Health CommitteeWritten evidence from the Faculty of Medical and Human Sciences, University of Manchester and the Manchester Academic Health Science Centre (ETWP 88)

1. Background and Summary

1.1 The Faculty of Medical and Human Sciences (FMHS), University of Manchester, with its NHS partners educate and train healthcare professionals across a comprehensive range of disciplines at both undergraduate and postgraduate pre and post qualifying levels and makes a significant contribution to preparing and honing the skills of the NHS workforce.

1.2 The Manchester Academic Health Sciences Centre (MAHSC) is a federation of the University of Manchester and six partner NHS Trusts. Academic Health Sciences Centres such as MAHSC exemplify partnerships working across Higher Education Institutions (HEIs) and service providers and provide a model for the integration and alignment of research, education and training with service transformation, workforce planning and patient care.

1.3 We welcome the opportunity to provide written evidence to the committee in relation to the crucial issues under consideration. We would be happy to provide further evidence, in writing and/or through oral evidence, if this would be helpful to the committee.

1.4 We note that the committee have requested evidence in advance of the Government ‘autumn’ publication—although we now understand that the proposals will not emerge until early 2012. These will hopefully set out in more detail the roles and responsibilities of key players within the new system as well as the system structure to take forward education, training and workforce planning.

1.5 We would therefore suggest that it would be helpful if the Committee were able to take further evidence from organisations on the new system following actual publication. The points below address key issues that we consider need to be addressed within the new system rather than our comments on the actual system itself or the roles and responsibilities within it which are as yet unconfirmed at the time of writing.

1.6 A summary of the key issues for FMHS/MAHSC are as follows:

Local Education and Training Boards (LETBs) must include HEIs as full partners with the providers of healthcare in order to achieve excellent and innovative education and training and thus improved patient care.

In establishing LETBs there must be consideration and co-ordination between the organisational networks that have within their remits service improvement and workforce development, such as the AHSCs and the HIECs. There should also be co-ordination in establishing LETBs and the recently proposed regional Academic Health Science Networks.

The experience of AHSCs in integrating education, research and innovation to improve patient care and service delivery should be central to informing the working arrangements of LETBs as integrated HEI/NHS partnerships essential to the transformational agenda.

Postgraduate deaneries and HEIs must be closely aligned to ensure a continuum in medical education, clinical training and academic development.

Health Education England (HEE) should be established as a matter of urgency with transparency as to the roles and remits of Professional Bodies and HEIs in curriculum development and quality assurance and how this should be co-ordinated to ensure consistently high standards. Thus constituted, this activity should be integral to the commissioning arrangements of LETBs.

A properly resourced Centre of Workforce Intelligence or equivalent body working on behalf of HEE should develop long-term workforce policies and commissioning decisions informed by high quality research. This body should ensure coherence across different organisations in identifying funding priority areas for workforce research. There should be co-ordinated multi-professional workforce planning and commissioning for pre-registration education across all professional groupings.

Education funding (including that for CPD) must be ring-fenced with clear systems of accountability for its use by those in receipt of finance to provide placement learning as well as HEIs.

Consideration of Clinical academic workforce planning must be an integrated component of workforce planning in the NHS

2. An Inclusive Approach to Partnership Working

2.1 The opportunity to change the education and training system offers a significant opportunity to ensure that effective partnership working transcends relationships between the NHS and Universities in the delivery of a world class workforce to deliver the highest standards of care for patients and service users going forward. However, there is also a need to ensure that the system architecture is able to support true partnership between HEIs and the NHS.

2.2 In line with others who have already given oral evidence to the committee we would strongly emphasise the importance of direct HEI representation (medical and non-medical education) on LETBs. This is essential to true partnership working in the co-production of the workforce and offers the opportunity to forge relationships and ways of working which focus more on transformational workforce change rather than transactional relationships between commissioners and providers.

2.3 We recognise that there are arguments about the need to avoid conflicts of interests. However, such arguments also apply to Teaching Hospitals (THs) who are at the same time commissioning education from HEIs whilst also providing significant components of practice education. In the proposals to date THs who are well represented on emerging LETBs will also be responsible for decisions about substantial financial flows for MPET to themselves related to placement tariffs as well as monitoring quality—some of which relates to their own educational provision/contribution through placements. Rather than excluding HEIs, such potential conflicts of interest (for HEIs and THs) can be managed through each LETB having an independent Chair and setting up commissioning sub committees to deal with commissioning issues. Partnership working is the way to overcome potential conflicts of interest.

2.4 In the NW the function of the Deaneries has been mapped onto the shadow LETBs. As HEIs are not represented on the shadow LETBs there will be further disconnect between HEI and Deanery functions and between undergraduate and postgraduate medical education and training. Our views on the future of postgraduate Deaneries are consistent with those of the Medical Schools Council, the Conference of Postgraduate Medical Deans and as outlined in the excellent commentary by Ovseiko and Buchan (2011).1 We support their key recommendations to establish formal interactions between HEIs and Deaneries through joint employment, governance and contractual procedures.

2.5 As well as the need for LETBs to include direct HEI representation there is also a need to ensure the system architecture as a whole is able to support and nurture the health professional education and research sector in order to ensure better outcomes for patients supported by an expert workforce. As part of the new system we would argue that there should be an explicit agreement on a statement of effective partnership between the NHS and Universities, advocating the role of university led health professional education in improving patient outcomes through co-production of the workforce. This should be agreed at national level, renewed every five years and form an integral part of the authorisation and monitoring arrangements between HEE and LETBs.

2.6 With reference to 2.4 above, in the NW establishing the shadow LETBs has been led by the Strategic Health Authority (SHA) but in the absence of clear national guidance. Whilst this approach has advantages in ensuring that key functions of the SHA are not lost in transition, broader issues such as the integration of the congruent activities of the HIECs and AHSCs have not been fully taken into account. This has meant that the valuable experience of such organisations in integrating education and training with workforce planning and innovation with the aim of improving patient care and outcomes has not informed the transitional process. Coupled with this is the recent proposal to establish Academic Health Science Networks which will extend the reach of the HIECs and the AHSC to include all regions and build on their progress. The development of LETBs should dovetail with such developments.

3. Workforce PlanningRobust Processes and Accurate Information

3.1 The House of Common Select Committee identifies key themes including how the proposals will ensure the right numbers of appropriately qualified and trained healthcare staff at national, regional and local levels and how future healthcare workforce needs are being forecast. Successful workforce planning is dependent upon reliable and comprehensive information. This will be particularly important for the medium-long term overview that HEE is being asked to provide in the future. For example the latest publication from the NHS Information Centre in October 2011 (which shows the movement in workforce numbers from September 2009 to July 2011) indicates an increase in the number of doctors by 2% but a fall in the number of nurses by 0.2%.

3.2 At present there is little oversight or debate on the education and training requirements of the whole multi-professional workforce at a national level in England. No single body is able to suggest the right direction of travel for the NHS workforce in the medium-long term or who is responsible for long term planning.

3.3 At present there are different approaches to the commissioning of pre registration education and workforce planning within each professional grouping. In relation to nurses, midwives and allied health professional commissioning and workforce planning is carried out by SHAs. For the 2011–12 intake, there have been projected cuts in commissioning of 10% for pre registration nursing courses, as well as 6.4% for allied health professionals pre registrations courses. However, whilst there has been a national initiative to consider undergraduate medical and dental school numbers going forward, there has been little discussion at a national level in relation to non-medical numbers (the largest component of the workforce) and specifically the cuts to education commissioning numbers and whether this meets long term workforce needs or is a short-term measure to control costs.

3.4 We need to avoid the “boom and bust” approach to workforce commissioning that has characterised recent times. If we are to ensure the principle of security of supply which underpins the new system, then commissioning must be conducted over a three to five-year cycle with a proper focus on ensuring an appropriate balance between short term requirements and long term sustainability for the provision of education and training in Universities.

3.5 There are problems with the current method used for workforce planning in the NHS in England:

It is often based on false assumptions about the effects of an ageing population and takes no account of changes in population need and productivity.

It is also undertaken separately for each specialty and staff group and is rarely related to service and financial planning.

Current mechanisms for identifying and funding priority areas for workforce research lack coherence and are fragmented across different organisations such as CfWI and various NIHR research programmes.

3.6 There needs to be a clear system to determine the workforce planning data required and a co-ordinated approach from the national bodies that will request information in a national minimum data set—HEE, CfWI, National Information Centre, NHSCB etc.

3.7 Workforce policy and planning decisions need to be informed by high quality research with these research outputs translated into evidence-based polices and commissioning decisions at national, regional and local levels. Such policy-relevant workforce research could be secured by establishing a national Workforce Policy Research Unit alongside the other policy research units established by the DH to support policy and planning decisions. Such a PRU requires long-term, substantial funding to develop the next generation of workforce planning tools based on “need” as opposed to “demand” for care, and to provide authoritative syntheses of available research into key areas of concern to policy makers such as how to improve workforce efficiency without compromising quality.

3.8 Given the lack of clarity around medium-long term commissioning and the uni-professional approach to commissioning, we strongly support the introduction of a multi-professional HEE which has a long term focus on workforce planning and which is supported by clear workforce planning information through an independent Centre for Workforce Information. This will allow, for the first time, a focus and discussion on evidence based, medium-long term workforce planning and the related commissioning of education and training. We would strongly recommend that in order to ensure a change in approaches to commissioning, HEE must be set up in a way which encourages multi-professional approaches and that the authorisation criteria it uses for LETBs should ensure evidence of both partnership working between Universities and the NHS, as well as transparent multi-professional approaches to commissioning by LETBs.

3.9 The relationship between HEE and LETBs will therefore be crucial. There could be a tension between the short-to-medium term priorities that LETBs would see as their responsibility and the medium-to-longer term perspective that HEE should take. If HEE is to have a medium-to-long term view of workforce planning (which we fully support) then there must be greater clarification over the powers that HEE will have over LETBs. We would advocate a power of direction for HEE over LETBs to ensure that wider workforce needs can be met and this will need to be considered as part of the functions of HEE within the second session Bill.

4. Sustainable and Ring Fenced Education and Training Funding

4.1 We welcome the commitment to ring-fenced funding of the overall health education and training budget and a continuation of a nationally negotiated benchmark price for health professional education where it already exists.

4.2 Since the ring-fence of the MPET budget has been removed, we have been concerned that not all of the central investment on education and training has actually been spent on education and training. The MPET Budget must be truly Multi-Professional based on a principle of equitable funding in relation to future workforce commissioning rather than the separate funding streams within the existing MPET. We fully support continued funding for junior doctors’ salaries and postgraduate medical-education placements but would also argue that there should there be similar funding for non-medical education post graduate pathways including preceptorships, career pathways structure and advance learning to deliver equity.

4.3 We have significant reservations about the proposal to make employers solely responsible for funding the CPD of their existing staff. CPD is a critical element of ensuring that the workforce can continue to develop to meet the health and social care challenges of the future. HEIs already deliver cost-effective CPD, building on their high-quality research. Too often it has been CPD budgets that are cut first and, given the current financial climate, there is a real risk to the development of the existing workforce. We would, therefore, recommend that CPD continues to be funded through the central education and training budget.

4.4 CPD must not become superficial or of poor quality in response to wider short-term priorities and needs to include the staff release costs for development and training. The proposed new duties on any provider of NHS care should be extended to ensure a duty on providers to deliver CPD to its workforce. It will be crucial that HEE has a role in monitoring and reviewing the CPD provision for existing staff as part of its remit. This will become increasingly important as revalidation requirements are prescribed by professional regulatory bodies.

5. Clinical Academic Workforce Planning

5.1 HEI’s must also be consulted on future workforce plans as this will impact on their own provision and the overall development of the clinical academic workforce. There is, both currently and in the proposed arrangements, a major lack of attention to Clinical Academic workforce planning particularly for the smaller disciplines. Without consideration of, and investment in, Clinical Academic Planning within overall NHS workforce planning and commissioning the future the academic workforce will be lacking in terms of quantity and quality and therefore unable to deliver the plans of LETBs which will ultimately impact on the quality of patient care.

5.2 HEE could take forward the development of the existing and future clinical academic workforce as another function. The cuts to planned student numbers and the ageing academic workforce could lead to a shortage of teaching skills and evidence based practice/research in the future. These issues must be addressed in future planning of education, training and workforce issues and form part of the initial agenda for HEE going forward if we are to ensure a sustainable clinical academic workforce and associated career structures and in particular nurture leaders in the research and development workforce.

6. Placement LearningMPET Placement Tariffs and Quality Monitoring

6.1 Within much Education and training a significant amount of learning is undertaken in practice. The new systems and processes must ensure greater engagement and ownership of practice placements and other learning opportunities by all health care providers. This should be a statutory duty for all those in receipt of funding for education and training. Whilst this has been increasingly well embedded in local Trusts and hospital settings, as care and treatment moves increasingly to community and other non-hospital providers, there must be greater commitment to and participation in providing high quality learning experiences within such contexts.

6.2 The transition to an MPET placement tariff, with greater transparency and clearer links between funding and education provision, provides ideal opportunities to incentivise participation and high quality education in practice provided that rigorous performance and quality assurance mechanisms are in place. However, it is essential that Universities, with students undertaking significant periods of learning in practice, are central partners to the quality and performance management of placement providers and the use of MPET placement funding (SIFT/DSifT/NMET etc). Whilst some consultation by SHAs who currently monitor this takes place University engagement and influence has to date been largely vicarious. We would argue that any future arrangements directly include universities in such performance and quality monitoring of placement providers.

December 2011

1 Ovseiko and Buchan (2011) Postgraduate medical education in England: 100 years of solitude. The Lancet 10 December 2011—Vol 378, Issue 9808, Pages 1984-1985.

Prepared 22nd May 2012