Conclusions and recommendations
The Centre for Workforce Intelligence
1. 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.
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2. 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.
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3. 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.
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4. 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.
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Changing skill mix
5. 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.
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6. 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.
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7. 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.
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Changing medical specialism
8. 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.
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Junior doctor training
9. 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.
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Different approaches to treatment
10. 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 Clinical Excellence.
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Overseas-educated staff
11. 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.
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12. 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.
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13. 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.
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Locum and agency staff
14. 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.
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The Secretary of State
15. We welcome the inclusion in the Health and Social Care Act 2012 of an explicit duty on the Secretary of State to secure an effective system of education and training. However we are concerned that there continues to be insufficient clarity about how the Secretary of State intends to discharge this duty. In particular, we seek reassurance that the Secretary of State shares our view that the effectiveness of the new system will be fatally undermined if it is not built upon a more accountable and transparent system of workforce planning.
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16. We also welcome the fact that the Secretary of State will have a clear responsibility for holding to account Health Education England. The Department must, though, spell out how exactly this will be doneincluding the part that the planned Education Outcomes Framework will play.
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Health Education England
17. We welcome the plan to set up Health Education England as an executive body with overall responsibility for education, training and workforce planning, drawing input from all healthcare professions and other stakeholders. The creation of such a body is long overdue and has the potential to be a significant step forward.
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18. However, we are concerned, given the centrality of this body to the Government's plans, that the Government has been slow in developing a coherent plan for the new organization. It is being set up in shadow form in July 2012 and will be fully operational in April 2013. There is an urgent requirement for the Government to publish a clear and detailed execution timetable.
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19. In the absence of this timetable there continues to be a lack of clarity about the role, responsibilities, powers and structure of Health Education England. Fears have been expressed to us that Health Education England, growing out of Medical Education England, could be predominantly focused on the medical workforce, despite its multi-professional remit. The Government must show that it is addressing and allaying these fears.
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20. Greater clarity is particularly needed about how Health Education England plans to ensure that it develops a dynamic view of the changing education requirements of the whole health and care sector.
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21. Greater clarity is also needed regarding the role of Health Education England in relation to the professional regulators and to its counterpart organisations in other UK countries.
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22. The Government has acknowledged the need to take account of the UK-wide dimension of education, training and workforce-planning policy. However, in that context we are concerned that there must be adequate emphasis on workforce planning in particular.
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Local Education and Training Boards
23. We welcome the Government's plan to create Local Education and Training Boards as provider-led bodies to take responsibility for education, training and workforce planning below the national level. We are concerned, however, at the Government's protracted failure to produce concrete plans in respect of the Boards, which poses a significant risk to their successful establishment.
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24. Between July 2010 and January 2012 the Boards were conceived of as loosely defined non-statutory "legal entities", to be developed at local level. The Government has now concluded that they should be "outposts" of Health Education England. There is, however, still little central guidance about the requirements for authorization, despite the recommendation of the NHS Future Forum that there should be "common terms of reference and a single model [
] to promote consistency across the country".
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25. It is unsatisfactory that so much about the Boards still remains vague and indeterminate. Crucially, the precise extent of their autonomy, and the means by which they will be authorised and held accountable, are still worryingly opaque. This must be spelled out as a matter of urgency.
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26. We welcome the Government's guidance that Local Education and Training Boards should be comprehensive bodies, not restricted to healthcare providers. However, concerns remain among higher-education institutions that their viewpoint will not be adequately heard. The Government should provide a definitive list of stakeholders which should be represented, as well as providing greater clarity on other aspects of governancenot least how potential conflicts of interest are to be addressed.
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27. We are also concerned that the geographical basis of Local Education and Training Boards remains obscure. Evidence submitted to us that there will be "10 to 15" (or alternatively "12 to 16") calls into question their ability to reflect local conditions. There is a definite need for structures at the level of local health economies and the Department must make clear how these are to be facilitated.
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Postgraduate deaneries
28. The integration of the postgraduate deaneries into the new system will be crucial to its success. We regret the fact that the Government allowed uncertainty about the future position of the deaneries to persist for so long. Although there is now greater clarity of intention, the period of uncertainty led to a regrettable loss of experienced staff.
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29. There continues to be an urgent need for more precision about how the deaneries will operate in future. The distinct position of postgraduate dean should continue to exist to provide an independent professional voice. There needs to be greater clarity about relationships with the General Medical Council, the Director of Medical Education and Health Education England. Finally, there must be a convincing plan to realise the Government's stated aspiration for deaneries to become "truly multi-professional" in their new role.
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Innovation bodies
30. We welcome the Department's intention to continue within the new system the work done in recent yearsthrough the Health Innovation and Education Clusters and Academic Health Science Centresto link innovation with education and training. We also welcome the intention to build on this through the creation of Academic Health Science Networks. However, there is a risk, through creating a yet more complicated landscape of Boards, Clusters, Centres / Systems, Networks and Collaborations, that the resulting arrangements could be incoherent and ineffective. The Department must develop a plan to rationalise these bodies and structures, to bring about as much de-cluttering and geographical coterminosity as possible without limiting local initiative and creativity.
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31. The same point applies to the planned new education, training and workforce planning system as a whole. The NHS Future Forum has rightly referred to the "number of players in the system" as a complicating factor. Nothing we have heard suggests that the new arrangements will be any less overpopulated with stakeholders, sometimes with overlapping or unclear responsibilities. If this is not addressed, it will be a serious shortcoming in the Government's reforms.
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The proposed tariff
32. The current arrangements under which providers are paid by the NHS for education and training are anachronistic and anomalous. Payment is only partially based on student or trainees numbers; it is not linked to quality; it is unjustifiably inconsistent between different professional groups, parts of the country and types of provider; and there is an almost total lack of transparency about how it is spent.
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33. Accordingly, we welcome the Government's intention to move payment onto a tariff basis, including a quality premium, as recommended by the NHS Future Forum. However, we note that there is so far slender evidence of progress in converting this desirable policy into a system that will work in practice. Bearing in mind that implementation of the new system is supposed to begin in April 2013, we believe this work needs to attract a greater sense of urgency.
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34. While taking this work forward the Government needs to recognise that there are significant difficulties involved in constructing a workable tariff. It is important that the transition to any new system avoids unnecessary turbulence, andin particularthreats to the quality of clinical services.
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The proposed levy
35. We support the Government's intention to introduce a levy on all healthcare providers (whether or not they supply services to the NHS) to provide a more transparent and accountable system of funding for education and training in the health and care sector.
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36. We heard from some independent-sector representatives that they fear a levy would put them at an unfair disadvantage. However, we are unconvinced by these arguments. If there is to be a comprehensive tariff system for funding education and training, as the Government intends, it should be possible for independent-sector providers to be remunerated for training that they undertake on a fair and transparent basis, alongside NHS organisations.
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37. We urge the Government to ensure that the levy system covers social care services, as well as healthcare, to ensure that the education and training system reflects the policy intention to deliver more integrated health and social care services.
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38. We recognise that there are particular concerns about the potential effect of a levy system on smaller voluntary-sector organisations. However, we believe that it is possible to construct workable exemption arrangements to cover these cases and this issue cannot be used to justify the current opaque and unaccountable system.
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39. Although, however, we support the Government's policy objective in this area we noteonce againthat there is slender evidence of progress in converting this desirable policy into a system that will work in practice. We believe this work needs to attract a greater sense of urgency.
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Funding in the transition period
40. We heard from the Department that its policy is currently to keep NHS funding for education and training broadly the same in cash terms from year to year. Against a background of inflation and major cost pressures, this is an extremely challenging financial settlement
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41. We have heard evidence that education commissions are being significantly cut. Given the wider financial situation in the NHS, there is also the risk that SHAs will raid education and training budgets in 2012-13, as they have done before.
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42. "Raiding" of education and training funds for other purposes has a long history. While we welcome the Government's willingness to apply a "ring-fence" to the Multi Professional Education and Training levy, we are sceptical about its effectiveness. We believe the Government's plans for more fundamental reform discussed earlier in this chapter represent a more realistic way of safeguarding education and training activity within the health and care system. In the meantime the Government must act to safeguard funding for education and training during 2012-13.
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