Health CommitteeWritten evidence from Macmillan Cancer Support (ETWP 72)

Summary

Macmillan hopes that the changes proposed to the NHS education and training system will allow more integrated workforce planning that responds more effectively to the needs of patients locally.

Key core skills should be agreed and set nationally. If not, standardisation of courses and hence skills and competencies of the workforce will be lost leading to differing standards of care that patients receive.

We are pleased that Health Education England will develop a National Education and Training Outcomes Framework.

Macmillan is extremely concerned that some employers have established complete embargoes on anything but mandatory training. Education and training budgets must be protected. Neglecting the continued development of the workforce will damage patient care in the short and long term.

We are concerned that Local Education and Training Boards (LETBs) include fair representation from all professions and sectors as well as users. The population size covered by LETBs will also be key to ensure economies of scale.

We would recommend that LETBs work closely with cancer networks to make use of their cancer workforce development expertise. We also believe networks will have a role to play in bringing LETBs together to plan at a more macro level for less common cancers.

LETBs will need to develop the cancer workforce to meet the changing needs of people with cancer, with a greater number of generalists helping to support people who have finished cancer treatment but may have ongoing needs.

Introduction

1. Macmillan Cancer Support welcomes the opportunity to respond to this inquiry. We have offered views and recommendations where we feel best placed to comment.

2. Macmillan Cancer Support improves the lives of people affected by cancer. We provide practical, medical, emotional and financial support and push for better cancer care. Cancer is the toughest fight most of us will ever face. The Macmillan team is there every step of the way. We are the nurses and therapists helping people through treatment. The experts on the end of the phone. The volunteers giving a hand with the everyday things.

3. Macmillan Cancer Support commends the Government’s attempts to ensure more integrated workforce planning that responds to local needs. We hope that these changes will facilitate inter-professional education (by and with other professionals), improve availability and access to courses, highlight local education and training needs and remove the secondary/primary divide; promoting a more patient centred approach to planning and training. We believe this is highly preferable to the development of different professions in isolation. Such an approach would help to address issues of shortages in the workforce by allowing up-skilling or development in one profession to fill gaps in other professions. For example up-skilling radiographers has helped to address shortages of radiologists.1 It should also help to ensure the training needs of all roles are addressed, such as those of practice nurses.

4. However, we are concerned that there are some potential difficulties with the plans as they stand. The effects of instability and poor workforce commissioning now could have devastating effects for healthcare provision in the future and in the long term.

Preventing Postcode Lotteries in Quality of Care

5. We are pleased that the Government accepted the NHS Future Forum’s recommendation for Health Education England to develop a National Education and Training Outcomes Framework. We hope that this would help to ensure consistency across the country. However, we are concerned that under the new system standardisation of courses, and hence skills and competencies of the workforce, will be lost. We suggest that key core skills should be agreed and set nationally, then commissioned locally, allowing for adaptation according to local need. For example much work was undertaken to nationally agree the National Connected Programme which has helped to standardise advanced communication skills across England.

6. Macmillan has several concerns resulting from devolution which we believe must be addressed:

(i)Local services may opt for short-term fixes to workforce issues and development rather than longer-term, more strategic options.

(ii)Services may opt to buy in services as this would prove cheaper than commissioning training to fill any workforce gaps. Areas of high staff turnover, such as London, will be disadvantaged by these new arrangements, having invested in staff who then move on.

There is a real danger that this could lead to a postcode lottery for patients in terms of both outcomes and experience. The NHS Commissioning Board and Health Education England will need to ensure that this does not happen.

7. We were also heartened by the Government’s acknowledgement that “Health Education England would need to build strong links with partners in Scotland, Wales and Northern Ireland to ensure consistency across the UK and better information for staff”.2 Both staff and patients travel across borders for work and treatment. Changes to the education and training system for the workforce in England can and will affect skills and knowledge in the other three nations. Transferability of skills for health professionals and consistency of patient experience must be assured across all four UK nations.

Protecting Education and Training

8. Macmillan is extremely concerned that under the current financial constraints education and training budgets are being cut. In addition there is not the capacity or funding to free up professionals to attend such training. Neglecting the continued education of professionals hampers their ability to advance their knowledge to meet the new and emerging needs of people with cancer and threatens the future supply of specialists. Macmillan is aware through its partner organisations and Macmillan professionals that some Trusts have established complete embargoes on both external and internal training (apart from mandatory training). Such actions undermine the culture of continued professional development and threaten the capability of the future workforce to meet patient needs. We are heartened that the Government will “consider how best to ensure funding for education and training is protected and distributed fairly and transparently”.3 We believe that protecting training budgets and setting aside time for development is crucial and will be looking closely at the Government’s plans on this.

9. More needs to be done to link education and training to patient outcomes, service improvements and increased efficiencies. For example it may be possible to link specifics outcomes in the National Cancer Patient Experience Survey to communication skills training. This would help incentivise commissioners and providers to invest in the continued development of staff.

10. In addition the Royal College of Nursing (RCN) has voiced concern that entry to register numbers should be centrally planned and accompanied by sufficient funding to ensure delivery of both theoretical and practical aspects of education (A Decisive Decade: mapping the future of the NHS workforce). While we support local determination of entry to register places, a central system to monitor applications, admission, attrition and outcomes is required to provide reliable and consistent information for workforce planning.

Local Education and Training Boards

11. Firstly, we would stress the need to ensure that expertise present in the existing system is not lost. In particular cancer networks have played a crucial role in facilitating the development of the cancer workforce. We would be extremely keen to see this continue. “Cancer” is a set of 200-plus different diseases—most of which have highly complex care pathways. Cancer is an acute sector disease dealt with by consultants and nurses in hospitals and, at the same time, a terminal illness and, increasingly, a long-term condition—both of which require care and support in the community. This means those responsible for developing the cancer workforce need to understand and be able to ensure that they meet both the clinical and longer-term needs of people living with and beyond cancer.

12. The success of local workforce planning, education and training will be dependent on the configuration and capabilities of local education and training boards (LETBs). Domination by, for example, secondary care or particular specialities will hinder attempts to join up education and planning. We fear that the medical profession may continue to dominate education and training planning. In addition there may be tensions between professional and local pull. We are also concerned about potential conflicts of interest with those sitting on the boards being tied too closely to the organisations they represent; in particular those healthcare providers that also provide education or training placements and/or courses will have a vested interest in the commissioning of these places/courses. Macmillan would recommend that Health Education England provides advice to local stakeholders to ensure there is balanced representation on boards with nursing, allied health professionals, social care and users all well represented.

13. Involving patients in the planning process would help to ensure that professionals have the skills that patients value but that are often not prioritised. For example the 2010 National Cancer Patient Experience Survey demonstrated that patients valued good communication skills.4 However, we are concerned that a duty to consult would result in tokenistic exercises by providers and would like to see patients and the public more fully involved in the development of commissioning plans. Allowing the public to fully engage and influence the process may prove difficult as the issues are complex and so we would recommend that providers make use of the expertise in SHAs and cancer networks. LETBs will also need to work closely with other partners such as charities like Macmillan who provide education and training programmes and grants.

14. The size of the population covered by LETBs will be crucial to the success of the Government’s reforms. It would be helpful if they were coterminous with other healthcare structures such as local Health and Wellbeing Boards and Clinical Commissioning Groups. If they are too small, economies of scale will mean costs rise and it will be hard to justify specific training or education. Health Education England and the NHS Commissioning Board will need to ensure that highly specialist training and education is not lost or hindered under the new system. Conversely they must ensure that macro-level training and education, not provided at a national level, is not considered too big and hence expensive to be commissioned by LETBs. Similarly we are concerned that cancer units, that provide cancer services on a smaller scale to the specialist cancer centres, will not prioritise and invest in the cancer workforce due to low numbers. Helping LETBs to come together to jointly commission such training may be required. Again we would suggest that cancer networks have a role to play here.

The Cancer Workforce

15. The nature of cancer care has changed dramatically over the last few decades, with two million people in the UK now living with or beyond cancer.5 This number is set to rise to four million by 2030. Many of these people are living with the long-term consequences of cancer and treatment and in many ways cancer can be compared to other long-term conditions.6 New skills are needed in the cancer workforce to meet the changing needs of people with cancer and the new system must address these. In particular they require:

the skills and knowledge to manage cancer as a long-term condition; and

the skills and knowledge to support patients to self-manage their condition.

In addition the wider, general workforce requires greater cancer awareness and skills to aid early diagnosis and support care in the community alongside other co-morbidities.

16. People with cancer require different levels of support throughout their cancer journey, depending on their individual needs and circumstances. This includes after treatment has finished when many patients continue to have ongoing, unmet needs. The system of aftercare therefore needs to change to meet these needs. Support may be provided by a number of different professionals, both specialists and generalists, working as a team, and will depend on the level and type of need of each patient. What is vital is that the person receives support from the right person at the right time and with the right level of skills to meet their needs. Macmillan is looking at how this support can be provided and how the cancer pathway and workforce will need to be redesigned to meet the future needs of patients. This will lead to improved outcomes at no additional cost. We will be trialling new roles, including a nursing role based in primary care. Primary care nurses will have a crucial role to play in helping patients to self manage but retirement figures suggest the practice nurse workforce will shrink in the future (research from the Royal College of Nursing shows that one in three community nurses are over 50 and one in five practice nurses are over 55 years old7). Improved understanding of demographics within the nursing workforce is urgent; as well as an effective selection and fast track process out of the acute setting and into the community. We would suggest that the Centre for Workforce Intelligence has a role to play in helping all those involved in workforce planning to better understand the changing workforce.

December 2011

1 Radiography Skills Mix: A report on the four-tier service delivery model 2003; Department of Health
http://www.cancer.nhs.uk/radiotherapy/documents/DH_4061260.pdf

2 Government response to the NHS Future Forum report, 2011
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf

3 Government response to the NHS Future Forum report, 2011
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_127719.pdf

4 National Cancer Patient Experience Survey Programme—2010: national survey report; Department of Health,
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_122516

5 Cancer Prevalence in the UK, King’s College London, Macmillan Cancer Support, National Cancer Intelligence Network (2008).

6 Macmillan Study of the Health and Well-being of Cancer Survivors—Follow-Up, Survey of Awareness of Late Effects and use of Health Services for ongoing health problems, Macmillan Cancer Support, 2008

7 RCN 2009
http://www.rcn.org.uk/newsevents/news/article/uk/rcn_warns_of_a_community_nurse_shortage_timebomb

Prepared 22nd May 2012