Health CommitteeWritten evidence from NHS Employers in the East Midlands (ETWP 05)

Summary

Employers in the NHS should take ownership of the Education, Training and Workforce agenda.

This would be best achieved by establishing employer owned networks.

Such a network would provide accountability and transparency in the management of this vital agenda, within a framework developed by the proposed Health Education England and an agreed running costs envelope.

East Midlands NHS employers are prepared to pilot such an approach since we see the development of our workforce as essential to our delivery of the challenges we face.

Introduction

1. We welcome the Health Select Committee (HSC) Inquiry on Education, Training, and Workforce Planning. We have been working together over the last year to plan for the reforms that will arise when Strategic Health Authorities (SHAs) cease to exist in March 2013.

Background

2. The East Midlands SHA, now part of the “Midlands and East Cluster”, includes the health services in Derbyshire, Nottinghamshire, Northamptonshire, Leicestershire with Rutland, and Lincolnshire. Twenty-six NHS Trusts and 630 general practices serve a population of 4.4 million; 8.5% of England. Together we employ 92,200 staff (78,900 FTEs) of whom 46,600 (40,900 FTEs), are professionally qualified clinical staffs.

3. The education and training needs of the East Midlands are met locally by contractual relationships with 11 higher education institutions, with 75 contracts supporting 12,500 students and trainees.

4. The services we deliver reflect the characteristics of our distinctive population and so should our local education and training.

The Workforce Challenge

5. The workforce being trained today will deliver services to patients and the public for many years to come. Healthcare changes very quickly and our workforce system must be responsive. Some examples follow.

Hospitals at Night

6. Delivery of care in hospitals overnight has been transformed in response to the need to improve safety of care and regulatory requirements limiting time spent on call. The best hospitals have embraced these changes and developed a wide range of extended roles for nurses and other staff.

7. Consequentially there are development needs for many staff, including communication skills, team working and leadership as well as new clinical skills. Much of the learning is inter-professional often in simulated environments. Senior professional attitudes and reactions to these initiatives, which challenge traditional ways of working, have been mixed, which creates additional demands.

The Heart Attack Victim

8. Care for patients diagnosed with this condition has been revolutionised, leading to dramatic improvements in survival. Formerly, such a patient would be given pain relief and diagnosed, admitted and cared for by monitoring and bed rest under a generalist, with a length of stay up to two weeks. This approach has been supplanted by a time critical, intervention driven pattern of care, involving potent medication and primary angioplasty for many eligible candidates.

9. These changes have affected the learning needs of many people: ambulance staff, primary care colleagues, A&E, specialist cardiology staff, junior doctors and nurses, healthcare scientists are all affected. Critical to the success of the modern system is the response from the first person to whom the patient turns when chest pain arises. Health promotion staff, communication experts who develop public awareness campaigns and staff in general practice receptions and NHS Direct all play a crucial role.

Patients with Early Dementia

10. The prevalence of dementia and its recognition have increased very substantially. New care pathways have been advocated by organisations such as NICE, to improve the professional response to patients with cognitive impairment and to develop memory assessment services. These will lead to more accurate diagnosis and more tailored management, including access to a range of new interventions.

11. The workforce development consequences of these developments are substantial and wide ranging, being of relevance to a very high proportion of the patient facing workforce of the NHS, especially as so many of these patients have co-morbidity that leads to their care in acute settings.

Cancer

12. For many people with cancer the last decades have seen a transformation in the prospects of survival. Ten fold improvements in the median survival period are seen in lymphoma, colorectal cancer, testicular cancer and others. Meanwhile the prognosis has not improved for other malignancies.

13. Some of the improvements depend on targeted treatment, based on new genetic or scientific diagnostic procedures. Others are driven by early diagnosis. All result in the need for new skills. Thousands of survivors suffer from the late effects of cancer treatment, demanding a new service response.

Primary Care

14. The role of primary care is becoming even more centrally important with the shift to a focus on long-term conditions. Through increased demand for consultation and longer consultation times the need for GP patient facing time has increased by 55% in a decade. However GP numbers (as FTEs) have been static and currently only 21% of new medical graduates see general practice as their preferred career.

The System for Education, Training and Development of the Workforce (“the System”)

15. A new system must be established to ensure the sustainable supply of all workforce groups. As employers who are prepared to rise to this challenge we have reached a consensus on the key issues to be tackled:

The primary drivers for change must be improvements in the quality of healthcare outcomes, improved safety of care and patient experience.

The system must become more proactive and innovative in relation to changing patterns of care.

Employers must lead, drive, and own the new system within the context of national regulation and requirements.

The system must reflect our local circumstances and labour market dynamics.

High quality services rely on a highly motivated workforce that aspires to excellence. Education, training and development are central to this objective.

Transparency and equitable access to funding must be achieved to create a fair system.

Value for money will be a prime consideration.

16. The connections between the plans for service improvement proposed by healthcare commissioners, translated into changed services by providers, and the consequent alterations to the education, training and development opportunities for staff, have been too weak. The quality of workforce planning has been poor because employers have been too remote from the process.

17. The changes proposed following the publication of “Liberating the NHS: Developing the NHS workforce” and the deliberations of the NHS Future Forum, are the once in a lifetime opportunity to address these shortfalls.

An Employers’ Network

18. We advocate the creation by employers of a jointly owned network to be accountable for the development of the responsive, effective system of education, training and workforce development that is required. This network would be the Local Education and Training Board (LETB) envisaged in the Future Forum report and would be directly accountable to and owned by local employers.

19. The LETB would design and deliver a system in response to the commissioning requirements of Clinical Commissioning Groups within the framework of accountability to be developed by Health Education England. It would provide transparent governance of the resources for education and training allocated to it. In return it would expect the freedom to deliver local solutions to local needs.

20. The LETB will work with local stakeholders, including Higher and Further Education providers, CCGs, and partners in local Government. We will engage the voluntary sector, and representatives of patients and carers. We will involve students, the professions, and local private providers of NHS services. This to develop a shared position on the balance between:

A view of those in training as students who need work experience with their being seen as employees who need development.

The need for healthcare students to access a liberal education with the need for curricula to prepare them for new and emergent service models and the reality of a career in healthcare.

Access to the expertise of the educationalist and professional perspective with the avoidance of an education provider driven pattern of training.

A central role for employers with the need for individual employers to be held to account by their peers if their support for quality education comes under question.

Greater innovation in healthcare education and development with the need to retain the strengths of the current system.

A truly multidisciplinary and inter-professional ethos whilst continuing to improve the training of specific disciplines.

Functions

21. The LETBs’ functions will be to:

assure workforce plans and educational commissioning requirements to ensure that sufficient numbers of appropriately skilled staff are available to deliver safe, high quality services;

support strategic workforce planning;

commission and contract education which incentivises the delivery of high quality, safe programmes, and promotes the recruitment and retention of staff and students to the East Midlands;

deliver Deanery functions including management of recruitment, of rotations, of the quality of clinical placements, the assessment of progress and the revalidation of doctors and dentists in training;

identify and deploy innovative solutions to local workforce issues, reflecting increased local responsibility, greater self sufficiency, informed by our understanding of local demand and labour market dynamics; and

engage in entrepreneurial activities to create additional revenue streams and to improve the value for money of the workforce development system.

Governance

22. The current multi-professional education and training budget for the East Midlands is £374 million. Whilst this is significantly less than would be an equitable allocation (representing 7.7% of the total MPET budget for 8.5% of the population) this large amount of public money needs to be well governed.

23. Whilst awaiting the accreditation criteria, which HEE will develop, we propose to establish a management board with an independent chair and non-executive directors chosen by the network, supported by an executive team, including a CEO, Director of Finance, a Director of Workforce and a Director of Education Quality (which remit would encompass the Deanery functions).

24. A particular emphasis will be to fully engage primary care colleagues in this system. The voice of GPs and their teams has been too indistinctly heard in workforce affairs in the past. They bring three perspectives; as employers; as those involved in the development of the future primary care workforce; and as service commissioners. We are consulting on how to ensure their future central involvement, with current input from LMC identified representatives, and cluster based primary care groups.

25. This management board will be supported by a partnership board, which will be the forum through which the LETB will ensure:

that all aspects of the work of the LETB is informed by a strong and meaningful voice for patients and the public through lay representatives;

that clinical commissioning groups can influence the education, training and development agenda appropriately;

that there is enhanced engagement with local authorities to strengthen the alignment with the social care workforce;

that the HE and FE sectors can be engaged in the co-creation of educational solutions to workforce challenges and can bring their expertise to the work of the LETB;

that employers of staff who deliver care funded by the NHS, be they in the independent or the voluntary sector are engaged with the work of the LETB; and

that students, trainees and staff representatives can contribute to the work of the LETB in a meaningful way.

Organisational Form

26. A new form of organisation will need to be established to provide these functions. There are the three leading alternatives.

A New Statutory Body

27. Typically local statutory bodies in health have been established as Special Health Authorities (SpHAs). The establishment of a series of new SpHAs would not be consistent with Government policy and an SpHA would not provide the level of employer ownership which we believe to be appropriate for a LETB. They also operate within a financial framework which is too inflexible for the more entrepreneurial approach advocated.

28. HEE is likely to be established initially as an SpHA. It has been suggested that LETBs could operate as local outposts of this body. This might limit running costs but would not, in our view promote greater employer ownership. Such an arrangement would also not provide the flexibility for a locally responsive service, in our view.

A Hosting Arrangement

29. An alternative would be to establish a hosting arrangement with an existing body, for example a Foundation Trust.

30. The experience of such arrangements for the hosting of other shared services has been mixed. Two variants have been explored. In the first, a host FT might take on the management of education and training funds in exchange for a management fee and the secondment of a group of staff. Full risk and liability would not transfer to the FT, but would be retained by DH, or perhaps by HEE.

31. In a second variant of “full hosting” the full levy budget and associated risks would become the responsibility of the FT and would form part of Monitor’s consideration of the risk rating of the organisation, with the resources consolidated into the FT accounts.

32. These options would avoid the establishment of a new organisation, and the financial regime of FTs has greater flexibility than that of SpHAs. However, there is an inevitable risk that those employers that are not the host will question the level of influence that they would have, especially in challenging circumstances. The scale of the MPET budget would be a significant part of the turnover of any local FT.

A Social Business

33. In this option (proposed in the initial consultation document) the employers of the East Midlands would establish a not-for-profit social business as a joint venture vehicle, specifically created to plan and manage the development of their collective workforce. The employers would be owners of the business and would agree through the articles of association the approach to collective decision making, and would appoint Directors to run the business.

34. The business could take one of a number of specific organisational forms. In all of these the legal entity could enter contractual relationships with educational providers and suppliers. In other areas of healthcare, staff transferring to such an organisation have retained their employment rights. Such an arrangement would need to meet the criteria to be established by HEE for LETBs and would need to operate within the running costs envelope agreed as part of the accreditation process.

35. Employers as owners would take full responsibility for this agenda. We believe this approach to have great merit, it is our preferred option, and we would be prepared to pilot such an approach.

Conclusion

36. The staff of the NHS are its greatest asset but employers have had constrained influence in the education, training and development of their workforce. We want to take the lead in creating a system that is accountable, responsive and transparent, which will deliver excellence in outcomes and in patient experience.

37. We are dealing with the challenging circumstances facing the NHS over the foreseeable future. The education, training and development of our workforce is fundamental to our meeting these challenges. A year on from the publication of “Liberating the NHS; developing the healthcare workforce”, and as we approach the last year of the stewardship of SHAs we need to be enabled to take the lead in this agenda as soon as possible.

December 2011

Prepared 22nd May 2012