Better Health, Better Care: Planning Tomorrow's Workforce Today

CHAPTER 2:
BETTER HEALTH, BETTER CARE: ACTION PLAN

The Better Health, Better Care: Action Planwww.scotland.gov.uk/betterhealthbettercare-actionplan sets out the strategic direction for service delivery. It directly links with the strategic outcomes of our vision for Scotland, and is very much aligned with the HEAT (Health Improvement, Efficiency & Governance, Access to Services, and Treatment) targets as part of NHS Board Local Delivery Plans. Achieving successful delivery of these services relies on a flexible and dynamic workforce that is able to respond to changing pressures and proactively adapt to new and emerging challenges and opportunities. This chapter outlines some of the impacts on workforce planning arising from a few select areas of the Better Health, Better Care Action Plan. This is not a comprehensive assessment of the whole action plan nor all potential impacts on each of the NHS Boards. However, the examples have been chosen to illustrate a number of the core workforce themes that NHS Boards will need to consider in order to fully align their workforce planning function with service delivery requirements.

To further support NHS Boards in this area of work, a horizon scanning exercise, undertaken across Scottish Government Health Directorates, identifies in further detail some of the key areas where change is required across the NHS workforce to support future service delivery. This is available online www.scotland.gov.uk/Publications/2007/12/BHBCWorkforcePlanning.

Action
NHS Boards to ensure workforce plans are fully aligned in support of service delivery that meets the needs of patients.

NHSScotland as an Enabler of Healthy Choices and Lifestyles

Stepping up progress towards a more local and accessible health service requires NHS Boards to consider service redesign, new roles and new ways of working to provide more effective utilisation of the current workforce. For example, the Better Health, Better Care Action Plan recognises that through promotion and support to improve mental health and wellbeing from early years to later life, people will have the opportunity to flourish, enjoy good physical health and contribute more positively to broader social and economic outcomes in our society. This can only be successful if the right workforce is in the right place. By ensuring that staff have the right competencies and skills in promoting better health and have access to information, educational and patient resources, the opportunities to engage and work together proactively with patients will increase.

Identifying and addressing the wider health needs of those with mental health problems impacts on a range of different roles across the workforce. For example, mental healthcare link workers in schools may impact on a range of community roles, such as school nurses, health visitors and community mental health nurses. There may also be education and training implications for new staff involved in roles that care for looked after and accommodated children, or with child and adolescent mental health roles. A new role involves the introduction of peer support workers in mental health, which involves employing someone who has experience of mental illness in mainstream services as part of the team providing care and treatment.

Action
NHS Education for Scotland and NHS Boards to focus on service redesign, new roles, role development and new ways of working to provide more effective utilisation of the current workforce.

Action
NHS Boards to work with NHS Education for Scotland and other educational partners to ensure educational support priorities reflect workforce development requirements.

The Best Possible Start

NHSScotland's maternity and antenatal services are uniquely placed to work in partnership with families, deliver early interventions and work constructively with other delivery partners in the public and voluntary sectors. This may require the workforce to operate in different ways, utilising different evidence-based models of care to deliver services that meet the needs of children and families with multiple or complex needs, to give every child the opportunity that they deserve. Models of delivery, applied in partnership at local, regional and national level with an increased focus on early years, can act to improve health and therefore reduce the need for intervention by care services later in life.

From the very early years, community nursing has a role to play in protecting and enhancing children's health and new ways of providing community nursing are being explored, as are the means of providing an enhanced school health resource. If all of these professionals work together, and with others across the public service in an effective, evidence-based way, and ensure that the needs of the most vulnerable are addressed, Scotland's health will be improved.

As part of the Review of Specialist Children's Services, those groups working on each specialist area have estimated the workforce implications of ensuring that the services are robust and able to continue delivering a high quality service in the future. In parallel, a new way of workforce planning is being explored through pilot work in specialist children's services using the Knowledge and Skills Framework to identify the skills and knowledge required to provide a specific service or intervention at any point along a care pathway leading to the development of multi skilled teams and new roles. This approach moves away from planning in professional group silos to using the Career Framework competencies to plan and deliver services at local and regional level.

Tackling Health Inequalities

Whilst the health of the people of Scotland as a whole is improving, some inequalities are widening. Such inequalities in health may be determined by the individual characteristics such as age, by health-related behaviours such as smoking and physical activity, and by family, community and general economic, cultural and environmental factors. Reducing health inequalities requires action across Government on all these domains. The NHS contribution is through ensuring access and through targeting resources; both services and staff, towards deprived areas and on groups in the population who are vulnerable or at particular risk. This has particular significance for primary care and preventative services and therefore the staff working in these areas. It also requires us, with our community planning partners, including local authorities and the community and voluntary sectors; to work together to deliver action on the wider factors underlying health inequalities.

The Scottish Government has established a Ministerial Task Force to agree priorities for
cross-cutting government activity across all strategic objectives to achieve measurable outcomes in reducing health inequalities. This is likely to have significant workforce implications. Redesigning service delivery to reach these vulnerable or at risk populations may require changes in the roles traditionally undertaken by some organisations where the provision of seamless service will include local authority, voluntary and community-led collaboration. Improving population health requires joined-up working beyond the boundaries of the health service. This will include equipping and developing staff to support patient pathways (not just patients but all clients including staff) to services provided by local authority, voluntary and community-led health groups. In these settings the skills, knowledge and behaviours required will be drawn from traditionally disparate vocations.

Action
NHS Boards to ensure future workforce planning is based upon the delivery of services focused on patient need.

Patient Centredness

Providing truly patient-centred care can only be achieved by staff and patient working together for the benefit of all. This requires an understanding of both patient and staff experiences of the NHS, which can be acted upon to deliver year-on-year improvements in patient care. This is why the Scottish Government announced the development of a Scottish Patient Experience Programme which will support staff and their patients in improving their experience of NHS services. The programme will in the first instance focus on inpatients, long-term conditions and GP Services. Workforce planners will need to engage with the programme locally to determine how they can support the delivery of patient-centred care, as determined by staff and patients.

Delivering safe, patient-focused care and improving the patient experience through the delivery of locally available services wherever possible, requires the right workforce in place to make it happen. Comprehensive and robust workforce planning is an essential component in the shift in the balance of care required to deliver healthcare service closer to the communities they serve. Workforce can improve access to local health services by supporting the development of services offered in primary care and community hospitals, encouraging flexibility in the delivery of primary care services and providing walk-in access to a range of primary and community-based services through community pharmacies, amongst others, to complement existing services.

Using the example of community pharmacy, work has begun to establish some community pharmacy-based walk-in service pilots. It is intended that the pilots will offer a mix of services in suitable locations, primarily in major shopping areas or close to main commuter points (or where there is identified local need), at more convenient times. Over time, the services provided will include, for example, nurse-led minor injury treatments, prescribing services, sexual health screening, simple diagnostic tests and some adult immunisations (including travel advice).

Different models of care and redesign of services enable the workforce to work in different ways and to deliver shifts in the balance of care. Workforce implications include the training needs of wider healthcare staff groups who will need access to additional training to deliver a wider range of services safely in community-based settings. The Scottish Enhanced Services Programme facilities opportunity for nurses to work in primary care with general practice to undertake casework with the learning disability population. Other solutions are through more specialists, such as geriatricians, paediatricians and psychiatrists providing out reach services or based in the community and also the contribution of GPs with Special Interest.

Ensuring the supply of a flexible workforce relies on the collation of comprehensive and robust workforce data. Although data on Board employed community primary care staff are available for use in workforce planning, data on staff working in, and employed by, general practices (including medical, nursing, Allied Health Professionals, managerial, administrative and reception) and the other contractor groups (dentistry, optometry and community pharmacy) are not so readily available. Some GP clinical work as well as work provided by other contractor groups is delivered by self-employed sessional doctors and locums - data on their contribution are particularly difficult to obtain. Steps are underway to improve the information on this "hidden" workforce so that the training and planning needs are addressed along with those of Board staff working in the primary care setting.

Action
NHS Boards, Scottish Government and ISD Scotland to work together to improve intelligence held on primary care workforce.

Action
NHS Boards and NHS Education for Scotland to focus on service redesign, new roles and role development, and different ways of working that will enable shifts in the balance of care.

Efficiency

Workforce planning is not just about how many staff there are in NHSScotland, but is also about how different groups work together, as part of a patient-focused team, to make sure the whole patient experience is the best that we can deliver. The NHS Career Framework has provided an opportunity to focus on skill mix within professional groups as well as across groups. As the healthcare delivery patterns shift to respond to the needs of patients and clients, the workforce demands are increasingly going to be inter-professional, working with roles based on recognised levels of capability and competence rather than professional background.

Modernising working practices, benchmarking, efficiency and improving productivity in the workforce, and in services, will enable the responsive delivery of services now and in the future. Improvement work will continue and become more important in order to ensure best value across NHSScotland. National Improvement Programmes for Long Term Conditions, Mental Health and 18 weeks Referral to Treatment Time will be launched in 2008, building on the experience of programmes in Primary Care, Cancer, Planned and Unscheduled care. National improvement and support programmes focus on continuous improvement through the use of tools and techniques for technical and behavioural change management and a widening approach to quality improvement to ensure sustainability. Work is also continuing to look at benchmarking and measurement; and moving towards the greater integration of finance and service in workforce planning through Local Delivery Plans and HEAT targets.

The workforce of today is the workforce of tomorrow, therefore further efforts are required to have a safe working environment, help to maintain their wellness and retain a dynamic workforce. Taking responsibility includes NHSScotland employers demonstrating exemplar practice, with local flexibility to design and recruit the workforce required to meet local needs. For example, there are significant benefits in actively promoting attendance at work and supporting staff to return to work, and providing support at an early stage can prevent escalation of medical conditions. The OHSxtra model of rehabilitation has been successfully piloted in NHS Lanarkshire and NHS Fife using a case management approach to fast track rehabilitation for NHS staff which offers Mental Health, Physiotherapy and Cognitive Behaviour Therapy ( CBT) services. Results have shown that the model is fit for purpose in preventing sickness absence, hastening the return to work of staff that were already off sick and preventing expenditure on unproductive time.

The new national NHSScotland Efficiency and Productivity Programme will enable NHS Boards to access information and support in relation to a range of efficiency and national improvement programmes, including the Tariff and Benchmarking projects. A national steering group, chaired by NHSScotland, will be established to provide governance, direction and advice on the programme; the integral link to each NHS Board; and to help define local targets. Work will be undertaken with NHS Boards to demonstrate where savings could be made while focusing on patient outcomes. It is anticipated that by bringing this work together, and by giving it some national focus, NHS Boards will be supported and developed to share best practice and new ideas working in the direction of the Better Health, Better Care: Action Plan.

Action
NHS Boards to build on current productivity and efficiency efforts, including pay modernisation benefits realisation.