Evidence submitted by Shared Solutions
Consulting (WP 03A)
NHS WORKFORCE PLANNING AND PRODUCTIVITY
INTRODUCTION
1. This workforce planning and productivity
paper has been written for the House of Commons Health Select
Committee meeting on 8 June. It is based on over 20 years workforce
planning experience, gained at Trust, SHA and Department of Health
levels. This paper has been circulated to SHA workforce planners
for comment and their contribution is gratefully acknowledged.
2. Concern about low UK productivity levels
goes back about 150 years, when our pre-eminent industrial position
was gradually lost to a range of competitors. A particular weakness
has been where regular improvements in working processes are required.
This has only been overcome in motor manufacture by foreign management
and imported working practices. On the other hand, where innovation
and advanced research skills are required, such as in pharmaceuticals
we have been successful. Therefore, it would be unsurprising if
the NHS were better at creating islands of excellence, rather
than rapidly imbedding advances in knowledge into working processes
that would accelerate the diffusion of best practice.
3. The workforce planning process has improved
in many ways, as indicated by other submissions. However, there
is scope for further improvement, particularly with regard to
productivity. This paper takes a pragmatic approach and places
the emphasis on recommending how information, planning and organisational
structures can best support productivity improvements. Those who
are interested in a more theoretical framework for productivity
are recommended to read The Productivity Agenda: Future Options1.
4. This particular report makes a range
of recommendation that include:
— Gaining greater clinician involvement,
through the development of extensive productivity and quality
key performance indicators. In order for clinicians to have a
sense of ownership, they need to have played an important role
in developing them.
— Integrating the service, financial
and workforce planning processes more closely.
— Increasing flexibility between capital
and workforce investment.
— Accelerating the introduction of
new roles.
— Deciding on the optimum organisational
size for a particular activity—the criteria to used to decide
whether to centralise or decentralise an activity or function.
GAINING GREATER
CLINICIAN INVOLVEMENT
IN PRODUCTIVITY
5. In order to improve productivity, it
is essential to engage clinicians. They decide how work is done
(working processes) and which staff group and which grade of staff
undertakes it (skill mix). However, engaging clinicians in productivity
improvements can be difficult, as they may feel that patient care
might suffer as a result, particularly when initiatives are driven
by financial pressures.
6. In order to address this concern, it
would be necessary to show that quality and productivity are often
mutually re-enforcing, rather than mutually contradictory. For
instance, factors that are important to clinicians, such as clinical
outcomes, hospital acquired infections, eg MRSA rates, or drug
errors also have an impact on productivity, as they can result
in longer lengths of stay. In instances where productivity improvements
are of less immediate interest to clinicians, these initiatives
need to be evaluated in terms not just of productivity, but also
from the perspective of the patient experience and clinical outcomes.
7. Furthermore, clinicians need to be involved
in managing productivity and quality, as a support to their clinical
work.
8. Currently, all these various measures
are difficult for clinicians to evaluate together, as they receive
them in disparate reports at different timescales. This is because
they are produced by many different departments and sections.
Recommendation 1: Greater clinician
involvement is needed in improving quality and productivity, by
demonstrating the close link between the two.
IMPROVING INFORMATION
FOR CLINICIANS
9. Timely, extensive and easy to absorb
information is essential for management. Therefore it is proposed
that a clinicians' dashboard be developed of quality and productivity
information. This might consist of key performance indicators
such as:
— patient outcomes and experience;
— throughput: length of stay; percentage
of day cases; finished consultant episode;
— staff indicators: sickness and absence:
turnover; staff satisfaction survey results;
— productivity indicators; and
— process information: time based targets.
10. The dashboard would be easy to read,
as the factors that required attention would be indicated by traffic
lights. The indicators would need to reflect differences in the
work between various specialties and professions, to ensure that
the indicators were relevant. It should use readily available
information. There may be value in implementing a simpler version
first and them following it up with a more comprehensive version.
This would apply the very successful "balanced score card"2
approach to healthcare. So far, the Department of Health as only
promoted this within one function, Human Resources. It would be
necessary to extend this approach to indicators covering all the
other key functions. One approach would be to learn from one or
perhaps more trusts that have implemented the balanced score card
approach and spread the approach much more widely.
11. For the clinicians' dashboard to be
successful, it would need to be developed with the active participation
of the clinicians themselves and their Royal Colleges and professional
bodies, SHAs and trusts. Clinicians would need to see the value
of the exercise for themselves, rather than for others. The attraction
to clinicians is that the quality indicators in the dashboard
would go a long way to allay some of their fears regarding the
impact of financially driven competition on patient care.
Recommendation 2: Clinicians need
more comprehensive information on quality and productivity that
is easy to absorb, by developing a clinicians' dashboard.
12. In order to ensure that future generations
of clinicians adopt an integrated approach to managing productivity
and quality, the use of these indicators should become an integral
part of student education. Students could be involved in producing
these indicators as part of their clinical placement, as this
would relieve busy experienced clinicians from this work.
Recommendation 3: students should
assist in the production of the clinicians' dashboard during their
clinical placements.
13. The sign of the success would be when
up-to-date dashboards are on display in most clinical areas.
IMPROVEMENTS TO
THE PLANNING
PROCESS
Integrating the service, financial and workforce
planning processes
14. There is a tendency for service, financial
and workforce planners not to work sufficiently closely together.
The Department of Health planning documentation tends reflect
the very different needs of their main functions, which makes
it harder to integrate at trust or SHA level. This is often mirrored
at trust level, where the three functions tend to work separately,
each with their own spreadsheets that do not link to each other
dynamically. Thus, it is difficult for last minute financial changes
to be accurately reflected in workforce figures. However, foundation
trusts are required to produce information in a more integrated
way, the issue is to spread this requirement to all trusts.
15. The NHS is not alone in silo working.
This is why British and American motor manufacturers took longer
to design and introduce new models than the Japanese. The latter
place their functional heads in multi-disciplinary teams.
16. The NHS planning exercise works well
in trusts when service, finance and workforce planners have known
each other for many years. However, what is needed is an organisational
structure that would make such interdisciplinary working a matter
of course, even when new staff are involved.
Multi-disciplinary planning teams
17. It is proposed that much greater use
is made of multi-disciplinary teams of functional experts who
would work together on a project basis.
Recommendation 4: multi-disciplinary
teams should be a feature of planning to ensure closer integration
between service, finance and workforce plans.
Integrated service, financial and workforce software
18. It is proposed that integrated service,
financial and workforce planning software is developed. Thus,
a new service development would have all the information needed
together, relating to activity, capital investment, non-staff
revenue costs and staff groups by grade and their associated costs
in the same database. So if for financial reasons, it became necessary
to slim down a scheme at the last moment, any reductions in staff
numbers would feed across into lower staff costs and reduced activity
levels.
19. For this software to be really useful,
it would need to be developed with trust staff, closely involving
SHA and Department of Health colleagues. This would mean that
trusts would find it easier to use and also much more valuable
to them locally, as well as in centrally driven planning exercises.
Recommendation 5: software integrating
service, finance and workforce plans should be developed to meet
the needs of trust, SHA and Department of Health staff.
Greater flexibility between capital and workforce
investment
20. There is an underlying assumption in
capital planning that the workforce will magically appear once
the decision to invest has been made. In some cases, bids are
made for capital equipment, even when it is known that it would
be incredibly difficult to recruit staff. This is because central
capital funding cannot be held over to the next financial year,
or whenever staff finally become available.
21. An example of where greater flexibility
is needed was with the introduction of new scanners. Their purpose
was to reduce patient waiting times substantially, as there is
a serious bottleneck in diagnostics. However, many existing scanners
could be used more intensively, as they are switched off at 5
pm Mondays to Fridays and at weekends, only to be switched on
again for emergencies during those hours. In a few cases, PCTs
did not have the money needed to fund additional posts, as this
had not been ring-fenced.
22. The argument is not that superb new
technology is not needed, rather that its introduction should
be more closely linked to the utilisation of existing equipment
and availability of staff. This would vary according to the local
circumstances.
Changes to the planning process
23. It is therefore recommended that trust
workforce planners or other human resources staff, along with
their service managers, evaluate the availability of staffing,
before capital investments are made. This could take the form
of "traffic lights". Where staff are readily available,
the scheme could be given a green light to go ahead. On the other
hand, if there were a significant number of vacancies before taking
into account the additional staff required for the new development,
this would necessitate a yellow light. This would mean that the
workforce plan would need to be very robust for the project to
proceed. Finally, where there were very serious staff shortages,
this should receive a red light and the investment would be postponed
for a fundamental rethink. This could include, could this service
be supplied completely differently, by radically altering how
patients access healthcare?
Recommendation 6: greater flexibility
is needed so that the investment in capital matches the availability
of staff more closely. This could be achieved through traffic
lights that would indicate the extent to which additional staff
would be available.
THE DIFFUSION
OF INNOVATION
Accelerating the introduction of new roles
24. Innovation is often a slow process.
This is because there are only a few innovators who like the excitement
of the new3. It takes a while before the innovation spreads more
widely. Therefore, it is entirely to be expected that the introduction
new roles, such assistant practitioners in radiography follow
the same pattern, with marked differences in the number in each
SHA4. This was in spite of an extensive and very well managed
skills escalator exercise to support the initiative. A competitive
labour market was insufficient in itself to encourage innovation,
as take up was particularly disappointing in London. Therefore,
more incentives are required to swell the number of innovators,
which is often the approach adopted by commercial organisations.
Providing incentives to implement new roles
25. Firstly, there would need to be evidence
that a particular new role would be cost effective. For instance,
it could reduce vacancies by attracting new sources of staff or
it could increase productivity. It would be necessary to estimate
the number of staff who could be employed in a new role when it
became fully established. This could then be turned into annual
targets. Incentives could be given to each trust meeting the target.
This could vary from a contribution to the cost of staffing for
a limited period, to additional monies for post registration education
or staff facilities. This size of the incentive could relate to
the potential benefit of the new role. It would be necessary not
to penalise trusts that have good reasons to employ fewer staff
in new roles, by being sensitive in setting targets.
Recommendation 7: the introduction
of new roles should be accelerated by giving incentives to service
managers, such as contributions to staff costs for a limited period,
funding for more post registration training or staff facilities.
Identifying good practice
26. This can be done through offering prizes
to competition entrants. While this already takes places, many
more ideas would be identified if more and larger prizes were
offered. Thus each specialty or discrete area of work should have
their own prize for the organisation making the greatest improvement
in quality or productivity.
Recommendation 8: the diffusion
of good practice should be accelerated through making more use
of competitions with more valuable prizes.
ORGANISATIONAL DESIGN
AND THE
ECONOMIES OF
SCALE
27. The optimal size of an activity varies
from activity to activity. For instance, small PCTs were originally
created to mirror the local clinical networks that were represented
in professional executive committees. However, this led to the
optimal size of the committee dictating the size for management
functions such as finance, human resources and IT. This has now
been recognised as very costly in management terms and many PCTs
have been amalgamated.
28. Some economies of purchasing were lost
when regions were abolished. The purchasing of medical equipment
was devolved from regions to trusts that have much less bargaining
power. This is not to argue against the creation of trusts and
their numerous achievements, but rather that more thought should
have been given to how purchasing power could have been preserved
under the new arrangements. This has been recently acknowledged
by the emergence of pathology networks, acting on behalf of a
group of trusts.
Key issues in deciding on the correct level of
activity
29. The first issue is not come up with
a "one size fits all" solution, which would create problems
for the functions that need to operate at a different level. In
the case of PCTs, the optimal size of professional executive committee
should have been treated separately from those of the management
functions. This would have enabled several small local committees
to have come under one chief executive. The size of the commissioning
and financial functions would need to be large enough to attract
the calibre of candidates who could look their acute counterparts
in the eye, on level terms.
30. In the case of pathology laboratories,
the cost of processing tests could be reduced by using highly
automated equipment covering hospitals within a reasonable travelling
time. In addition, hospital laboratories would lose some other
work to clinicians who take tests at point of care themselves.
Thus, some developments in technology can increase the economies
of centralisation, while others increase the economies of decentralisation.
31. Any reorganisation should answer the
following questions:
— What functions need to be undertaken?
— What is the optimal scale of operation
for each function?
— What type of organisational structure
would best suit this operation?
— What were the benefits of the previous
organisational structure?
— How could these benefits continue
to be realised, to some extent or other, under the new arrangements?
Recommendation 9: much more consideration
needs to be given to the economies of scale that vary hugely between
activities. This is particularly the case for reorganisations.
CONCLUSION
32. Greater clinician involvement is fundamental
to improving productivity. This would need to be supported by
information systems that cover all the key indicators for clinicians,
in a way that best meets their needs. In addition, service, finance
and workforce plans need to more closely integrated. There is
scope to improve the diffusion of innovation through providing
more incentives to services managers. Finally, more consideration
needs to given to the economies of scale in organisational design.
Table 1
IMPACT ON PRODUCTIVITY OF ISSUES RAISED IN
THIS PAPER
| Theme in paper |
Impact on productivity |
| 1. Increasing clinician engagement |
Emotional capital |
| 2. Improving information for clinicians: clinicians' dashboard
| Monitoring trends to assist in more effective management
|
| 3. Multi-disciplinary working | Better capital utilisation and staff productivity through more robust plans
|
| 4. Integrated planning software | Better capital utilisation and staff productivity through more robust plans
|
| 5. Greater flexibility between capital and workforce investment
| Better capital utilisation and staff productivity through more robust plans
|
| 6. Accelerating the introduction of new roles
| Improving productivity by faster spread of innovation
|
| 7. Identifying good practice | Improving productivity by faster spread of innovation
|
| 8. Deciding on the correct level of an activity
| Economies of scale |
| |
REFERENCES
1 Blair, George (2005) The Productivity Agenda: Future
Options www.sharedsolutions.net
2 Kaplan, R S and Norton, D P (1996) The Balanced
Scorecard: Translating Strategy into Action "Imagine
entering the cockpit of a modern jet airplane and seeing only
a single instrument there". Boston, MA: Harvard Business
School Press.
3 Everett M Rogers (1995) Diffusion of Innovations.
New York: The Free Press.
4 While only one SHA had 25 or more assistant practitioner
radiographers, 16 SHAs had five or fewer, by March 2004. The number
of SHAs with over 25 increased to three and the number with five
or fewer declined to four by December 2005. However there were
13 SHAs with 10 or fewer. Source: South West London SHA.
George Blair
Managing Consultant, Shared Solutions Consulting
May 2006
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