Examination of Witnesses (Questions 740-759)
MS ANNE
RAINSBERRY, MR
JOHN SARGENT
AND MS
TRISH KNIGHT
14 DECEMBER 2006
Q740 Dr Taylor: Could you take us
through those very quickly?
Ms Rainsberry: Yes. I feel I am
repeating myself, but, firstly, I think there is a real issue,
as I have just described, about bringing together workforce planning
for all groups, and, aligned with that, the way in which we manage
commissioning of education and training. The point I would make
on that is that we need a paradigm shift with that, we are commissioning
a workforce. We are not commissioning education per se.
I think from my perspective we need to be able to understand what
workforce we need and use the budgets available to deliver that.
We need more flexibility with that. The last point is just to
re-emphasise the need to have a much clearer strategic direction
at departmental level on the workforce with clear, longer term
planning priorities within which the strategic health authorities
would then deliver the integration, because I think they are best
placed to do that.
Q741 Dr Taylor: Turning to Trish,
we gather that in your part the medical deanery has merged with
the SHA. Is that right?
Ms Knight: The medical and the
non-medical deaneries have merged. The old WDC and the medical
deanery have merged. We are in the process of merging two deaneries
across the patch which will again remain as what is called a healthcare
workforce deanery. My fears about that are that the non-medical
side gets swamped by the issues around the medical side. There
is a real need for strategic leadership of non-medical education.
Q742 Dr Taylor: At first sight it
looked a good thing but there might be some disadvantages?
Ms Knight: Yes, I think that would
be fair.
Q743 Dr Taylor: Is this happening
in other parts of the country?
Ms Knight: I am aware that is
has happened in the West Midlands. It is the proposed direction
of travel that was outlined in the paper from the Department of
Health. One of the other fears is that it divorces workforce planning
from education to a certain extent or it can do. The skill that
we may be losing is the ability to translate a workforce development
plan into a plan for education. That is a skill that is very scarce.
Q744 Dr Taylor: HEFCE funds medical
undergraduate education and MPET does virtually everything else
with NMET, MADEL and SIFT. The MPET things are under the pressures
that the NHS has. HEFCE seems to be very cheap to run and not
under attack, so why should we not be pushing that everything
goes to HEFCE?
Ms Knight: We would have to be
careful. It is an option that needs to be looked at and examined.
The problem I would see is that the NHS as a whole would have
less influence on the education that was provided. We would have
less influence on producing this workforce that we wanted.
Q745 Dr Taylor: Should undergraduate
nurse training go to HEFCE?
Ms Knight: I think it is an option
that should be looked at but it needs to be looked at with that
proviso, that we do not lose the link between what the NHS requires
and what the universities deliver.
Q746 Dr Taylor: It is not an automatic
response from any of you?
Mr Sargent: No. You are quite
right that HEFCE does pay for medical undergraduates. However,
there are still the deaneries and these link very closely into
workforce needs in the medical arena, however well or not so well
assessed. That is not the case for everything else that HEFCE
funds where effectively they are funding undergraduate programmes.
In most cases if you are going to be an engineer, an accountant
or whatever you start your professional after. The risk is if
you put nurse training responsibilities and education responsibilities
that way is there anybody who has a clear eye on commissioning
the workforce needs of the future health service of this country.
If HEFCE were to go about it the same way they do for most other
programmes, we could either have big shortages or big surpluses.
Ms Rainsberry: I would agree with
John.
Q747 Dr Naysmith: Mr Sargent, in
your written evidence you said that local delivery plans are not
a suitable tool for workforce planning because they only cover
a three year period. I think you have already hinted earlier that
there is evidence that the National Health Service is starting
to develop longer term workforce plans. I wonder what you think
the timescale should be for these plans if it is not three years.
Mr Sargent: You are quite right.
The three years is difficult because for most of the people who
come through the traditional programmes the minimum period is
three years so the commissioning decision was taken a year before
that. The first time you can begin to influence change is in the
fourth year, which is the year after the plan finishes.
Q748 Dr Naysmith: That is not much
good then, is it?
Mr Sargent: That is just the LDP.
My own view is if you believe that the service and patient requirements
are such that significant modernisation is required, it is folly
to try and do it overnight and certainly within the three years.
I think you do need a much longer strategic perspective on that.
Your question was exactly how long. My own view is that unless
you have a reasonable run through over 10 years to make an impression
on the overall shape of the workforce, you just cannot do it because
the numbers are so huge. I quote the example I know best which
is through my colleagues in greater Manchester who have significant
experience now of putting assistant practitioners into the workforce.
There are now over 600 of them. Their assessment is that 15% on
average of work that is done in clinical teams could be done now
by assistant practitioners. If you tried to move to that nationally,
even over 10 years, you would so destabilise schools of nursing.
Going back to a question that somebody asked, if you took the
numbers down you would need them back again, say, in 10 years'
time and you would have lost the expertise to do it. I think a
minimum of 10 years is required. In some cases, you need to look
at a programme that probably goes to 15 years. That is not to
say that you set it in tablets of stone. I believe that as new
knowledge comes along each year you can incrementally change it
so what maybe you think is 15% this year could be 14% next year
or 16%. Because you can only bring people through a year at a
time, I do not think that is disastrous at all. Quite the opposite.
I think you need a clear strategic direction, a view over 10 to
15 years, and then keep revising it as better knowledge and experiences
come through.
Ms Knight: What we have to be
very careful about is a boom and bust. Any changes in commissioning
decisions should be done gradually, not in great step changes.
There is a real danger at the moment that because of the financial
problem you just cut commissions to save money and I think we
have to guard against that.
Mr Sargent: A very important point
in this is the gearing effect. Roughly 5% of the healthcare workforce
retires or otherwise completely leaves work in a year. That is
five in 100. When we have been in a period where we have seen
workforce growth at, say, 3% to 4%, that sounds like a fairly
low number but it is three or four students on five, so that is
why we have seen the 60%, 70%, 80% growth in numbers. It is quite
difficult to deliver very small numbers in workforce changes because
even very small changes in the whole workforce level have major
implications in the numbers in percentage terms, when we look
at the commissions. If you try to make the sorts of changes I
referred to over short periods of time, the numbers at the commissioning
will take the end of the scale either down to nearly zero at one
end or put such intolerable strains on the other that you really
do need a longer term view if you want sustainability.
Q749 Dr Naysmith: The Department
of Health in their evidence told us that the new Integrated Service
Improvement Programmes (ISIPs) will help to ensure that workforce
planning is more effective and better integrated. They think it
will; do you agree?
Ms Rainsberry: Not on its own
I do not think. An ISIP is an extremely useful tool by which health
economies can pull together the integration of finance, service
and workforce, but I think it needs to be done in the context
of an overall strategy for that.
Q750 Dr Naysmith: How does it tie
in with local delivery plans?
Ms Rainsberry: I would see it
as a delivery mechanism of the plans. If the local delivery plan
is saying, "This is what we are going to deliver in healthcare
outcomes", there will be certain areas within a health economy
that will require parties to sign up and to give specific attention
to A&E waits or whatever it might be. I think ISIP is extremely
useful in targeting and integrating resource around those areas
but I do not think it is the answer to all the things we have
been discussing this morning.
Q751 Dr Naysmith: How is it affected
by the need for the financial stringency that we spent such a
long time talking about to start with?
Ms Rainsberry: It would have to
take into account that there is always a balance between what
you want in workforce terms and what you can afford.
Q752 Dr Naysmith: You are saying
it will help but it is not the answer?
Ms Rainsberry: It will help in
making those decisions—ie, in framing those decisions. If
I want a certain number of staff of a certain level and a certain
qualification, that is going to cost me a certain amount of money.
I know that sounds basic but it is getting organisations to look
at that and to understand that I can either do it in this way
and it will cost that much or that way and it will cost this much.
I think it is useful in that way but as a delivery mechanism for
the overall plan for a health economy.
Ms Knight: The one thing it does
do is to make people think outside organisational boundaries and
that really helps.
Q753 Chairman: We have been told
that clinical engagement is vital to the effectiveness of workforce
development activities such as skill mix change. I wonder if I
could ask Anne and Trish if they agree with that notion and what
you are doing if you do agree with it?
Ms Rainsberry: If you are going
to work through on the timescales that John has been talking about
and if you take Your Health, Your Care, Your Say, and look
at what that is going to mean in models of care and how that might
play through to the configuration of services and workforce then
you need to work with clinical colleagues to understand the workforce
element. If we are going to provide care in that way, what will
that mean for the workforce? That is absolutely key. You then
have a second set of discussions which are, "That is our
ideal model of how we would like to deliver something" and
the discussion we have just had about ISIP which is, "How
does the ideal balance with the money we have and the timescales
and so on?" That is where I think sometimes tensions can
be caused in those relationships. You have to make judgment calls
about how you are going to deliver but clinical engagement and
understanding what skills you need in order to deliver a particular
model of care are key.
Q754 Chairman: Would you agree with
that?
Ms Knight: I would agree and I
would add also that we have seen quite a lot of attempts at new
ways of working that have not been sustainable because they have
not had proper clinical engagement. Some of these new ways of
working are far better if they bubble up from the bottom rather
than getting imposed from the top. We have an example at the moment
within pathology where they came to us and said, "What we
want is assistant practitioners to underpin our biomedical scientists
and we would like a foundation degree developed for them."
It was definitely their engagement, their initiative, and I am
sure it will be sustainable.
Q755 Chairman: Would you say overall
clinical engagement is crucial to the overall success of workforce
planning and development, as opposed to just care which is pretty
obvious?
Ms Rainsberry: Yes. At its most
basic level workforce planning is an estimating exercise, forecasting,
and you cannot do it in a vacuum. If you say, "We are going
to provide this type of care in this sort of volume" you
need some clinical input to understand what skills and volume
of skills you require to deliver that. Getting an estimation of
what you need right is absolutely fundamental.
Ms Knight: I do not think you
can do workforce planning without understanding where the service
is going. The only people who can tell you where the service is
going are the clinicians.
Mr Sargent: My personal view is
that it is quite a sophisticated mix of top down and bottom up.
Clinical engagement runs through that. Top down is the overall
strategic direction. The Working Time Directive is coming. All
these things are coming and they are going to impact on you and
your teams. Our best guess in overall terms is it might look something
like this. Would you like to have a go with you and your colleagues?
What does it really mean for you? You have the engagement through
the clinical teams and they will have some brilliant ideas about
how to address that that the people at the top down will not have
thought of. Then you need the discussion in the middle of it and
it can be quite tricky because inevitably, if the top down and
bottom up do not meet first time round, there does need to be
a discussion because if the bottom up comes up with something
that is either totally unaffordable or you could not possibly
run a course to do that or whatever it might be, that is the way
to do it. You get the clinical engagement and quite a sophisticated
mix of strategic top down and bottom up with real team engagement—not
just the doctors, by the way, but all the team members, because
if you change the role of anyone in the team, by definition, you
change the role of all the others.
Q756 Chairman: We have been told
that the prominence given to workforce planning by A Health
Service of All the Talents has been seriously lost and dissipated.
Do you agree with that? If so, why has this happened and what
can be done about it?
Ms Rainsberry: Can you expand
on the question?
Q757 Chairman: People tell us that
the document A Health Service of All the Talents is not
focused any more.
Ms Rainsberry: It has lost its
direction?
Q758 Chairman: Yes. Do you think
that the rapid growth in staff numbers and resultant financial
difficulties have caused parts of the NHS to effectively abandon
long term workforce planning, for the time being anyway?
Ms Rainsberry: I think there is
a genuine danger of that.
Q759 Chairman: Do you think it has
happened?
Ms Rainsberry: I do not think
it has happened but there is a genuine danger of that if you do
not have the proper strategic focus around it, where people at
the right level are making the right decisions about the interplay
between needing to achieve financial balance in year and also
understanding the need to ensure the future workforce supply.
Sometimes, there is a risk that the pressure to balance the books
in some areas can mean that people focus only on that and therefore
do make some short term decisions. The department and the Strategic
Health Authorities need to act as the counterbalance to that so
that we are maintaining the right direction and so that the way
in which those short term measures are taken does not fundamentally
affect the longer term direction, which is I think what John was
saying earlier.
Mr Sargent: There are a couple
of other differences that are worth reflecting on. WDCs were set
up as member organisations, whereas SHAs are effectively performance
management organisations. In my time in Greater Manchester, we
went out of our way to be a member organisation so that it was
not the WDC chief executive who was doing A, B and C. We tried
to get the engagement so that the members own what comes through
their WDC rather than it being something that is done to them.
We tried very hard to make sure that amongst those members were
the employees from the non-NHS part of the sector. There is a
risk that the NHS can be too introspective and not give as much
attention as it ought to to that section of the healthcare sector.
Ms Knight: I would echo Anne's
point about the strategic issues around workforce planning because
I am very aware that there is an awful lot of extremely good,
longer term workforce planning going on in provider organisations
in Strategic Health Authorities, but it is making sure strategically
it still has a place.
Ms Rainsberry: Strategic Health
Authorities are fundamentally changing their role to strategic
commissioning organisations and moving away from performance management.
If we genuinely have a role around understanding, getting the
maximum health gain for the money spent on behalf of the population—in
my case, London—the workforce has to be integral to that.
It is not commissioning education; it is commissioning a workforce
that is going to deliver that health gain.
Chairman: That might be an appropriate
opportunity to move onto issues around education and training.
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