The response to the workforce gap provider trusts face is not only about numbers. We also need a clinical workforce that is skilled and equipped to work in new ways to support service transformation to deal with the changing needs of the population. Sustainability and transformation partnerships (STPs) are a placed-based approach to delivering integrated care and addressing the mounting pressure the NHS faces. STPs are intended to improve quality, health and wellbeing, and help local care systems achieve financial balance.
To achieve this, STPs are expected to deliver new care models, developing more integrated workforces to move care closer to home, with much focus currently on accountable care organisations and accountable care systems.
As the original Five-year forward view, which began the move towards new care models and ultimately STPS, recognised: “We can design innovative new care models [and, we could add, STPs], but they simply won’t become a reality unless we have a workforce with the right numbers, skills, values and behaviours to deliver it”.
As one trust leader put it: “We are trying to transform services at a time when the pressures on daily delivery have never been greater. We therefore face both a capacity and capability gap across all areas. This gap is being managed by staff working harder and longer and we have to question how sustainable this position is.”
Today’s workforce is to a large extent tomorrow’s workforce. And so workforce development has to be at the heart of STPs and new care models.
Local workforce action boards (LWABs) have been set up across England by Health Education England (HEE) to lead the workforce element of STPs, but trusts tell us that as yet their progress is mixed. It is not yet clear that most STPs have been able to develop robust workforce plans.
One promising example of how HEE can support the development of a regional plan through the local workforce action board is Greater Manchester. The workforce strategy and 2017/18 implementation plan developed by Greater Manchester Health and Social Care Partnership (GMHSCP) and HEE takes a joined up, long-term, and practical approach to developing the health and social care workforce the region needs. The GMHSCP strategic workforce board is the LWAB as part of a unique memorandum of understanding agreement.
Greater Manchester Health and Social Care workforce strategy
The Greater Manchester Health and Social Care Partnership is overseeing the devolution of responsibility for the region’s £6bn health and social care budget. Greater Manchester’s (GM’s) workforce strategy is a key enabler of their ambition to transform, integrate and improve healthcare for their population. It provides a compelling strategic vision and practical plan to develop the capacity and capability of the workforce of today and in the future. The strategy identifies key priorities based on local needs and outlines system-wide implementation plans. Priority areas include investing in talent development and system leadership, growing their own staff, improving the employment offer and brand, and filling staff shortages. By working closely with Health Education England, NHS England and NHS Improvement, the GM region has demonstrated how an innovative approach to working with national bodies as well as local stakeholders can support the design and delivery of an integrated health and social care workforce strategy. The new mayor has also identified the NHS and wider workforce as a key priority. This joined-up approach to workforce planning is a promising example of devolved strategic workforce planning across a geographic footprint. However, it is important to note that organisations in this region have been working collaboratively for years, which supports change at pace and at scale.
The Nuffield Trust report, Reshaping the workforce to deliver the care patients need, commissioned by NHS Employers, sets outs how trusts can develop the workforce in these ways to support new care models and meet the changing needs of patients. The report includes helpful case studies of how changes have been successfully made.
Examples of workforce development
Having the right mix of staff and skills is essential for the delivery of high-quality care. In the context of the wider health and care sector increasingly working together across organisational boundaries, trusts are redesigning the workforce to meet the needs of their population and deliver new models of care. This workforce redesign has also been part of the solution in some areas and specialities to the absence of sufficient numbers of nurses and doctors. These changes to skill mix in teams and the way in which staff work together can therefore deliver improvements for patients, staff and an organisation’s finances.
Developing new roles can also enhance multidisciplinary team working, free up others’ workloads and reduce agency spend on hard to recruit to positions. Examples of these new roles include:
- assistant nurse practitioners screening patients in A&E departments
- nurse-led intravitreal injection services
- nursing associates that bridge the gap between registered nurses and healthcare assistants
- nurse angiographers (coronary angiography is an X-ray test which uses dye to check for blocked or narrowed coronary arteries)
- prescribing pharmacists.
However, provider trusts need support from the NHS national bodies and professional bodies to successfully develop, embed and scale up the expansion of these new roles. The royal colleges have a role to play in not only acknowledging the potential of these new roles but also taking a brave step forward and supporting trusts to embed them in all their flexibility. Regulation, at an appropriate level, is required to give the professional bodies this confidence and to enable trusts to fully adopt and benefit from these new roles. Both trusts and the professional bodies need national understanding, support and agreement from the Care Quality Commission and NHS Improvement. The regulators need to appropriately incorporate these new roles into their regulatory approach where necessary. Although trusts recognise that this may need changes in the law that are unlikely in the short term, there is a real need for national support to enable trusts to redesign the workforce and provide patients with the best quality care
It’s concerning, however, that as noted previously, workforce development funding for non-medical clinical staff distributed by HEE has been cut 60% in two years. It is not reasonable to expect staff to work in new ways and in new settings, such as in the community, when there is little funding for training to support them to do so. The cut to this funding is a barrier to workforce development and the deliver of new care models and STPs.
Productivity
The response to the workforce challenges provider trusts face also involves improving workforce productivity to narrow the workforce gap.
Lord Carter’s productivity review identified a potential £2bn saving from the NHS workforce budget (NHS Employers) through better use of clinical staff, including skill mix changes described above, reducing agency spend and absences, and adopting good people management practices.
The clinically-led Getting it right first time (GIRFT) programme also points to better patient outcomes leading to potential workforce productivity improvements. A pilot, focused on orthopaedic surgery, delivered a £50m saving over two years. GIRFT is now being rolled out to other clinical areas. It is estimated that £160m annually could be saved through applying GIRFT to general surgery.
Trusts have already worked with NHS Improvement to reduce agency spend by almost £1bn since the introduction of price caps and rules. In part this has been achieved through better use of e-rostering for clinical staff.
Improving workforce productivity is an important part of how the provider sector can address the current workforce challenges. Trusts must do all that they can, with support from the NHS national bodies. However, productivity is not the whole answer and on its own will be insufficient to close the workforce gap provider trusts face.
What needs to happen – workforce development and productivity
Provider trusts should:
- continue to make the most of opportunities to develop the workforce and improve workforce productivity.
The NHS national bodies, professional regulators, and royal colleges should:
- support and enable provider trusts efforts to introduce new roles at scale and pace and develop the existing workforce to work differently, by aligning professional and institutional regulatory approaches and offering professional support.
The Department of Health and the NHS national bodies should:
- continue to support provider trusts with programmes to enhance workforce productivity by reducing agency spend and implementing the workforce elements of Lord Carter’s productivity review and GIRFT.