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

CHAPTER 3:
MOVING TOWARDS TOMORROW'S WORKFORCE

Recognised collectively as one of the largest employers in Scotland, NHSScotland has a workforce made up of highly trained professional staff; the majority of whom are involved in direct clinical care and those who provide support to that clinical care. The size of this workforce has increased by around 18.5% over the last 10 years to 129,274 WTE staff in 2006; accounting for about 70% of the NHSScotland budget. However, considering that the level of growth in resources which has been experienced since devolution is now slowing across the public sector in Scotland, including NHSScotland, this high level of growth in the workforce will no longer be sustainable in the future. NHS Boards will now need to reassure themselves that their workforce projections remain both affordable and robust in line with the Scottish Spending Review. Through integrating workforce planning more fully with financial planning systems at local, regional and national level, NHS Boards will be able to demonstrate in a more transparent manner that their workforce projections have been developed in a way that supports the sustainable delivery of services.

In recognition of the crucial role that workforce plays in delivering flexible and responsive services, it is essential to continue investing in the education, training, and development of NHSScotland staff; both in relation to the existing workforce and new training supply.

Action
NHS Boards to ensure workforce plans fully aligned with financial plans to demonstrate that staff projections are both affordable and sustainable.

General Workforce Assessment

Overall, NHSScotland is well placed to meet future service demand with evidence of emerging new and extended roles with underpinning education and training in place. Reconfiguration of services is driving this movement and pay modernisation benefits are assisting this process. That is not to say that supply and demand are in balance across the workforce and more needs to be done to improve workforce planning and identify potential hotspots and action for front-line and supporting staff. For example, in relation to the ageing profile of estates staff, positive action has been taken by some Boards to introduce apprenticeships. There are a number of areas which are causing concern for the Allied Health Professions, for example experienced practitioner posts in orthoptics, learning disability within dietetics and physiotherapy, paediatric occupational therapy and physiotherapy, and speech and language therapy are hard to fill. Generally, there are issues in relation to recruitment in remote and rural areas and strategies include the need to provide career pathways from student placement, through junior and senior posts through to advanced practice to support the delivery of sustainable and team based care. The development of joint appointments of medical staff between NHS Boards has also helped to recruit and retain highly skilled medical staff to posts within rural settings.

NHSScotland has a wealth of talent and experience to draw on within the existing workforce and this needs to be maximised and fully deployed in providing solutions to sustainable clinical teams. Nurses, midwives, allied health professionals and clinical scientists for example, can all provide alternatives to traditional models of medical leadership in perioperative care, radiology, laboratories, diagnostics, long-term and complex condition management and rehabilitation. Moving away from more of the same staffing models brings many benefits to patients and staff alike in achieving efficient and cost-effective solutions to healthcare delivery including utilising new technology and making more use of assistant practitioners and support workers to free up valuable clinical time.

Future workforce planning needs to be widened to take account of key partners in delivering healthcare to the population at local level, reflecting changes in policy regarding care available, and delivered closer to clients and patients. This will have considerable implications for the NHSScotland workforce with some groups of staff working across health, Local Authorities and the voluntary sector.

Through investment in developing and training existing and potential healthcare staff, the NHSScotland workforce contributes to far more than the traditional hospital and community care. This benefits the wider Scottish economy providing routes into employment for those from deprived populations and NHS Boards have a number of initiatives underway to bring together the need for skills within their organisation with the support they are able to give to ensure availability. Ensuring the Scottish population is healthier should also increase the productivity of Scotland's workforce, which will have a positive impact on wider economic growth in the long run.

Training Numbers

In this changing fiscal environment it is essential that the NHS Board workforce planning function is able to predict the level of demand for different roles and the impact of this on different staff groups across the workforce. At national level these projections inform the national training numbers for controlled staff groups. To this end, the training numbers for the medical, dental and nursing and midwifery workforce in 2008/09, which have been informed by NHS Board workforce projections, are published in Annex A.

To ensure a sustainable and effective workforce over the longer term, the priority must now be to maximise productivity through development of the existing workforce. Gearing educational support priorities to reflect the workforce development requirements of individual NHS Boards is essential, especially in relation to educational support for the development of new and extended roles to support service re-design.

Emerging Roles

Education and training for the NHSScotland workforce makes a significant contribution to improving quality, addressing excessive variation in practice and ensuring the highest standards of patient safety. NHS Education for Scotland is well placed to take this forward and develop further the engagement processes between individual NHS Boards and NES to ensure that service requirements are fully articulated and understood. Throughout this process new roles are emerging such as that of the Physician Assistant which is being piloted across Scotland. Consultant and specialist nursing, Allied Health Profession and Healthcare Scientist roles are pioneering leadership in service delivery and best practice in defined clinical areas. The introduction of a consultant grade for hospital pharmacy practitioners will assist in modernising the hospital pharmacy service and the development of the community pharmacy workforce to support a wider range of services supported by the pharmacist's assistant will bring added value to community service provision. Ambulance staff, particularly paramedics, are also developing their roles to support front-end services and there is also a move to strengthen the public health workforce in its widest sense to serve the local community supported by appropriate education and training. Alongside this there is a steady planned growth in supporting roles, such as the clinical care assistants, whose contribution has increasing potential to release registered professional staff from tasks that can be undertaken by others with appropriate training. There is also a decline in some roles due to the effects of advancing clinical knowledge, expertise and technology, for example in cardiothoracic surgery where improved models of treatment in cardiology has meant a reduction in invasive surgery for patients.

Clinical practice is under continuous and rapid change. Key drivers of this change are new discoveries about the nature of disease and its prevention, new means of clinical investigation and practice and the development of new treatments. The spirit of enquiry and research that generates these discoveries is an essential part of the culture of a healthy NHS and is for the benefit of all patients. Clinical academics (across the spectrum of professions working in the NHS) who undertake research are a crucial part of the workforce that will shape the future of the NHS. It is of importance therefore to ensure maximum benefit is derived from the development of academically talented individuals, who are likely to be highly influential in the future development and delivery of clinical services within Scotland.

Action
NHS Boards and NHS Education for Scotland to work together to ensure skills and expertise of staff meet patient need.

Workforce Regulation

With the emergence of new roles, there is a need to keep under constant review requirements for patient safety and public protection. It is therefore necessary for NHS Quality Improvement Scotland, NHS employers and other stakeholders to work together within statutory frameworks for clinical and staff governance to ensure that staff are safely recruited, are adequately prepared for the roles required of them, meet recognised standards for performance, and conduct their duties in a safe and professional manner.

It is also necessary for the requirement for statutory professional regulation of new and emerging roles to be assessed as appropriate, taking account of the need for proportionality, balancing regulatory effort with the risk associated with the role. Work progressing on a UK-wide basis on identifying criteria for statutory professional regulation will support this.

Action
NHS Boards and the Scottish Government to work together to identify professional groups that are appropriate for statutory professional regulation.

Education and Training

Education and training of the NHSScotland workforce is a key determining factor in the supply and quality of all groups of workforce. The further development of links between the higher education sector and NHSScotland, through the construction and operation of strategic alliances of interested parties, will underpin the future supply of people appropriately prepared to deliver patient care in the evolving context of NHSScotland. Many of these changes are linked in to the requirements of regulatory bodies to ensure safe and effective practice for the benefit of patients.

Modernising Medical Careers ( MMC) is a UK-wide initiative which has brought about substantial change in the way doctors are trained. This means a substantial change to the shape of the medical workforce in the longer term so that service is delivered primarily by trained doctors as opposed to doctors in training. There is a need for Board workforce plans to reflect this change, as well as giving due consideration to the wide-ranging impact of MMC on other staff groups, and the potential to develop other new roles, such as the Advanced Practitioner and Physicians Assistants roles. It is both clinically and cost effective to review the work that is currently undertaken by doctors and to consider what can be safely undertaken by other healthcare professionals. The review of MMC conducted by Sir John Tooke in 2007 has produced a series of recommendations for further changes in postgraduate medical training, including consideration to be given to the role of the trained doctor. The Scottish Government plans to consult on these recommendations shortly.

Education and training of healthcare scientists presents NHSScotland with particular challenges. Education capacity and delivery approaches need to reflect the diversity of disciplines, relatively low numbers of staff and alternative (non- NHS) career options that many healthcare scientists have available to them. Shifting roles and the impacts of service redesign including the 18 week referral to treatment target and new technology will also influence workforce demands and education needs. Safe, Accurate & Effective: An Action Plan for Healthcare Science in NHSScotland, has just been developed and was published in November 2007.

Modernising Nursing Careers gives priority across the UK to the development of a competent and flexible nursing workforce, updating career pathways and career choices, preparing nurses to lead in a changed healthcare system and modernising the image of nursing and nursing careers. In Scotland, our frameworks will be broader to encompass nursing, midwifery and the allied health professions. As part of this work an advanced practice toolkit is in development aimed at providing the key elements which can be used to validate existing practitioner roles and support their application to new roles. This will aid the development of sustainable clinical teams with leadership coming from across the healthcare professions where appropriate. An initiative is also underway in four pilot sites across Scotland to test out a generic community nursing role, which integrates the skills of district nursing, public health nursing (health visiting and school nursing) and family health nursing within one discipline. The evaluation findings of this model are expected Spring 2009. Taking into account the work of the Facing the Future Subgroup for nursing and midwifery, we will also continue to work to ensure that we recruit and retain students to nursing, midwifery and allied health professions in a way that enables NHSScotland to meet growing demands of local communities both now and in the future.

Discussions have also been taking place with the Scottish Funding Council and Higher Education Institutions regarding future education and training requirements to meet changing service needs. Initial discussions have focused on the benefits of common core training for some staff groups to maximise the opportunities of learning together and applying team working in practice on qualification.

Action
NHS Education for Scotland to continue to develop links with NHS Boards and Higher and Further Education Institutions to ensure education and training provision reflects the needs of the workforce.

Action
NHS Education for Scotland to continue to develop wider education and training support to meet the needs of all staff groups of the NHS workforce.