House of Commons - Health

Select Committee on Health Fourth Report

5 The future workforce planning system

226. We saw in Chapter 3 that there are serious problems with the current workforce planning system, most importantly the lack of integration between different parts of the system and the lack of people, systems and skills to do the job effectively. In Chapter 4 we pointed out the need for significant changes to the structure and make-up of the workforce in order to meet future demand. Such changes will not be achieved unless the workforce planning system itself is improved and unless the shortcomings we have highlighted are addressed. In this chapter we consider how to improve the workforce planning system.

227. The value of workforce planning is often overlooked, in part because it tends to be viewed as an abstract number-crunching process, remote from (particularly financial) reality.[346] Such a narrow and limited form of planning would indeed be of little value. However, workforce planning should in fact be the key means for the health service to understand and anticipate the impact of demographic, technological and policy trends on future service requirements. Responding earlier and more effectively to such trends is vital to ensuring the long-term sustainability of the health service. Thus workforce planning, in its broader sense, is a crucial activity which must be done properly in order to avoid future boom and bust in staff and training numbers, and in order to improve the productivity of the health service.

228. Because of the complexity of workforce planning and of the health service itself, there is no single or easy solution for improving the planning system. As Phil Gray put it,

We recognise that workforce planning is not easy, and I have been involved in the system long enough not to pretend that it ever is a simple magic formula.[347]

Instead, improving workforce planning will require a range of steady changes by a number of different organisations. Essentially, this is about ensuring that people and systems do their job well. In particular, we examine the need for improvements in the following areas:

Improving the long-term, strategic elements of workforce planning;
Making the workforce planning system more aligned and integrated;
Improving particular aspects of the education and training system; and
Maximising the effectiveness of organisations at each level of the workforce planning system (Strategic Health Authorities, Primary Care Trusts, employers, the education sector and the Department of Health) and the linkages between them.

Improving strategic, long-term planning

Introduction

229. One of the most important challenges facing the workforce planning system is to improve the long-term, strategic element of planning, something which has often been badly neglected.[348] Long-term planning is important because some of the changes to the shape and structure of the workforce identified in Chapter 4 cannot be achieved in one year or even three years; instead they require plans to cover the next five to ten years and beyond. In the past, long-term planning has been undermined by lack of suitable tools and mechanisms,[349] persistent organisational changes,[350] and the short-sighted pursuit of financial savings.[351]

230. Strategic planning is important because of the sheer complexity involved in changing the health service workforce: a range of interlocking and overlapping problems require a similar range of interacting solutions. This has not always been done well in the past. As we saw in Chapter 2, for example, the rapid expansion of the workforce after 1999 was achieved mainly through a combination of increased international recruitment and increased UK training capacity. However, international recruitment expanded so quickly that there was a shortage of opportunities for UK-trained staff once output increased after 2004.[352] There was a clear lack of alignment between the two approaches to increasing staff numbers. It is vital that the health service becomes more adept at understanding sets of problems and solutions rather than considering each one in isolation. This is what we mean by taking a more strategic approach to workforce planning.

Planning mechanisms

231. Improving long-term, strategic planning requires appropriate mechanisms to support the planning process itself. It is clear, for example, that the current 3-year Local Delivery Plan (LDP) cycle does not represent a suitable mechanism for incorporating the long-term element of workforce planning.[353] SHAs need to think carefully about how to supplement or reinforce the LDP process so that it is possible to produce workforce plans stretching at least 5-10 years ahead.[354]

Analysing demand and supply

232. More importantly, effective long-term, strategic planning requires accurate analysis of future workforce demand and supply. Witnesses stressed that analysis of future demand must consider the impact of a wider range of information, including the following:

Demographic trends, for example the impact of the ageing of the UK population on future demand for health and social care services;[355]
Changes in technology, for example the increasing use of robotic surgical techniques which will affect medical training numbers and operating theatre staffing requirements;[356]
Social trends, such as the continuing rise in obesity rates, which will have implications for the public health and primary care workforces;
Key policy changes and central targets, such as the 18-week hospital treatment pathway, which will require a short-term increase in surgical workforce capacity in order to reduce waiting lists and a long-term increase in information support staff in order to monitor patient journeys; and
The combined impact of all of the factors described above.

233. Assumptions about future supply of health service staff have in particular tended to consider different problems and initiatives in isolation. Witnesses proposed that analysis should focus particularly on the following areas:

Demographic trends, for example the impact of future retirement patterns (described by one witness as a "time-bomb" and by another as a "red herring");[357]
Legal changes, such as the 2009 European Working Time Directive regulations (whereby junior doctors can work a maximum of 48 hours per week), which one witness estimated would cause her hospital to lose 3,000 hours of junior doctor time per week by 2009;[358]
Changes to the UK labour market, for example as a result of the increasing number of people entering higher education; such information can be obtained from Labour Market Intelligence and other sources;[359]
Changes to the international labour market, for example the likely growth in the number of doctors and other healthcare professionals imported by countries such as Australia and the US;[360] and
The combined impact of all of the factors described above.

We discuss below how information about supply and demand should be collected, challenged and analysed.

234. The areas of focus suggested above are by no means comprehensive which demonstrates the scale and complexity of the analytical work which is needed to underpin effective long-term planning. This is turn shows how hard it is to forecast workforce supply and demand accurately in healthcare, particularly given the long lead times from training plan to fully trained clinician. As a result, steps must be taken to increase flexibility to change workforce skills quickly. As we described in Chapter 4, such change can be achieved by the use of 'competence-based' approaches in all training, which recognise basic and progressive levels of skills and enable staff to acquire skills for new tasks in a shorter period of time.

Conclusions and recommendations

235. Ensuring that the health service is able to respond to future service demands will require a reformed and improved workforce planning system. Workforce planning has been badly hampered by the absence of effective long-term planning and the failure to take account of the complexity of the strategic 'big picture'. Long-term planning is important because changing the structure and make-up of the workforce takes a long time, particularly in healthcare where workers take up to 15 years to train. Strategic planning is important because the complexity of workforce supply and demand mean that a lazy or over-simplistic approach to change can have serious negative consequences, as shown by current job reductions and graduate unemployment.

236. Some of the current mechanisms for workforce planning, such as the 3-year Local Delivery Plan cycle, do not support a long-term approach and this should be addressed by SHAs and the Department of Health as a matter of priority. Improved planning systems, however, are useless without good quality information to support them. In the past, analysis of workforce supply and demand has tended to be limited and has failed to concern itself with wider developments such as future demographic and technological changes. In future it needs to take account of a much wider range of factors, including demographic, technological and policy trends and the interaction between them. Adopting a genuinely long-term and strategic approach to workforce planning will allow planners to anticipate the need for change rather than constantly responding to it, something which is key to the sustainability of the health service.

Making workforce planning more integrated

Introduction

237. Improving workforce planning will require the health service and the Department of Health to bridge divisions which exist between professions, organisations and functions.[361] The persistence of such divisions shows how difficult it is to achieve properly integrated planning but bridging them must be a fundamental goal of improving the workforce planning system.

Workforce, financial and service planning

238. Perhaps the most serious division that we heard about is the continuing disjunction between workforce planning, financial planning and service planning. Improving integration between workforce, financial and service planning, described in one submission as the "Holy Grail" for the planning system, must be a major priority.[362] The following improvements were suggested by witnesses:

Better alignment of planning cycles so that workforce, financial and service planning do not take place at different times of year, and particularly so that short-term financial plans cannot disregard workforce issues, and long-term workforce plans cannot disregard financial issues;[363]
Closer working between people working in Finance and Human Resources departments in all organisations, bringing together the expertise of both distinct functions to inform overall service planning;[364]
Improved forecasting of workforce supply and demand and of future funding levels;[365]
Improved skills for workforce planners in understanding the costs and benefits of workforce developments, such as skill mix changes, which will allow organisations to become more adept at increasing productivity rather than simply employing additional staff in response to changes in demand;[366] and
Better oversight of provider organisations by SHAs (or Monitor, the Foundation Trust regulator, in the case of Foundation Trusts), so that the alignment of workforce and financial planning is properly examined and challenged and so that organisations do not recruit staff that they cannot afford to pay.[367]

The use of financial incentives

239. Increasing and improving the use of financial incentives to influence workforce behaviour is another important element of bringing together workforce and financial planning and management. We saw in Chapters 3 and 4 that increasing workforce productivity is a vital goal which was badly neglected during the period of rapid recent expansion. If productivity is to be improved, incentives systems such as the QOF and consultant job planning need to be better exploited.[368]

240. Commissioners should also use contract negotiation to create incentives for providers to increase productivity, focussing on improving patient outcomes rather than just increasing activity levels.[369] The Better Care, Better Value indicators (which we described in Chapter 4) provide a good source of information to support the creation of measurable incentives to increase productivity,[370] for example by reducing staff turnover or increasing day surgery rates.[371] Without improved use of financial incentives, the alignment of workforce and financial planning is likely to remain limited or tokenistic.

Planning across different staff groups

241. Another serious and long-standing problem has been the failure to plan for overall workforce requirements rather than just looking at the needs of each professional group in isolation.[372] This process is complicated by the different features of planning for different professions, for example variations in training times and in the distribution of staff between the public and independent sectors. However, if productivity and flexibility are to be improved, it is vital that workforce planners bridge these stubborn and persistent divides, particularly that between planning for the medical workforce and for other staff groups. Witnesses suggested that the following improvements should take particular priority:

Increasing the role of SHAs in medical workforce planning by giving them a greater say in the content of training and control over the number of medical students, Foundation trainees and Speciality and GP trainees in their area;[373] SHAs also need to work together to ensure appropriate national distribution of medical staff and trainees.
Ensuring that there is flexibility for education and training funding to be moved between medical and non-medical spending;[374]
Increasing the flexibility of education and training provision, for example by allowing students to move between different courses (this is covered in more detail in Chapter 4);
Ensuring that analysis of future supply and demand, by the Workforce Review Team at national level and by SHAs at regional level, takes account of requirements for the whole workforce rather than looking at each professional group in isolation;[375] and
Measuring required competences, rather than simply counting the number of doctors and nurses traditionally needed, in order to assess future workforce requirements, so that a range of responses to future service demands are available.[376]

242. Professional roles and standards continue to be vital to the functioning of the health service, but there is a growing need to acknowledge the limitations of defining the workforce simply as a series of professional groups or 'silos'.[377] As John Sargent put it,

…the competences that are inherent in particular staff groups historically are not God-given. Each of the professions has been invented by Society to meet particular needs in a particular way at a particular time.[378]

Planning across NHS and non-NHS organisations

243. Another area where improved integration is required is in planning across the whole health service and bridging the divide between NHS and non-NHS organisations, something which remains a serious problem.[379] This will be an increasingly important priority as the proportion of NHS services provided by non-NHS organisations increases.[380] The following changes were suggested to support improvements in this area:

Improvements to the quality and consistency of workforce information from non-NHS organisations, for example by providing data to SHAs in a standardised form;[381]
Increased involvement by non-NHS organisations in workforce planning and decision-making, particularly at SHA level, which has been lacking in the past;[382]
Increasing the use of non-NHS organisations to provide education and training and developing integrated training pathways between NHS and non-NHS organisations;[383] and
Ensuring, wherever, possible that there is free movement of staff between NHS and non-NHS organisations, for example by further relaxing 'additionality' rules for Independent Sector Treatment Centres so that only staff groups where the NHS has a serious, long-term shortage are covered.[384]

Involving clinicians

244. A final improvement which will help to create a more integrated workforce planning system is to increase the level of clinical engagement and involvement in all areas of workforce planning and development and particularly within provider organisations. We heard evidence of the need for increased clinical involvement in a range of contexts, including the design and implementation of skill mix changes, improving the quality of productivity information and managing the health service.[385] Deborah O'Dea, Director of Human Resources at St Mary's NHS Trust, summarised the importance of engaging clinicians in workforce development activities:

At the coalface, I think clinicians have always been involved where projects have been successful. When they are not involved, projects are not.[386]

Increasing clinical involvement should therefore be a particular priority within attempts to create a more integrated planning system.

Conclusions and recommendations

245. Workforce planning has too often been a series of isolated decisions and initiatives rather an integrated process. A number of changes are required to improve integration: most importantly, workforce planning, financial planning and service planning must be more closely aligned in all NHS organisations. This will require closer working between staff in Finance and Human Resources departments and more accurate, joint forecasting of future supply and demand. It is important that there is proper oversight across the system; the work of local organisations should be scrutinised by SHAs, the work of Foundation Trusts by Monitor and the work of SHAs by the Department of Health. The planning system should also pay much greater attention to the use of financial incentives, such as the Quality and Outcomes Framework, to increase workforce productivity, focussing wherever possible on improving health outcomes.

246. Planning must cover the whole workforce rather than looking at each staff group as a separate 'silo'. The persistent divide between medical and non-medical workforce planning must be addressed; SHAs currently pay for postgraduate medical training so in future they must have much more influence on training numbers and content. The Department should make clear to SHAs that money can be transferred between medical and non-medical training pots; there is currently confusion over whether this is the case. Analytical work by SHAs and the Workforce Review Team should focus on total workforce requirements rather than examining each profession and sub-discipline in isolation. The use of competences to measure overall workforce requirements will help to support this approach.

247. Workforce planning should take account of the requirements of the whole health service rather than looking exclusively at the NHS. Private and voluntary sector organisations should be more involved in planning at local and regional level and standardised workforce data should be available from non-NHS organisations. Free movement of staff between sectors should be permitted, expect in the case of staff groups where the NHS has serious and persistent shortages. The private and voluntary sector should increasingly be used to provide education and training and integrated training courses should be developed between NHS and non-NHS organisations. Attempts to create a more integrated planning system must be supported by increased clinical involvement, so that workforce planning and development are not regarded as back office, managerial tasks.

Improving education and training

248. Many of the improvements to the workforce described in Chapter 4 can only be achieved through changes to the education and training system. However, it is important to recognise that high-quality, flexible education and training is not an end in itself, but rather the principal means of realising workforce plans and making changes and improvements to the workforce. As Anne Rainsberry commented,

…there is a real issue…about bringing together workforce planning for all groups, and, aligned with that, the way in which we manage commissioning of education and training. The point I would make on that is that we need a paradigm shift in that we are commissioning a workforce. We are not commissioning education per se.[387]

SUPPLY AND DEMAND

249. Unfortunately, many of the problems in the education system continue to relate to mismatch between supply and demand, as demonstrated by recent cuts to undergraduate training commissions and high levels of unemployment amongst nursing and physiotherapy graduates.[388] Concerns have also been expressed about capacity within the new Modernising Medical Careers scheme,[389] with some witnesses predicting future unemployment amongst UK medical graduates.[390] These are serious and fundamental problems: high levels of unemployment among newly qualified staff in particular represent a regrettable waste of resources and talent.

250. The Committee heard two main suggestions for improving the stability of the education system in response to these problems: removing commissioning responsibilities from SHAs and guaranteeing jobs for newly qualified staff. We consider these proposals below.

SHA responsibilities

251. Representatives of the higher education sector suggested that responsibility for commissioning non-medical training places should be removed from SHAs and passed to the Higher Education Funding Council for England (HEFCE), which currently commissions medical student places.[391] It was suggested that HEFCE would be more effective than SHAs at protecting education and training funding from short-term budget cuts.[392] However, other witnesses pointed out that moving responsibility away from SHAs would make it much more difficult to integrate workforce planning with service and financial planning and make it harder for NHS organisations to influence future workforce supply. Increasing workforce flexibility would also be more difficult if SHAs were to lose control of education commissioning.[393] Given the central importance of ensuring a more integrated planning system and increasing workforce flexibility, we recommend that SHAs should retain responsibility for commissioning undergraduate training courses for non-medical staff.

Newly qualified staff

252. Another suggestion, made by representatives of professional membership groups, was that newly qualified UK-trained healthcare staff should have a fixed period of guaranteed employment in the NHS. It was suggested that this would resolve the current problem of high levels of graduate unemployment and increase the stability of the training system.[394] It would also encourage employers to become more involved in decisions about education and training, thus improving the integration of the planning system. On the other hand, there is a risk that guaranteeing jobs for graduates would reduce the flexibility of workforce planning as employers would have no choice about the number of new staff recruited each year.[395] Also, given the sheer scale of the current problems affecting physiotherapy, for example,[396] it is hard to imagine that some shortages would not occur in one or two years time if jobs were guaranteed for this period. There would be advantages and disadvantages in guaranteeing a fixed period of employment for newly trained staff; however, such a strategy has potential to improve the integration of the planning system and ensure that a cohort of graduates trained at the public's expense is not lost to the NHS. We recommend that its implications be examined in more depth.

COMMISSIONING AND CONTRACTS

253. A number of other possible changes to the education and training system were proposed. A particular requirement was for SHAs to improve the quality of education and training commissioning.[397] SHAs need to give greater priority to the commissioning process and to ensure that they have staff with the skills and experience for effective commissioning.[398] They need staff who can work consistently with education and training providers to develop more flexible courses and to encourage new providers to offer training places.[399] SHAs also need staff with contract management skills who can ensure that good value for money is achieved once contracts are agreed. The Government has indicated that it intends to introduce "a more robust service-level agreement between the Department and SHAs" in order to improve the standard of education commissioning.[400]

254. Improved commissioning will allow SHAs to make the most of changes to education contracts themselves. In order to increase flexibility and improve the alignment of financial incentives within the education system, the following changes to contracts were proposed:

Education and training contracts need to be simplified, particularly through the development of standard prices for different types of training activity.[401] This would effectively create a 'tariff' for training provision to match the existing tariff for service provision. Such a tariff would make the cost of training more transparent and allow organisations that do not currently provide training to assess the costs and benefits of doing so;[402]
Commissioners also need to ensure that contracts are more flexible and that particular types of training activity are not disproportionately vulnerable to cuts.[403] In the recent round of training cuts, for example, community nursing courses were often more heavily cut than general nursing courses because legal obligations limited reductions in general nursing places.[404] In future, legal distinctions of this type should wherever possible be removed so that changes to training numbers reflect future service requirements rather than contractual obligations; and
Contracts should support and encourage a flexible, competence-based approach to the provision of education, something which we described in Chapter 4.

Student financial support

255. The Committee also heard proposals for changes to student funding. Both current levels of funding and systems for distributing funding were heavily criticised.[405] Louise Silverton of the Royal College of Midwives agreed with the suggestion that some healthcare students should have access to loans instead of bursaries which would be repaid automatically if graduates went on to work in the NHS for a specific period of time. There are international examples of loan repayment schemes linked to required periods of public sector employment, for example in the US.[406] The introduction of such a system would mean that students could receive more money, something which would in turn reduce attrition rates.[407] It would also provide an incentive for graduates to remain within the NHS, something which could be supported by the fixed-term employment guarantees discussed above. However, such a scheme would require a short-term increase in public expenditure to finance initial loans.

Academic staff

256. Finally, the Committee heard worrying evidence, from both the medical and non-medical education sector, of recent reductions in the number of clinical educators.[408] One witness described current entry routes into academic posts as "serendipitous" and proposed that better career pathways should be established so that junior staff have a clear understanding of how to get the skills and experience required for an educational role.[409] Like workforce planners themselves, clinical educators are vital to the future functioning of the workforce planning system. As one witness put it,

…without a well founded educator workforce the next generation of professionals cannot succeed.[410]

Conclusions

257. Education and training needs to support a more flexible approach to workforce planning. In order to achieve this, we recommend that:

SHAs give greater priority to education and training commissioning and ensure that they have enough staff with the right skills for effective commissioning.
Standard prices be used to develop a 'tariff' for training so that new providers have an incentive to offer education and training.
Education contracts be made more flexible so that if changes are required, they are determined by the future needs of the health service rather than by legal distinctions within contracts.
The Department of Health and SHAs examine new approaches to student funding, for example the possibility of introducing loans to replace bursaries. Such loans should have repayment structures which reward staff for remaining within the NHS.
The decline in the number of clinical academics and teaching staff for healthcare courses be addressed as a matter of urgency.

Organisational roles and responsibilities

258. Achieving the improvements set out so far in this chapter will require organisations with a strong focus on workforce planning. Repeated structural changes and re-organisations have damaged the workforce planning system, causing disruption and loss of planning capacity.[411] Further structural change therefore seems unlikely to prove beneficial. Rather than making a case for restructuring or overhauling the workforce planning system, we look at how improvements can be made in the work of existing organisations in particular by giving workforce planning a higher priority. We examine the role of:

Strategic Health Authorities;
Primary Care Trusts;
Provider organisations;
Other organisations such as NHS Employers and the Workforce Review Team; and
The Department of Health.

STRATEGIC HEALTH AUTHORITIES

Introduction

259. As we described in Chapters 2 and 3, Strategic Health Authorities (SHAs) took on a range of key workforce planning functions after they absorbed Workforce Development Confederations (WDCs) in 2004. SHAs were reduced in number from 28 to 10 in 2006 but retained broadly the same responsibilities, including the commissioning of education and training. We heard serious doubts about the likely effectiveness of SHAs at workforce planning, particularly in light of the disruption and loss of personnel which followed two re-organisations in 3 years.[412] The significant cuts to education and training provision implemented by the new SHAs in recent months have done little to mitigate these doubts or to allay fears that SHAs will prioritise financial balance over long-term workforce requirements.[413] In short, SHAs have a lot to prove, both in terms of their capacity for workforce planning, and their willingness to prioritise it sufficiently.

260. In spite of these justified concerns, there are good reasons for SHAs to remain at the heart of the workforce planning system. First, while recent education and training cuts have been damaging, they have in many cases been a direct response to the Department of Health's decision to restore financial balance in 2006-7; moreover, some SHAs appear to have made genuine efforts to minimise the long-term impact of cuts.[414] Secondly, neither local nor national organisations are able to do the job. Local organisations have little capacity for or experience of workforce planning; more importantly they do not cover wide enough areas to plan strategically.[415] Workforce planning by central organisations has proved too remote and unresponsive in the past, something which Lord Hunt himself acknowledged.[416] SHAs, by contrast, are sufficiently local to take account of distinctive workforce requirements for their area, but large enough to bring together the different elements of the system in one place and ensure that planning becomes more joined up. Thirdly, the majority of the limited number of planners are already located at SHA level and finally, further restructuring of the workforce planning system is undesirable: it is the function that must be the priority for improvement, not the form.[417] Thus there is a strong case for SHAs to retain their current range of workforce planning responsibilities.

Key priorities for SHAs

261. The 10 new SHAs need to re-establish their workforce planning credentials and demonstrate that they are committed to long-term workforce development rather than short-term cost-cutting as a means of restoring financial balance. They also need to address the shortcomings in the current workforce planning system outlined in Chapters 2 and 3. Witnesses proposed that SHAs should:

lead work to improve the analysis of workforce supply and demand at regional level; in particular they should work to improve the quality of workforce information and be more pro-active in challenging information provided by local organisations rather than simply acting as a conduit;[418]
use supply and demand assessments to produce strategic regional workforce plans; these plans should be used in the commissioning of education and training;[419]
ensure that there are forums for the full range of relevant organisations to participate in planning and decision-making, including education providers, medical Deaneries and independent sector providers; and
involve themselves more in national workforce planning, for example working with the Workforce Review Team to establish a national overview of trends and dynamics, and influencing the content of medical training.[420]

SHA workforce planning capacity

262. In order to live up to this challenging remit, witnesses argued that SHAs need to increase the number of staff involved with workforce planning and improve the skills of current staff.[421] They will also need to improve information systems and make full use of systems such as the new Electronic Staff Record.[422] Such changes should be a priority as investing in capacity at SHA level will represent good value for money if it helps to improve the overall workforce planning system.

263. SHAs will also need strong leadership if they are to make a success of workforce planning. The 10 SHA Directors of Workforce have a central role to play. They need to become effective champions for improving workforce planning and to lead many of the changes and improvements outlined. They should also work together to collectively assert the importance of workforce planning and development at national level. Department of Health officials commented on the importance of the new Workforce Directors and outlined plans to support them individually and as a group.[423] Such support is vital if workforce planning at SHA level is to make the improvements so clearly required.

264. There is a strong case for the 10 new SHAs to continue to play a central role in the workforce planning system. However, there are justified misgivings about their performance to date. The new SHAs must prove their commitment to workforce planning and development as the bedrock of future financial stability, rather than a luxury which can be dispensed with in times of financial difficulty. To this end, we recommend that SHAs:

improve their understanding of workforce demand and supply and the factors which influence them;
do more to challenge existing assumptions by PCTs and other organisations about what workforce is required and how it can best be achieved;
involve education providers and independent sector organisations in planning and decision-making; and
take collective responsibility for improving planning at national level and for ensuring that NHS Employers performs its role effectively.

Such changes will allow SHAs to produce flexible, long-term, workforce plans which should inform their commissioning of future education and training.

265. In order to achieve these ambitious aims, many SHAs will require more staff, better training and improved information and planning systems. Whatever the requirements, SHAs must act quickly to ensure they have the necessary capacity. The 10 SHA Workforce Directors have a key role to play collectively in improving workforce planning at regional level and across the health service. SHA Chief Executives and the Department of Health's Director General of Workforce must ensure that SHA Workforce Directors are of a high calibre and have suitable training. Improving workforce planning should be one of the key performance targets for SHA Chief Executives and their progress should be closely monitored by the Department of Health.

PRIMARY CARE TRUSTS

266. While SHAs must play a central role in improving workforce planning, this is not a task which they can accomplish alone. In particular, Primary Care Trusts (PCTS) must play a bigger role. Witnesses suggested that the small size of PCTs had prevented them from playing an effective role in workforce planning in the past.[424] However, with the reduction to 150 PCTs in late 2006, there is a clear opportunity for PCTs to play a more active role.[425]

Analysis of future demand

267. In particular, we heard that PCTs should work with SHAs to improve the analysis of future workforce demand.[426] As commissioners of services, PCTs are best placed to anticipate future service demands and must become adept at translating these into workforce requirements, using competence frameworks where appropriate. Only if SHAs receive accurate forecasts from their constituent PCTs can they hope to make reasonable assumptions about future workforce requirements across the whole SHA area. PCTs commission services, but SHAs must commission the workforce that will provide those services; it is vital therefore that the two sets of organisations work closely together.

The shift towards primary care

268. PCTs also have central responsibility for leading the shift towards a more primary care-oriented workforce.[427] PCTs commission all services and will therefore be aiming to move resources increasingly from secondary to primary care; this shift will only be possible if the workforce is able to support it. PCTs must give clear information to SHAs about primary care workforce requirements and particularly about gaps in education and training provision. Also, PCTs remain a major provider of primary and community care services and are therefore have direct responsibility for ensuring that these services have the right workforce to support increased levels of activity, as we described in Chapter 4.

269. SHAs cannot achieve effective workforce planning single-handedly and must work with PCTs, which have played too small a role in the past. The new, larger PCTs are better placed to contribute to workforce planning and should ensure that they have enough people with the right skills to do so. As commissioners, PCTs must help SHAs to analyse future workforce demand and to ensure that service planning and workforce planning become integrated and complementary processes. As providers, PCTs must forecast the number and type of staff and the kind of training needed to support the move towards a more primary-care centred workforce and the shift of hospital services into the community.

PROVIDER ORGANISATIONS

270. Provider organisations, including NHS Trusts, Foundation Trusts, PCTs and private and voluntary providers, also have an important role to play in the future workforce planning system. We heard that the roles and responsibilities of provider organisations with regard to engaging in workforce planning should be similar, regardless of whether they are NHS or non-NHS organisations.[428]

Improving information

271. Provider organisations employ the vast majority of health service staff. As a result, they have responsibility for improving the quality of workforce data; this is a key priority as poor quality information undermines the current planning system. For example, recent reports of a potential future oversupply of allied health professional were criticised because information provided by employers was inaccurate or incomplete.[429] Providers can improve information partly by sharing accurate data about current workforce supply with SHAs and ensuring that new data collection systems, such as the Electronic Staff Record, are widely used.[430] As providers of primary care and community services, PCTs have an important role to play in improving the quality of information, as the understanding of workforce needs in this area is particularly poor.[431] Non-NHS providers and Foundation Trusts should provide the same types of information, and have the same access to the planning dialogue, as other provider organisations.[432]

Improving efficiency

272. As employers of most health service staff, provider organisations also have a major role to play in improving workforce productivity, particularly by achieving the savings targets set out in the 'Productive Time' initiative and measured by the Better Care, Better Value indicators.[433] Some of the Better Care, Better Value targets are based on measures specific to employers, such as reducing staff turnover, sickness absence and agency costs. Others relate to the wider efficiency of the health system, but will fall largely to providers to achieve; these include increasing day-case surgery rates and reducing average length of hospital stay.[434] In both cases, improving performance and increasing productivity will depend upon the efforts of provider organisations.

Foundation Trust status

273. The government intends that most NHS providers will achieve Foundation Trust status in the near future.[435] It is important that becoming a Foundation Trust does not reduce the involvement of provider organisations in workforce planning. Department of Health officials reassured the Committee on this point, arguing that Foundation Trusts "do not have the freedom to opt out of workforce planning" and would play a similar role to other NHS providers, for example by supplying the same level of workforce information.[436]

274. However, other evidence we received gave cause for concern. NHS Employers argued that the central role of SHAs in workforce planning may be undermined by increasing conflict with Foundation Trusts, in part because Foundation Trusts are overseen by Monitor rather than by SHAs.[437] Witnesses also expressed serious concerns that Foundation Trusts are not obliged to maintain the Agenda for Change agreement, an important element of workforce reform.[438] NHS Employers commented that they did not know of any Foundation Trusts intending to break with Agenda for Change,[439] but the Committee subsequently heard that Southend University Hospital NHS Foundation Trust is planning to do exactly that.[440] It is clear that there are justified concerns about the effect of Foundation Trust status on the role of NHS providers in workforce planning and on the impact of other attempts to introduce competition to the health service. We discuss these in more detail in the box below.

275. Acute trusts and other provider organisations have an important role to play in workforce planning and development, particularly by collecting and sharing consistent and reliable workforce information with SHAs. Providers also have the main responsibility for two goals of the highest priority: increasing workforce productivity and improving the integration of workforce and financial planning. It is vital that there is consistent involvement of providers in workforce planning, regardless of whether they are NHS or non-NHS organisations, and irrespective of Foundation Trust status.

Competition versus collaboration
A number of witnesses to the Committee highlighted the uncertainty inherent in predicting future workforce requirements, particularly in the current policy context. For example, a number of current policies (including Payment by Results, the use of independent sector providers and the creation of Foundation Trusts) are designed to encourage competition between healthcare providers. The think-tank Reform suggested that efficiency gains as a result of competition would result in a reduction in future staff numbers of at least 10%.[441] Sir Jonathan Michael argued that market forces should increasingly regulate workforce supply and demand, asserting that "grown-up organisations" such as Foundation Trusts should be left to determine their own workforce requirements.[442]
The Department of Health's submission took a different view, however, stressing the importance of collaboration between organisations as part of the planning process.[443] Other key organisations, including NHS Employers and Skills for Health, also argued for a more integrated and cooperative approach to planning. There is a contradiction between efforts to introduce competition and market forces to the health sector and the need for a collaborative approach to workforce planning. Without a shared and accepted vision of future requirements, workforce planning is unlikely to succeed.

OTHER ORGANISATIONS

276. There are a number of other national, regional and collective organisations (full details of which are provided in the Annex) which form part of the workforce planning system. Many of these organisations are very new and we heard little evidence about their effectiveness to date. Given their lack of proven usefulness, one option would be for the Department of Health to take back some responsibilities from these independent organisations. However, this would cause yet more disruption to the planning system, something which has done serious damage in the past.[444] Moreover, many of these organisations are so new that they have not yet had the opportunity to get to grips with their role.[445] Witnesses did not recommend a radical overhaul of these organisations but stressed the importance of them doing their jobs effectively.[446] In particular we heard that:

In order to improve productivity, the benefits from the new medical contracts and Agenda for Change need to be fully realised: NHS Employers has much of the responsibility for achieving this;[447]
For workforce planning to become more long-term and strategic, the quality of analysis of workforce supply and demand needs to be improved; at a national level, this is the responsibility of the NHS Workforce Review Team;[448]
The NHS Institute for Innovation and Improvement, has an important role in increasing workforce productivity, particularly by improving the quality of productivity information through the Better Care, Better Value indicators;[449]
The overall quality of workforce information needs to be improved and this depends in part on the work trades unions, Royal Colleges and other membership organisations which can provide expert information about particular staff groups.[450]
As the Sector Skills Council for health, Skills for Health should play a central role in workforce planning. It has made good progress in writing and disseminating the 'competence frameworks' which will allow workforce planners to increase the flexibility of the workforce.[451] Given the number of organisations involved with the planning process, however, there is a need for further clarity on where Skills for Health fits in, particularly as there is little evidence that this organisation has made a wider impact on workforce planning; and
Increasing workforce flexibility by creating new and amended roles requires greater involvement of healthcare regulators in workforce planning to ensure that roles can be disseminated quickly and that patient safety is maintained.[452]

277. A number of other organisations have key roles to play in improving workforce planning. Many of these organisations are very new and it is important that they are given enough time to establish themselves before their performance is assessed In particular, we recommend that:

NHS Employers ensure that local organisations have the right advice and information to realise benefits from the new staff contracts, for example by developing consultant productivity measures;
The NHS Institute for Innovation and Improvement has a vital role in helping to increase efficiency, particularly by providing accurate overall productivity information for local organisations;
The NHS Workforce Review Team continue to improve the quality of analysis of national workforce trends and work with SHAs, individually and collectively, to improve analysis at regional level; and
The role of Skills for Health in the workforce planning system and the health service itself be clarified as there is little evidence that this organisations has yet made an impact on workforce planning beyond the production of competence frameworks.

THE DEPARTMENT OF HEALTH

278. The role of the Department of Health in workforce planning has been inconsistent in recent years. For example, the Department set central targets for increasing the size of the workforce and the number of undergraduate training places in 2000 and 2002 but has not set such targets since.[453] The Department negotiated the terms of the new consultant contract and Agenda for Change but has subsequently passed responsibility for such negotiations to NHS Employers.[454] Also, the Department has remained closely involved with the planning of the medical workforce but has devolved responsibility for non-medical workforce planning to SHAs. Such inconsistencies demonstrate that there is continuing uncertainty about the appropriate role for the Department of Health in workforce planning. Below we consider what the Department's role should be.

Overseeing workforce planning

279. Witnesses argued that the Department should avoid micro-managing parts of the workforce planning system or setting central workforce targets.[455] This point was acknowledged by Lord Hunt, who commented that,

…you cannot micro-manage the Health Service from the centre, but you have got to put your trust in people locally to do the best that they can.[456]

Instead of micro-managing, therefore, the Department should play a more strategic role by providing good quality information and overseeing the work of SHAs.[457]

280. The Department's role in improving the quality of workforce information can be achieved in part by contributing high-quality information to the work of the NHS Workforce Review Team (WRT) and ensuring that WRT recommendations are in keeping with future service requirements and are acted on by SHAs and other workforce planning organisations. The Department should also ensure that SHAs have a good understanding of the current and future financial position, both in terms of changes in MPET allocations and changes in the overall health service budget.[458] Without a reasonable understanding of the global financial position of the NHS, SHAs cannot carry out effective medium or long term workforce planning.

281. The Department should play a more direct role in workforce planning and development by overseeing the work of the new SHAs. The Department must ensure that SHA Chief Executives make workforce planning a high priority and do not sacrifice long-term workforce developments in order to achieve financial balance. The Department should support the new SHA Workforce Directors as champions of workforce planning and development at national and regional level. However, the Department must do this without interfering excessively with the autonomy of SHAs or pressuring them into achieving specific numerical targets, as has been the case in the past.[459] This is a difficult balance to strike effectively, but it is an important goal if the workforce planning system is to be improved.

282. As part of its oversight role, the Department must ensure that Foundation Trust reform does not fragment the workforce planning system. Foundation Trusts will not be accountable to SHAs for their overall performance, but it is vital that they continue to collaborate with them on workforce issues.[460] Otherwise, as we explore in the box above, there is a risk that cooperation within the system will break down.

283. Finally, the Department must play a more effective role in overseeing active international recruitment by the NHS. In view of the boom and bust in international recruitment described in Chapter 2, the Department of Health needs to work more effectively with other departments, notably the Home Office, to ensure that international recruitment is fair and consistent and that those who come to the UK in response to active international recruitment receive fair treatment and equal opportunities. The Department's Code of Practice on international recruitment, which received necessary strengthening in 2004, has proved effective in most areas, but there is still evidence that employers are able to exploit loopholes in order to acquire staff from restricted countries and this must be addressed.[461]

Improving forecasting

284. Another important area for the Department is improving on its poor track record for costing national workforce changes, notably pay reform. The significant overspends on the consultant contract, GP contract and Agenda for Change, which we highlighted in Chapters 2 and 3, demonstrate that the Department has consistently struggled to accurately forecast future pay costs. It is hardly surprising that representatives of SHAs expressed uncertainty about the Department's assurances that the Modernising Medical Careers scheme will not lead to an increase in medical pay costs.[462] Department of Health officials assured the Committee that changes are already being made to improve the quality of modelling and forecasting.[463]

285. On a related note, the Department must do more to ensure that the workforce implications of new policies are properly assessed. Witnesses consistently stressed that new policy initiatives do not always include a clear analysis of related workforce requirements.[464] As one witness put it,

…some of their policies they actually have not really considered the financial implications of the workforce. If we take Our care, our health, our say, it is an excellent policy document, but actually what does that mean, not just in workforce terms but in the finances of workforce…[465]

In the case of Our Health, Our Care, Our Say, it is especially worrying that workforce implications were not apparently considered, given the importance of this policy for shifting activity into primary care. Again, Department of Health officials argued that improvements are being made in this area, but there was little evidence of their impact to date.[466]

286. The Department of Health must play a more consistent role in workforce planning. We welcome the Minister's acknowledgment that the Department should not micro-manage the planning system. Instead the Department should provide effective strategic information about, and oversight of, workforce planning and development. In particular, we recommend that the Department:

ensure that workforce planning is prioritised by SHAs and that SHAs employ capable Workforce Directors;
provide national information, for example about future funding levels, to form the basis of SHA decision-making;
issue guidance to Foundation Trusts to ensure that they play a full and consistent role in workforce planning;
ensure that future international recruitment is both ethical and better managed, taking account of the number of clinicians qualifying in the UK; and
improve its own ability to forecast the financial impact of workforce reforms and the staffing implications of all new policies, particularly following its consistent failure to cost new contracts accurately.