standard productivity measures for each hospital specialty. Wherever possible, productivity measures should be based on existing data sources such as Hospital Episode Statistics or the Better Care, Better Value indicators.

221. Increasing workforce flexibility should be another of the main future priorities for workforce planning and development. Increasing flexibility will support efforts to improve productivity and allow the workforce to adapt more quickly to changing service demands. Using staff in new and amended roles is an important way to increase flexibility. The Committee is pleased to hear that the Department intends to review the many new roles that have been introduced and to assess their cost effectiveness, particularly as such evaluation had often been lacking or limited in the past. This review should be based on hard evidence rather than opinion; but skill mix changes should be given enough time, and done on a large enough scale, to take effect before they are reviewed. Where new roles are shown to be effective, they must be quickly disseminated across the health service. However, it is equally important that ineffective roles are rejected and that staff in new roles do not duplicate the work of existing staff.

222. Increasing flexibility will require a more adaptable training system which is able to respond quickly to changing requirements. The use of competence frameworks is an important element of this. However, the health service must also be quicker to change the pattern of training commissioning in response to service demands. SHAs need to do more to protect new and innovative training courses from budget cuts. Education and training provision itself must be made more flexible with more opportunities for staff to transfer between courses and more part-time courses. Rather than training all staff from scratch, more opportunities are required for groups such as Health Care Assistants to upgrade their skills and take on more challenging responsibilities.

223. The balance of the health service workforce must be shifted significantly towards primary care if the government's future ambitions are to be realised. Basic clinical training should involve more time in primary care. Most importantly, the health service needs to develop ways for staff to move from secondary to primary care and to work between the two sectors. Unfortunately, progress to date on achieving these aims has been limited and appears to be further threatened by recent training cuts. The public health workforce has been particularly badly affected. If the shift of 5% of activity out of hospitals and the adoption of a more preventative model of healthcare are to be achieved, then far more needs to be done to ensure that the primary care workforce is able to support these developments. The new PCTs should take particular responsibility for this change although there is little evidence that they are currently equipped to do so.

224. Managers are a crucial component of the health service workforce; their importance is too often overlooked and their role has been undermined by the continual reorganisations of recent years. However, the quality of managers is highly variable and the absence of minimum standards or training requirements is a concern. NHS organisations need to recruit managers of a high calibre. They should ensure that all managers are appraised and have access to relevant training; improving quantitative and workforce planning skills should be a particular priority.

225. The Committee welcomes the Minister's acknowledgment that the contribution of clinicians to managing health services needs to be made more effective. This means both improving their ability to carry out everyday management tasks within their existing roles, and encouraging more clinicians to transfer into general management roles with the potential to become a Chief Executive. Clinicians need appropriate training and support if they are to take on more management responsibility. Clinical training should contain a larger management component and senior clinical roles with a management specialism should be developed, particularly for medical staff. More senior clinical staff should be trained and assisted to take on general management roles, particularly at Board level.