National health and social care workforce plan: part one

Chapter 3 - Planning the current NHS Scotland workforce

1. Around £6 billion is spent on the NHS workforce annually and 99.6% of all NHS care is delivered by NHS staff. Those staff do an excellent job, often in challenging circumstances, and people receiving treatment and care in Scotland can be assured that staff are in place in the right numbers. To continue delivering high quality care into the future, our staff will also need to be doing the right things, in the right place and at the right time.

2. Fifteen per cent of the workforce in Scotland is employed in health and social work, representing over 400,000 staff in Scotland. The diagram below shows its size relative to other industrial sectors:

3. The most recent NHSScotland workforce statistics were published on 6 June 2017 by ISD Scotland and show data recorded as at 31 March 2017. The data shows that a record number of NHSScotland staff are now delivering care in response to the ever more complex demands. Since September 2006, NHSScotland staff have increased by 12,646 headcount (12,369.0 wte), up 8.4% (9.7% wte). ^[5]

4. For NHSScotland ^[6] , the nursing and midwifery workforce is the largest staff category by some way, with almost 60,000 whole time equivalent ( WTE) nursing and midwifery staff in employment within NHS Scotland in March 2017. The medical and Allied Health Professions workforces account for around 12,000 WTE and 11,500 WTE respectively. Healthcare Science has around 5,500 WTE and there are almost 5,000 GPs in Scotland (though this is headcount rather than WTE). An "other therapeutic" category numbering around 4,000 WTE includes a range of other professional groups, including pharmacists, who do not fall within the main medical, nursing, AHP or healthcare science categories. The chart and table below set out the numbers from 2007 to 2016.

5. Many efforts are being made to help secure this workforce, recognising the diverse skills they possess and their high levels of training, dedication and professionalism:

Commitments to secure the NHS Scotland workforce

• Over £23 million invested to increase the number of medical school places.
• 50 additional undergraduate places and the introduction of a pre-medical year and a graduate entry programme with a primary care focus.
• 100 more training places for GPs, moving from 300 to 400: from 2019 onwards, additional GPs will be available to work in the community.
• 4.7% increase in trainee nurses and midwives for 2017/18 - a fifth successive rise.
• NHS Scotland now continues to meet the Royal College of Midwives recommended midwife to birth ratio.
• 500 additional Health Visitors - significant numbers of whom are in training to deliver this Scottish Government commitment.
• The development of innovative nursing and midwifery workforce planning tools mandated for use across NHS Boards
• Investment in the wider Primary Care team, with substantial increases in Paramedic numbers, pharmacists and other health professionals to support GPs in creating sustainable primary care solutions.

6. Although statistical evidence also shows that vacancies for consultants and nurses have increased slightly, many new posts created in NHS Boards have helped increase overall numbers, benefiting from the mandatory nursing and midwifery workload and workforce planning tools which help NHS Boards to plan staffing levels. Combined medical & nursing agency spend represents just 2% of the overall NHS Scotland staffing spend - less than a third of that in NHS England - and bank and agency staff help NHS Boards to cope with peaks in demand and provide service continuity during times of planned and unplanned staffing gaps. Significant priority is given to working with NHS Boards to reduce the overall use of agency staff, which will be assisted by establishing Regional and National Staff Banks, which give NHS Boards greater access to a high quality temporary NHS workforce. The Scottish Government is also working with NHS Scotland to reduce both the use of locum doctors, and their cost to the health service, through a "preferred supplier" framework contract for agencies that supply medical locums.

7. The picture of the NHS Scotland workforce given by current statistical evidence is only partial. More proactive planning is needed to enable NHS staff to fully respond to the significant changes being made to NHS Scotland services and to the people whose care they provide. Workforce planning needs to evolve so in the medium to longer term, the service is better able to determine the workforce it will require in future. The purpose of this Plan is to provide a framework in which to achieve this aim at national, regional and local levels - for example, by:

• projecting forward to meet national needs on reported workforce statistics;
• enabling NHS Boards to identify opportunities to share efforts regionally to alleviate capacity issues and provide clarity between hospitals and elective centres; and
• to enable more consistent local reporting by NHS Boards, reflecting current and potential challenges to workforce issues at NHS Board level, and allowing progress with multi-disciplinary teams to be tracked.

Future planning - broadening the approach

8. Each NHS Board must take account of a range of factors, including clinical need or geographical location, in determining the right blend of skills, knowledge and expertise to provide high quality services for the people it serves. Ultimately it is how the professional groups combine to deliver this care most effectively that has the biggest influence on outcomes for people. Workforce planning must be able to meet changing models of care as set out in the Health and Social Care Delivery Plan.

9. The Health and Social Care Delivery Plan sets out a vision for health and social care services that focus as much on prevention, early intervention and enablement as they do on the effective treatment of illness, injury and multi-morbidity. As these new models of care become embedded, workforce development must reflect the optimum skill mix that makes best use of the talents of the whole team to underpin effective multi-disciplinary working. This will ensure staff can work at the top of their clinical skill set and people who use services are able to access health care professionals with the right skills at the right time.

10. Planning for the future NHS Scotland workforce has often focussed on individual professions and in particular on those where staff numbers are "controlled" by student intakes. It now needs to involve a broader range of professions, recognising the inter-dependence of staff groups and a more distributed model of professional leadership - combining "first point of contact" practitioners with advanced practitioners from across the disciplines. This stronger multi-disciplinary approach should provide more sustainable services and help reduce the need for agency staff expenditure and outsourcing.

11. While there needs to be a new emphasis in future on multi-disciplinary approaches, many issues for the main professional groups must also be considered. The importance of a "whole of workforce" integrated view should be underlined, built on teams, with full recognition given to the different skills and qualifications that different workers bring - whether they are delivering care, or supporting those who deliver care.

12. Workforce planning will need to develop further to describe clearly how multi-disciplinary working will enable the shift. That will be assisted by the scenario planning model we are developing by Autumn, and by the work being done by NES to reorganise workforce data nationally, regionally and locally. Future editions of the Plan will include reference to developing models for multi-disciplinary working which apply at each level, taking account of existing developmental work in primary care. This work will also be considered in the context of the developing remit for the new National Workforce Planning Group.

Medical workforce

13. National statistics have shown increasing numbers of doctors within NHS Scotland, with over 28% more doctors over the last 10 years ^[7] . Numbers of consultants, the most senior grade of doctor, have increased in the same period by a record 46.2% since 2006. The General Medical Council has published data which demonstrates that Scotland has more licensed doctors per head of population on both the GP and specialist registers, and that it also has significantly more medical undergraduates and doctors per capita compared to the UK as a whole, as demonstrated in the following graphic:

14. However, continued difficulties in filling posts for individual specialties, at particular times and in particular parts of Scotland have demonstrated that while numbers in employment are important, what people are trained in is also highly relevant. For this reason, Scottish Ministers have committed to investing over £23 million to increase the number of medical school places.

15. The diagram overleaf shows medical training flows.

16. Scotland is currently addressing a number of key challenges for the medical workforce with a view to better matching undergraduate education and post graduate training to service need. These challenges occur at various stages of training, as follows:

• A long training 'pipeline' from entry to medical school to end of postgraduate training of up to 15 years;
• Ensuring the supply of trained doctors meets the future requirement for GPs and consultants. Detailed medical specialty supply/demand profiles are providing increasingly specific modelling on this. This depends on effective modelling, requiring flexibility in high quality training capacity and in funding (with potential to realign current agency and locum spend to meet training and service need);
• Matching what services are needed to match graduates' ambitions, and adjusting university curricula accordingly:
  • Only 19% of graduates from Scottish medical schools are in GP training in Scotland 4 years after qualification. For General Practice, there is a pressing need for locally-recruited students to return to work in their communities;
• Ensuring sufficient medical graduates to fill foundation programmes in the context of a recently emerging overall UK undersupply position. This is being addressed by initiatives to increase Scottish medical graduate output;
• Ensuring sufficient Foundation programme completers to fill an expanding requirement for specialty training. This requires both sufficient Foundation capacity and improved retention of completers in Scotland;
• Understanding and addressing the factors which result in only 50% of graduates from Scottish medical schools being in training in NHS Scotland 4 years later. This will require more systematic use and development of available evidence about the proportion of graduates who are of international origin, or who may not be able to stay in Scotland.

17. Many different effects apply at each of these stages. However these challenges demonstrate the need to engage with the higher education sector and post graduate training providers more closely to match the medical workforce with what services, and crucially the people who receive them, actually need.

18. Much work is already underway to increase medical student numbers and training places, to invest in training and to address the sustainability of the medical workforce. Improvements to workforce planning hold much potential to support further changes to existing arrangements. But because it takes years for clinicians to complete their training, some changes, particularly those to education, cannot have immediate effect. This presents challenges to all organisations involved in medical workforce planning, requiring in-depth discussion on training and development issues.

Increasing the number of radiologists in Scotland

What is being done?

• Radiology training posts increased by 26 in 4 years.
• This 20% increase in training numbers is in response to medical supply/demand data revealing an ongoing undersupply.

What will this add?

• Improved recruitment of consultant radiologists
• Better ability to meet the National Cancer Strategy

19. Current recruitment and retention challenges in both hospital specialities and general practice are well documented, and several strands of work aim to enable medical staff to feel both valued and engaged in NHS Scotland work. National and regional initiatives linked to staff wellbeing and engagement include resilience training in NHS Tayside, use of the Professional Compliance Analysis Tool ( PCAT) by workforce planning, and the NES-led StART (Strategy for Attraction and Recruitment) Alliance promoting measures to improve recruitment and retention. This work is being mapped to help share best practice more widely.

Valuing the Medical Workforce

What is being done?

• Over £23 million investment over next 5 years increasing number of medical school places by 50 a year (from 850 to 900) - with a new entry level programme for students from deprived backgrounds.
• Creating first Scottish graduate entry programme for medicine, with a strong focus on primary care and remote/rural component - both to encourage entry into general practice.
• Mapping of national and regional initiatives relating to workforce wellbeing
• Expansion of PCAT 's health and wellbeing strand
• Developing NES strategy on engagement

20. However, sustainable recruitment to medical specialties and GP needs concerted, long term action, especially for remote and rural areas or in areas of higher socio-economic deprivation. This begins with recruiting the correct absolute numbers at each stage of training, builds through high quality training and education and is consolidated by best practice employment behaviour.

Undergraduate medicine

21. Scotland currently has five world class medical schools which are an attractive destination for students from across the world. While this is a strength in the context of a competitive, global marketplace, the requirement for a sustainable medical workforce for NHS Scotland is important given the length of medical training and the high costs associated with it. Current priorities for Scottish Government include producing more graduates who are likely to enter training for GP and other shortage specialities. But there needs to be a clearer systematic focus on recruiting the doctors of the future with training and education which reflects the needs of patients and service providers, the changing demographic of the population and the fact that more care will require to be delivered in the community.

22. More graduates from Scottish medical schools also need to stay in Scotland, to work in NHS Scotland. Recent increases in places will potentially amount to 250 additional medical trainees by 2021. Scotgem ^[8] - Scotland's first graduate medical school, will open in autumn 2018 with a curriculum focussing on GP and remote and rural medicine as well as an element of "bonding" - likely, in this instance, to involve an element of return of service to NHS Scotland in exchange for a bursary. The Scottish Government is also funding two pre-medical entry courses for entrants from less socially advantaged backgrounds which commence in Autumn 2017.

23. Further work is however required to address challenges around undergraduate education, such as how to recruit students with the right values into medical schools; how teaching and culture in medical schools needs to adapt to ensure a closer match between student learning and experience and the needs of NHSScotland; and how to retain more graduates from Scotland's medical schools in NHS Scotland and encourage them into the specialities that NHS Scotland needs.

Postgraduate training

24. Postgraduate training pathways also need to adapt. Professor Sir David Greenaway's Shape of Training review recognised that medical training must adapt to meet the changing needs and expectations of patients, and to meet the needs of service providers. Preparatory work is already underway to implement the key recommendations from this review.

25. National decisions taken to support high quality training can have a profound impact on local service delivery. Scotland is competing with the rest of the UK and the rest of the world and remains an attractive destination for students, so the training it offers to health and social care professionals must remain competitive in the wider market. There is therefore a case to look again nationally at reducing the barriers to overseas recruitment as part of a more co-ordinated initiative to market Scotland as a desirable place to live and work in.

26. For specialty and associate specialist ( SAS) doctors, an SAS development guide ^[9] was recently agreed by Health Education England, NHS Employers, the BMA and the Academy in England, which describes actions that can be taken to ensure best practice is applied in the development of SAS doctors and dentists. This joint working has been in place in Scotland for some years and is manifest in the SAS Development Programme, funded by Scottish Government, managed by NHS Education for Scotland.

Medical Specialty Profiles

27. Medical Specialty Profiles use modelling information from several sources to develop a picture of the medical education and training "pipeline". This data is used to identify and inform responses to differences in the supply of and demand for doctors. To date, detailed specialty profiles have been completed for all established hospital specialties. These profiles have been used for a wide range of specialties to:

• Provide advice in the context of annual setting of training numbers;
• Develop strategies in response to anticipated shortages;
• Address "gap management" issues - ie informing the process of filling gaps in service rotas.

28. The profiles are now being developed further to predict the sustainability of particular specialties in shifting care to the community and determining new multi-disciplinary staffing and service delivery models. The profiles' predictive capacity can be used to inform the recruitment and retention strategies NHS Boards use to fill gaps and vacancies. The profiles are an important tool, and further discussions with NES, working with ISD Scotland, will help to determine how NHS Boards might use them as part of a suite of effective workforce planning tools covering the majority of the NHS workforce. The aim is to have a project specification and plan ready by July 2017.

Medical Specialty Profiles are used to describe how training programmes meet both population and local service requirements, with intake numbers set by future demand for trained GPs and consultants.

What is being done?

• 115 more specialty training posts since 2014, targeted to areas of need.
• 25-30 posts less than full-time training posts, improving supply for "hard to fill" specialties;
• GP training places increased by 100.

What do the Profiles add?

• More insight into training and trainee destinations.
• Better evidence base to support action for medical specialties with difficulty in recruiting consultants.
• More targeted support for medical specialties from allied health professions.
• Improved demand forecasting, taking account of changing specialty workforce participation and growth.

Junior Doctors

29. Junior doctors are NHS Scotland's future medical leaders and Scottish Ministers are committed to making Scotland as attractive a place as possible for them to work. The Scottish Government has identified a need for improving the way the day to day hours of junior doctors are managed through a system called DRS Real-time which is designed to automate this process, provide real-time online access to rosters, allow the easy management of these by employers and employees, and provide real-time working hours information for all junior doctors.

30. There has been considerable success in improving the working hours and conditions for Junior Doctors by implementing the Working Time Regulations; ending 7 full night shifts in a row and ensuring that rotas comply with guidance that no junior doctor should be rostered to work more than 7 days or shifts in a row. Delivering a maximum 48 hour working week for Junior Doctors has many implications for services and staffing, with an impact on future workforce planning arrangements. On-going work is being undertaken to assess this impact and once an initial evidence base has been developed, further work will ensure these complex arrangements are fully understood. A phased approach will ensure that this is delivered in a safe and sustainable manner.

General Practice

GPs

What has been done?

• Training places increased from 300 to 400
• Investment in bursaries
• Investment in recruitment and retention increased to £5m
• Funding more pharmacy work in GP practices to reduce GP workload

What more will be done following this Plan?

• Publish evidence based target numbers
• Improve Primary Care Workforce Survey
• Plans to attract more GPs via schools and universities
• Enhance Multi-Disciplinary team working
• GP Pharmacy Fund expanded to £12m from £7.8m
• Develop supply/demand profiling work.

31. General Practice is facing unprecedented challenges through increased workload; increased risk relating to staff and premises; and in recruitment and retention of new and existing GPs. Although "headcount" numbers of GPs have increased substantially in recent years, numbers of whole time equivalent GPs are reducing, with the workforce increasingly choosing to work part-time against a backdrop of increasing demand on GP services, an ageing population and a continuing drive to shift the balance of care from acute to primary and community settings.

32. For those reasons, Scottish Ministers have committed to increasing the number of GPs working in communities, and have augmented the number of GP training places from 300 to 400 a year, bringing the total GP training establishment up to 1,200 from 2017.

33. Simultaneous action is needed to improve arrangements for GPs' education and early career and recruitment and retention. There is potential for considerable impact from educational changes, but they will take many years to deliver. There are plans to generate interest in GP as a profession through schools and universities and attract students from socio-economically deprived backgrounds. The Scottish Government has also set up a Recruitment and Retention fund, increasing from £1m in 2016/17 to £5m in 2017/18 (as part of the £60 million in direct support of General Practice in 2017/18). This increased investment will enable the scheme to expand and continue to explore with key stakeholders the issues surrounding GP recruitment and retention across Scotland.

34. GP shortages affect the sustainability of primary care services in the out of hours ( OOH) period, which is after 6pm in the evening and during the weekends when GP surgeries are closed. Across Scotland, out of hours services are under pressure due to an increasing lack of GPs willing to participate.

35. A national review of primary care Out of Hours Services "Pulling Together: Transforming Urgent care for the People of Scotland" was published in 2015. It included recommendations for the future contributions of the GP workforce, as well as the nursing, pharmacy, paramedical, other allied health professionals and social services workforce. It recognised that while GPs will continue to be an essential part of multidisciplinary teams providing clinical leadership and expertise, particularly for complex cases, they will no longer be the default health care professionals to see patients for urgent care.

36. GP contract negotiations will play a key role in determining what further progress can be made, and how quickly. To ensure that the appropriate actions are taken forward, a supplement to this Plan - Part 3 - will be published towards the end of this year, following these negotiations. Workforce numbers will be an important part of the GP contract, and the supplement will address GP workforce matters and will include an evidence based target of numbers of GPs needed to maintain and sustain high quality General Practice services.

Primary Care

37. Primary Care sits at the heart of an integrated health and social care system, offering GP and community services including district and community nursing, mental health, dentistry, community pharmacy, and optometry, as well as social care services, third and independent sector provision. These are services which are the responsibility of the new Integration Authorities.

38. General Practice increasingly involves team working. More multidisciplinary teams ( MDTs) working in practices will help ensure that people see the right professional at the right time to better meet their needs. While leading their MDTs in improving the health of the wider population, GPs must also have the space they need to focus on complex issues including end of life care. MDTs are the right approach because they enable better health outcomes, more efficient use of resources and enhanced job satisfaction for team members. These teams consist of a range of professionals whose core members already exist in Primary Care - including GPs, Practice Nurses, Practice Managers and Receptionists. New roles (clinical, non-clinical, social care and Third Sector) are already evolving and others will need to be introduced to ensure teams meet patient needs.

General Practice is about teams

• £2 million is being invested in 2017 in training for General Practice nurses (training of new ones or additional training of current ones), who are core to effective multi-disciplinary teams and good patient care.
• At least 250 Community Link Workers are being recruited to work in GP surgeries, directing people to local services and support.
• 1,000 more paramedics will be trained over the next five years to work in the community, helping to reduce pressure on A&E services.
• A further £500,000 is being invested to develop the skills of practice managers and other non-clinical staff such as practice receptionists, delivering primary care through multi-disciplinary teams, with GPs and social care partners working in clusters of practices.
• General Practice nurse roles and educational requirements are being refreshed under the Chief Nursing Officer's Transforming Nursing Roles programme.

39. General Practice nurses in 2012/13 accounted for 33% of GP and practice nurse contacts, an increase of 5% from 2003/4. ^[10] They are essential to the future of general practice. General Practice Nursing provides primary care services, mainly through GP independent contract employment, with general nursing skills and extended roles in health protection, urgent care and supporting people with long term conditions. There has been a continued increase in numbers of consultations for general practice nurses compared to GPs, illustrating the continuing shift of chronic disease management from GPs to nurses.

40. In parallel with these developments, it is particularly important that the quality of primary care workforce data allows for effective workforce planning to be undertaken for the future. Current workforce planning arrangements are informed by a biennial Primary Care Workforce Survey, which gives incomplete information. There is therefore a pressing need to strengthen the data currently collected. Ways to access and use the robust GP workforce data required to strengthen planning are being explored by the Scottish Government and Scottish General Practitioners Committee of the British Medical Association as part of negotiating the new GP contract. Wider discussions are also proceeding between the Scottish Government, NES, ISD Scotland and others about how to improve the range, frequency and quality of primary care workforce information.

Dental

41. Within independent dental contractors' services, there is also broad agreement to a shift towards prevention, building on successful work in preventing dental disease in children. This reduces pressure on the acute sector, where theatre time is currently used to treat people with advanced decay, and there is scope to move other secondary care services into primary care. The increasing needs of the frail dentate older person who cannot be treated in a surgery also require to be met.

42. All of these developments impact on the dental workforce, and therefore on the workforce planning necessary to meet these service aims. At one end of the skills spectrum, dental practitioners continue to be expected to work at the limit of their scope of practice, for which they will need training. At the other, more input from dental care professionals, such as Therapists and Hygienists, will help to implement more preventive dental services.

Pharmacy

43. Pharmacists are core members of the healthcare workforce within community pharmacy teams, supporting GP practices with everyday medicines-related care. In hospital and specialist care services, they work with other clinicians to ensure the best pharmaceutical care decisions are taken and are appropriate to the patient's condition. Significant progress has already been made to meet changing healthcare needs: for example, over a quarter of all practising Pharmacists are qualified as independent prescribers, and pharmacy undergraduate education is being strengthened.

Optometry

44. There are 1,453 Optometrists and 3 ophthalmic medical consultants listed to provide general ophthalmic services ( GOS). 142 of these Optometrists have been funded to become independent prescribers through NHS Education for Scotland, The development of general ophthalmic services ( GOS) to support community eye care has reduced the burden on GPs and has allowed more patients to be discharged from the hospital eye service. Age is the greatest risk factor for developing eye conditions, and training is being developed to enable safe and high quality community care for patients with long-term ophthalmic conditions. However more capacity within the community is needed to reduce demand on hospital provision. While rising workload and recruitment outside the central belt present challenges, numbers of optometrists entering Scotland from elsewhere in the UK have started to increase.

The Allied Health Professional ( AHP) workforce

45. The 13 main AHP professions (such as Physiotherapists, Dieticians, Speech and Language Therapists, and Podiatrists) play a key part of the Delivery Plan's aims, providing prevention, early intervention and enablement support to people of all ages to live well, be physically active, manage their own conditions, remain in or return to employment, and live independently at home. Over the last 10 years, the AHP workforce has increased by over 30% - from 8,800 in 2006 to around 11,500 in 2017. This reflects the growing need for professionals with a diverse range of specialist skills who can make a vital contribution as first point of contact practitioners to diagnostics, early rehabilitation and enablement.

AHPs are already supporting the shift in the balance of care from acute to primary care and the community - where increasingly they are working - as in the examples below:

AHP roles supporting a shift in the balance of care

• Radiography "plain film" diagnostic reporting frees up (consultant) Radiologists, addressing the annual 15% increase in demand for diagnostics and reducing agency spend and outsourcing of services.
• More Physiotherapists and Occupational Therapists will be required in multi-disciplinary teams within primary care and A&E departments. In acute settings, evidence shows that 1 hour of therapy time can reduce in length of stay by 1 day.
• Physiotherapists treating MSK patients in GP practices can free up GPs' time to see more urgent cases.
• The Specialist Paramedic role developed by the Scottish Ambulance Service will help to reduce unnecessary hospital admissions and to relieve pressure on general practice.

46. Future demand for AHPs is likely to rise, alongside the increase in demand for services associated with an ageing population. The numbers entering the AHP professions are not currently controlled, and are largely determined by supply and demand factors. The potential for a more controlled approach to workforce planning for those training to become AHPs, particularly in the three largest professions - Radiography, Physiotherapy and Occupational Therapy - is being explored. We will also need to engage with NHS Board AHP Directors and workforce planners to set out their potential demand needs and projections for the AHP workforce going forward, and to consider how we engage with higher education institutions to help build that into their supply.

47. This process needs to be informed by better targeted, more predictive workforce planning which fully recognises the significant contribution made by the AHP workforce in developing NHS Scotland services. Recruitment issues have persisted for some AHP professions, suggesting a need for a more evidence-based approach to workforce and workload measurement. Nationally, action is already being taken to explore an AHP workforce planning tool to help predict future need as well as capture current and future ways of working. Allied Health Professions Co-creating Wellbeing with the People of Scotland ^[11] , launched in June 2017 under the Active and Independent Living Programme in Scotland, sets out more detail on this. AHPs will also play a central role in meeting workforce planning needs at regional level. And locally, action is being taken to develop advance practice and support worker roles that use nationally agreed definitions, ensuring AHPs are working effectively and in an integrated way across health and social care. The recommendations in this Plan will help ensure a more robust data platform for AHPs can better support workforce analysis, intelligence and modelling.

Nursing and Midwifery

Footnote: Qualified nurses for September 2007 excludes nursing and midwifery staff who had not assimilated into new Agenda for Change ( AfC) terms and conditions.

48. As at March 2017, Nursing and Midwifery staff represent 43% of NHS Scotland's total workforce and play a vital role in achieving the vision for health and social care in Scotland. There is growing evidence about the relationship between registered nurse staffing and educational level, quality of care and patient outcomes. In March 2017, there were 59,798.6 whole time equivalent Nursing and Midwifery staff in post, representing an increase of 0.7% in the last year. There are over 3,300 WTE more Nursing and Midwifery staff working in NHS Scotland compared to 5 years ago, with 5 years of consecutive growth. The number of community Nursing and Midwifery staff has increased by 473.1 WTE (4.1%) in the past year alone.

49. As at March 2017, around 73% of the nursing and midwifery workforce are qualified (registered) staff ^[12] . The number of qualified Nurses and Midwives in NHSScotland has increased by 6.7%, by 2,731.7 WTE to 43,757.9 WTE since 2006. We have more qualified nurses and midwives per 1,000 population in NHSScotland (8.1 WTE - March 2017) than in NHS England (5.6 WTE - March 2017).

50. There are around 10,000 student nurses and midwives in training in Scotland, with an average of around 1,000 more nurses and midwives in training each year between 2007-2015 compared to 2000-2006. Recent supply and demand trends point to:-

• higher demand for nursing and midwifery staff since 2012, with additional posts being created within NHS Boards;
• short-term downturn in student numbers and in subsequent supply of newly qualified nurses and midwives - although this trend is reversing as five successive increases in intakes begin to flow through the system;
• uncertain future supply of staff due to variable retirement patterns and a competitive higher education and employment market, making it more difficult to attract and retain newly registered staff in Scotland (this is replicated across the UK);
• current and future recruitment challenges in different areas and specialities;
• evidence that roles need to be more responsive to demographic changes and changing service needs.

51. These patterns also vary across - and within - each of the five main branches of nursing - Adult, Mental Health, Learning Disabilities, Children's Nursing and Midwifery.

52. Nursing and midwifery vacancies have increased, driven in part by the creation of new posts in NHS Boards (for example, for health visiting) - reflecting patients' needs and informed by application of nursing and midwifery workload and workforce planning tools. There were 2,818.9 WTE nursing and midwifery vacancies in NHS Scotland at 31 March 2017, equating to an overall vacancy rate of 4.5%. ISD Scotland has noted that increased vacancy rates in the last year are also due to improved recording. Vacancy rates vary across regions (highest in the North of Scotland); between Boards; and across specialties. The highest vacancy rates are currently in health visiting (reflecting the Scottish Government's commitment to deliver 500 additional Health Visitors to meet the requirements of the Children & Young Persons Scotland Act), paediatrics, district nursing, adult and mental health nursing.

53. The age profile of the nursing and midwifery workforce is also changing, and the proportion of those aged 50 years and over has increased significantly in recent years. A high proportion of nurses and midwives fall within the current retiral band of 55 to 60 years. Further detail is provided in Chapter 4.

54. In 2015, a Short Life Working Group identified the demographic challenges facing the midwifery profession, with an ageing workforce and a reduction in qualified midwives. Work has been undertaken with NHS Boards to map the issues and to ensure robust forward planning.

55. Further consideration is needed about how to enable the older workforce to remain in post. NHS Scotland employers should recognise that the unique skills, knowledge, experience and wisdom of the older workforce underpins its overall capacity and capability, and make appropriate arrangements to facilitate working longer.

56. Ensuring a sustainable supply of appropriately skilled nurses and midwives is a key challenge, not just for Scotland but for the rest of the UK and internationally. Among other factors, the wider UK nursing and midwifery labour market influences the supply of available nurses and midwives within Scotland. Across the UK, attention has focused on the potential impact of Brexit on supply of registered nurses, and changes in migration rules on the UK nursing and care workforce. In March 2016, the Migration Advisory Committee recommended that nurses remain on the Home Office's shortage occupation list ( SOL), driven in particular by evidence of current shortage of nurses in England.

Ensuring a sustainable, high quality Nursing & Midwifery workforce

57. Much is already being done to deliver sustainable solutions to nursing and midwifery workforce challenges. Some key building blocks are in place, including evidence based workload and workforce planning tools; significantly higher numbers of qualified staff; well developed and strengthened student intake planning; work to transform nursing roles; and a clear strategy for nursing education ( Setting the Direction for Nursing & Midwifery Education ^[13] ). Example of measures being taken include:

Measures to address Nursing and Midwifery demand and supply

• Creating 1,000 extra training places in the lifetime of current Parliament;
• A 4.7% increase in student intakes for 2017/18 - the 5th successive rise;
• 2015 investment of £450,000 over 3 years in Return to Practice;
• 60 additional training places for the North East in 2017/18, enhancing access to training in remote and rural areas;
• Commitment to enshrine safe staffing in law, placing nursing and midwifery workload and workforce planning tools on a statutory footing, to further support consistent, evidence based planning;
• Work to transform nursing roles and education and to widen access to nursing and midwifery education and careers.

58. Scotland has led the UK in its development of evidence based nursing and midwifery workload and workforce planning tools. The Nursing and Midwifery Workload and Workforce Planning Programme provides a validated framework and suite of tools to enable NHS Boards in Scotland to make decisions regarding Nursing and Midwifery workforce requirements. These tools help determine the right number of nurses and midwives depending on clinical needs of patients, professional judgement and particular specialty areas.

59. A suite of 12 tools is now available, covering 98% of clinical service areas. Application of these tools has been mandatory for all NHS Boards since April 2013, as part of Local Delivery Planning. The tools were developed in partnership with staff representatives, and are endorsed by the Royal College of Nursing Scotland and the Royal College of Midwives.

60. Steps are now being taken to enshrine safe staffing in law - placing the tools on a statutory footing - to support more consistent approaches and assure the required levels of nursing and midwifery staff are in place. The Scottish Government is currently consulting on proposals that would require organisations to:

• Apply nationally agreed, evidence based workload and workforce planning methodologies and tools;
• Ensure that key principles - notably consideration of professional judgement, local context and quality measures - underpin workload and workforce planning and inform staffing decisions;
• Monitor and report on how they have done this and provide assurance regarding safe and effective staffing.

61. Proposals focus intentionally on the approaches to nursing and midwifery workload and workforce planning tools because we already have a validated approach and suite of available tools. As part of the consultation, we are also exploring whether the approach to nursing and midwifery workload and workforce planning could be extended to other staff groups and care settings.

62. The current model for the Nursing and Midwifery Student Intake Planning Process is the well-established, well-developed process for projecting the required numbers of newly qualified nurses and midwives required in 4-5 years' time and, thereby, the number of students that therefore need to commence training programmes now. Further detail is provided in Chapter 4.

63. To help secure future workforce supply, in January we announced a 4.7% increase in intakes to pre-registration Nursing and Midwifery programmes for 2017/18 - an extra 151 places across Adult, Mental Health, Learning Disabilities, Children's Nursing and Midwifery - the fifth successive rise, equating to 3,360 entry places. To take account of remote and rural challenges, we are funding 60 additional training places for North East of Scotland training providers in 2017-18, over and above existing numbers.

64. We have also retained free tuition and the nursing and midwifery bursary to help attract and retain our future workforce, are providing enhanced financial support to students most in need to ensure we continue to attract a diverse future workforce. There have been an average of 9,939 students in training each year between 2007-2015, compared to 8,950 between 2000-2006.

65. Although applicants to pre-registration programmes in Scotland have fallen in recent years, nursing and midwifery training places continue to be oversubscribed. Latest UCAS applicant data (April 2017) indicated a 2% drop in the number of Scottish domiciled applicants making at least one choice to nursing, although applicants aged 25 and over increased by 1%. This contrasts starkly to the 19% fall in applicants across the UK overall and, in particular, the 23% decrease in the number of English domiciled applicants to nursing.

66. As well as training new nurses and midwives, we are also encouraging former registrants to retrain and re-enter employment. In 2015, to expand short-term supply, we reintroduced funding for the national Return to Practice scheme and to date round 290 former nurses and midwives have completed or are currently undertaking retraining -- exceeding our initial target of 75 places per year.

67. Although Scotland already attracts and supports individuals from diverse backgrounds into nursing, Scotland's Chief Nursing Officer has recently launched a Commission to review ways to support and widen access to Nursing and Midwifery education and careers; this will report later this year. CNO's Transforming Roles programme is also helping to develop nursing, midwifery and AHP (as well as some Healthcare Science) roles to meet the current and future needs of Scotland's health and care system.

68. Evolving or emerging nursing roles, such as Advanced Nurse Practitioners ( ANPs), and Physician Assistants can also contribute to new models of care, and we therefore need to know how many we will require in future. The Transforming Nursing Roles Group has produced guidance on the ANP role and 500 additional ANPs are being trained by 2021, supported by £3m funding.

69. This is not just about having the 'right numbers'. Setting the Direction (2014) ^[14] - the strategy for nurse education - focuses on nurses' roles, skills and education over the course of their careers. A new "Transforming Nursing, Midwifery and Health Professions ( NMaHP) Roles" group is also helping to develop nursing, midwifery and AHP (as well as some Healthcare Science) roles to meet the current and future needs of Scotland's health and care system.

Healthcare Scientists

70. Healthcare Scientists are the fourth largest clinical group, and their work underpins over 80% of all clinical diagnoses. ^[15] The NHS Scotland workforce covers over 50 different scientific specialities in the three main strands of healthcare science - life sciences, physical sciences and physiological sciences. Healthcare Scientists respond directly to advancing scientific and technological change and their work has a significant impact on waiting times. No modern evidence-based healthcare service could operate without the core services Healthcare Scientists provide to primary and secondary care. Further technological advances will bring many more opportunities for Healthcare Scientists to work across disciplines and NHS Board boundaries, consistent with the regional agenda set out in the Delivery Plan.

71. Healthcare Scientists already provide many solutions to clinical teams, through task shifting and role substitution, in the context of rising demand and cost. However a number of healthcare science professions experience difficulties in recruitment and retention, recognised by the inclusion of some on the Migration Advisory Committee's UK Shortage Occupation List, and these challenges are often compounded in remote and rural settings. In a Shared Services, "Once for Scotland" context ^[16] , some of these issues are being explored for laboratory services:

Healthcare Science - planning the laboratory workforce

As part of the Shared Services Portfolio, a programme has been put in place to explore a shared services approach to workforce planning for laboratory services that will meet the future needs of NHSScotland. A national approach to delivering an appropriately designed and resilient healthcare science workforce could deliver significant benefits:

• improved sustainability through a scalable, flexible, innovative service;
• improved resilience through an ability to transfer work across borders;
• improved equity of service across the country through standardisation of service offering and approaches;
• access to latest technologies at enabled centres accessible to all Boards;
• increased efficiency to either realise cost savings or increase capacity through reduced waste and economies of scale.

72. Workforce planning needs to take fuller account of the part played by Healthcare Scientists in enabling accurate and timely clinical diagnostics and developing their roles around assistive technologies, mobile devices and telemedicine. That will require better quality information about Healthcare Scientist numbers and more detailed intelligence about the shape of this workforce.

73. To initiate this, a more robust data platform needs to be developed, enabling the constituent professions within Healthcare Science to be identified, tracked and analysed for workforce planning purposes. This should enable multi-disciplinary workforce modelling to be supported, developed and implemented across this important workforce, and particularly for those professions which are experiencing sustainability challenges.

Psychology Services

74. ISD Scotland currently publishes quarterly reports on Workforce Planning for Psychology Services in NHSScotland. ^[17] These provide statistics and commentary on characteristics of this workforce, which extends across a number of professions engaged in delivering Psychology services.

75. Though a small professional group, it is instrumental in service delivery. There has been a considerable increase in the number of professionals working in psychological therapies in recent years, and the expansion and modernisation of Psychology training is now leading to more well trained professionals entering the workforce. While the work Psychologists do to deliver faster access to CAMHS and psychological therapies is backed up by significant funding for mental health, there is scope to link statistical data, and the effects of increasing service demand on this workforce, more closely to the rest of the NHS Scotland workforce so we have a clearer picture of what is available for mental health. There is also a need to understand more about how this Plan can apply to the Public Health and Mental Health workforces, which include many who work in different sectors.

Small Occupational Groups

76. Within the NHS Scotland workforce, there are a number of small occupational groups, broadly defined as having less than 100 whole time equivalent ( WTE) staff. Examples of these smaller staff groups include:

• Sonographers
• Operating Department Practitioners ( ODPs)
• Clinical Perfusionists

77. While the very specific roles these staff play in clinical settings are important, gaps have persisted in national workforce planning intelligence around the sustainability of, and risk management for, some of these staff groups. Shortages for some health professional staff groups, such as Sonographers, are defined in Home Office immigration rules and are included on UK-wide and Scotland-only Shortage Occupational Lists, informed by evidence from the UK Migration Advisory Committee. ^[18] A more co-ordinated approach to workforce planning for these groups is required across NHS Scotland.

Non-professional staff

78. Many different non-professional roles within NHS Scotland - including care assistants, ancillary staff, call handlers, technicians and others - are critical to achieving and sustaining services. While statistical data is collected on these groups to allow for local workforce planning purposes, there is further scope a) to consider the adequacy of available data and how this is relevant for Part 2 of the Plan; and b) to analyse and compare workforce information for these staff with available data for similar workers in the social care sector. This would give a better, more integrated understanding of supply and demand issues as they affect health and social care in different parts of the country. It would also help illuminate what is known about labour markets nationally, regionally and locally, and lead to better co-ordinated steps taken to recruit and retain staff across the health and social care sector as a whole.