Evidence submitted by Reform (WP 80)
STAFFING AND HUMAN RESOURCES IN THE NHS—FACING
UP TO THE REFORM AGENDA
DEFECTS OF
CURRENT SYSTEM
1. The effects of centralised manpower planning
are negative. There are three general defects of the central planning
system:
1.1 Human resources are planned on a silo
basis without regard to team building, contrary to the fact that
it is impossible to make sensible decisions about medical manpower
without regard to other team members and supporting staff that
play vital roles in patient care. In primary care, where there
is more scope for local initiative in staffing, the chosen mix
is now very different from the hospital service with fewer doctors
and more practice nurses and support staff. The number of consultants
has increased by 70% in the past 10 years while the number of
GP's has risen by 10-15%.
Table 1
NUMBER OF DOCTORS, 1994-2004, FULL TIME EQUIVALENT
| 1994 | 1996 |
1998 | 2000 | 2002
| 2004 | 1994-2004
% increase
|
Consultants | 16,500
| 18,600 | 20,400 | 22,200
| 24,800 | 28,100 | 70
|
| Hospital registrars | 10,600 |
10,700 | 11,600 | 12,200
| 13,000 | 16,100 | 52
|
| Other doctors in training | 115,500
| 17,300 | 18,500 | 19,000
| 20,900 | 24,500 | 58
|
| Other medical and dental staff | 24,900
| 5,600 | 6,400 | 7,100
| 8,200 | 8,600 | 76
|
| GMPs including registrars | 27,500
| 27,500 | 27,800 | 28,200
| 28,700 | 30,800 | 12
|
| All doctors | 76,800 | 81,800
| 86,600 | 90,200 | 97,000
| 109,200 | 42 |
Source: Department of Health. NB Figures are rounded and do not include retainers.
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1. Includes PRHOs, SHOs, F1 and F2 pilots and equivalents.
2. Includes associate specialists, staff grades and community
and public health medicine and dental staff*
1.2 A total lack of focus on cost and economics. Doctors
and other staff represent a major cost yet decisions on staffing
levels appear to have been taken without reference to levels of
funding. The Department of Health has yet to bring forward long
term cost estimates for staffing (and other programmes).
1.3 An emphasis on quantity rather than quality. Healthcare
Commission analysis has shown that inexperienced nurses achieve
lower levels of patient satisfaction than a smaller number of
experienced nurses.
2. These defects are now about to impact on services
and on staff ability to deliver care:
2.1 The combination of a doubling in the number of medical
trainees, a low level of retirements and a very tight financial
environment means that there is likely to be severe medical unemployment
in coming years. There are far more young doctors graduating than
the number of funded posts likely to be available. Even before
the recent financial problems of the NHS there was clear evidence
of a gap between numbers graduating and numbers retiring. Recent
financial problems mean that the problem is likely to be brought
forward as acute trusts which carry out most of the training are
most affected.
Table 2
MEDICAL SCHOOL INTAKE, ACTUAL OUTPUT AND PROJECTED OUTPUT,
ENGLAND: 1991-92 to 2008-09
| Academic Year |
Intake | Graduate Output
|
| 1991-92 | 3,191
| 2,788 |
| 1992-93 | 3,263
| 2,759 |
| 1993-94 | 3,374
| 2,866 |
| 1994-95 | 3,514
| 2,911 |
| 1995-96 | 3,486
| 2,983 |
| 1996-97 | 3,594
| 3,025 |
| 1997-98 | 3,749
| 3,261 |
| 1998-99 | 3,735
| 3,097 |
| 1999-2000 | 3,972
| 3,373 |
| 2000-01 | 4,300
| 3,286 |
| 2001-02 | 4,713
| 3,280 |
| 2002-03 | 5,277
| 3,522 |
| 2003-04 | 6,030
| 3,734 |
| 2004-05 | 6,294
| 3,935 |
| 2005-06 | 6,2981
| 14,394 |
| 2006-07 |
| 5,083 |
| 2007-08 |
| 5,676 |
| 2008-09 |
| 5,798 |
Source: HEFCE
1 This figure is provisional until November 2006 when a finalised
figure will be declared.
2.2 There are serious shortages in some key areas of staffing.
The expansion in staffing has been very patchy with some areas
of care likely to have situations of rising workload and declining
staff hours. This can be illustrated particularly in areas as
diverse as midwifery and in radiotherapy for cancer patients where
there will be little change in hours available.
Table 3
NUMBER OF WORKING MIDWIFE HOURS PER WEEK, UK
| 1994 |
2004 | Change |
% change |
Full time hours per week | 783,338
| 487,463 | -295,875 | -37.8
|
| Part time hours per week | 320,355
| 465,480 | +145,125 | +45.3
|
| Total hours per week | 1,103,693
| 952,943 | -150,750 | -13.7
|
Source: Statistical Analysis of the register, Nursing and Midwifery Council, August 2005
Assumptions: full time hours per week = 37.5; part-time median hours per week = 22.5
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2.3 The NHS has much higher rates of sickness absence
and lower morale than many smaller independent organisations.
The recent Royal College of Nursing report, At breaking point?
A survey of the well being and working lives of nurses in 2005,
is a striking indictment of the system as it has worked. There
is good recent survey evidence that stress levels among nurses
have already risen and are now nearly twice as high as in the
population generally.
2.4 There is a tendency to exaggerate the increase in
human resources in nursing, especially in relation to on-the-ward
hospital nursing. Increased entry into training is likely to be
accompanied by a higher drop out rate in the early career years
and many experienced nurses have moved to new posts as specialist
nurses and nurse consultants. The realistic outlook for nursing
is one in which there will be little or no increase in experienced
staff hours in a situation where nursing care has become much
more complex and clinically demanding.
REFORM
3. Centralised silo manpower planning has produced a
staffing investment which is unbalanced and unaffordable. We welcome
moves towards family-friendly policies and better human resource
management as set out in Agenda for Change but such improvements
are likely to be undermined by the overall crisis of affordability
which is likely to lead both to reduced options for staff in post
as well as to further redundancies.
4. There is an urgent need for a new approach to human
resources which will support reform. The new approach will be
driven by elements of the current reform programme:
4.1 Foundation Trusts, a greater variety of providers
and practice based commissioning of new services will drive the
system towards much more local and flexible systems of staff roles
and pay structures. National agreements will play a declining
role, based on defining minima.
4.2 Payment by results and patient choice will come increasingly
to mean that pay levels will be related to the competitive performance
of the local healthcare enterprise.
4.3 Commissioning which sets quality standards will drive
forward innovations in quality of care and will reward higher
productivity. Equally, competition can empower staff by rewarding
teams which achieve outstanding performance. The centralised NHS
still suffers from the old problem of perverse incentives where
additional effort or change leads to serious problems with budgets
and workload.
4.4 Foundation Trusts could give a strong lead in developing
roles as care boundaries change. Independent treatment centres
will also show what can be done through team-working to raise
productivity and to provide patients with a one stop shop experience.
5. The new NHS human resource approach has to ensure
that patients can fully benefit from these changes. There will
be a tendency to freeze innovation and to restrain changes which
may threaten the hallowed tradition of a job for life.
6. The transition will certainly be difficult. It is
likely that productivity gains will mean that staff numbers are
reduced by at least 10%. This reduction should occur across all
generic staff, skilled and unskilled.
7. This change will make it possible to improve quality,
with more investment in fewer people. One strong gain from reducing
the number of hospital beds will be that of concentrating time
and available skill on fewer services and giving staff better
support.
8. In the longer term staff will have gains from more
choice, higher morale and greater job satisfaction from working
in smaller, more independent organizations. Reform can produce
gains for patients but it can also produce gains in control, rewards
and job satisfaction for many staff as well.
9. Staffing reform could mean a system with flexible,
local, initiative and scope for team building which will create
much greater job satisfaction and professional pride. Reform can
help to ensure that we make full use of the great commitment and
ability of so many staff in the NHS, replacing the frustrations
caused by the failed system of centralized manpower planning.
10. A smaller workforce with more effective support can
be empowered to deliver quality in care. A quality approach could
also reduce cost pressures and free up funding for new services.
We would see a 10% reduction in numbers as a realistic medium
term outcome from the new incentives. Such productivity gains
reflect the experience of ITCs and of primary care and payment
by results will create powerful new incentives to lower costs.
11. This submission is based on the Reform report
Staffing and human resources—facing up to the reform
agenda by Professor Nick Bosanquet, Andrew Haldenby, Henry
de Zoete and Roger Fox. The full report can be found at www.reform.co.uk.
Reform
5 May 2006
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