House of Commons - Education, training and workforce planning

Education, training and workforce planning - Health Committee Contents

2 The challenge of workforce planning

6. We believe that the new structures for education and training must be built around a stronger, more transparent and more accountable system of workforce planning. For too long our system has been characterised by "boom and bust"—alternating oversupply and undersupply of trained staff—with shortages eased by large-scale recruitment from overseas. This inability to identify and manage developments of the skill mix required in the health and care workforce has resulted in waste and inefficiency, as well as frustration and disappointment for individual trainees.

7. Effective workforce planning is not, of course, straightforward. It needs to take account of changes in technology and clinical practice as well as changing patterns of demand and expectations from patients and the wider community. Addressing all these issues effectively through workforce planning requires close alignment with service commissioning and funding, as well as linkages with employers, educators and trainers.

8. Furthermore, as we have noted in our previous reports, Sir David Nicholson (Chief Executive of the NHS) has highlighted the fact that the NHS now faces an unprecedented requirement to increase efficiency by four per cent a year over four years, and probably longer. This "Nicholson Challenge" arises because the NHS has to meet demand rising at its long-term trend rate of approximately four per cent a year out of marginal increases in real-terms funding. In our view this challenge can only be met through service redesign and reconfiguration (with many aspects of care moving from hospitals into primary-care and community settings); and integration of the NHS and social care services.

9. Workforce planning has a key part to play in achieving these objectives, allowing the NHS to enhance both the efficiency and quality of care delivery, at the same time as enabling flexibility in the face of rapid medical progress and varied other challenges.

The Centre for Workforce Intelligence

10. Sound, comprehensive and up-to-date data and intelligence are crucial to the success of workforce planning. In 2010 Mouchel Management Consulting Limited[4] was contracted by the Department of Health (DH) to set up and run the Centre for Workforce Intelligence (CfWI).[5] The Centre told us that it acts as "the national authority on workforce planning and development and the primary source of workforce intelligence for health and social care", working with academic and other partners.[6] Peter Sharp, the Chief Executive of the CfWI, explained to us that the Centre was addressing longstanding issues around workforce data (concerning completeness and quality) and working towards "the construction of a core national minimum data set for health and social care".[7] He told us:

We have an expansive stakeholder map of people who hold that data. We have tried to do the equivalent of "Trip Advisor" on it as to its relevance, value and whether or not you would want to use it and so on.[8]

The Centre aimed:

to get from national down to regional […] and then local and hyper local.We have a project where we will have GPS [Global Positioning System] plotting right down to a hospital level where we will say where there are shortages. We will have a "red, amber, green" of any of the professions, whether doctors, nurses or midwives.[9]

11. Mr Sharp emphasised that "We are not a data warehouse. Our job is not to house data. It is to use data and turn it into intelligence."[10] (This distinguishes the role of the CfWI from that of the NHS Information Centre, which does effectively act as a data warehouse in relation to NHS providers.)[11] It also aimed "to work closely with the stakeholders to make sure the advice and guidance we produce is tailored to their needs".[12]

12. In Developing the Healthcare Workforce (December 2010) the work of the CfWI thus far was stated by the DH to be one of the achievements of the existing system that must be built upon.[13] Data from providers would need to be collected locally, aggregated and made available to the CfWI.[14] The Centre would "be in a position to advise healthcare providers on future skills needs and to share the latest thinking about the different workforce models able to support improved services and new care pathways".[15]

13. In evidence to us in November 2011 Jamie Rentoul, the DH's Director of Workforce Development, explained something of the CfWI's intended role in the system. The Centre would enable "challenge [to workforce plans] at a sufficiently granular level that people are able to do something with it":

part of the purpose in having the Centre for Workforce Intelligence contracted but out of the system is that they are doing the analysis. It is their analysis for the colleges, professional bodies, patient groups, commissioners and employers to have a go at, to get it as good as it can be, and give that challenge.[16]

14. We heard in evidence that there is general support in principle for the role of the CfWI. However, we also heard that, as a relatively new organisation, the CfWI was still only just beginning to establish its position within the NHS workforce system ("it is early days", we more than once heard).[17] At that time it was also seen as concentrating on issues at the national level and particularly around medical staff.[18] Questions were also raised concerning the way that "the function of the organisation currently has focused on profession specific information and has had little engagement at organisational level".[19]

15. There was some criticism, too, of the quality of the CfWI's output. Public health experts in the north west told us that "Recent statistics published by the CfWI regarding public health posts were seriously flawed" and that "Currently the Centre for Workforce Intelligence is not able to collate sound, up to date and accessible data on the public health workforce."[20]

16. It was queried in several submissions whether the CfWI had the necessary resources for the task it had been given[21]—and this was linked by some to the perceived quality of its work. The Chartered Society of Physiotherapy told us:

recently we have been concerned about the quality of reports from the CfWI, because of a reduction in the CfWI staff resources available to produce them. We have been unable to support their conclusions based on inadequate time and professional resources. It is essential that the CWfI is properly resourced by the Department of Health.[22]

17. Conversely, the Society and College of Radiographers argued that, "despite considerable investment in the Centre for Workforce Intelligence", it had:

not delivered the new/better approach that is needed. In particular, it has not sought to derive workforce need from service delivery and healthcare need (which seem to us to be the right starting points), but has used current workforce numbers and affordability as the main influences. This perpetuates the short-term approach to workforce planning which drives a boom/bust (or glut/famine) cycle in relation to workforce supply, and fails to help deliver long-term skills-mix based solutions to cost and quality effective health care delivery.[23]

18. Mr Sharp told us that the CfWI was working with the medical Royal Colleges on medical workforce issues[24]—and written evidence from the Academy of Medical Royal Colleges seemed to support this, stating that Colleges were feeding their data sets on specialty workforce numbers into the Centre.[25] (Other evidence emphasised the Royal Colleges' possession of quality data which the CfWI must use, rather than duplicating it unnecessarily.)[26]

19. The Royal College of Pathologists said it had "previously had great concerns over the viability and fitness for purpose" of the CfWI, given its use of data that were "flawed and outdated". However, subsequently the Centre had "engaged more comprehensively with the Royal Colleges", recognising the data that the Royal College of Pathologists held.[27] Dr Peter Nightingale, President of the Royal College of Anaesthetists, told us:

There is no doubt that the Centre for Workforce Intelligence has had a fairly sticky start inasmuch as it did not have good quality data on which to begin making its projections. It is improving, but it can only do a very good job if it gets very good data.[28]

The Royal College of Obstetricians and Gynaecologists clearly harboured continuing doubts about the CfWI, arguing that it needed to "be more robustly managed and its workplan better supported".[29] The Joint Epilepsy Council thought that, given the inaccuracy of the Centre's report on neurologists, it could not have been working as closely with the Royal Colleges as it claimed to have done.[30] The CfWI's recent "horizon scanning" report on the medical workforce does appear to be evidence of a closer working relationship with the Royal Colleges.[31] It should be noted that the CfWI is maintaining a commendably regular output of publications across a range of topics[32] and it may well be that the criticisms we heard of some of its work do not apply to more recent studies.

20. Another area of concern has been the extent to which the CfWI will be supplied with an adequate quantity and quality of data in the new NHS, where providers—whether NHS Foundation Trusts (FTs) or independent sector bodies—will be autonomous organisations. The Director of NHS Employers, Dean Royles, sought to reassure us that FTs would happily provide data if they were certain that it was not merely a bureaucratic chore but would help improve patient care.[33] However, there have been failures by some FTs to supply the NHS Information Centre with data that clearly does relate to improving care (in relation to patient complaints), as we have noted in a previous report.[34]

21. As regards independent-sector providers, Mr Sharp told us that the CfWI had "started to negotiate points of entry for collecting data" from the private sector.[35] Sally Taber, the Director of Independent Healthcare Advisory Services, told us that her organisation already provided data to the devolved administrations in Wales and Scotland. The independent sector would happily do the same in England if there were a clear mechanism for doing so.[36] Nevertheless, past experience (for instance, the poor track record of Independent Sector Treatment Centres in furnishing data)[37] does throw doubt on the extent to which private providers can be relied on in this regard.

22. Local Education and Training Boards (LETBs) will clearly have a key role in ensuring data are collected from all providers at the local level—but the question does arise of what obligations providers will be under to supply data and what sanctions can be used against them if they fail to do so. Developing the Healthcare Workforce (December 2010) proposed a duty on all providers of NHS-funded care to provide data about their current workforces and future workforce needs;[38] and this was supported in the subsequent consultation.[39]

23. From Design to Delivery (published by the DH in January 2012) envisaged that the existing Electronic Staff Record (which provides information on directly-employed NHS staff) would continue to be the main source of workforce data. However, it noted that "with an increasingly diverse range of healthcare and public health providers there is no guarantee that all providers will use [the Electronic Staff Record] in the future." Accordingly, arrangements would be made for the provision of data by providers that did not use the Electronic Staff Record.[40] This would include developing a minimum data set.[41] In addition, the Health and Social Care Bill allowed the Secretary of State to direct the Information Centre "to collect information that is necessary or expedient to have in the interests of the health service". This would be "sufficient to enable directions to be given to require the provision of workforce data" from all providers of NHS-funded services.[42] At the same time:

The provisions set out in the current Health and Social Care Bill for the provision of relevant data and information will include a requirement on providers to make available workforce and workforce planning data so that LETBs, the Information Centre and the Centre for Workforce Intelligence have access to the data and information needed for effective workforce planning.[43]

In this regard, David Worskett, Director of the NHS Partners Network (which represents independent-sector healthcare providers in the NHS), anticipated, based on discussions with Monitor (the planned NHS economic regulator), "some very tight licence conditions about provision of information and data".[44] Nevertheless, it still remains unknown what the specification will be for the minimum data set, what the exact compliance mechanisms will be and what the penalty will be for non-compliance.

Conclusions and recommendations

24. Effective workforce planning in the NHS depends on the availability of up-to-date, high-quality data and intelligence, yet only in recent years have steps been taken to ensure that this is fully and comprehensively available. We welcome the remit that has been given to the Centre for Workforce Intelligence; we also commend its ambition to tackle deficiencies in workforce data and to establish a core national minimum data set.

25. It is clearly not sufficient for the Centre simply to collate and interpret data. It should also challenge data from individual health economies against current clinical standards to ensure their workforce plans make adequate provision for the best skill mix.

26. We appreciate that the Centre is still a relatively new body and that its establishment pre-dates the full implementation of the new workforce planning system. However, we are concerned at some of what we have heard regarding its capacity and capability, in particular its capacity to test workforce plans against the requirement to match the best clinical standards. We are also concerned at the apparent lack of clarity about how it will fit into the new workforce planning system. The Department needs urgently to explain how it is ensuring that the Centre is adequately resourced to fulfil its remit, as well as to clarify the Centre's role in the new system, particularly its working relationships with Health Education England and the Local Education and Training Boards. It must also set out how the Centre will be effectively performance-managed in the new system and held to account.

27. The Centre is substantially dependent for its success on data that are provided by employers. In future those employers will be autonomous organizations and Local Education and Training Boards will be responsible for gathering data from them. The Government must ensure that there are clear contractual obligations on all providers of NHS-funded services to provide full, timely and accurate workforce data; these obligations must be backed up by clear, strong and enforceable penalties. At the same time, there must be a clear complementary requirement on the local Boards in respect of gathering and passing on data—with a definite remit for Health Education England rigorously to performance manage the Boards in this respect.

Changing skill mix

28. In Developing the Healthcare Workforce (December 2010) the Government recognised that there had been "real strides in implementing skill mix changes to support more productive care, modelled around quality and the needs of patients".[45] However, it identified as a key deficiency in the current system that it "is too top-down, such that employers do not have the incentives and levers to innovate and secure the skill-mix that they want". It argued that "supply-and-demand factors [are looked at] in single professional silos [so that] […] potential for improving quality and productivity through skill mix change and developing the wider healthcare team […] is underdeveloped".[46]

29. Skill mix is far from being a new issue in healthcare. There has been a long-term trend towards the extension of non-medical clinical (and other healthcare) roles. These developments have been notable within nursing and the Allied Health Professions (AHPs), where recent years have seen the creation of enhanced and advanced roles, such as those of Nurse Consultant, AHP Consultant and Nurse Practitioner, with additional qualifications, skills and responsibilities—even including the authority to prescribe drugs. At the same time, unregistered healthcare assistants (HCAs)—sometimes referred to as clinical support staff, healthcare support workers, nursing auxiliaries or auxiliary nurses—have become a much more important and numerous part of the workforce. More highly trained staff of this type are also now being introduced, known as Assistant Practitioners. The Nursing and Midwifery Council (NMC) has estimated that there are as many as 300,000 HCAs (not including Assistant Practitioners)—about a quarter of the NHS workforce.[47] The Royal College of Nursing (RCN) told us that there were as many HCAs again outside the NHS in settings such as care homes;[48] and we heard about increasing numbers of HCAs working in the community, providing care in people's homes.[49] HCAs can perform a range of duties, from personal care (e.g. helping patients with washing and dressing) through to simple medical tasks, such as taking blood, and taking and recording vital signs. Under NMC guidance, a nurse who delegates a task to an HCA is professionally accountable for ensuring that the HCA is competent to carry out that task.[50]

30. The creation of new roles and role substitution are widely seen as having the potential to enhance significantly the productivity and effectiveness of the healthcare workforce (allowing the more qualified members of teams to concentrate on the most challenging clinical tasks). In a memorandum that we received from Professor Alan Maynard, a longstanding advocate of changes in skill mix, he said that evidence indicated nurses in general practice, "particularly the 30,000 who have full prescribing rights, have the potential to replace GPs in the delivery of much of primary care". However, there was a lack of good quality studies on this subject. Similarly, in secondary care, there was a "paucity of good evaluative studies of effectiveness and cost effectiveness" in relation to substituting nurses for doctors.[51]

31. We heard from the Society and College of Radiographers about the adverse effects of failing to make full use of Assistant Practitioners: "These staff are essential to enable the skills of radiographers to be utilised more effectively such that radiographers are able to support medical staff to spend proportionally more of their time with patients with complex radiotherapy and clinical imaging or intervention needs." At the same time, there had been a "failure to invest in developing advanced and consultant practitioners to deliver both 'routine' service needs […], and to deliver service innovations that have been shown to improve quality and effectiveness". There were "some very good examples in individual NHS Trusts of innovations that deliver the highest quality of care through excellent development of its whole radiographic workforce", but these innovations were not widespread.[52]

32. On the other hand, however, fears were expressed about the possible dangers of inappropriate changes in skill mix. Sara Gorton, Senior National Officer for Health at UNISON, told us:

we are hearing that role substitution is simply taking place, with sometimes registered staff being taken out of the system and replaced by assistant-practitioner level staff without a clear understanding of where the layers of accountability and supervision sit within those structures. We would like to see a consistent approach and a recommendation that we look at this issue from a whole-system perspective.[53]

33. We also heard of concern about the perceived failure to recognise the importance of training and development for unregistered staff in general (NHS Pay Bands 1-4). John Rogers, the Chief Executive of Skills for Health (the Sector Skills Council for Health), emphasised to us that more needed to be done to "upskill" this group, so that skill mix could be changed, and productivity and quality improved.[54] While Skills for Health is doing much good work in this respect,[55] Mr Rogers told us that only three per cent of the NHS training budget was being spent on the 40 per cent of the workforce who are not healthcare professionals.[56] We also heard from UNISON (the main union representing unregistered staff) and others about the failure to provide these staff with adequate appraisal, training and Continuing Professional Development (CPD), as well as proper career paths.[57]

34. Concern about the level of professional training and development for HCAs raises the issue of their unregistered status. In July 2011, following our annual accountability hearing with the NMC, we endorsed the idea of statutory registration for HCAs.[58] In November 2011 the Government announced that from 2013 there would be a voluntary register for HCAs, accredited by the Council for Healthcare Regulatory Excellence. This would be underpinned by a common code of conduct and basic training standards, to be developed by Skills for Health and its social-care counterpart (Skills for Care).[59] However, there is controversy as to whether these measures are sufficient.

35. Professor Ieuan Ellis, Chair of the Council of Deans and Heads of UK University Faculties for Nursing and Health Professions, told us that he opposed statutory regulation:

Support workers should be working under the supervision of a registered practitioner. It is ensuring the appropriate supervisory arrangements and also ensuring that there is the appropriate education and training. That in itself does not mean that they need to be statutorily regulated […] The education, training and supervisory arrangements for support workers are crucial, but that in itself does not lead me to conclude that there needs to be statutory regulation.[60]

36. We heard the same view from Mr Royles, of NHS Employers. He argued that there was:

a variety of other things that you can do in terms of standards, right from how we recruit people, the values they have, the training they are given, the qualifications they have, the supervision they receive on the ground and the ongoing training and development.

It was "offensive" to call HCAs "untrained", when they had National Vocational Qualifications and apprenticeships; and statutory regulation would "reduce flexibility".[61] A "culture or an environment where people can raise appropriate concerns" was needed; regulation would not guarantee this.[62]

37. Dr Peter Carter, Chief Executive of the RCN, told us that HCAs were an essential part of the workforce, but "while some employers at one end of the spectrum educate and train them to a very high degree and some do it okay, there are copious examples of employers giving them next to nothing." It was "wholly unacceptable" to put someone in a tunic, place them on a ward and expect them to "pick it up as they go along."[63] The Queen's Nursing Institute told us: "There is a danger that our current approach to HCAs is recreating all the problems and risks of Victorian nurse training, which led to the registration of nursing being set up to protect the public nearly 100 years ago."[64]

38. The subsequent Delivering Dignity report stated that the Commission on Dignity in Care for Older People had heard "a compelling case" that "all staff who provide care on our wards should be suitably qualified and have the appropriate regulatory mechanism in place". It concluded that:

The Department of Health should consider setting minimum training and qualification standards for healthcare assistants in the NHS. If this recommendation is accepted, the Department of Health will need to resolve how healthcare assistants are registered and regulated.[65]

39. When we raised this issue with the Minister of State for Health, Rt Hon Simon Burns MP, he insisted the Government's approach was "proportionate" and said it would wait to see how voluntary regulation worked rather than rushing into statutory regulation.[66]

Conclusions and recommendations

40. Innovation in skill mix and clinical roles is crucial to achieving a more efficient and flexible workforce. However, it is important for policy to be grounded on solid evidence—both to overcome restrictive practices in support of sectional vested interests and to prevent inappropriate de-skilling in pursuit of mere cost-cutting.

41. Effective workforce planning requires effective training and professional development. Given the increasingly important role of healthcare assistants, it is essential that the Department of Health develop proper guidelines for the training requirements of this group of staff; and commissioners should take these requirements into account when commissioning care from healthcare providers.

42. We note that the Government has announced arrangements for the voluntary registration of healthcare assistants. However, in the absence of a professional regulator, we urge the Government to keep under review the requirements of this key element of the workforce for training and professional development. In the longer run, we reiterate our view that independent professional regulation of this group of staff provides the best assurance to patients.

Changing medical specialism

43. In its January 2012 report, the NHS Future Forum called attention to the fact that there was unfinished business from Professor Sir John Tooke's report, Aspiring to Excellence (2008), in three important respects. Firstly, the Forum believed that the lack of flexibility in medical career pathways needed to be addressed. Secondly, it noted the major concern of employers that "the current system has resulted in too few generalists".[67] Thirdly, it reported "there was an almost unanimous view that the length of postgraduate GP training should be extended".[68]

44. The DH gave its response to the Forum in From Design to Delivery (January 2012). The Department emphasised that "evidence of improvement in this area will be a critical part of HEE [Health Education England] and LETB quality assessments".[69] Medical Education England (MEE) was "working with the GMC, Wales, Scotland and Northern Ireland to establish an independent review of the shape of medical education and training", and HEE would take this forward.[70] On extending GP training, the DH was working on this with the Royal College of GPs, bearing in mind the need for changes to be "affordable and sustainable financially, as well as the right thing to do educationally and in the interests of patients". Proposals were promised in spring 2012.[71]

45. When members of the Future Forum gave evidence to us in January 2012, Dame Julie Moore (Chair of the Forum's education and training group) explained that greater flexibility in medical career pathways would have benefits in terms of workforce planning:

The problem with workforce planning is I can say next year that I need more [Ear, Nose and Throat] surgeons, but it takes 10 or 12 years to make one and by the time you make one somebody might have invented a cure […] [W]e believe there should be more flexibility in training so that, if somebody did invent a cure that meant you did not need a certain specialist, or you needed far fewer, then it would not take forever to retrain somebody.[72]

46. Professor Tooke, who sat on the Forum—and is now the Head of the School of Life and Medical Sciences at University College London (UCL)—explained the need to move away from the current inflexible system of career pathways. This was a "snakes and ladders" arrangement, whereby a doctor would ascend the ladder of "one of the myriad specialties" and could only switch to another specialty by sliding back down to retrain from the beginning again. We also heard from Dame Julie that the Forum thought "there should be more stop off points […] in a career for somebody who does not want to undertake the full range of consultant responsibilities."[73]

47. Professor Tooke echoed Dame Julie's argument that creating more flexible career pathways could go hand-in-hand with fostering greater generalism—which was necessitated by an ageing population in which "co-morbidity is an increasing feature". Trainees needed to be given "a grounding in generalism". With this "profound foundation^"under their belts, they would then be able to switch more easily between specialties during the course of their careers. Professor Tooke said that Aspiring to Excellence had proposed "some ways of converting foundation year 2 and the early part of core training into, say, four broad based generalist starts to specialist training", yet thisapproach had not been widely adopted.[74]

48. Dame Julie pointed out that there would also need to be a reversal of the attitude that generalists were of lower status than specialists. She pointed out that "In actual fact, you need a wider range of skills to be a generalist", and referred to the situation in the United States, where generalist "diagnosticians" had "a very high status".[75]

49. In emphasising to us the case for longer GP training, Professor Tooke explained how this too was about achieving a broader generalist grounding:

we are fairly unique in Europe in assuming we can train a generalist—a general practitioner—in three years. We know, for example, that only half of GPs will have had relevant paediatric experience and probably the same proportion of relevant psychiatric experience. Yet those two disciplines account for a huge amount of the workload in the primary care setting.[76]

50. Another Forum member, Dr Nightingale, of the Royal College of Anaesthetists, told us that having more generalists in the acute sector meant:

a reduction in the availability of specialist consultants' advice. The only way to get round that is either to expand that section of the medical workforce or to reorganise services […] There is a need to put more of the specialised services in fewer numbers of larger hospitals if we are not going to expand the consultant workforce to work in more hospitals […] There is no doubt that quite a lot of the service and training tension that is in there, where trainees are not adequately supervised, is due to there being too many hospitals trying to teach those specialty areas.[77]

Dr Nightingale related this to the Forum's view that "perhaps not every hospital should be having trainees"[78]—or, as Dame Julie added, "Not every department within a [training] hospital" should have them.[79]

51. In February 2012, subsequent to our taking evidence from the Future Forum members, the CfWI published a study on the medical workforce. This suggested that, if medical services continue to be delivered as they are at present, by 2020 the NHS will have 2,800 more consultants than it needs (given the numbers currently in the training pipeline). This could be addressed by the proposed shift to more consultant-present services, but other measures would be needed too—such as having different levels of consultant, introducing a "consolidation" year into the career pathway and training more junior doctors as GPs.[80]

52. When we heard evidence in February 2012 from Mr Royles, of NHS Employers, he told us that moving towards less reliance on trainees for service delivery would be "a fundamental shift for us". He favoured the idea of patients being seen by "an appropriately qualified doctor", but it was necessary to make optimum use of the "entire medical workforce", including Non-Consultant Career Grades, as well as how members of the non-medical workforce were deployed.[81]

53. The Chair of the Junior Doctors' Committee of the British Medical Association (BMA), Dr Tom Dolphin, spoke in a similar vein:

The model we are proposing is not so much consultant-present as trained-doctor service. A trained doctor, of course, can include not just consultants, GPs and clinical academics but also staff and associate specialist doctors [i.e. Non-Consultant Career Grades] who are trained for the role that they are performing […] While training occurs through exposure to patients and delivering patient care, our view is that junior doctors ought to be viewed as being employed primarily to train. There will be service provision arising from that, but their primary focus should be training. It is the current arrangement they have for GP trainees and we think that ought to be the same in hospitals.[82]

Dr Dolphin rejected the idea that there was a risk of trainees being "over-supervised"; he was more concerned that they should not be "under-supervised" and thought that "the days of 'do not hesitate to cope' have to come to an end."[83]

54. On the length of GP training, Dr Dolphin thought there needed to be "a good educational case made for it"; this had almost been made "but not quite yet", and there were concerns about the impact on training places in hospitals. He expressed concern at the possibility of more "break points" in training (for people to consolidate their learning by focusing on service provision at a junior level). There was a danger that people could find themselves "stuck", without a way back into training, as had happened with such arrangements in the past.[84]

55. When witnesses from the DH gave evidence to us in March 2012, Dr Patricia Hamilton CBE, the Director of Medical Education, told us the Department recognised that Non-Consultant Career Grades had not been sufficiently recognised and that greater use could be made of them within the medical workforce.[85] On the issue of career pathways, she reiterated that these were under review and that a more broad-based approach to post-Foundation training had been developed, to allow doctors to "go into the specialty of their choice without having to go—snakes and ladders—right to the beginning of training".[86] Dr Hamilton also restated the Department's commitment to change working patterns to reduce dependence on trainees for the delivery of services through having more consultant-present services.[87]

56. Regarding the CfWI's forecast of an oversupply of consultants, the Minister told us that it would be addressed by more services being delivered outside hospitals—but he did not explain how.[88] Dr Hamilton mentioned that it was hoped to "direct more trainees into general practice";[89] more consultant-present services would require more consultants;[90] more consultants could work shorter hours (over longer careers); and the development of "the seven-day week hospital" would require more consultants (in fewer hospitals).[91]

Conclusions and recommendations

57. Four years ago Professor Tooke set down a clear agenda on the future of the medical workforce which was widely accepted. An acid test of the effectiveness of the new education and training arrangements will be their ability to deliver the more flexible medical training programmes which were described by Professor Tooke and endorsed by the NHS Future Forum.

Junior doctor training

58. It has been argued that changes to junior doctors' working hours have had the effect of undermining generalist training by limiting the range of clinical experience of newly qualified doctors.

59. From 2004 the European Working Time Directive (EWTD) was partially applied to doctors in training, limiting them to working no more than 58 hours per week. The Tooke Report recognised that this was having a very significant impact, leading in many cases to the introduction of multidisciplinary teams to deal with clinical problems outside normal working hours (under the "Hospital at Night Team" initiative). The EWTD's impact has been all the greater since 2009, when the Directive's full limit of 48 hours per week was extended to trainees—a limit which is widely seen as excessively restrictive.

60. The outcome of a review by Professor Sir John Temple of the impact of the EWTD on medical training (Time for Training) was published in 2010.[92] This confirmed that, in the context of traditional models of training and service delivery, learning opportunities for trainees were being lost. Professor Temple concluded that service delivery and training models both needed to be reconfigured and redesigned. This meant particularly that there would have to be more "consultant-delivered" services around the clock, with less reliance on trainees to provide out-of-hours services.

61. A review of another aspect of postgraduate training, the Foundation Programme, was undertaken by Professor John Collins, resulting in the publication of his report Foundation for Excellence (2010). This recommended that supervision for trainees should be strengthened, as many were being required to act beyond their level of competency.[93]

62. When we took evidence from officials of the DH in November 2011, Dr Hamilton assured us that work was underway in response to the Temple and Collins reviews through a programme called "Better Training Better Care". The intention was to avoid "service issues trumping training"[94] and to move away from a situation of "our most junior doctors providing most of the service", which meant they could not be trained within the constraints of the 48-hour EWTD limit. This entailed moving to "a more consultant-present service and different ways of working across and within the professions".[95]

63. Christine Outram, the Chief Executive of MEE, explained that the need for junior doctors to be on out-of-hours rotas had led to their missing training opportunities in-hours. Some hospitals had already addressed this by structuring their hours differently "so there is greater availability of senior doctors to oversee the work of juniors and be available when juniors need particular guidance or advice";[96] the intention was to spread this good practice.[97]

64. Another witness from MEE, Professor Sir Christopher Edwards (the Chairman), reiterated the point that some hospitals had shown it was possible to change working patterns to accommodate the EWTD and allow junior doctors to access training opportunities.[98]

65. Professor Sir Peter Rubin, Chair of the General Medical Council (GMC), emphasised the need to distinguish training from mere experience—the two were "completely different", and training required time to be set aside by both trainees and trainers for that purpose.[99] Professor David Sowden, Chair of the Conference of Postgraduate Medical Deans of the UK (COPMeD), denied that there was a risk of de-skilling junior doctors by increasing the level of consultant supervision: "good supervision does not mean the consultant doing the job".[100] He also told us that there was a case for a new "modularised" approach to training, based on "credentialing". This would involve "saying you have reached a certain level which allows you to do a certain range of activities within the system", allowing trainees to step "on and off an education and training escalator"—in contrast to the current "relatively inflexible system".[101] Sir Alan Langlands, Chief Executive of the Higher Education Funding Council for England (HEFCE), drew attention to the importance of maintaining the "hugely significant progress" that had been made in rebuilding the clinical academic workforce.

Conclusions and recommendations

66. While we recognise that introduction of the European Working Time Directive has had a significant impact on working and training practices, we do not feel any rose-tinted nostalgia for a system which used to rely on over-tired and under-trained junior doctors. We have received a broad basis of evidence which shows how it is possible to reconcile reasonable hours for junior doctors with high quality training and, most importantly, high standards of care for patients.

Different approaches to treatment

67. We asked Dr Hamilton, the Director of Medical Education at the DH, about the need to take account in workforce planning of different types of treatment (including Complementary and Alternative Medicine). This is relevant both to patient choice and to the role of the National Institute for Health and Clinical Excellence in evaluating the effectiveness and cost effectiveness of interventions. Dr Hamilton told us:

We certainly need to be aware of the different therapies and ways in which patients would choose to be treated, and the place in which they need to be treated. For example, we have asked the Centre for Workforce Intelligence to look at patient pathways: to look at the various ways in which patients present to the Health Service and the various options they might have for meeting different sorts of therapists in different ways. We can then help plan and train the workforce we think they need.[102]

Her DH colleague Mr Rentoul added that employers needed to work together to see what training was needed (considering "what services we want to offer, the mix of skills and therapies to do it"); and there might also need to be national input too.[103]

68. When Dr Hamilton again gave evidence to us in March 2012 she told us that "our curricula are being increasingly driven by service need and employers". Complementary and Alternative Medicine, though, "work on a slightly different framework than the more scientific, evidence based framework from which we compose the rest of the curriculum."[104]

Conclusion and recommendation

69. A clear mandate must be set for the new system to take account in workforce planning of the full range of evidence-based treatments—subject to the evaluations carried out by the National Institute for Health and Clinical Excellence.

Overseas-educated staff

70. The NHS, like most healthcare systems in developed countries, has a long tradition of being open to staff trained outside the home country. Originally, such NHS staff came predominantly from former British colonies and Dominions, and from the Republic of Ireland. More recently, substantial numbers have come from other countries in the European Economic Area (EEA),[105] as well as from a wide range of non-EEA countries. This migration has been, and is, driven by both "pull" factors in the UK (including active recruitment by the NHS) and "push" factors in migrants' countries of origin.

71. These employment patterns have both positive and negative implications. It is important that the UK healthcare system is open to new ideas, and the diverse backgrounds of members of staff are an important source of new perspectives. Overseas recruitment of staff can, however, also be a symptom of failure of local workforce planning; and significant employment of overseas-trained staff can raise other concerns, particularly about language competence as well as the ethical implications of attracting staff from poorer countries which have their own needs for well-trained clinical staff.

72. The GMC states that—as at April 2012—91,262 of its registrants (37 per cent of the total) held a primary medical qualification obtained outside the UK, with the largest single overseas-qualified group (10 per cent of all registrants) being from India.[106]

73. NMC data show that in 2010-11 it registered 3,858 people from outside the UK. Of these, 2,715 came from the EEA and Switzerland (the single biggest group being from the Republic of Ireland); and 1,143 from the rest of the world (the single biggest group being from the Philippines).[107] According to recent press reports, 3,197 nurses from the EU registered in the UK between November 2010 and November 2011, compared to 2,256 in the previous 12 months.[108] It has been reported that London hospitals are recruiting as many as a third of their nurses from abroad.[109]

74. We heard in evidence that the contribution of overseas-trained staff to the NHS was widely valued. Mr Royles, of NHS Employers, told us:

overseas staff have made a fantastic contribution to the NHS, from those who came over in 1948 on MV Empire Windrush and started working in our hospitals to those who are coming from Europe now, or doctors who have come over and transformed things like general practice or care of the elderly […]

He noted that there was now an international labour market in healthcare staff, with many British-trained workers wishing to pursue their careers abroad. It was necessary to recognise that "that the world is much smaller now". It was possible within that global labour market to recruit staff from developing countries who could "get learning, education and training" in the UK and then "take something back to their countries".[110]

75. Ms Taber, of Independent Healthcare Advisory Services, told us that her organisation had experienced problems convincing the UK Border Agency's Migration Advisory Committee that operating theatre staff should not have been removed from the Committee's list of shortage occupations. While it was accepted that more had to be done to "grow our own theatre staff", while vacancies existed they needed to be filled by overseas staff.[111]

76. We heard from the development organisation VSO and also from the Wellcome Trust about the Medical Training Initiative, which allows overseas medical graduates from developing countries to undertake short periods of training (up to two years) in the UK, filling locum posts. However, the success of this scheme was under threat from a possible reduction in the maximum length of stay allowed by the UK Border Agency under a Tier 5 visa from 24 months to 12.[112]

77. Professor Tooke, of UCL, thought that "if we had the most accurate workforce planning that we could" the NHS could be less dependent on overseas staff. However, given that "we are not always going to get it right":

it would be far more preferable to find a way of increasing the number of overseas medical students that we could accommodate, who would go back to their own country once they were trained. They would be a very significant export for us, would be good for global health, good for future relationships between our country and theirs and yet provide a reservoir of talent were we to get the numbers wrong and under-pitch in our own estimates. That is far more ethical than under providing and then taking away people from whence they have been trained.[113]

Conclusions and recommendations

78. The NHS has historically welcomed large numbers of staff from overseas, including healthcare professionals who have been educated and trained in other countries. Their contribution to the success of the NHS has been rightly acknowledged and celebrated.

79. We believe that the openness of the UK to clinical staff trained overseas, and the ability of UK-trained staff to work overseas, is a continuing source of strength to UK healthcare, and that this openness should continue to be reflected in workforce planning.

80. However, we also welcome the Government's view that planning of the UK health and care workforce should not be dependent on significant future flows of trained staff from overseas, both in order to improve "security of supply" and in order to avoid "poaching" skilled staff from developing countries. This approach should apply to public and private healthcare employers.

Locum and agency staff

81. The NHS makes substantial use of locum and agency staff to deal with staff shortages. Concerns at the high cost of this approach led to the development of in-house "banks" of temporary staff and in 2001 NHS Professionals was set up to run a national in-house NHS bank organisation on a non-profit basis. Since 2004 NHS Professionals has been constituted as a Special Health Authority. It has over 50,000 staff available to it, including doctors, nurses and other healthcare professionals, as well as administrative and clerical workers.[114]

82. However, Developing the Healthcare Workforce (December 2010) argued that the cost of locum and agency cover was still too high (at over £1.9 billion a year).[115] As recent publicity has shown, there is a widespread perception that the NHS wastes money through such spending.[116] Mr Rentoul, of the DH, told us:

the NHS is spending too much on agency staff at the moment […] we have seen significant growth in terms of the number of people in different professions coming through training such that you would expect us to be making progress in reducing agency usage, though not seeking to eliminate it.[117]

83. Professor Edwards, of MEE, told us that the use of agency staff was "a complicated issue". It was an expensive way to employ staff and "they do not have the same allegiance, attitudes and local knowledge", so the percentage of such staff did need to be restricted, although "You are going to need some". Professor Sowden, of COPMeD, added that use of locums was an inevitable consequence of the current system of postgraduate medical training and the gaps it created. With a different approach to workforce planning, the use of locums could be reduced—although not eliminated.[118]

84. Mr Royles, of NHS Employers, told us:

agency and locum staff play an important part in having a flexible workforce. Therefore, occasionally, we need to bring in staff temporarily for short term increases in activity or to cover unexpected or more long term sickness absence. All those things are a legitimate use of agency and locum spend.

His understanding was that the Government did not wish to eliminate the use of such staff completely, only to ensure that it was done "in the most strategically efficient way that you can."[119]

Conclusion and recommendation

85. We accept that locum and agency staff provide a necessary element of flexibility in NHS staffing arrangements. We do not believe, however, that they provide an optimum solution, either in terms of quality of care or value for money. We, therefore, urge the Government to proceed quickly with improved arrangements for workforce planning, which should reduce the importance to the NHS of locum and agency staff.

4 The core business of the Mouchel parent company is road-building (it began as a manufacturer of reinforced concrete in 1907). It was reported in late 2011 that Mouchel had recorded major losses as a result of cuts in public spending and the discovery of an actuarial error in calculating its pension liabilities. It remained solvent by borrowing £180 million but its share price dropped dramatically as a result of continued uncertainty about the company's future - "Mouchel 'disappointed' after losses treble", BBC News website, 30 November 2011. Back

5 Q 79 Back

6 Ev 111 Back

7 Q 81 Back

8 Loc. cit. Back

9 Q 99 Back

10 Q 81 Back

11 www.ic.nhs.uk Back

12 Q 82 Back

13 Department of Health, Liberating the NHS: Developing the Healthcare Workforce - A consultation on proposals, December 2010, para 3.18 Back

14 Ibid., paras 5.13-4 Back

15 Ibid., para 6.10 Back