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 staffwith 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
was contracted by the Department of Health (DH) to set up and
run the Centre for Workforce Intelligence (CfWI).
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.
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".
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.
The Centre aimed:
to get from national down to regional [
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.
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."
(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.)
It also aimed "to work closely with the stakeholders to make
sure the advice and guidance we produce is tailored to their needs".
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. Data
from providers would need to be collected locally, aggregated
and made available to the CfWI.
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".
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.
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).
At that time it was also seen as concentrating on issues at the
national level and particularly around medical staff.
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".
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."
16. It was queried in several submissions whether
the CfWI had the necessary resources for the task it had been
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
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.
18. Mr Sharp told us that the CfWI was working
with the medical Royal Colleges on medical workforce issuesand
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.
(Other evidence emphasised the Royal Colleges' possession of quality
data which the CfWI must use, rather than duplicating it unnecessarily.)
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.
Dr Peter Nightingale, President of the Royal College of Anaesthetists,
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.
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
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. 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.
It should be noted that the CfWI is maintaining a commendably
regular output of publications across a range of topics
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 providerswhether
NHS Foundation Trusts (FTs) or independent sector bodieswill
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.
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.
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.
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. Nevertheless,
past experience (for instance, the poor track record of Independent
Sector Treatment Centres in furnishing data)
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 levelbut 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;
and this was supported in the subsequent consultation.
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. This
would include developing a minimum data set.
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.
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.
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".
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
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 datawith
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
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".
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 responsibilitieseven 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 nurseshave 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. The
Royal College of Nursing (RCN) told us that there were as many
HCAs again outside the NHS in settings such as care homes;
and we heard about increasing numbers of HCAs working in the community,
providing care in people's homes.
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.
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
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
], 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.
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
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.
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.
While Skills for Health is doing much good work in this respect,
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.
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.
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. 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).
However, there is controversy as to whether these measures are
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
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
It was "offensive" to call HCAs "untrained",
when they had National Vocational Qualifications and apprenticeships;
and statutory regulation would "reduce flexibility".
A "culture or an environment where people can raise appropriate
concerns" was needed; regulation would not guarantee this.
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." 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
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
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
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 evidenceboth 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".
Thirdly, it reported "there was an almost unanimous view
that the length of postgraduate GP training should be extended".
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
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.
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.
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
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
46. Professor Tooke, who sat on the Forumand
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."
47. Professor Tooke echoed Dame Julie's argument
that creating more flexible career pathways could go hand-in-hand
with fostering greater generalismwhich 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 this approach had
not been widely adopted.
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".
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 generalista general practitionerin 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
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 [
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
Dr Nightingale related this to the Forum's view that
"perhaps not every hospital should be having trainees"or,
as Dame Julie added, "Not every department within a [training]
hospital" should have them.
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 toosuch as having different levels
of consultant, introducing a "consolidation" year into
the career pathway and training more junior doctors as GPs.
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.
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.
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."
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.
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.
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 gosnakes
and laddersright to the beginning of training".
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.
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 hospitalsbut he
did not explain how.
Dr Hamilton mentioned that it was hoped to "direct more trainees
into general practice";
more consultant-present services would require more consultants;
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).
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
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
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 traineesa
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.
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
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.
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"
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".
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";
the intention was to spread this good practice.
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.
65. Professor Sir Peter Rubin, Chair of the General
Medical Council (GMC), emphasised the need to distinguish training
from mere experiencethe two were "completely different",
and training required time to be set aside by both trainees and
trainers for that purpose.
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".
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
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.
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
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."
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 treatmentssubject to the
evaluations carried out by the National Institute for Health and
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),
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
72. The GMC states thatas at April 201291,262
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
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).
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.
It has been reported that London hospitals are recruiting as many
as a third of their nurses from abroad.
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".
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.
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.
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.
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.
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).
As recent publicity has shown, there is a widespread perception
that the NHS wastes money through such spending.
Mr Rentoul, of the DH, told us:
the NHS is spending too much on agency staff at the
] 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.
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 reducedalthough not eliminated.
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."
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
Q 79 Back
Ev 111 Back
Q 81 Back
Loc. cit. Back
Q 99 Back
Q 81 Back
Q 82 Back
Department of Health, Liberating
the NHS: Developing the Healthcare Workforce - A consultation
on proposals, December 2010, para 3.18 Back
Ibid., paras 5.13-4 Back
Ibid., para 6.10 Back
Q 35 Back
Qq 84, 228 Back
Q 84; Ev 110 Back
Ev w185 Back
Ev w264; cf. Ev w165, w210 Back
Ev w132, w169, w204 Back
Ev w175 Back
Ev w134 Back
Q 81; cf. Q 85 Back
Ev w41 Back
Ev w108, w260 Back
Ev w101 Back
Q 229 Back
Ev w96 Back
Ev w67-8 Back
Centre for Workforce Intelligence, Shape of the Medical Workforce:
starting the debate on the future consultant workforce - a discussion
document for leaders, February 2012 Back
Q 319 Back
Health Committee, Sixth Report of 2010-12, Complaints and Litigation,
HC 786-I Back
Q 81 Back
Q 319 Back
Healthcare Commission, Independent sector treatment centres:
the evidence so far, July 2008 Back
Department of Health, Developing the Healthcare Workforce -
A consultation on proposals, December 2010, paras 5.12-4 Back
Department of Health, Liberating the NHS: Developing the Healthcare
Workforce - A summary of consultation responses, August 2011,
paras 4.12-4 Back
Department of Health, From Design to Delivery, January
2012, para 150 Back
Ibid., para 151 Back
Ibid., para 149 Back
Ibid., para 85 Back
Q 319 Back
Department of Health, Developing the Healthcare Workforce -
A consultation on proposals, December 2010, para 3.18 Back
Ibid., para 3.19 Back
Health Committee, Seventh Report of Session 2010-12, Annual
accountability hearing with the Nursing and Midwifery Council,
HC 1428, para 59 Back
Q 385 [Dr Carter] Back
Ev w16 Back
Ev w265-7 Back
Ev w134-5 Back
Q 372 Back
Qq 169-70 Back
Qq 165, 170, 172 [Mr Rogers], 178, 179, 180 [Mr Rogers], 183 [Mr
Rogers], 280-5 Back
Q 169 Back
Ev 140, w134-5, w215; Qq 169-70, 174, 333 Back
Health Committee, Seventh Report of Session 2010-12, Annual
accountability hearing with the Nursing and Midwifery Council,
HC 1428, para 64 Back
Q 297 Back
Q 342 Back
Q 343 Back
Q 385; cf. Ev 137 Back
Ev w17 Back
Commission on Dignity in Care for Older People, Delivering
Dignity, February 2012, Recommendation 47 (p 34) Back
Qq 500-7 Back
NHS Future Forum, Education and Training - next stage: A report
from the NHS Future Forum, January 2012, para 82 Back
Ibid., para 84 Back
Department of Health, From Design to Delivery, January
2012, para 18 Back
Ibid., para 19 Back
Ibid., para 20 Back
Q 218 Back
Q 239 Back
Q 235 Back
Q 237 Back
Loc. cit. Back
Loc. cit. Back
Q 239 Back
Q 240 Back
Centre for Workforce Intelligence, Shape of the Medical Workforce,
February 2012 Back
Q 333 Back
Q 378; cf. Q 380 Back
Q 378 Back
Q 379 Back
Q 475 Back
Q 477 Back
Qq 478-80 Back
Q 465 Back
Q 476 Back
Q 479 Back
Q 482 Back
Professor Sir John Temple, Time for Training: A Review of the
impact of the European Working Time Directive on the quality of
training, May 2010 Back
Professor John Collins, Foundation for Excellence: An Evaluation
of the Foundation Programme, October 2010 Back
Q 11 Back
Q 12 Back
Q 13 Back
Q 17 Back
Q 153 Back
Q 156 Back
Q 154 Back
Q 157 Back
Q 30 Back
Q 31 Back
Q 490 Back
The EEA countries are the 27 members of the EU, plus Iceland,
Liechtenstein and Norway. Back
Unpublished data provided by the Nursing and Midwifery Council Back
"Overseas nurse numbers rise by 40%", Nursing Times
website, 9 January 2012 Back
Michael Howie, "Third of hospital nurses in London are foreign
as training is cut", London Evening Standard website,
27 February 2012 Back
Q 326; cf. Q 327 Back
Q 323; cf. Q 326, Ev 166 Back
Ev w49-50, w152-3 Back
Q 234 Back
Department of Health, Developing the Healthcare Workforce -
A consultation on proposals, December 2010, para 3.19 Back
Laura Donnelly and Melanie Mulhern, "NHS pays £20,000
a week for a doctor", Daily Telegraph website, 17
March 2012 Back
Q 37 Back
Q 152 Back
Q 323 Back