Supplementary evidence submitted by NHS
London (WP 34A)
1. EXECUTIVE
SUMMARY
1.1 This memorandum provides a re-submission
of evidence from NHS London to the Health Committee—workforce
needs and planning for the health service.
1.2 The memorandum describes how NHS London
is developing a health strategy for London that will inform health
care commissioning and inform workforce planning for London. The
workforce plan in turn will be implemented through commissioning
of service through PCTs.
1.3 The memorandum presents evidence in
response to each of the Health Committees terms of reference.
1.4 Since the publication of "A Health
Service of All the Talents" there has been some progress
with workforce planning. However the evidence points out that
the planning of medical training numbers is still carried out
separately from workforce planning for all other NHS staff.
1.5 The impact of "Commissioning a
Patient led NHS" on workforce planning is considered alongside
the impact of an ageing population, advances in technology and
other policy changes. In particular it considers how CPlNHS puts
the focus on community health care delivery being managed through
commissioning. The evidence highlights how this will require consideration
of workforce planning, development and education commissioning
to be carried across different providers from health, social care,
independent and voluntary sectors.
1.6 How the workforce and workforce planning
is affected by financial constraints is also considered. The evidence
makes the case that as long as future funding broadly aligns with
future demand financial challenges should not in themselves represent
a threat to the workforce. However to plan a workforce able to
respond to the demands of future health care provision the NHS
must be able to use funding flexibly rather than have it tied
to particular targets or specific project.
1.7 The evidence looks at demand for clinical
and non-clinical staff, and the need to ensure that workforce
plans are sustainable over the longer term. As growth in funding
slows we need to manage the NHS workforce closely, ensuring that
it is appropriately directed at service need and that workforce
productivity is maximised.
1.8 The memorandum makes three recommendations
for future workforce planning:
— To facilitate integrated workforce
planning for all staff groups (medical and non-medical) in order
to ensure that workforce planning appropriately underpins service
commissioning.
— Ensure that the NHS can direct funding
flexibly to underpin workforce plans.
— At a national level, integrate workforce
policy with health policy to support the alignment of workforce
planning with service commissioning.
2. INTRODUCTION
2.1 The original submission of evidence
to the Health Select Committee was submitted on behalf of the
5 SHAs for London in March 2006. NHS London, the Strategic Health
Authority for London, came into being on 1 July 2006.
2.2 The DH in May 2006, described one of
the key function for SHAs as:
"Workforce development, including (a) ensuring
all aspects of workforce supply—including education, training,
and workforce planning—best support service demand; and
(b) leadership development, including talent management; all in
partnership with PCTs and providers".
(PCT and SHA roles and functions, May 2006).
2.3 NHS London will be discharging this
responsibility through the Director of People and Organisational
Development and senior workforce strategy and planning posts.
The organisation structure enables NHS London to manage the development
of PCT Commissioning separately to the development of providers
into Foundation Trusts which is undertaken by the Provider Development
Agency an arms length body of the SHA. A Health Strategy for London
will inform the commissioning of services for the capital and
direct workforce planning to support it.
2.4 The key priorities for NHS London currently
are:
— Managing the financial position of
the NHS in London. This will have an impact for workforce planning
in NHS London as service and workforce is reconfigured to address
the both the immediate and long term financial position.
— Developing a health strategy for
London. A complimentary workforce plan for London will be key
to ensuring that the appropriate workforce is available to deliver
the required healthcare outcomes for London.
— Managing the transition from the
five previous health authorities due to be completed by 31 March
2007. This process will see the reduction in the number of staff
employed at health authority. Workforce planning is a key component
of the structure for NHS London at a senior level.
2.5 This re-submission of evidence re-frames
evidence previously submitted reflecting the role that one SHA
for London has and reflecting the strategic priorities. The evidence
is presented under each of the Committee's terms of reference.
3. HOW EFFECTIVELY
WORKFORCE PLANNING,
INCLUDING CLINICAL
AND MANAGERIAL
STAFF, HAS
BEEN UNDERTAKEN
AND HOW
SHOULD IT
BE DONE
IN THE
FUTURE?
3.1 Historically workforce planning for
most NHS staff including nursing, allied health professionals
and managerial staff has been carried out in a bottom up method
with trusts and PCTs informing the intermediate tier (SHA or WDC)
of their workforce plans and linking this into their local delivery
plans. This has relied on each employer having the workforce planning
knowledge and expertise to do this effectively which is often
not the case.
3.2 Workforce planning that informs education
for undergraduate medical staff is carried out away from NHS Providers
by the DH through the national quota system delivered through
HEFCE based on information from the NHS Workforce Review Team's
replacement model. PMETB is a national body responsible for the
assuring the quality of training of junior doctors, SHAs sign
off the MADEL allocations and the Deaneries approve the trusts'
training posts every three years. The implementation of Modernising
Medical Careers is underway and London is assessing the impact
of full implementation next year.
3.3 These two separate approaches to workforce
planning has often resulted in disjointed workforce planning for
the NHS.
3.4 The WDCs and SHAs have done much to
ensure that workforce planning is integrated with financial and
activity planning at an intermediate and local level. The work
of the WDCs has improved workforce planning to the education commissioning
process particularly as the LDPs have become the main focus for
integrated planning.
3.5 In response to "A health service
of all the Talents" the commissioning and provision of education
and training has developed longer contracts and forged strong
relationships with education providers of both pre-and post-registration
training. WDCs in London have developed strong stakeholder engagement
through stakeholder boards with both education providers an NHS
employers represented. Clinical placement facilitators have ensured
that there are sufficient clinical placements for the increased
numbers of students coming through training. However the introduction
of the national contract and national contract price has been
slower than envisaged owing to the length of term of existing
contracts and further negotiations with all parties.
3.6 The Modernisation Agency and subsequently
WDCs promoted the development of new roles and new ways of working.
The NHS in London adopted the methodologies and was an early implementer
for many new ways of working. However this work is in it infancy
and there needs to be more sharing of the learning and embedding
new roles.
3.7 "A Health Service of all the Talents"
also gave rise to Agenda for Change and the new GP and consultant
contracts which have all been implemented across London. The focus
has been on implementation to national timetables and now the
benefits arising form the pay modernisation need to be realised
in terms of productivity gain.
3.8 Workforce planning for primary care
staff still remains a challenge as many staff employed in primary
care are not directly employed by the NHS but by independent GP
practices. Workforce and service data is currently largely unavailable
for this key area.
The Future
3.9 NHS London will develop a health strategy
for London that will set out the strategic direction for health
and social care across the capital to achieve the government health
policy objectives. The Health Strategy will inform PCT commissioning
intent and therefore the workforce plan will necessarily closely
aligned.
3.10 The Commissioning regime for London
has three key elements to its five year strategic plan:
The Strategic Plan establishes direction
and sets priorities in light of the changing environment. It will
be submitted annually, have a major refresh every three years,
and provide a five- to 10-year outlook.
The Operating Plan describes in-year
working priorities with detailed targets, financial plans and
action plans to accomplish the Strategic Plan's goals. It will
be produced annually.
The Capability Development Plan sets
out the capabilities required to deliver the strategy, current
capability gaps, and how these will be filled. It will be produced
in parallel with the Strategic Plan: annually, with a major refresh
every three years.
3.11 The plan will be future focused and
will be developed in conjunction with stakeholders, education
providers, national bodies and other health care providers to
ensure that it reflects future health care provision in London.
It will necessarily be a working document that reflects different
scenarios and expectations of health care providers. It will act
as a template for employers providing some expertise but will
also provide a model from which to monitor workforce performance.
4. IN CONSIDERING
FUTURE DEMAND,
HOW SHOULD
THE EFFECTS
OF THE
FOLLOWING BE
TAKEN INTO
ACCOUNT?
4.1 Recent policy announcements, including
Commissioning a Patient Led NHS
The NHS Plan heralded significant investment
in the NHS and growth of the healthcare workforce. Since 2000
NHS employers have had workforce targets that focus on growth
of the health care workforce. However the investment to implement
the NHS plan is to end in 2008. The continuation of improvement
in health care will rely on greater workforce productivity and
alternative approaches to workforce development.
4.2 The Health Strategy for London will
reflect "Our health Our care Our Say" and the shift
form acute care provision to health care closer to home. The workforce
plan will reflect this by considering the impact on the workforce
of changing models of care and associated care pathways. We will
need to become effective at planning across employer organisational
boundary (independent, voluntary and social services sectors)
to ensure that the appropriate workforce is recruited and trained
to effectively deliver the changes required.
4.3 Technological change
4.3.1 Electronic Staff Record will provide
a much needed consistent baseline of information for NHS employers
about current workforce—how many staff with details on WTE,
occupation code, leavers, joiners etc available through the data
warehouse to SHAs and the central DH team without the need to
specifically collect any data. Therefore ESR will make analysis
of the current position much easier but, on its own, will not
be able to project future staffing or training requirements as
this requires an advanced level of informed estimation.
4.3.2 Connecting for Health—there
has been no specific exercise by CFH London to assess the implications
for workforce planning in London of the implementation of NPfIT.
The expectation is that as Trusts and PCTs update their workforce
plans, they would anticipate changes in workforce that will be
enabled by the new IT available to them through Connecting for
Health.
4.3.3 To assist Trusts and PCTs in doing
this, CFH is:
— Making clear to the NHS what functionality
will be available.
— Supporting the NHS on the identification
of benefits to be gained from implementation of new products.
— Ensuring there is a process for the
sharing of lessons learned.
— Working with BT and the NHS on process
redesign to implement the system and to support wider service
change.
4.3.4 Overall there is a planned approach
to ensuring appropriate training of NHS staff to use the new technology.
This involves developing both the capability and capacity within
the NHS for IT Training. The underlying expectation of the new
IT is that in the future health and care professionals involved
with direct patient and service user care will have safe, fast,
modern IT to support them routinely in their work.
4.4 An ageing population
4.4.1 The highest population projection
for London for 2015-16 predicts an increase of 850,000 on top
of the current population of approx 7.5 million (+11.3%) and the
lowest predicts an increase of 500,000 (+6.6%).
4.4.2 The chart shows the planned change
in age structure for London (using the ONS projections) and compares
this with the projected age structure for England. This demonstrates
that nationally the over 65s will increase by 50% compared with
London where the increase will be much lower at 26% (but still
a substantial increase). The change in the over 85s is a particular
concern for healthcare planning as this age group uses significantly
more health resources than younger people.
4.4.3 The Older persons NSF states that
as well as chronic illness, older people are also more likely
to have a disability. Nearly half of disabled people are aged
65 or older. The most common problems relate to movement and to
vision and hearing. Sensory impairments become increasingly common
as people age: around 80% of people over 60 have a visual impairment,
75% of people over 60 have a hearing impairment, and 22% have
both a visual and hearing impairment. These disabilities can reduce
the ability of older people to look after themselves, resulting
in a need for personal care. This in turn will have an impact
on the nature and provision of health and social care.
4.4.4 London is anticipating a significant
rise in the 45-54s which indicates that the local labour market
will still be available but older; the reduction in 35-44s (less
marked in London) however indicates that there will be a shortfall
in the succession market.
5. THE INCREASING
USE OF
PRIVATE PROVIDERS
5.1 Through commissioning of health care
for London NHS London will engage with both health care providers
and providers from the independent sector. The workforce will
be affected as providers change as a result of commissioning decisions.
Therefore we need to plan flexibly to ensure that the appropriate
skills, competence and education support is available in the workforce
to deliver the health care desired.
5.2 NHS London, through the development
of the workforce strategy for London will make links with health
care providers across London (social care, independent and voluntary
sectors) to ensure that we take a whole systems approach to workforce
planning and development in London.
6. HOW WILL
THE ABILITY
TO MEET
DEMANDS BE
AFFECTED BY
6.1 Financial constraints
6.1.1 In response to the NHS Plan workforce
numbers have grown considerably over the past six years with the
number of non-medical staff in London increasing by 26% (compared
with England at 20%). The majority growth has been in clinical
support posts (+280%) rather than in qualified nursing numbers
(+4%). Medical staff has grown by 45% during the same period.
London employs more than one fifth of the total NHS labour force.
6.2 MPET funding
6.2.1 Up to 2006-07 central training funding
has enjoyed significant levels of growth commensurate with the
overall levels of increased investment in the NHS as a whole.
This additional funding made a significant contribution to addressing
historic workforce shortfalls (ie vacancies) even through a period
of rapidly increasing workforce demand.
6.2.2 It is clearly important to ensure
that the NHS both locally and nationally has a financial strategy
for workforce which supports and underpins the broader workforce
strategy itself. This is both in respect of the overall amount
of investment but perhaps as importantly in the flexibility of
how resources are used.
6.2.3 It would be difficult to argue that
the level of funding alone, unless significantly out of line with
the broader workforce strategy should be a material constraint
to meeting workforce demands.
6.2.4 The specific financial challenges
faced in 2006-07 should not in themselves represent a material
threat to meeting future demand, as long as future funding broadly
aligns with future demand. The fact that this funding is now a
component of a wider "bundle" of central funds delegated
to SHAs will only become an issue if this resulted in funding
and demand becoming misaligned. We would anticipate that future
funding for workforce development will mirror the context for
NHS funding in general ie lower levels of growth in funding compared
to recent increases.
6.2.5 There is still significant additional
value for money which can be extracted from current investment.
Such additional value can be delivered through improved delivery
of existing activities, both in respect of innovation in delivery
and through a more thorough approach to education procurement
and performance management.
6.2.6 However the greater value for money
is likely to be delivered by ensuring investment is targeted at:
(i) delivering a workforce which is closely
aligned with emerging service strategy and service developments;
and
(ii) delivering a workforce which it supports
productivity in service delivery (including assuring appropriate
quality and patient safety).
6.2.7 It is in meeting services demand for
a more productive workforce that the inflexibility in the existing
funding regime can represent a constraint. For example the shift
to out of hospital care will require a significantly different
skill mix eg primary care paramedics. however the funding regime,
with its focus on funding defined activities can act as a barrier
to developing new staff with such skills, by preventing the rapid
redeployment of resources.
6.2.8 Activities which are clearly "self
funding" in terms of productivity should not require central
resources to be delivered, but it is imperative that we improve
our ability to demonstrate the "bottom line" value of
workforce development so health & social care organisations
make improved use of there own resources.
6.2.9 These two areas highlight the importance
of being able to use resources flexibly, rather than being constrained
by either funding methodology or the ring fencing of resources
for specific activities.
6.2.10 Alternative models for funding and
commissioning workforce activity continue to be discussed, but
it is important that any proposal that addresses perceived weaknesses
in existing arrangements do not have unintended consequences of
limiting the ability to generate maximum value from this important
use of public funds.
6.3 Gershon Efficiencies
6.3.1 The Gershon productivity targets focussed
on the following workforce issues:
6.3.2 Spending on agency has decreased over
the past two years—work done by the National Agency Project
has shown that the 33 participating trusts have reduced their
agency spend by £50 million in the year and that £45
million of this saving was achieved by the participating 17 trusts
in London. Across London, Trusts and PCTs in London will spend
approximately £200 million on medical and non -medical agency
fees in 2006-07 and this represents 3.5% of the total paybill
compared with the national rate of 2.5%. Although acute trusts
employ two thirds of the staff in London they only account for
just over half the total agency spend.
6.3.3 Bank staff represented approximately
7% of the total workforce at the beginning of the year and this
had fallen to 6% by the end October 2006. This means that the
WTE of bank staff has fallen by 13% in seven months to 8,000wte.
6.3.4 London is currently below plan for
agency spend (-9%) compared to the national picture (+5.3%) and
slightly above plan for medical locum spend (+1.3%) compared to
the national (+30.8%).
6.3.5 Turnover has fallen by an average
1% year on year for all staff to an average of 14%.
6.3.6 Sickness has also fallen and is slightly
lower in London than in England.
|
| Sickness Rate | National
| London |
|
| 2003-04 | 4.70% | 4.30%
|
| 2004-05 | 4.60% | 4.20%
|
| 2005-06 | 4.50% | 4.10%
|
% Decrease over Period |
-4.26%
|
-4.65% |
|
6.3.7 The task for NHS London is to work closely with the DH to develop workforce productivity measure that measures change efficiency in working practice.
| | |
7. THE EUROPEAN
WORKING TIME
DIRECTIVE AND
MODERNISING MEDICAL
CAREERS
7.1 Modernising Medical Careers aims "to improve
patient care by delivering a modernised and focused career structure
for doctors through a major reform of postgraduate medical education.
To develop demonstrably competent doctors who are skilled at communicating
and working as effective members of a team. MMC will also bring
about significant changes to career structures, providing qualified
staff who are able to meet the needs of patients."
7.2 Running alongside MMC implementation is the need
to reduce junior doctors' hours to 48 by August 2009 in line with
EWTD. Most London Trusts have made some progress, but still have
a long way to go in the next two years to reduce the hours of
all their trainees.
7.3 MMC has not led to an increases overall in the number
of doctors employed though some specialties will be training more
doctors and some less. Therefore the additional reduction in hours
by 2009 at the latest means that Trusts will have to review all
service provision to ensure that it is appropriately covered and
undertaken by doctors or by other appropriately trained health
professionals. Many of these professionals are already employed
in Trusts, some such as the recently approved medical and surgical
care practitioners are currently being recruited to training programmes.
Alternatively MMC and EWTD will promote the need to look at different
models of provision such as clinical networks.
7.4 Expansion in UK medical schools will increase the
number of graduates. These graduates will have an expectation
of being recruited onto a training programme and there is a risk
with anticipated reconfiguration of the acute sector that there
may well be an oversupply of doctors in future years. The workforce
planning implications of this will need to be reflected in the
workforce plan.
7.5 The increase in medical school places should mean
that most MMC places will be filled by UK trained graduates. This
should reduce the London NHS' historical reliance on doctors from
overseas, and this is already becoming apparent.
8. TO WHAT
EXTENT CAN
AND SHOULD
THE DEMAND
BE MET
FOR BOTH
CLINICAL AND
MANAGERIAL STAFF?
8.1 The nature of the demand for health workforce has
changed. The demand in terms of workforce growth has been achieved.
The requirement now is for new roles to support the changing health
care provision and increased productivity. NHS London will manage
this workforce agenda through delivering the health Strategy for
London through service commissioning.
8.2 New models of care arising from the health strategy
may have an impact on the configuration of services and this will
need to be reflected in the workforce plan and managed appropriately
to minimise impact on the workforce.
8.3 In response to the changing financial context plans
are in place to reduce the workforce establishment in London from
135,000 to 130,000 posts (-4%) by April 2007; These changes will
be managed in a number of ways—closely managed recruitment,
reducing temporary staff usage (bank and agency), capitalising
on turnover and redundancy as a last resort.
8.4 Finance Information Monitoring System (FIMS) already
show that the WTE staff in post in London have fallen by 2000
(-1.5%) in the last seven months. Comparing this with the redundancy
data shows that over 80% of this reduction was achieved through
staff turnover rather than redundancies. During this period the
PCTs have lost 2.7% of their staff whilst the acute trusts and
mental health trusts have lost approx 1.5% of their substantive
staff at the end March 2006.
| | |
|
London NHS
WTE Staff in post
|
end March
2006 | end
October
2006
| Forecast
outturn end
March 2007
|
| in 000s |
in 000s | in 000s
|
| | |
|
| Acute trusts | 84.5 | 83.1
| 82.0 |
| PCTs | 25.3 | 24.6
| 25.5 |
| Mental Health trusts | 17.0
| 16.8 | 17.1 |
Total | 126.8
| 124.5 | 124.6
|
| | |
|
| | |
|
8.5 London is currently below plan for staff in post
(-3%) and for paybill (-2%)—these percentage variances are
similar to the national figures.
9. HOW SHOULD
PLANNING BE
UNDERTAKEN?
9.1 The Workforce Plan for the NHS in London will reflect
the health strategy and will be relevant to health care outcomes
required for London. This will provide a long term view of the
workforce in London to inform health care commissioning expectations
and to inform health and education commissioning. In addition
NHS London will provide workforce planning expertise and over
view for employers to use as a template for local planning.
9.2 The SHA will need to build alliances with a number
of stakeholders—education providers, social care, independent
and voluntary sectors to ensure that workforce planning at the
intermediate tier informs health care commissioning and appropriately
reflects health care provision now and in the future.
9.3 The NHS London workforce plan, to support the Health
Strategy for London, will rely on a robust national picture of
the workforce, local employer baseline data and education forecasting.
Therefore workforce planning should be the concern of the employer,
the SHA and Department of Health as each level contributes to
the overall plan.
9.4 However In order for workforce planning to be sustainable,
the whole workforce should be planned as one. Medical and non-medical
workforce must be a planned together to ensure that the interdependencies
are recognised, and to ensure that workforce planning truly reflects
health care provision.
9.5 At a national level health policy and targets should
not constrain the flexible use of funding to support commissioning
by tying resource to particular projects or to specific targets.
The use of funding will be informed by the health strategy and
supporting workforce plan.
9.6 In addition, at a national level, the close integration
of workforce policy with finance and health policy will assist
with the alignment of workforce planning with service commissioning.
9.7 In conclusion although much has been done to improve
workforce planning in the NHS over recent years, there remain
a number of steps to take to ensure that activity, finance and
workforce planning are further integrated for the whole health
care workforce. Current policy provides further challenges with
the encouragement of a plurality of providers, but also provides
an opportunity to ensure that workforce is at the centre of health
care planning with the focus on commissioning of health services
for the future.
NHS London
11 December 2006
| 
