Health CommitteeWritten evidence from Yorkshire and the Humber Strategic Health Authority (ETWP 73)

The Yorkshire and the Humber Workforce and Education Directorate of the North of England SHA Cluster welcomes the Health Select Committee (HSC) Inquiry on Education, Training and Workforce Planning and the opportunity to contribute in the form of this written submission. The inquiry is wide ranging in its examination of the Government’s plans regarding the future healthcare education arrangements.

Our comments below reflect what we have already submitted through the Future Forum, following consultation with all NHS employers and key stakeholders in Yorkshire and the Humber and covers the key themes and specific issues as set out in the Committee’s terms of reference.

1. The right numbers of appropriately qualified and trained healthcare staff (as well as clinical academics and researchers) at national, regional and local levels

This will be addressed by strategic workforce planning, effective partnership working and use of planning models. Employers are more likely to take workforce planning seriously if they also have some responsibility for training budgets as they will then be able to more directly link priorities and risks.

2. Training curricula reflect the changing nature of healthcare delivery, including the medico-legal context

This will be addressed by continuing to work in partnership with regulators, service colleagues and education providers.

3. All providers and commissioners of healthcare (both NHS and non-NHS) play an appropriate part in developing the future workforce

This will be addressed by engagement, partnership working and providers own desire for an effective and efficient workforce. The governance arrangements and statutory duties will also play an important role as non-NHS organisations will need to sign up to training commitments in order to benefit from outputs of training in order to create a more level playing field.

4. Multi-professional and multidisciplinary leadership and accountability (encompassing the full range of healthcare professions, specialties and grades) at all levels

Learning in and from teams on clinical placements is being actively promoted. The significant investment in clinical skills facilities across Yorkshire and the Humber is an example of how Multi- Professional and Education (MPET) funding has been used to promote multi-professional training and development as this is only really successful if focused on the patient pathway rather than professions, though it is absolutely right that specialist skills are acquired separately as appropriate and professional identity is created.

The most successful initiatives also tend to be where traditional hierarchy has been levelled and all grades of staff are encouraged to contribute to discussions about patient care and where there is the potential for it to be less than excellent.

Accountability is first and foremost from the individual to their employer and, where regulated, to their profession. This requires a focus on good team management where every individual is held accountable for their contribution regardless of whether regulated and professionally qualified or not.

Patient safety is also enhanced by ensuring all staff have good levels of literacy and numeracy, accessing SfA/NAS funding as required to achieve basic skills as required.

5. High and consistent standards of education and training

High and consistent standards are promoted through the use of Learning and Development Agreements and formal contracts with education providers. Regular reviews against these agreements take place.

There is a huge amount of quality assurance that takes place through regulatory bodies, including the Qualifications and Curriculum Authority (QCA) in the case of Higher Education Institutes (HEIs) and OFSTED in the case of colleges and other education providers funded by SfA/NAS.

A large amount of activity takes place to gain feedback on the student/trainee experience and there has been a great increase in the involvement of patients and carers in devising training, taking part in training and feeding back on trainees.

More consistency and portability in training has been achieved through more standardisation of qualifications where possible, with much greater widening participation in learning to support skills development and provide better standards of care.

The Education Commissioning for Quality and Medical Quality Indicator frameworks recently introduced are going some way towards even greater consolidation of quality markers across professions. The Education Outcomes Framework, whilst in early stages of development, is attempting to make a more explicit link between training provided and outcomes for patients and service delivery, utilising the domains of the general outcomes framework for NHS services.

6. The existing workforce can be developed and re-skilled for the future (through means including post-registration training and continuing professional development)

A key emphasis for workforce modernisation is the development of support workers (AfC Bands 2–3) and Assistant Practitioners (AfC Band 4). Current areas of work include pharmacy technicians, Operating Department Practitioners, maternity support workers, higher level apprentice scientists, mental health support workers as well as those in intermediate care and primary care. Roles at this level are seen as key to improving skill mix within teams.

Training for non-medical prescribing is also much in demand to enhance the patient experience and avoid delays, with very specific training and responsibilities given in specific areas and for specific drugs.

Work is also continuing on developing Advanced Practitioners, particularly in areas where there may be vacancies in traditional roles and more innovative solutions are required. This has been particularly successful in primary care, where practice nurses take on many of the roles that were previously seen as those of GPs with clear boundaries and protocols set. There is increasing usage of paediatric and neonatal specialist nurses, trained by consultants in the workplace setting as well as having underpinning academic learning, to take on the duties that might previously have been done by junior doctors.

7. Open and equitable access to all careers in healthcare for all sections of society (by means including flexible career paths)

SHAs are focusing on widening participation initiatives, ie both widening access to Higher Education through access/bridging/foundation courses, but also in widening participation in learning—particularly where the individual’s experience of school or personal circumstances meant that they did not gain many formal qualifications. There are now several assistant roles that can provide the stepping stones into registered training at graduate level and above, and many stories of individuals starting out with no GCSEs and ending up at PhD level study through their course of their working life within health care.

The use of flexible training routes and part time courses are often important ways of providing equitable access to career progression, with accumulation of learning credits in smaller chunks rather than one continuous qualification.

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

Plans for the transition to the new system are being actively developed. ie Interim Boards of Local Education and Training Boards (LETBs) are being established with providers looking at plans for next year.

9. The future of postgraduate deaneries

Postgraduate Deaneries are a critical element of LETBs and their work alongside other professions and the wider health workforce is critical in the focus on patient centred learning and development and the quality management/assurance systems in place across the board.

10. The future of Health Innovation and Education Clusters

It will possibly be for LETBs to find funding to support HIECs if it is considered that they have been effective—should focus on share and spread of existing innovation and developments rather than trying to create other things.

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

It will be important for the Secretary of State to have overall accountability and to ensure that MPET funding is appropriately protected in the new system.

12. The proposed role, structure, governance and status of Health Education England (including how it will take on the roles of Medical Education England and the Professional Advisory Boards), and its relationship to professional regulators and to the other parts of the new NHS system architecture

The multi-professional nature of Health Education England (HEE) will provide important opportunities to address the changing nature of healthcare and the requirements of workforce development. It is recognised that clear accountability arrangements between LETBs and HEE are essential but that HEE must acknowledge and respect the need for appropriate local determination. A key enabler will be the ability to utilise some funding to meet training needs around patients and service needs in addition to meeting a specific training number in regulated professions in undergraduate or post-graduate medical/dental. Also to be able to utilise unused funding within traditionally allocated numbers across different professions to support more skill mixing and, therefore, appropriate use of skills and expertise for more of the time.

This is possible as, despite national numbers, trainees do not opt to distribute themselves according to theoretical geographical allocations, resulting in some shortages (often in rural areas) whilst popular cities and locations have a wide choice of employees.

13. The proposed role, structure, status, size and composition of local Provider Skills Networks/Local Education and Training Boards, including how plans for their authorisation by Health Education England 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

Conflicts of interest will be dealt with by all board decisions being based on principles rather than application to specific organisations. Members of LETBs will be representative of their constituencies rather than organisation and board members will withdraw if a decision is specific to their organisation. The key issue is having strong and effective governance arrangements. HEE will have to have appropriate links to the NHS Commissioning Board to ensure triangulation of service, finance and workforce plans with appropriate links to the Care Quality Commission (CQC) and Monitor. Clinical Commissioning Groups will need to have appropriate local links to LETBs.

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

As they do now but with even greater involvement of providers. Examples: HEI partnership boards for placements, NMC consultations on curricula.

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

There has always been a diverse provider market eg Nursing Homes, independent healthcare providers. It is acknowledged that that there have been difficulties with engaging with the independent sector, particularly as social care does not have an equivalent of SHAs. Networks will need to involve wider partners to ensure there is maximum collaboration, eg training of care home staff in End of Life Care—a joint programme to meet patient needs driven by SHA, service partners (including care home managers) and skills for care. Will focus on training to prevent unnecessary emergency admissions at end of life by increasing confidence in staff and creating sustainable training programmes given high staff turnover prevalent in this sector.

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

By effective workforce strategy and planning for NHS commissioned care rather than specific providers. Always limited when looking at social care requirements.

17. The role and content of the proposed National Education and Training Outcomes Framework

Good high level but now needs further development for detail so appropriate metrics and/or indicators are developed that allow linkage to patient outcomes. There is already a lot of evidence and data to support the training process, but less analysis of its effective application. ROI type methodology is useful here so employers are clear about why staff are undergoing training, what expected product or outcomes will be and how these will be applied in practice.

18. The role of the Centre for Workforce Intelligence

To provide high quality workforce intelligence data, particularly the national picture and any meaningful benchmarking or comparative data that is useful in more local planning.

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

Both sector skills councils should continue. There is a view that they should not be merged as the workforces are distinct though it is possible for some joint working.

20. The role of NHS Employers

NHS Employers should play a key role in pay and conditions national negotiation. It also has an important role as an independent body for providers.

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

By funding going to HEE and LETBs, HEE can build in control and accountability to LETBs for use of funding through the authorisation process and formal contract However, this cannot be overly prescriptive as needs will differ locally but usage should be transparent with clear accountabilities.

Education funding is sometimes carried over to the following year, which is not unusual in a business of this scale where some contingency funding is required to cope with in-year pressures and any emerging priorities. This element of public spending requires robust management within LETB arrangements by those familiar with the likely pressures and pitfalls as many new to this area of work can be caught out by short termist reactionary measures that cause unintended consequences due to the time lag from commissioning to qualification and, therefore, potential impact on services in the longer term.

Differential tariffs being proposed for medical and non-medical training have the potential to de-stabilise pre-registration training provision for the non-medical professions as the medical tariff is much greater so may lead to employers choosing not to support other areas. These have always been supported without direct payment for placement support and training so, whilst the introduction of a tariff that follows the student is helpful, measures should be encouraged that do not allow employers to only offer medical training as this would seriously restrict the number of trainees in other professions due to the limited number of training placements available.

22. How future healthcare workforce needs are being forecast

Good strategic workforce planning—this will require a strengthened approach within employers to co-ordinate all workforce needs. This has not been strong in the past as the responsibility for education and training budgets largely rested with SHAs, so the new system should strengthen interest and understanding.

Employers within LETBs will quickly need to get to grips with the advance planning that is required to address the service issues several years hence rather than thinking about today’s issues and, therefore, commissioning education on that basis. This will require a strong senior commitment to high quality OD work to help determine service models of the future around which workforce planning can then take place.

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

This is taken into account by effective workforce planning and modelling to align with education commissioning.

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

This is very limited now due to immigration controls. It is important to enforce regulator standards of language fluency, credentialing of qualifications—the NHS is experienced in doing this. There is a potential risk of greater recruitment of overseas students by HEIs onto health courses in future to help compensate for reduced commissions and other financial changes in Higher Education. This may pose some difficulty in that overseas students may be willing to pay more to participate in placements, which would disadvantage MPET funded students and apply more pressure to this already difficult aspect of training to organise in ensuring sufficient placements. Whilst non-EU students may have to return to their country of origin, EU students will be in the market, but there will be limited information about them to take account of in workforce planning and education commissioning.

25. How the new system will relate to healthcare, education, training and workforce planning in the other countries of the UK

It will be the role of HEE to link with the other countries of the UK and sector skills councils which cover the UK. Links already exist between UK countries in education commissioning and workforce planning networks, which should be continued.

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

This will be part of what LETBs will do, linking with local authorities. The Public Health workforce is as important as other parts of workforce and will be treated the same. Important that both specialist and non-specialist public health training taken into account as non-specialist roles still have a health promotion responsibility. Making Every Contact Count competence framework developed in Yorkshire and the Humber is helping to embed a greater awareness of this across a range of health professionals.

December 2011

Prepared 22nd May 2012