Conclusions and recommendations
Chapter 2
1. The
health service workforce has changed dramatically in recent years,
most notably through the major increase in staff numbers which
took place between 1999 and 2005. Rapid workforce expansion was
a necessary response to the "crisis" in staffing numbers
described in the Committee's 1999 report. However, the rate of
growth considerably exceeded expectations, and far outstripped
the targets set in the NHS Plan. Given the increase in
funding levels, such a high level of growth was inevitable. Many
new staff were recruited from overseas because of limited availability
of UK staff. Eventually, many organisations recruited more staff
than they could afford to pay. This was a major cause of the widespread
deficits which emerged across the NHS from 2004-05 onwards. (Paragraph
72)
2. In response to
the deficits which emerged in 2004-05, the expansion of the workforce
has slowed down and, in places, reversed. Overall staff numbers
are now falling. Provider organisations have made large numbers
of job reductions and some compulsory redundancies and many healthcare
graduates have experienced unemployment. Strategic Health Authorities
have cut the number of domestic training places, immediately after
a period of sustained growth. During the growth phase, employers
mainly increased capacity through international recruitment as
they could not wait for domestic training output to increase.
Now international recruitment has in turn been suddenly and sharply
restricted. (Paragraph 73)
3. In parallel with
the expansion in staff numbers, pay rates for the majority of
health service staff have increased substantially in recent years.
Senior doctors have received the most generous pay rises but the
Agenda for Change agreement has ensured that virtually
all NHS staff have benefited from increases. The costs of pay
reform have been extremely high and have absorbed a large proportion
of the extra money allocated to the health service in recent years.
Actual costs have consistently exceeded Department of Health projections
and this has contributed to deficits in some organisations. As
with staff numbers, pay growth is now being curtailed with below
inflation increases for all staff in 2007-08. (Paragraph 74)
4. There have been
a number of attempts in recent years to introduce new ways of
working to the health service. A range of new clinical roles have
been established in order to increase workforce flexibility, and
there have been some efforts to improve retention, increase productivity
and reform education and training. However, the scale of progress
on workforce reform pales in comparison with the scale of staffing
growth and pay increases which took place over the same period.
Reform has also been hampered by repeated changes to organisational
structures and by recent cuts in education and training provision.
(Paragraph 75)
5. There is clear
evidence of a boom and bust cycle within each of these areas.
The boom occurred between 1999 and 2005 as staff numbers and pay
levels increased with unprecedented speed. The emergence of deficits
after 2005 triggered the start of a bust phase with widespread
job reductions, sweeping education and training cuts and severe
pay restrictions. During both phases, workforce changes have tended
to respond to prevailing financial trends, and the workforce reform
agenda, articulated by A Health Service of all the talents,
has too often been overlooked. The expansion of the workforce
was reckless and uncontrolled and increases in funding were often
seen as a blank cheque for recruiting new staff. Such problems
raise serious questions about the effectiveness of the current
workforce planning system. (Paragraph 76)
Chapter 3
6. There
are a number of weaknesses in the current workforce planning system.
Most fundamentally, there is a shortage throughout the health
service of the people, organisations and skills required for workforce
planning. Persistent structural changes have exacerbated this
problem, particularly at regional level. The new SHAs seem to
lack capacity for workforce planning even though they have a vital
role to play. The removal of Workforce Development Confederations
and the Modernisation Agency left gaps which remain unfilled.
Local organisations have struggled even to provide accurate workforce
information to support decision-making. Workforce planning appears
to remain a secondary consideration for many organisations. (Paragraph
148)
7. Lack of integration
between different parts of the planning system remains a widespread
problem. The difficulties caused by the separate planning systems
for medical and non-medical staff groups were pointed out by this
Committee 8 years ago but have still not been effectively addressed.
Medical and non-medical planning is still done by separate organisations
with separate funding streams, which inhibits the ability of SHAs
to plan effectively by looking at total workforce requirements.
The workforce planning system has also failed to involve the private
and voluntary sectors adequately, particularly since the loss
of separate Workforce Development Confederations. This is a serious
failing, particularly in the context of the increasing use of
the independent sector to provide NHS services. (Paragraph 149)
8. Of particular concern
is the continuing lack of integration between workforce planning
and financial planning. There are shocking examples of failures
at local level with some organisations continuing to recruit large
numbers of staff in spite of rising financial deficits. But the
Department of Health has made equally serious mistakes at national
level, in particular by failing to ensure that targets for increasing
staff numbers were consistent with the level of funding available.
Both in local organisations and at the Department of Health, workforce
planning and financial planning have been done by separate teams
in separate places and little has been done to bring the two processes
together. (Paragraph 150)
9. Effective workforce
planning, particularly in healthcare, must include a long-term
element. This has been badly wanting in health service workforce
planning, partly because there is no formal long-term planning
system, but more importantly because NHS organisations tend to
be too focused on short-term priorities. Recent cuts to training
provision and other workforce development activities have shown
an especially worrying disregard for long-term workforce priorities.
The Committee is deeply concerned to hear from a key workforce
leader that long-term planning is at risk of being abandoned in
parts of the NHS. (Paragraph 151)
10. Increasing workforce
productivity is a vital goal that has been badly neglected by
the workforce planning system. The Committee was dismayed to hear
that improving productivity was not an explicit aim of the NHS
Plan. The resultant lack of focus on increasing efficiency
during the recent period of rapid growth in staff numbers was
reckless and unwise. We were equally concerned by the suggestion
that the new consultant and GP contracts may have reduced the
productivity of these vital staff groups. Pay rates for senior
doctors have increased substantially without evidence of corresponding
benefits for patients. This is indicative of the lack of overall
focus on improving workforce productivity. (Paragraph 152)
11. Increasing workforce
flexibility is an important and related goal and some progress
has been made in recent years, particularly through the development
of new and amended roles. However, not enough has been done to
prove that all these changes are cost effective. Even when skill
mix changes have proved to be effective, recent cuts in training
capacity have targeted staff in new roles and hampered attempts
to increase flexibility. The current structure of education funding
does not support the development of a more flexible workforce
and there is a shortage of flexible training opportunities. (Paragraph
153)
12. A Health Service
of all the Talents set out a blueprint for improving workforce
planning through a stable system with dedicated workforce organisations
and a clear focus on improving flexibility and productivity. The
health service has lost sight of this vision and marginalised
workforce planning. The situation has been exacerbated by persistent
structural change. The system remains poorly integrated and there
is a shortage of staff with the necessary skills for effective
workforce planning. In light of the need for increased activity,
organisations tended to throw extra workers at the problem rather
than increasing the efficiency of existing staff. Even when positive
changes which might improve productivity, such as the new contracts
and new clinical roles, have been introduced, benefits have not
been properly realised. In particular, the current wave of education
and training cuts has led to a number of backward steps for workforce
development. Basic problems such as the disjunction of workforce
and financial planning persist at all levels of the system. Despite
great efforts in some quarters, the workforce planning system
is not performing noticeably better than 8 years ago. (Paragraph
154)
Chapter 4
13. 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. (Paragraph 215)
14. 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.
(Paragraph 216)
15. 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. (Paragraph 217)
16. 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. (Paragraph 218)
17. 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. (Paragraph 219)
18. 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.
(Paragraph 220)
19. 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. (Paragraph 221)
20. 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. (Paragraph 222)
21. 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. (Paragraph 223)
22. 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. (Paragraph 224)
23. 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. (Paragraph 225)
Chapter 5
24. 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. (Paragraph 235)
25. 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. (Paragraph
236)
26. 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. (Paragraph 245)
27. 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. (Paragraph 246)
28. 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. (Paragraph 247)
29. 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. (Paragraph 251)
30. 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. (Paragraph 252)
31. 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. (Paragraph 257)
32. 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. (Paragraph 264)
33. 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. (Paragraph 265)
34. 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. (Paragraph 269)
35. 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. (Paragraph
275)
36. 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. (Paragraph 277)
37. 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. (Paragraph 286)
Chapter 6
38. In
2000 the Government published an excellent blueprint for workforce
planning entitled A Health Service of all the talents.
Figures were set for a large increase in the number of staff employed
by the NHS in the NHS Plan. There was also to be a significant
expansion in the number of training places for clinicians. However,
the huge growth in funds provided by the Government, together
with the demanding targets it set, ensured that the increase in
staff far exceeded the NHS Plan. By 2005 there were signs
that the NHS was spending too much. Boom turned to bust. Posts
were frozen, there were some, albeit not many redundancies, but,
most worryingly, many newly qualified staff were unable to find
jobs and the training budget was cut. (Paragraph 287)
39. Although the Government
argued for improvements in productivity, in practice little happened.
It was too easy to throw new staff into the task of meeting targets
rather than consider the most cost-effective way of doing the
job. There were large pay increases but adequate steps were not
taken to ensure increases in productivity in return. There were
attempts to create a more flexible workforce and improve the skills
of staff so they could take on more complex and responsible tasks.
The results of these efforts have been mixed: in some cases there
have been no savings, in others the results have been successful.
Unfortunately, the cuts in the training budget threaten what successes
there have been. (Paragraph 288)
40. In sum, there
has been a disastrous failure of workforce planning. Little if
any thought has been given to long term or strategic planning.
There were, and are, too few people with the ability and skills
to do the task. The situation has been exacerbated by constant
re-organisation, including the establishment and abolition of
WDCs within 3 years. In sum, the health service, including the
Department of Health, SHAs, acute trusts and PCTs, have not made
workforce planning a priority, with the consequences we can now
see. (Paragraph 289)
41. Given the pace
of change, including technological developments and the unpredictable
consequences of policies such as Payment by Results, we cannot
know precisely what future workforce will be needed. This means
we will need a more flexible workforce. There are currently many
opportunities to increase productivity and obtain better value
for money. There will be more opportunities in future. It is important
that the workforce has the incentives to take them. (Paragraph
290)
42. To avoid the boom
and bust of recent years and produce a workforce appropriate for
the future, there has to be change. However, we do not support
further restructuring. Persistent reorganisation has caused many
of the current problems. It matters less which organisation does
the job than that it is done well and taken seriously. Therefore,
despite their failings to date, we recommend that workforce
planning continue to be undertaken by SHAs. (Paragraph 291)
43. We propose one
key change: workforce planning must become a priority for the
health service. In practice, this means a number of straightforward
but important improvements. SHAs must recruit as workforce planners
people of the highest calibre and ensure that they are supported
by staff with the appropriate skills. Most human resources staff
do not have these skills. Others organisations, including trusts
and the Department of Health, must improve the quality and accuracy
of the information they produce on a range of matters, including
workforce forecasts, productivity and the cost of new policies.
Finally, the Department of Health must stop micromanaging. In
addition to ensuring SHAs have information of a high quality,
the Department should act in an oversight capacity ensuring that
SHAs are giving workforce planning the priority its importance
requires. (Paragraph 292)
| 
