Health CommitteeWritten evidence from De Montfort University (ETWP 38)

We are a University which provides quality and distinctive education and training in numerous healthcare professions. We currently have many courses directly commissioned by NHS commissioning bodies and we do this at both undergraduate and postgraduate levels.

We have particular concerns about how universities will play a part in informing transition to the new system(s) and how universities will subsequently work in true partnership with education-commissioning bodies.

We are unsure as to the routes of communication of all these new initiatives around changes in education commissioning. We have consulted widely with our stakeholders, NHS Trusts and partners, and knowledge of some of the bodies outlined below is patchy.

The outcomes of the proposed National Education and Training Outcomes Framework must be linked to the health outcomes frameworks if we are to address health need and health inequalities within England; we need to fix the line of cohesive actions into one of seamless attention. At De Montfort University, we are doing this within our new pilot of communities of practice: for example our health visitor/children’s community of practice links the educational curriculum to breast feeding rates, safeguarding, speech and communication outcomes. This clear line of sight between education and outcomes for the people we serve is essential. If there is one item from this consultation response that is identified as crucial, it is this point.

We would welcome the opportunity to present evidence to the committee verbally.

1. Plans for the transition to the new system, up to April 2013

It is important to have clarity and a recognition of the time required to implement change as a number of bodies, both new and old are involved. Communication is paramount in gaining clarity of the transfer of functions and staff. At present communication on process leading to final destination is unspecified and therefore at the front line is unclear. HEIs and Trusts may deal with more than one SHA/LETB so a national overview of the transition process would be beneficial. Action must be taken to prevent loss of education and training expertise/experience and organizational memory in Strategic Health Authorities (SHAs) and Deaneries that has evolved over many years.

2. The future of Health Innovation and Education Clusters

It is difficult to fully evaluate the impact or importance of HIECs at this stage. It is too early to assess the individual project successes and hence the functionality of the HIEC. Locally projects are progressing well with innovation at the forefront. This cohesion is an important component of building relationships and outcomes for patients. Generally though, HIECs have been well received as their role has become clearer and their operational structures have been embedded. It would be important to facilitate this local response to innovation, directed by clearly laid out local priorities.

3. The role of the Secretary of State for Health in the new system

The secretary of state for Health needs to remain fully and personally accountable for the education and training needs of the NHS. There must be no devolution of these responsibilities. There are suggestions that the precise wording of the Health & Social Care bill currently going through the legislature will remove ultimate responsibility of the SoS from duty and provision of care, but essentially it asks a fundamental question about where responsibility lies and whether politicians should or should not have a role in health care delivery—it could be said they shouldn’t, for fear of micromanagement, however realistically in a democracy and a publicly-funded system, what is the alternative; accountability to a non-elected head of a “quango”?

4. The proposed role, structure, governance and status of Health Education England and its relationship to professional regulators and to the other parts of the new NHS system architecture

This issue has a lot to do with professional standards and the institutional nature of professions. Professional regulators like the GMC, GPhC, HPC and NMC have significant influence over their member professions and how they want them to be trained. Some may argue this is about protecting professional interests, others may say it’s about maintaining standards. The “truth” probably lies somewhere in between, but there is no doubt that the traditional ways of delivering care are no longer appropriate given the underlying social causes of health (eg do we need as many specialists in traditionally-defined medical and clinical specialties working in a multitude of hospitals when one of the biggest threats to health is lifestyle and obesity)?

The Chair of HEE should be a senior academic with recent HEI experience of healthcare education. We feel strongly that the role of chair of HEE should be open to all qualified applicants, regardless of them being a “clinical academic”. The chair of HEE being a non-medical healthcare professional would send out a strong message that HEE is inclusive and reflecting the changing nature of UK health needs. HEE needs to appropriately balance the national and local picture of workforce development needs. Local workforce need may require commissioning of education that may not be a national priority and vice versa. The role of CfWI in informing HEE regarding these competing pressures is crucial but obtaining sufficiently robust information may be problematic.

5. The proposed role, structure, status, size and composition of local Provider Skills Networks/LETBs, including how plans for their authorisation by HEE will address issues relating to governance, accountability and potential or perceived conflicts of interest, and how the Boards will relate to Clinical Commissioning Groups and the Commissioning Board

Care needs to be taken in the establishment of LETBs: there should be requirements to involve universities from the outset, including their formation in shadow format and to have an independent Chair. There needs to be two-way communication with universities (the reporting arrows need to be bidirectional, otherwise it does not reflect a true communication strategy). There is little doubt that CCGs are about to be given enormous spending power and how they are regulated is key, not to mention whether they have the skills to commission for large populations (hence DMU trying to develop education provision in Clinically-led commissioning). As purchasers but also providers of care, who is to say whether their decision not to refer and instead self-supply the treatment is the right thing for the patient’s well-being or part of a wider strategy to contain costs?

6. How professional regulators, healthcare providers and commissioners, universities and other education providers, and researchers will all participate in the formulation and development of curricula

It is important that those who deliver the required professional leadership are clinical academics from all healthcare backgrounds who have a unique and valuable position of being involved in the delivery of healthcare and health education, and are at the forefront of relevant bioscience and healthcare research. It is essential that academics, educationalists, healthcare professionals and employers work together to create programmes that will be proper foundations for entire careers and which take account of patients’ requirements and the need to embrace scientific advances and innovation in healthcare. There is currently little respect for university planning, quality and delivery processes around commissioned education and this needs to be redressed.

There needs to be a clear understanding that HEIs have to straddle both public and private markets. Universities cannot take a passive stance and wait to see who wins contracts for services where, but need to be planning education provision from the outset of policy. This will need all governance mechanisms to be reviewed across the system. Locally we will use existing machinery in place and invite additional members (other education providers and professional regulators).

7. The implications of a more diverse provider market within the NHS

Has this consultation gone out to potential private providers? A large proportion of pharmacy graduates enter community pharmacy for example where there is extensive interaction. From a university point of view there appears to be a grey area of commissioning education for NHS workforce planning needs but graduates going into the private sector (as with learning disabilities nursing for example). The move towards “any qualified provider—AQP” needs urgently reflecting in workforce planning.

How are we going to manage the cost of training our future clinical experts? If the public purse is concerned with value for money, efficiency and cost containment, alternative providers may not quite have the same moral commitment to providing training alongside ultra-efficient processes of care, eg training junior ophthalmic surgeons means you can’t reduce patients on a cataract waiting list, as training necessitates a focus on “learning” rather than throughput. The private sector markets itself on speed and efficiency. We do not feel, unless it goes into legislation, they have any incentive to take on training grades and therefore raise their cost-base through lower productivity. Another issue is continuity of care—there is a real danger of a loss of continuity as patients move around the system. We ideally need an integrated cross-sector approach to patients’ health care records, (such as the carte vitale in France) if we are to mitigate against continuity of care issues within a diverse market.

8. How the workforce requirements of providers of NHS and non-NHS healthcare will be balanced

The needs of the patient population should be the first consideration above all else. Related to the above comments regarding diverse providers, there needs to be some form of agreement around training, ensuring that the skills required for the future are developed in those going through the peri-training grade part of their career, wherever they happen to work. Community pharmacy services in particular lie largely within the private sector whilst also delivering an important and growing NHS agenda that must be recognised in any future educational strategy.

9. The role of the Centre for Workforce Intelligence

The visibility and profile of the CfWI is poor, certainly amongst us, our partners and stakeholders. The ideology behind the CfWI is laudable but its aims may be hard to achieve in practice, and may end up being aspirational. Real time information in this kind of arena is impossible to keep accurate. Will the CfWI have effective systems of communication with those bodies it interacts with?

Workforce planning is currently subject to acute events. This means that there is no continuity or cyclical nature of workforce planning. Links with HEIs are poor or non-existent in some cases. There is a sense of apathy. Workforce planning should be centred on patient need. There should be a recognition that when HEIs plan courses that they are also planning provision for graduates to work outside the NHS/public sector but in arenas which will collaborate with the NHS/public sector. Better resources will be needed to allow CfWI to provide LETBs with the information required. Workforce planning must also take a four country approach. When considering “cross-boundary flows” thought must be given to movement within the four countries of the UK and into the UK from overseas.

10. The roles of Skills for Health and Skills for Care

The importance of utilising research as an informant is vitally important here: readiness to learn, to study and consequential readiness to work is a sequence of events that all contributing organisations need to work on. HEIs are well placed as a central place to assist with this progression.

11. How funding will be protected and distributed in the new system

Universities and service providers need to know how funds will be protected for such a dynamic agenda as healthcare education. How will these funds be protected and allocated with respect to the diversification of the workforce and in particular “any qualified provider” provision? There needs to be clarity and transparency about the equality of distribution across medical and non-medical areas. It is critical that DH understand that currently postgraduate provision and “Learning Beyond Registration” (LBR) is how universities react quickly and adapt to acute and new policies. Perhaps the most important factor in developing a workforce responsive to service need is this LBR type education. Devolution of funding to individual Trusts will need careful management to ensure education providers receive coherent commissioning intentions that offer sufficient economies of scale.

12. How future healthcare workforce needs are being forecast

It is extremely difficult to know what will be needed in the future. However, we expect diseases/conditions to come to the fore that relate to social determinants and lifestyle factors so we may need a balance which favours more generically trained staff and not specialist trained staff (of course, we will still need specialist experts to deal with acute medical/surgical issues). Where is the incentive for this to be done at population level for the benefit of the future population, if we devolve this responsibility to individual organizations, who will want to look after their own interests? How flexible and responsive a workforce can we have given the nature of collective bargaining and professional interests? There is currently little confidence that national agendas are being properly translated regionally. Local workforce planning is subject to knee-jerk reactions to acute policy events or workforce “gaps”.

13. The impact of people retiring from, or otherwise leaving, healthcare professions

Again linked to the above, this would give us an immediate skills gap and in the past we have recruited from overseas to plug such a gap. More needs to be done to attract young people into health careers, without frightening them with the skill levels required. We need to be creative about routes into employment—perhaps a proper apprentice-type scheme that eases them into it, or even given the likelihood of the future disease burden, more training on issues around generic health concerns (as we do on our Health Studies course at DMU), or those that are about nutrition/exercise/behaviour. As for retention, often staff leave because of frustrations with the system and the political nature of it (succeed at all costs or be put under enormous pressure to be seen to be successful). We feel it is timely that we have a robust debate about what we can afford to do or not and how much money we want as a country to spend on health care. Then we can start to all be a bit more realistic about what we can actually achieve and educate our politicians and public about the nature and purpose of our health service.

14. The place of overseas educated healthcare staff within the workforce

One of the main reasons we’ve stopped recruiting abroad is the concern over the “brain-drain” left behind in countries when we recruit overseas staff. Of course, there are also issues about acclimatisation and language/culture for overseas staff and those do lead to safety concerns. There is a large diversity of overseas staff coming to work in our healthcare sector—who makes the decisions about the amount of extra training required in each case? Education up-skilling for these staff is as much about cultural education as it is about clinical education. There needs to be a resource to allow overseas staff to adapt (ironically, currently there are restrictions to overseas entry on those countries who would need this kind of adaptation less—US/Australia/Canada).

15. How the public health workforce will be affected by the proposals

We feel strongly that there is a real requirement for Health & Wellbeing “promoters” for all healthcare education across all healthcare professions. The public health workforce includes third sector workers extensively and “public health” needs to acknowledge the whole agenda rather than simply secondary care (eg to cover the roles of social workers, youth workers etc).

December 2011

Prepared 22nd May 2012