Examination of Witnesses (Questions 462-479)
DR SALLY
PIDD, MR
ROB DARRACOTT
AND MR
BILL O'NEILL
15 JUNE 2006
Q462 Chairman: Thank you very much for
coming along. Could you, for the sake of the record, give us your
name and the organisation you represent?
Dr Pidd: I am Dr Sally Pidd, Associate
Dean for Workforce at the Royal College of Psychiatrists. I am
also a practising clinician in the North West of England.
Mr Darracott: I am Robert Darracott,
Director of Corporate Development at the Royal Pharmaceutical
Society of Great Britain, the professional and regulatory body
for pharmacists.
Mr O'Neill: I am Bill O'Neill,
Head of Education and Development for the London Ambulance Service.
Q463 Chairman: Thank you very much for
coming along. This is our fourth evidence session on Workforce
Planning. Your organisations have all recently been involved with
changes to skill mix and the development of new and extended clinical
roles. How effective are current workforce planning systems in
helping to make these changes?
Dr Pidd: The mental health professions
as a whole have worked very hard over the last few years to look
at new ways of working in mental health. This was led initially
by concerns about psychiatrists and their roles. People were finding
increasingly that consultant psychiatrist roles were becoming
over-extended and they could not deliver an adequate service,
and because of those concerns a national steering group was set
up to look at new ways of working for psychiatrists which has
moved into now looking at new ways of working in other mental
health professions as a whole. That work went alongside the work
of the Mental Health Care Group Workforce Team which has now been
disbanded. That is of some significance because that Group had
an overarching remit to look at the mental health workforce as
a whole and make recommendations, for example for increasing commissions
for clinical psychologists or training numbers for psychiatrists.
With that joint remit of looking both at the numbers needed and
then at the changing roles not only of psychiatrists but other
mental health professionals, the Mental Health Care Group Workforce
Team was able to tie together quite well the planning aspect for
the service as a whole. With the demise of the Mental Health Care
Workforce that has been lost to some extent. To balance that,
the changing remit of the Workforce Review Team to cover not only
doctors, which it initially did, but all other relevant professions,
it remains to be seen how that works out. In a time when we have
seen a huge development of new roles in mental health, particularly
in response to the NHS plan and the working out of the National
Service framework for mental health, it is a critically important
time to get the workforce planning right, both from the top down
and from the grass roots up, when so many roles are changing,
in order to deliver a service. There are some things where central
control has its place, but in looking at changing skills mix you
have to start down at the service level.
Mr Darracott: We very much welcome
this opportunity to come and talk here today because workforce
is a particular issue for us at the moment and we have spent time
looking at that. Pharmacy is a little bit complicated because
the majority of pharmacists delivering service on behalf of the
NHS, or to NHS patients, are employed in the private sector which
makes workforce management a little more complicated. You are
right to highlight the fact that we have, in both secondary care
roles and in primary care now increasingly, pharmacists moving
into more clinical activities and, therefore, extending their
roles into those areas. We have been working with the Department
of Health and the Welsh Assembly government on developing a workforce
planning model which covers both the NHS and the private or community
sector, which, rather than providing any answers, supported the
need for some of the changes which have been proposed in recent
legislation, particularly with regard to skill mix within the
pharmacy workforce. The planning model, which hopefully we will
be launching to the world at some point very shortly when we have
dotted the "i"s and crossed the "t"s, highlights
the gap that currently exists, which everybody felt was there
in the first place but we now have some evidence and a rather
robust model for that. The workforce team have also made some
recommendations as to how pharmacy needs to adapt to resolve some
of those issues. It is fair to say that while it has highlighted
the gap there as well, some of the recommendations we have already
seen starting to happen. For instance, the move from an essentially
manipulative activity in the supply and provision of medicines
into working more closely with patients about medicine as utilisation.
What we are seeing now is the start of automation, and the greater
involvement of automation both in the secondary and also primary
care sector. One of the suggestions that comes out of the workforce
model is we need to look at different ways of doing existing tasks,
and we welcome the opportunity to talk to you about it.
Mr O'Neill: We are in a slightly
unique position in some respects in so far as the major impact
for us has been the introduction of the role of ECP (Emergency
Care Practitioner).
Q464 Chairman: We will go into some
detail about that. It is about this overall workforce planning
system that we have at national level and the helpfulness that
has been.
Mr O'Neill: The reason I mention
that is because that has been, in many respects, the catalyst
which has led to us look at the rest of our workforce. To be honest,
we are still in a "what about the rest of the workforce"
situation at the moment, and it is hard to describe it without
bringing the ECP into it.
Q465 Chairman: Maybe that would be
a good way of doing it. What I was trying to probe was whether
the workforce planning systems inside the NHS particularly are
well funded or should be better funded or better allocated in
terms of where funding goes to which body. I do not know if you
have any firm views in that area, or maybe you could pick it up
later on. Let us move on.
Q466 Mike Penning: If you feel you
want to answer that question later on, that is fine. How can we
encourage individual organisations and managers to do more work
of this type to move this on?
Dr Pidd: This is where there is
a need for national work to filter down, and to filter down effectively,
to local organisations. If I give some examples from mental health,
the New Ways of Working group, which produced its final report
last year, demonstrated that it is possible to pilot different
ways of working and then to evaluate those pilots, but then you
need a mechanism for disseminating the results of those pilots,
of changing roles, for example changing the role of pharmacists
to be involved in clinical activities within mental health. For
that work to be overseen by a national body, in this case the
National Institute of Mental Health, you then need a mechanism
for disseminating that out to areas and then encouraging that
down to local level.
Q467 Mike Penning: Are you saying
those mechanisms are not in place at the moment?
Dr Pidd: They are in place at
the moment through the regional development centres, but I think
often to take those results and implement them locally there often
needs relatively small pump priming monies, for facilitators for
example, if you are looking at changing the skill mix within a
team. If I give another example, one of the outputs of the New
Ways of Working Group has been the development of a creating capable
teams toolkit which enables local teams of any sort, be it in
children's services or community mental health teams, to examine
the local needs, the local skills, and the local skill mix to
see if the service could be redesigned to produce better outcomes
for patients. Service users are a part of implementing that. The
work has been done at a national level to produce this toolkit,
but in order to implement it locally you may need some skilled
facilitation and some time.
Q468 Mike Penning: Would money be
the driver for this to happen?
Dr Pidd: I do not think it is
a lot of money; it is often a small amount of money.
Q469 Mike Penning: Clearly it is
not coming through now?
Dr Pidd: It is not coming through
in the way it perhaps needs to. I think a lot of learning from
the national pilot sites in New Ways of Working both for psychiatrists,
advanced practitioner nurses, and so on, is not getting down quickly
enough.
Mr Darracott: I think we are in
the process at the moment where there are some key building blocks
in place. If you look at the community pharmacy side for a moment,
there are proposals in the Health Bill which will enable some
of these skill mix things that may be need to happen in the community
to take place. We need some legislative change. There are some
long-standing provisions by which pharmacist's responsibilities
in community pharmacies require them to be present, there is a
physical presence aspect, and some of the proposals in the Health
Bill take us a little bit further forward on that. We welcome
the opportunity to talk about flexibility because as pharmacists
do get into more clinical roles, either spending more time with
individual patients within the pharmacy itself or outside the
pharmacy location, then you need some flexibility to sort out
the problem of the physical presence which has been a feature
of the law for some years. We are really looking forward to discussing
the regulations that may fall out of that. We are in the process
of actually doing something about it, which means sorting out
some of the legislative aspects. There then comes a point at which
we need to really highlight to the profession at large what those
new possibilities are, how people who start to take those opportunities
can use them and how that improves services for patients. It is
incumbent upon us all to highlight that to the profession. With
all of these things you are looking at people working a particular
way for a long time. Some of these opportunities are quite different
ways of working and we need to highlight that. I am not saying
it is necessarily a matter of funding. We have a new pharmacy
contract in the community which is bringing about some of these
new roles anyway, but there is a legislative issue there. In the
secondary care sector we are still coming out of the finishing
of the completion of the Agenda for Change programme. That has
left us with some issues that still need to be resolved and I
can discuss those at some length. We are waiting to see how that
all falls in place. There are one or two key things coming up
which I would highlight at this stage which are pinch points in
the system, and they are rather further back in the generation
of a pharmacist than the actual service delivery, in the sort
of training programme. Pharmacists currently are trained as scientists
so the funding stream for pharmacists is through HEFCE, so science
funding as opposed to clinical funding. As pharmacists get into
more clinical roles, there is a question mark about how that training
is funded, particularly the exposure of pharmacy students and
pharmacy at the pre-registration level to patients and how that
is facilitated. If you just have a science funding stream, there
is little provision within that for clinically based training.
Q470 Mike Penning: It is a very tight
gateway, is it not?
Mr Darracott: The higher education
institutions have a range of ways of dealing with that but it
would help if some of that was looked into.
Q471 Mike Penning: Perhaps we can
come back to that. What about the ambulance service?
Mr O'Neill: That comes into the
issue for us as well. We had the publication last June of the
Ambulance Service Review from the Department of Health. That,
alongside with the work that has been conducted by the Ambulance
Service Association employers and the British Paramedic Association,
is giving us far more of an idea of where we are going in terms
of our skill mix and the way that we implement some of that. I
am trying not to touch on ECPs yet, but for us the issue is about
how we get that funding. We traditionally provide our training
in-house so it has not been associated with higher education which
has been gradually coming in over the last decade I would suggest.
Certainly now with the standards of education that are set by
the Health Professions Counsel, with the curriculum guidance published
by the British Paramedic Association, we see ourselves in a far
more higher education direction, which is right. We do not want
to throw the baby out with the bath water and move away from the
in-house apprentice route, but we are scratching our heads, to
some extent, how we are going to fund this because nothing seems
to be coming to light. No matter which way we turn, we seem to
be getting some blank faces in terms of how to make this transition.
Q472 Mike Penning: You get that from
politicians sometimes. Have these new workers in these new extended
roles replaced existing workers or have we put a whole new tier
in? Have we kept the existing workers and put in a whole new tier
of skilled workers.
Dr Pidd: In mental health they
have largely come in alongside existing practitioners, so within
community mental health teams there has always been a mix of social
workers, community nurses, doctors and occupational therapists.
New workers coming in, for example working more on the primary
care/secondary care interface, is a new layer if we are talking
about gateway workers or graduate workers.
Q473 Mike Penning: They have not
replaced but there is a whole new layer.
Dr Pidd: They have not replaced
them in function, but one of the workforce issues has been that
as new roles have been identified the existing workforce have
moved into them which has sometimes left gaps.
Q474 Mike Penning: Have people then
come in to fill those places so there is an increase in provision?
Dr Pidd: Certainly within mental
health services the new roles have enhanced the service. For example,
there is no shortage of psychology graduates interested in moving
into clinical work. There have never been enough training places
for clinical psychologists which has left a gap in the service.
We have now created a new role for psychology graduates to come
into the mental health workforce in a primary care setting gaining
skills, and doing this at a time when the notion of the skills
escalator within the NHS means that people are coming in and can
progress along different career pathways than used to be the case.
Q475 Mike Penning: We will go on
to ECP quickly, but I do not know if it affects you.
Mr O'Neill: It is too early to
say because we are not sure the extent to which the introduction
of this new role is going to impact on numbers of other roles
we have.
Q476 Mike Penning: Your main problem
will be funding, as you just discussed.
Mr O'Neill: Yes.
Mr Darracott: In pharmacy, as
an example of the secondary care sector, some of the new roles
pharmacists have gone into have followed a recognition that medicines
are important parts of the health care system. There is a lot
money spent on them, and the appropriate use of the pharmacy skills
around use, and the use of the medicines, if you invest more time
and energy in that as part of the clinical team, then you end
up with better outcomes for patients. In terms of what the pharmacist
does there, the additional parts of those roles really have taken
over some of the roles that might be elsewhere in the team. They
are carving out a role in independent prescribing and this will
save time elsewhere in the system. As to what the pharmacists
were doing which now allows them to do these new roles, that has
largely been delegated to more technical staff.
Q477 Mike Penning: It does not look
as if you have increased your workforce but have delegated skills
around so the skill base has increased within the existing staff.
Mr Darracott: The roles around
the supply of medicines have been largely delegated to technical
staff, yes.
Q478 Charlotte Atkins: You have been
incredibly patient but you can now tell us about emergency care
practitioners, what they do and how they fit into the emergency
care workforce.
Mr O'Neill: I think it would be
fair to say that I can only really tell you how they work within
London. It would be fair to say how they work in other areas of
the country is not necessarily the same as the way they work in
London. One of the issues that we do have is there does not seem
to be a consistency in what is understood as an ECP across the
country. In terms of what they do in London, they effectively
support both our operational response to 999 calls and are given
the opportunity to work with other local health care providers
to be able to help with some of the out-of-hours work, et cetera.
The way it is working at the moment is we do not have anybody
who has come through the ECP programme fully trained and out the
other end; they are all in what you might call a development stage.
Q479 Charlotte Atkins: How long have
you had these?
Mr O'Neill: The current cohort
are in their second year. They will end up with a diploma working
through St George's at Kingston University. I have to be somewhat
vague about some of this because some of it is quite vague in
terms of why it has been planned the way it has been planned.
If that sounds like I do not know what I am talking about, to
an extent this whole thing grew up outside of the auspices certainly
of my department and my remit within the organisation. It was
kept in this vacuum and developed there and we are now picking
up some of what may have been mistakes that were made along the
way in trying to develop this role. We do have a situation where,
at the moment, there is a lot of development time with our ECPs
and not a great deal of operational time. That is something we
are trying to address and pull that back around. We are not seeing
the effectiveness we might have expected to see at this stage,
but it would also be fair to say that the evidence is not telling
us anything other than they are being as effective as could have
been projected at this point.
| 
