Health CommitteeWritten evidence from NHS South of England, Workforce Development Directorate (ETWP 63)

Background

South of England Strategic Health Authority (SoE SHA) welcomes the opportunity to submit written evidence to the House of Commons Health Select Committee Inquiry on Education, Training and Workforce Planning in the form of this written submission. The SoE SHA was formed recently by bringing together, under a single leadership team, staff from the South West, South Central and South of England Strategic Health Authorities. SoE SHA believes that any future education commissioning and workforce planning system needs to:

move from being predominantly supply led (HEIs and professions determining numbers via historical commissioning patterns), to being more demand led, based upon the needs of NHS service providers determining the numbers (in collaboration; with HEE), type of professional and skills and knowledge required of newly qualified staff;

be planned, commissioned and provided in an integrated and multi-professional way that prioritises patient needs above those of individual professions;

better integrate workforce planning—across the workforce (medical and non-medical), across the NHS (finance and service), and across healthcare (NHS and non-NHS organisations);

deliver a more productive workforce; and

deliver a more flexible workforce.

Summary

Education and training should not be seen as an end in itself but integral to achieving the NHS and Public Health Outcomes Frameworks and demonstrably improve the patient outcomes and experience.

NHS Commissioned services (organisations commissioned to provide NHS services including Social Enterprises, voluntary and private companies etc) should hold responsibility for the planning and commissioning of education and training for all parts of their workforce with Local Education and Training Boards (LETBs) providing leadership, co-ordination and brokerage between all stakeholders (inc Higher Education Institutes, Local Authorities and other agencies) to inform “sub-national” plans.

Local networks need to be authorised and managed based upon outputs not only infrastructure. Whilst the final form of the legal entity should be the same for all LETBs, the local structure should fit local circumstances.

The interdependent role of innovation, leadership development, and quality improvement to the attainment of the best workforce possible are significant and clarity of their role within LETBs and between HEE and the NHS CB is critical. The assumption is that there will be clear guidance about the relationship and roles of LETBs and Academic Health Science Centres/Networks to avoid duplication.

A clear definition of the terms “workforce planning” and “current and future workforce”, would be extremely helpful to build a clear and shared understanding, as the terms do not mean the same thing to all people. Clarity is required as to where the responsibility and accountability for these activities lie in the new system. LETBs, and HEE, should not be accountable for both supplying the future workforce and being held accountable for assuring the current workforce.

Issues for Consideration

1. Education and training should not be seen as an end in itself but integral to achieving the NHS and Public Health Outcomes Frameworks and demonstrably improve the patient experience

1.1 High quality patient care is dependent upon robust service planning underpinned by effective workforce development which informs educational investment and workforce productivity, improvement and innovation.

1.2 Education and training should not be seen as an end in itself but one way of contributing to the patent experience and Quality, Improvement, Productivity and Prevention (QIPP), through increased productivity, quality and effectiveness (getting it right first time) and not divorced from service, therefore it is integral to achieving the Outcomes Framework, Operating plans and improving patient safety. The new structure should be deliberately designed to achieve excellence, retaining what currently works well and addressing and improving areas of weakness, it should not be designed as a by product or to merely fit into other system changes.

1.3 Educational quality mechanisms are complex and often bureaucratic and Health Education England (HEE) is well placed to address areas of similarity and commonality to reduce duplication and increase efficiency. The role of the Care Quality Commission (CQC)—monitoring workforce/education and training: standards 12, 13 and 14—should be seen as a critical component of the educational workforce assurance process not just assurance of service delivery. Currently local arrangements are being strengthened with CQC but the future relationship with HEE and Local Education and Training Boards (LETBs) needs to be clarified.

2. NHS Provider services should hold responsibility for the planning of education and training for all parts of their workforce with LETBs providing a co-ordinating role between all stakeholders (inc Higher Education Institutes, Local Authorities and other agencies) to inform “regional” plans

2.1 Strengthening demand led planning and commissioning requires all NHS service providers to assume responsibility for workforce planning, including Continuing Personal and Professional Development (CPPD) for existing staff (ie NHS Trusts work on a one to three year financial timeframe). For undergraduate and Post Graduate Medical and Dental education (PGMDE) it is more likely that service commissioners (Clinical Commissioning Groups with Health and Well Being Boards through Joint Strategic Needs Assessment & Clinical Senates) should influence how many of what type of undergraduate/pre-registration students to commission for their strategic service development plans. Therefore the role of the NHS Commissioning Board (CCGs, Health and Well Being Boards and Clinical Senates) in providing guidance for the workforce of the future (four years and beyond) needs to be considered.

2.2 There are two obvious constraints that continue to make it difficult for medical workforce planning to be as flexible and responsive to employer demand as non-medical workforce planning, these are:

The setting of undergraduate medical numbers at national level—these numbers then flow through into F1, F2 and specialty training, the decisions that can then be made locally are about the spread of training across the specialties not the overall number of trainees which has already been set.

The long lag time between setting the specialty training numbers and completion of training which means medical workforce planning is done over a longer time frame than all other areas of health care workforce planning.

2.3 At the moment there is no demonstrable connection between service needs and the number of medical undergraduate entering University and PGMDE Deaneries (within LETBs) have no control over the number of F1s entering the system. It is essential that service considerations are taken into account and considered when determining the number of medical undergraduate places available at University and therefore the relationship between the Department of Business, Innovation and Skills (BIS), Higher Education Funding Council for England (HEFCE) and HEE is critical if oversupply of doctors in the future is to be tackled and avoided.

2.4 The future architecture needs enable more dialogue between service and traditional ownership of curricula and specialty roles by Royal Colleges. The landscape of NHS delivery of care going to change rapidly from hospital to intermediate to community and changing service must be anticipated and not delayed by training pathways.

2.5 The inclusion of strategic partners (HEIs, LA and other non NHS providers of NHS services) is critical to the work of the LETBs in the future. Local LETB structures should include representation of these bodies in the infrastructure of the organisations. Each LETB will need to have clarity over how, specifically, the strategic partners are incorporated into the decision making structure of LETBs, be it as a member of the Board or Partnership Council without compromising their ability to bid for business from the LETB or present a conflict of interest.

3. Local networks need to be authorised and managed based upon outputs not infrastructure. Whilst the final form of the legal entity should be the same for all LETBs the local structure should fit local circumstances

3.1 Local networks need to be authorised and managed based upon outputs not infrastructure: it should be the responsibility for the local LETB to determine if running costs demonstrate value for money. If local providers want LETBs to be ambitious and take the lead on new ways of working and be innovative, then the NHS providers should determine (via the Board) if the running or management cost represent value for money, not DH on a % of MPET.

3.2 Further clarity of role of the Centre for Workforce Intelligence (CfWI) and HEE and the contribution of the NHS Commission Board to ensure that regional plans are balanced with national demand would be welcomed. The impact upon LETBs and NHS provider organisations (resources, funding, and availability of placements) of any “additional” nationally required commissions over and above those locally required needs careful consideration as does the ability of the LETBs to resist central imposition of targets when appropriate.

4. The contributory role of innovation, leadership development, and quality improvement to the attainment of the best workforce possible are significant and clarity of their role within LETBs and between HEE and the NHS Commissioning Board (NHSCB) is critical. The assumption is that there will be clear guidance about the relationship and roles of LETBs and Academic Health Science Centres/Networks to avoid duplication

4.1 The future of innovation and leadership are key components of service transformation through getting the right people to work in the most effective ways. If LETBs are to do more that merely replace SHAs under a different name, by continuing to do the same with less and be truly patient focussed, we need to raise the ambition of the guidance to date.

4.2 There is uncertainty over the precise role and ambition of LETBs, ranging from providing “pre-registration education commissioning” (procurement and contract management) and “Deanery” activity through to a more sophisticated and responsive transformational role that includes innovation and leadership development as significant components of the LETBs. A key advantage of the LETB will be the ability to see across the whole system and understand how different elements (service providers, commissioners, and education providers) are impacting upon each other. The LETB will be capable of taking a wider perspective and, using workforce and education intelligence and sharing good practice, it can take a strategic approach to developing transformational change at scale across several agencies and sectors.

4.3 LETBs should work in partnership with both academic and research focussed organisations and networks and should have senior representation in decision making forums from these organisations. HEE has a remit to developing the whole workforce and due consideration has to be given to the 40% or so of staff that are neither “professional” nor “academic” and their learning, training and development requirements should be addressed and met by the LETBs as much as they are for the former.

5. A clear definition of the terms “workforce planning” and “current and future workforce”, would be extremely helpful to build a clear and shared understanding as the terms do not mean the same thing to all people. Clarity is required as to where the responsibility and accountability for these activities lie in the new system. LETBs, and HEE, should not be accountable for both supplying the future workforce and being held accountable for assuring the current workforce

5.1 The previous House of Commons Health Select Committee (2007) signalled three areas in which better integration of NHS workforce planning was required:

across workforce, financial and service planning;

between medical and non-medical workforce planning; and

between NHS and non-NHS providers.

5.2 All LETBs in the South of England cluster are signed up to an integrated inter- professional, multi agency entity (taking into account education commissioning, workforce, leadership, innovation and transformational service development) and recognise that whilst local infrastructures may vary, any devolution of these component parts from the main business of LETBs, eg by making Deaneries independent of LETBs and service, will compromise this ambition and potential.

5.3 A clear definition of the terms “workforce planning” and “current and future workforce”, would be extremely helpful to build a clear and shared understanding as the terms do not mean the same thing to all people. Workforce planning can be separated out into;

workforce planning as an element of an integrated business plan (operating plans one to two years);

workforce planning across a health system (QIPP plans three to five years); and

workforce supply planning (training and development plans—short term) and education commissioning plans (longer term).

5.4 Whilst integration of workforce planning is seen as essential, responsibility for workforce performing/assurance is not seen as a function of the LETBs.

Service commissioners hold contracts and should therefore have the performance responsibility for service provider’s workforce—balancing the competing requirements of quality and financial constraints.

HEE and LETBs would be held to account for the workforce supply element of any national ambitions such as health visitors.

HEE and LETBs would be responsible for performance/assurance of education and training through for example eg Learning and Development Agreements (LDA) and quality assurance of training placements. It should be noted that, in addition to SHAs and Deaneries, the CQC, Royal Colleges, and HEIs currently all have a role here.

5.5 The use of the terms “current and future workforce” is vague? For example: are PGMDE trainees the current or future workforce, given that they are employees of the NHS providing a valuable contribution to service yet are also considered trainees? Most other students are supernumerary and therefore delivery of service is not dependent upon them and there is little impact upon patients if students are withdrawn from the clinical area, for whatever reason, the same is not true for medical trainees where withdrawal of placements impacts greatly upon service provision as rotas are likely to be compromised.

5.6 The most challenging part of medium/long term planning for providers is understanding the implications of future commissioning intentions on the workforce that they need to employ. It would also be helpful if CCGs, health and wellbeing boards (H&WB) and Clinical Senates had a specified role in workforce strategic planning as their role is developed. The SHA would not want to see a separation between the workforce work led by HEE and the commissioner work led by the NHSCB. Workforce development plans will need to be closely linked to policy and strategic planning as well as embedded in provider responsibilities. The NHSCB strategic commissioning intentions need to be part of the longer term strategic workforce planning process.

5.7 These types of planning are inter-related but also distinct approaches. In the new system we need to be clear which type of workforce planning we are talking about and therefore how it will be done by whom and at what level.

December 2011

Prepared 22nd May 2012