House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Evidence submitted by John Sargent (WP 94)

INTRODUCTORY REMARKS

1. This memorandum of evidence is being submitted by myself, John Sargent, in a personal capacity. I am the only person in the country who has been Chief Executive of a Health Authority, an NHS Trust and a Workforce Development Confederation (WDC). The specially relevant experience that I have relates to the period from 2001-04 when I was Chief Executive of Greater Manchester Workforce Development Confederation. During this period I also chaired the "Standing Conference of Workforce Development Confederation Chief Executives" nationally; which meant that I also needed to become reasonably conversant with healthcare workforce planning issues at a national level as well as at a local level.

2. Greater Manchester WDC was assessed by the Audit Commission as the best performing WDC in the country. In large part this was attributable to the very clear strategic vision that had been agreed (to eliminate vacancies in healthcare employing organisations in Greater Manchester); and the systematic strategies that were formulated and implemented in order to deliver that strategic vision. (It needs to be borne in mind that the big issue in 2001 was staff shortages.)

3. Of particular interest to the Committee may well be my experiences in formulating and then implementing the "Delivering the Workforce" programme—which is still the only large scale and systematic example in the country (and probably the world) of designing healthcare job roles around the competences required to deliver safe, effective and high quality patient care.

4. Since being required to take early retirement as a result of yet another NHS reorganisation in 2004; I have since tried to promote many of the same ideas with various NHS organisations through my current role as a "Workforce Development Consultant".

STRATEGIC CONTEXT

5. In order to fully appreciate the relevance of the "Delivering the Workforce" initiative in Greater Manchester; and to assess its potential for transferability; it is first necessary to give some strategic context by reference to a number of strategic drivers. Some of these strategic drivers were around in 2001 and remain just as relevant today. Others have emerged since; and doubtless new as yet unknown drivers will materialise in the future.

6. These strategic drivers include:

— Reduced financial growth for the NHS after the next Spending Review—ie from 2008 onwards.

— The requirement for improvements in "Productive Time".

— Growth of the independent sector as a provider of NHS services.

— Demographic changes—both in the population at large (eg more very elderly people) and in the workforce (eg changes in retirement trends).

— Current financial pressures within healthcare in 2005-06.

— Retirement "hot spots" in certain professions (eg GP's).

— Workforce shortages in diagnostic services.

7. More information and analysis can be found in the document entitled "The Case for Change" published by Skills for Health.[44]

8. The critical issue that arises from this; and the inescapable conclusion is that the healthcare employer of the future will need to evolve a more flexible workforce if it is to survive and thrive. Further, probably in collaboration with other employers, at least part of the planning for that workforce will need to be based on competences, rather than relying entirely on a workforce built solely round the traditional healthcare professions.

EFFECTIVENESS OF CURRENT WORKFORCE PLANNING ARRANGEMENTS

9. The first point to make is that despite the bewildering complexity of the arrangements; and the many different organisations that have a role in them; in truth the current arrangements have hitherto been relatively effective in overall terms. This is evidenced by the fact that workforce shortages have been relatively small scale and short lived on the one hand; whilst surpluses causing significant unemployment levels amongst healthcare workers have similarly been relatively small scale and short lived. However, that is a historic perspective. If healthcare employers are to respond positively to the already known strategic drivers on which their futures depend, there simply has to be a paradigm shift towards reform of the workforce planning system that reflects the impact of these strategic drivers.

DEFICIENCIES IN THE CURRENT WORKFORCE PLANNING ARRANGEMENTS IN ENGLAND

10. This analysis quickly exposes some of the deficiencies in the current workforce planning arrangements in responding to the strategic drivers. These deficiencies fall into the following main categories:

— The workforce planning arrangements pay scant regard to the very large numbers of healthcare workers that are not registered healthcare professionals. Furthermore, the education and training resources to support future workforce planning and development are almost exclusively devoted to the professionally qualified section of the workforce.

— The workforce planning approach is based on the numbers assessed as being required in each of the already established healthcare professions. The investment in education and training follows the same course. Increasingly this fails to respond to the innovation that is needed to ensure that staff have the competences they need to deliver modern healthcare. Unsurprisingly, given the explosion in knowledge and technology, not all the job roles currently required conveniently fit into the professional "silos" that were designed many years ago. None of the workforce planning returns and other workforce information submissions required by the Department of Health contain any reference to such new roles. Consequently, the scope for investing in the development of such roles at local level is extremely limited.

— Whilst the Department of Health's approach may well be sensible and coherent at a national level; this does not always translate easily at local level. For instance, an SHA may be required to invest in more student nurse commissions; even though there is no demand locally for such an increase; and is thereby denied the opportunity of investing in local priorities—including innovative priorities such as Assistant Practitioner programmes.

— The strategic element of workforce planning is insufficiently developed within the current arrangements. For example in 2001, the Department of Health had issued workforce expansion targets that would have increased the size of the NHS workforce in headcount terms by almost 120,000 people by 2008. At the same time, the financial settlement arising for the Department from the Spending Review settlement was sufficient to fund workforce growth about two and a half times greater than this. This gap has now been filled in the NHS from a variety of sources including international recruitment and a spectacular rise in the number of pre-registration students. For example, the annual student nurse/midwife intake has increased from its low point of 12,500 in 1994-95 to about 25,600 in 2005-06—an increase of over 100%. Many of these students have already qualified, or will shortly do so; and this has been a principal source of overall workforce growth in the NHS which averaged 4.5% per annum in the years from 2001-02 to 2004-05. However, the strategic dimension is still missing. In fact the number of new student nurses/midwives increased between 2004-05 and 2005-06 from 25,000 to 25,600. At the same time, the Comprehensive Spending Review (CSR) is imminent and it is inconceivable that the NHS will continue to receive year on year real term funding increases of 7.3%. Given all the other financial pressures facing the NHS, even a fairly generous CSR settlement of 3-4% average real terms funding growth would only be sufficient to fund overall workforce growth of the order of between zero and 1%. The point is that the increasing number of students who have commenced their training in 2005-06 will not qualify until 2008-09—ie after the start of the next CSR period. Therefore, far from increasing student numbers in 2005-06; there is a substantial argument that the number of new starters should have been significantly reduced from 25,600 to perhaps 18,000-20,000 or thereabouts. This would still leave provision for the anticipated increase in nurse/midwife retirements from staff born in the "baby boom" years. Future further changes would of course be required, informed by more up to date information as it emerges—including the actual outcome of the CSR process. However, reductions to student nurse/midwife intakes of less than 18,000 should not be ruled out at this stage. Unless this strategic issue is addressed urgently in 2006-07; the risk of having significant numbers of unemployed, qualified healthcare staff becomes very tangible. Furthermore, this is only the "tip of the iceberg" in the sense that it is but one example of the impact of one strategic driver. As the Health Committee has indicated, there are others too. Taken together, they cannot be ignored; and the case for a changed approach to workforce planning in the health and healthcare sector becomes undeniable.

— Workforce planning is still not truly integrated with service and financial planning. Some improvements have been made in recent years; but there is still much to do. For example, the Local Delivery Plans (LDP's) which NHS organisations are required to compile and then submit to SHA's; and then on to the Department of Health only cover a period of three years. To many people this may seem like a long time in to the future; and yet in strategic workforce planning terms it is almost useless. This is because the supply for the next three years or more for all the registered professions is already known and can't be changed—they started on their courses up to three years ago! If the LDP is to be meaningful in planning for future workforce changes at all; it simply has to look to year 4 and beyond—probably to year 10 or thereabouts. It is only in this timescale that material changes in the workforce can be planned for and implemented, bearing in mind that in practical terms it takes several years of student cohorts to deliver enough competent healthcare workers to make a material difference at a whole workforce level.

11. Despite these difficulties, there are some very good examples around the country where NHS organisations have tried to overcome some of these difficulties at local level; and have developed a strategic workforce vision which they have proceeded to implement. The example I am most familiar with is the "Delivering the Workforce" initiative in Greater Manchester. The rest of this memorandum of evidence gives an overview of my own experiences and draws heavily on the excellent work done by the "Delivering the Workforce" Project Director, Chris Mullen and the rest of her team.

THE "DELIVERING THE WORKFORCE" VISION FOR GREATER MANCHESTER

12. "Delivering the Workforce" was conceived in 2000; and approved by the Greater Manchester WDC at its first Board meeting in March 2001. It was a response to the analysis that had been done at the time which showed that the NHS in Greater Manchester was under-supplying compared with the demand during the expansionary phase of large real terms funding growth. The extent of the "under-supply" was assessed at about 2,000 staff over a five year period unless a large scale and systematic initiative was taken to fill the gap.

13. It was also recognised that, even if the money was available (which it wasn't) or if the University and clinical placement capacity was available (which it wasn't); the lead time to produce additional "traditional" registered professionals in the numbers needed was way beyond the five year period.

14. Nonetheless, despite the vacancies, the fact remained that applications for some job categories were still heavily oversubscribed. Healthcare Assistant vacancies rarely attracted less than 30 applications, many of them excellent. However, all except one were turned away as there was only one Healthcare Assistant vacancy—despite the large numbers of vacancies for newly qualified registered staff. Further, it was already known that many Healthcare Assistants were sufficiently talented to acquire NVQ levels 2 and 3; and then progress to pre-registration programmes. Thus in analytical terms, the answer was very obvious—the NHS in Greater Manchester needed to recruit many more of the talented applicants for Healthcare Assistant and similar job roles; and develop them more quickly than traditional pre-registration programmes such that they could safely deliver patient care based on the specific "bundles" of that was required in specific patient care settings. The term "Assistant Practitioner" was coined to describe the staff who would be appointed to such roles after completing their development programmes.

15. By the same token, it was also recognised that the combined effect of the European Working Time Directive in 2009 and the implementation of "Modernising Medical Careers" meant that it was no longer tenable for hospitals to rely on junior doctors to provide medical services, especially during "out of hours", in the traditional way. Some of the impact might be overcome through massive service reconfiguration and hospital closures. However, much of the problem could not be solved this way because merely reorganising would not reduce the workload per se in the "busy" specialties. Furthermore, hospital closures would be deeply unpopular and contested—and even if the opposition was overcome, it would still be impractical and unaffordable to deliver the change required by 2009; and still only have a partial solution.

16. The alternative which was promoted by the WDC was to recognise that 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. However, the world is changing very rapidly and the probability of the same bundles of competences being maintained within professional boundaries whilst still optimising patient care appears to be remote. The competences themselves are "non-denominational"; and indeed, despite the widespread mythology to the contrary, there is virtually nothing in the statutory regulatory system that I am aware of that requires particular competences to be "owned" by particular professions. Thus, the conclusion reached was that experienced registered professionals needed to be developed such that, as part of the development programme, they acquired a range of competences which had hitherto been solely in the domain of junior doctors. The term "Advanced Practitioner" was coined to describe the staff who would be appointed to such roles after completing their development programmes.

17. However, it was also recognised that given all the operational pressures and vacancies, it would be very difficult to persuade healthcare employers to release large numbers of their most experienced clinicians onto Advanced Practitioner development programmes. It was principally for this reason that the decision was taken to start the process with the planned commissioning of 500 Trainee Assistant Practitioners for each of the four years to 2005-06. The logic was that the first step needed to be a demonstration to employers that vacancies were being eliminated. Once this was recognised, it then ought to be much easier to persuade employers to release registered practitioners onto Advanced Practitioner development programmes. Firstly, it could be argued that the "backfill" would already have been provided through the development of Assistant Practitioners, albeit with consequences for the overall "shape" of clinical teams. Secondly, the European Working Time Directive implications for 2009 would no longer seem to be quite so far over the horizon to NHS senior managers. Thirdly, it was recognised that the development of Advanced Practitioner programmes was far from straight forward and that even more time than for the Assistant Practitioner programme was required if an appropriate initiative was to be successfully planned for and implemented in collaboration with several of the established professions. This collaboration was deemed essential because if roles are planned that cross professional boundaries, even though there may not be any regulatory restrictions, the fact remains that the only people who are currently competent to assess the competences of potential Advanced Practitioners are members of the different professions!

18. Taken together, the initiative to develop significant numbers of Assistant Practitioners and Advanced Practitioners over a strategic period was given the title "Delivering the Workforce".

ASSISTANT PRACTITIONERS

Definition

19. The definition that was coined in Greater Manchester to describe Assistant Practitioners is as follows:

"An Assistant Practitioner is a health and social care worker who delivers health and social care to patients with a level of knowledge and skill beyond that of the traditional healthcare assistant or support worker. He or she would be able to deliver elements of health and social care and undertake clinical work in domains that have previously only been within the remit of registered professionals. In many cases this healthcare delivery role would also transcend many of the boundaries that have hitherto been strictly demarcated between different professions. He or she would also have the underpinning knowledge and assessed level of competence to undertake such a role".

20. This can be represented visually as follows:

Core Characteristics of the Assistant Practitioner Role

21. The Assistant Practitioner role, (per the paper "Assistant Practitioners—Delivering the Workforce 2002-07—The Core Characteristics" produced by the Delivering the Worksforce Project Director[45]), varies depending upon the service in which he or she is based. However there are some core characteristics that relate to the role of the Assistant Practitioner regardless of the service area:

— Provide direct health and social care; and treatment.

— Where relevant, provide day to day management of a group of patients.

— Assist in the assessment of patient needs.

— Undertake a variety of clinical skills—eg catheterisation, insertion of a peg tube, swallowing assessment, mobility exercises, assist in ADL assessment, venepuncture, immunisation, ECG's etc.

— Undertake Health Promotion work.

— Undertake clinical work and the application of the essence of care.

— Possess communication skills.

— Act on the authority of a Registered Healthcare Practitioner.

— Work in a way that ensures the scope of practice is constrained to protocol or a prescribed plan of care determined by a Registered Healthcare Practitioner.

— Is subject to clinical supervision.

— Engages in Continuous Professional Development.

— Takes responsibility for own actions.

— Supervise other support workers.

— Undertake A1 award to support colleagues working towards NVQ Levels 2 and 3.

Education, Training and Development

22. At the start of the initiative, it was agreed that formal educational training was required that would be transferable, credible and work based. Thus, in partnership with service and education providers, it was decided that a Foundation Degree in Health and Social Care would be the appropriate vehicle. This is a two year course and is at diploma level educationally on completion. It is a flexible course that has blended learning with an emphasis on combining knowledge with competences in practice. The national occupational competences have been used to inform the assessment process. From the external evaluation that has been undertaken, it is clear that the Assistant Practitioners at the end of the course have acquired new knowledge. The key areas of knowledge are shown below:

— Awareness of confidentiality issues for service users.

— Increased confidence and abilities to challenge.

— Familiarity with legislation relevant to caring for service users.

— Accountability of the caring professional.

— Legislation issues related to record keeping, data protection and freedom of information.

— Knowledge and application of principles of equality and diversity.

— Information technology skills.

— Reading and digesting evidence of clinical and care practice.

— Reflection on practice with theory.

— Written and oral presentation skills.

— Time management (through working with competing demands of study, work and home).

— Psychology and mental health (to differing levels depending upon the service).

— Care planning and a focus on processes related to admission and discharge.

— Team working.

— Health, safety and risk management.

Key Features Designed to Assist the Implementation of Assistant Practitioner Roles

23. From the outset it was recognised that the Assistant Practitioner programme represented a major challenge; especially as there were no similar programmes elsewhere in the world; and therefore no body of evidence, experience and learning on which to draw. In consequence, it was also recognised that if implementation was to be successful, the WDC needed to ensure that a number of key features were in place which were calculated to facilitate the implementation process. These key features included:

— The appointment of a Project Director who would be viewed as clinically credible by most registered practitioners. (The person appointed was a Director of Nursing at a large Teaching Hospital Trust prior to taking up the post.)

— The WDC took the decision that the initiative should be "fully funded" such that employers did not have to bear any costs whatsoever as part of the initiative. This was in recognition of the fact that whenever NHS organisations are under pressure to balance their books, all too frequently the decision is taken to pull out of support for such initiatives on the grounds there is no money in the short term—regardless of the long term consequences for having the right staff to deliver patient care in the future.

— The concept of "fully funded" included funding for project management and dedicated Practice Based Educators for the trainees—one Educator for each cohort of 15-20 trainees.

— The WDC recognised that by introducing one new role into a clinical team, almost by definition this changed the roles of the other team members. It also provided an opportunity to review the way services were delivered and a chance to plan for "service modernisation"; This involved considering the competences needed to deliver care; and how those competences should be distributed amongst team members.

— Wherever possible, trainees were allocated to organisations on the basis of "deep rather than wide"—ie several trainees in one service area rather than one trainee for each of several organisations. This was in recognition of the fact that all too often individual members of teams are developed, but use is not made of their skills because of the prevailing culture in the teams. It was felt that by developing a critical mass of trainees in a few service areas it would be much more difficult for the teams to avoid addressing the cultural changes needed to make best use of the skills and competences of Assistant Practitioners.

— The intention was that Assistant Practitioners should be capable of being deployed in almost any service area, including Social Care—and including roles that delivered care across the Health/Social Care "divide" when this was in the best interests of the patient, for example in an Intermediate Care Centre. To achieve this, the Trainees' programmes are designed such that they all participate in the same core modules in the first year and then access modules in their second year which are particularly relevant to the service areas in which they are deployed.

— In return for this investment in their future workforces, employers who accepted Trainee Assistant Practitioners had to commit to creating posts for Assistant Practitioners on a one for one basis on the successful completion of their programmes. (Such posts were not to be automatically filled by any particular ex-trainee to ensure compliance with equal opportunities legislation.)

— In addition, employers had to commit to disestablishing posts for registered practitioners in the clinical teams concerned at the same time. Firstly this was to ensure affordability. Secondly it was an explicit statement of the need to make cultural change. Thirdly it was the opportunity to avoid reliance on bank and Agency staff. Fourthly it was the opportunity to develop a registered practitioner for new challenges such as those inherent in the Advanced Practitioner role. (Thus, whilst it may be that a "junior" practitioner post was to be disestablished, the postholder should not be made redundant. Instead the expectation was that the "junior" practitioner should be developed into a more senior practitioner in the team and so on, with perhaps the most experienced practitioner in the team released and put on an Advanced Practitioner programme.)

— The Foundation Degrees which trainees received on completion of their programmes should be designed such that they would be fully recognised by healthcare and education providers alike when contemplating Assistant Practitioners' subsequent development. (Thus, for example, Assistant Practitioners could step onto year 2 of a pre-registration programme in recognition of the knowledge and skills they already possess.)

— Because of the innovative nature of the initiative, it was deemed essential to commission an independent evaluation to ensure that a full and honest account of the lessons to be learned was openly available. This was with a view to planning future improvements in the programme in Greater Manchester; and also to assist other parts of the country who may wish to set off down the same path.

The Story So Far

24. As of February 2006, 32 separate organisations were participating in the Assistant Practitioner programme. 480 people had completed their training and were deployed as Assistant Practitioners. A further 500 trainees were part way through their courses. Whilst this is still a massive achievement, it still falls some way short of the original aspiration. This reflects a number of factors, including:

— The WDC, like all WDC's, was reorganised away in 2004. Thus some of the focus and drive was lost and inevitably some of the key people were lost as always seems to happen in NHS reorganisations. (The same group of people have been subjected to yet another reorganisation in 2006.)

— Other sources of workforce supply (eg international recruitment) were accessed by some organisations, thereby reducing the amount of under-supply and hence the demand for Assistant Practitioners.

— The change management effort required to successfully take on trainees, deploy them appropriately when trained and make the other workforce and service changes is not universally welcomed. This can be a particular problem when there is rapid turnover of management staff—eg when a committed manager is replaced by one who is less committed.

— The financial pressures in the last two years have driven many managers to address short term financial savings as a very high priority agenda item. This means that they have had little time or enthusiasm for workforce development initiatives—even when such initiatives would deliver large and sustainable financial savings in the medium and long term.

ADVANCED PRACTITIONERS

Overview

25. The information given below is per the paper "Two New Roles: Assistant and Advanced Practitioners" produced by the Delivering the Workforce Project Director.[46]

26. "Delivering the Workforce" moved to the second phase of its development with the express objective of developing registered professional non-medical staff into Advanced Practitioners. There were six main reasons for developing the role:

— To modernise the workforce through developing roles that are based on the needs of patients/clients; and not restricted by professional boundaries.

— To support the development of new services such as case management, "tier two" services, surgical and diagnostic centres/services, out of hours services, and joint services with social care.

— To improve existing services through the modernisation of roles.

— To prepare for the impact of changes to the medical profession so that wider teams of professionals can undertake some of the duties currently undertaken by medical staff. The main issues are:

— The introduction of foundation training for House Officers and Senior House Officers which impacts on service delivery (Modernising Medical Careers).

— The Consultant Contract and the associated modernisation of the working arrangements for Consultants.

— Pressures facing organisations due to the reduction in working hours for doctors, to be achieved by 2009.

— The high numbers of medical staff expected to retire in the next few years.

— To support the NHS Plan and HR workforce targets.

— To develop teams based on an appropriate skill mix.

— To support the development opportunities for staff within the context of learning at work and developing wider career opportunities.

What is New About the Role of Advanced Practitioner?

27. The Advanced Practitioner is "new" in some ways but not in others. Many would say that some staff already work as Advanced Practitioners; sometimes with the same title and sometimes with a different one. That is to be expected with such a large workforce. The main difference however with this role is:

— The "driver" for the role is service need and the role is designed around the needs of the patient/client.

— These roles form part of the organisations strategic service and workforce plan. (LDP)

— The design of the job is not pre-determined or fixed by either a profession or a previous post. It is contextualised to the service in which it is based, with clearly identified "measurable" outcomes.

— The roles are open to practitioners from any professional background.

— The role builds on the professional skills, knowledge and competences of the recruited person. At the same time, it will support the development of new skills and competences often outside the domain of the individual's own profession.

— The additional skills and competences for the role will vary but will mostly likely come from the following fields:

— Medical skills

— Medicine management

— Social care skills

— Radiological skills

— Diagnostic skills

A Summary of the Education and Development Aspects for the Posts

28. There are two education providers who have been working in partnership with service to develop a masters level, work based course. The key information about the course is:

— It is a two year Masters programme.

— It is work based.

— It is called a Masters in Advanced Practice (Health and Social Care).

— The providers are the Universities of Salford and Bolton.

— There are two intakes a year—there had been three intakes as of early 2006; February 2005, September 2005 and February 2006.

— The programme is tailored to meet the needs of the role and the individual—ie it is learner centred.

— The support in practice involves:

— One Learning Facilitator for 20 trainees who will be based in practice and employed by the universities.

— A mentor.

— A number of assessors throughout the course depending upon the learning support required for particular modules.

— Link tutors from the universities.

— The champion and line managers in service.

29. Many organisations have "signed up" and are participating in the development. This includes primary care, mental health and acute services organisations. The trainees can be recruited from all professional backgrounds (non-medical); and the first three cohorts were from nursing (mental health, midwifery, community nursing and adult nursing), physiotherapy, podiatry, occupational therapy and radiography. The participating sites have typically recruited three to six practitioners per site. As of February 2006, there were about 150 people in training.

30. The roles are in development; and each role will vary depending upon the needs of that service. However there will be some characteristics of the "Advanced Practitioner" role that will be common to the majority of these new posts. It is anticipated that the new role will:

— Work across organisations and different agencies.

— Provide advanced levels of clinical practice, knowledge and skills.

— Be self-directed, manage risk, have high levels of communication skills and be a member of a wider clinical/ service team.

— Include in many cases managing medications including assessment, review and prescribing.

— Include managing a patient/client caseload with decision-making responsibilities.

— In most cases, undertake a physical, psychological and social examination.

— Complete a patient's history, diagnosis and treatment plan.

— Refer to others, signpost patients to services, and coordinate care and treatment.

— Promote health and the prevention of ill health.

How Will This Affect the Patient?

31. The impact for patients is intended to be positive. The aim of the role is to ensure patients are seen in a timely way by competent staff. This may mean that a patient's first contact will be an assessment done by an Advanced Practitioner, rather than a doctor. Assessments occur in a variety of places including GP centres, primary care facilities, patients' own homes and hospitals. However, as well as completing an assessment, the Advanced Practitioner will also at the same time undertake other aspects of patient care and/or treatment needs. This will potentially reduce the number of people the patient sees and may reduce the waiting time for patients. It will certainly ensure that the patient does not wait any longer for his/her assessment and treatment.

32. A key role of the Advanced Practitioner will be to manage the coordination of care and or treatment through effective signposting; so that people get the right care/treatment in the right place at the right time and by the right people. This will hopefully improve the patient's journey and experience.

How Will This Affect the NHS Organisations that Provide Services?

33. It is intended that NHS organisations will benefit from these roles by ensuring they can continue to meet the waiting times required; and by meeting the new challenges of providing more services in the community described in the White Paper "Our Health, Our Care, Our Community".[47]

34. The Advanced Practitioner development also has the potential to provide services with increased flexibility whilst promoting a competent, clinically safe service. It supports the retention of staff and provides career opportunities for those staff; and thus also supports the notion of being an attractive employer.

SUMMARY

35. This memorandum of evidence demonstrates that whilst the workforce planning arrangements have served the health and healthcare sector in England reasonably well hitherto; they are extremely unlikely to be "fit for purpose" in the future. This is partly because they undervalue the contribution of a large section of the workforce, partly because they are focussed on the individual "traditional" professions and partly because they are not sensitive enough to local requirements—but mainly because they are simply not strategic enough to take account of strategic drivers and the lead times needed to develop changes in the "shape" of the workforce.

36. This all suggests that healthcare employers are going to require a more flexible workforce in the future; and that they need to plan accordingly. Whilst it is impossible at this stage to define precisely what "a more flexible workforce" would look like; I do believe it is possible to suggest a strategic direction such that perhaps 30% of the future clinical workforce might be in "new roles", of which about half would be in Assistant Practitioner or similar roles. This assessment is based on of the proportion of clinical work which could, on average, be undertaken by Assistant Practitioners is based on the evidence that is emerging from Greater Manchester (ie 15%), the number of Advanced Practitioners required to solve the European Working Time Directive plus sufficient other posts to facilitate the career development of those registered practitioners who chose to develop some competences outside of the narrow confines of the particular professions they originally registered with.

37. However, the exact figure is not the essential issue at this stage, although it would probably helpful if some well informed modelling work was commissioned to try and derive a more authoritative figure. The practicalities are such that it would take about 15 years under the most practical scenario to achieve a 30% figure. The sheer scale of the numbers of people involved means that the transformation could only take place within manageable numbers on a year by year basis—partly because of financial constraints, partly because of capacity constraints in the NHS and Education sectors—but mainly because the consequences of a rapid transformation would be too destabilising to contemplate. There is also a very positive aspect to such a considered approach, as it allows new learning to emerge on a year by year basis; and new strategic drivers to be taken into account as they emerge. Thus, even if the 30% figure needed to be amended by even a quite substantial amount in later years; it does not affect the strategic direction and it does not affect the need for the transformation to take place through reasonably sized increments on a year by year basis. Those increments can be flexed up or down in due course to reflect any future changes needed based on the learning that takes place and on any new strategic drivers that emerge.

38. In order to deliver the modernised approach to workforce planning suggested in this memorandum of evidence, there will continue to be aspects which should be undertaken centrally, aspects which should be undertaken locally—and aspects which can best be addressed by "the intermediate tier" (currently Strategic Health Authorities). The key difference as compared with the current arrangements is the need for a more strategic approach—beginning with clear leadership from the Department of Health; and the development of Strategic Workforce Plans that demonstrate that they deliver the more flexible, competency-based workforce that is needed.

39. It does though need to be borne in mind that this more sophisticated approach to workforce planning and development needs to be matched a determined and effective implementation process. However, it also needs to be borne in mind that the prize is very great. Quite apart from the service and patient related benefits of a more flexible workforce; the financial contribution is enormous. A move to 15% of the workforce in Assistant Practitioner roles would alone release recurrent financial savings which exceed the whole of the NHS deficit in 2005-06!

John Sargent,

Workforce Development Consultant

3 November 2006