National health and social care workforce planning: discussion document

1 - What Is This About and Why Are We Doing It?

Introduction

1. The need for a National Health and Social Care Workforce Plan was recognised in the Programme for Government which set out a commitment -

" To ensure we have the right staff for our health and care services now and in the future we will shortly publish a new draft National Workforce Plan. This will outline a range of workforce planning improvements required to deliver enhanced primary and secondary care in Scotland, including work on bringing together a range of professionals into GP surgeries."

2. In its widest sense, the Plan will be about upwards of 360,000 people who deliver health and social care services which support people across Scotland, enabling them to live longer lives in better health, and empowered to deal with challenges circumstances which arise. It is the largest public service in Scotland, encompassing people working in a wide range of settings - from people's homes to hospital theatres - and with a wide range of skills and expertise - from interpersonal skills to dealing with highly technical equipment. There are many new approaches being developed to meeting the challenges facing services - demographic change, rising demand and expectation, financial constraints - but the fundamental contribution to transforming services will be made by this workforce.

3. Recognising the scope of this workforce, it is important to reflect on the reasons why development of the Plan can only be done collaboratively:

• This workforce is highly valued by the Scottish Government, by the employing organisations and, most importantly, by the people who use services and by the wider public. It is right, therefore, that shared effort is focussed on developing this workforce and in planning for the workforce which is needed now and into the future.
• This workforce is diverse in many ways including skills, employers, work context, governance and levers for change. Approaches to workforce planning and development will need to reflect, and be responsive to, this diversity.

The Plan's purpose will be to deliver a workforce which is deployed in the right places, in the right numbers, doing the right things.

4. The forthcoming and future workforce Plans will need to ensure the needs of different employers are addressed, that the different roles and responsibilities which relevant employers have are fully understood, and that their views are reflected in agreed actions. This requires careful consideration of the individual and joint roles within health and social care workforce planning. If this is not clearly understood, then achieving an improved workforce planning process with clear and identifiable impacts will be difficult if not impossible, given the recent addition of 31 new Integration Joint Boards engaged in planning, alongside existing NHS Boards, local authorities and community planning partnerships ( CPPs).

5. The Scottish Government will publish, in Spring 2017, a National Health and Social Care Workforce Plan that takes forward its commitment to a sustainable workforce to support the Health and Social Care Delivery Plan ^[1] published in December 2016. This Workforce Plan will help decide how to close the gap between what we have and what we will need, in order to deliver high-quality, safe, effective and person-centred integrated services to those who need them. It will help to align workforce planning more effectively to identify capacity challenges at an earlier stage and deal with them effectively; and improve workforce planning practice, making clearer what should be planned at national, regional and local levels and how this links to planning at a social care employer level.

6. Any discussion about a health and social care workforce Plan must reflect recent developments in health and social care integration and existing approaches in each sector. This document therefore aims to cover the workforce engaged in providing all health and social care services in Scotland, including adult social care, children's social care services, mental health and primary care. While the NHS and local authorities are major employers, third and independent sector organisations are, collectively, major providers in these areas, and their input to this document is welcomed.

7. Employers and providers find themselves in different places on workforce planning. Workforce capacity challenges are complex and distinctive: they can be difficult to overcome, and solutions may work for some areas and parts of the health and social care sector, but not for others.

8. It should be emphasised that this discussion document is not about "one size fitting all". Scottish Ministers have committed to strengthening NHS Scotland workforce planning to develop its regional capacity; but it is also the right time to consider how workforce requirements are assessed and planned in a coordinated way across the range of organisations involved in providing care and support, to ensure people's healthcare and social care needs are met.

9. Input is welcomed from across all areas of delivery, including the independent contractor sector - General Practitioners, General Dental Services, Pharmacy and General Ophthalmic Services - to the development of the Plan. As part of the wider NHS, these independent contractors employ the vast majority of health staff that fall outside our normal approach to workforce planning. They are significant employers, and their views on the issues and questions raised in this document are actively sought.

10. All workers require training - but for many healthcare professionals, training is often long, complex and subject to regulation at UK level. While social care professional regulation is a devolved matter, training for social workers, and those then progressing to be mental health officer or child protection specialists, is similarly long and complex. This cannot be ignored in bringing about improvements to workforce planning, in whatever part of health and social care. Organisations and individuals involved in regulating, training and developing our workforce are invited to contribute their views on the questions posed by this document.

11. Our aspiration is that the Plan becomes more inclusive over time. As we move to the first iteration of the Plan, we want to start from a realistic position which recognises that different providers face complex and distinct challenges, and these differences need to be understood and reflected in any agreed approach.

12. For those reasons, the Plan will be part of a developing approach. It will be the first in a regular series aimed at improving the workforce planning system and practice, as well as developing more effective and informed intelligence.

13. We know that the many professional staff groups across health and social care face challenges which are very specific in nature. Reference to these has been deliberately kept to a minimum in this document. Its focus lies on consulting organisations and individuals on workforce planning in a more strategic context about how to achieve workable solutions across different sectors. It will, though, be necessary to consider profession-specific issues in more detail as we move towards a published Plan in Spring 2017.

14. Further information on the context, timescale and approach to this work has been set out at Appendix 2 to the Health and Social Care Delivery Plan ^[2] .

Why is a national workforce Plan needed?

15. Health and social care in Scotland is shifting away from hospital and residential care towards community based services supporting people to live in their own homes where possible. The demographic challenges are well known, and in common with similar economies, Scotland's population is ageing - and this will contribute towards an increase in the complexity of health and care needs in the longer term. While the methods we use to plan a workforce have taken us so far, these challenges require us to look again at what we have, make adjustments and develop new models.

16. For NHS Scotland, the past 10 years have seen an expansion in numbers of staff working in NHS Scotland, and overall staff levels in the NHS are now at their highest level ever. This is also true for the workforce in social care services. We now need to go beyond numbers in responding to changing demography, social attitudes and career aspirations, changing demands on staff time and skills, and systemic change in how and where care is delivered.

17. This is true for all providers of health and social care services in Scotland. Combining reliable and useable intelligence will help determine not only whether the numbers of staff we have are sufficient, but whether they are the right balance; working where they need to be, when they need to be there; and applying their professional knowledge and skills to best effect in providing safe and high quality health and social care and support - regardless of which organisation employs them.This will allow us to take a person-centred approach to our workforce strategy, to ensure people using care are at the heart of decisions about the workforce.

18. The challenges are many and complex.

• An ageing population living longer, but with increasing presentations of mental health problems, obesity, dementia, diabetes and other long term conditions.

• Significant developments in the social care service sectors will require national and local workforce planning and need to be reflected in further discussion, including the expansion of early learning and childcare.
• Rising standards and expectations about the quality of care from people who experience care, and from the Scottish Government - and the consequent need to ensure the future workforce can support the delivery of increasingly complex and high-quality care.
• Recruitment and retention presents all employers with challenges for different professions and in different geographical areas across Scotland, and in some cases, in areas of multiple deprivation.
• A changing workforce age profile, coupled with recent pension changes, mean that in future staff will retire later, with the workforce average age increasing. A significant proportion of staff are due to retire in the coming years, while many of those currently working retain protected entitlements around retirement. These all have implications for workforce planning.
• Planning for a more sustainable workforce will require a more sensitive understanding of supply and demand, and of risk-based intelligence to inform recruitment decisions and education requirements.
• Treatment and care must achieve a better "fit" with the needs of the population covered and with the geography of that population, or risk over-provision in some areas and under-provision in others.
• Gaps in some parts of the workforce and increasing demand, in conjunction with requirements to meet performance targets, also create additional pressures on the service that workforce plans will need to consider.
• Working patterns are changing: if trained professionals are increasingly working less than full time, then more need to be trained to achieve the same contribution to people's healthcare needs and outcomes.
• Integration will require responsive and appropriate workforce planning, while respecting governance structures and responsibilities in place within different sectors.
• The role and prevalence of carers and unpaid staff and volunteers in meeting people's needs, particularly in social care.
• Workforce planning for the primary care sector needs to be improved. In primary care the development of multi-disciplinary teams in and out of hours will need to be promoted; and to do that, better data and planning will be required, and innovation in recruitment and retention by both the NHS and independent contractors supported and encouraged.
• National data needs to build in more intelligence about the shape of the future workforce, as well as more focussed intelligence on our current staff.
• We need to fill gaps within our workforce, as far as possible from within employed staff resources, rather than from expensive agencies.
• The processes involved in workforce planning need to be less labour-intensive and less based on historical roles and models;
• The long timescales required to produce many healthcare professionals - eg a minimum of 10 years for a GP;
• Financial challenges across the wider public sector;
• Professional and cultural issues;
• The need to embed the principles of safer recruitment into workforce planning and growth.
• Communication issues between boundaries and sectors, which frustrate the development of regional working;

19. It is therefore the right time to invest our efforts in a co-ordinated Plan at a national level. We envisage that work around national and regional workforce plans will compliment and improve services across the health and social care sectors. This would help to ensure that health, social care and support provided by staff is directed to the most appropriate setting, and ensure the resources and capacity required to deliver services is recognised and planned for. The aim is to accurately identify the gaps in supply and actions required to close them so that the vision for health and social care can be delivered. That vision, set out in the Health and Social Care Delivery Plan and in the National Clinical Strategy, is for community based care, delivered through appropriate locally determined multi-disciplinary teams, with regional specialist centres focussed on more complex needs, to bring about direct and positive effects on people's health and wellbeing.

20. Achieving a "shift" in the balance of care therefore means that some services currently delivered within large institutions are likely in future to be delivered in a variety of smaller community settings. If workforce planning is fully to support that shift, the changes envisaged will require a proactive workforce, able to respond quickly and effectively where people most want services - within their homes and communities.

21. The most effective use of the workforce means working to the top of clinical skill set - whatever the professional field; and ensuring patients get access to the right health professional at the right time, whether an AHP, a nurse or a doctor. "Triage" and evidence-based models of care delivery, which make best use of the talents of the whole team, help to free up the most expert of staff for high level and complex work that only they can undertake. Making the most of AHP expertise has helped manage demand and reduce waiting time for consultant appointments, for example in Musculoskeletal pathways being developed in Orthopaedics, or through a more sustainable, digitally enabled, regional model for image reporting involving both consultant Radiologists and AHP Radiographers.

22. We expect the Plan published in 2017 to be:

i. a strategic document, setting out the workforce vision for health and social care services, the priorities to be taken forward, the assessment of current resources to deliver the vision, actions to close the gap between what we have and what we need, and clarity on the distinct roles each party will take on to ensure we have a coherent whole system approach.

ii. at a national level, drilling down appropriately to regional/local levels;

iii. active and useable. It will make coherent workforce planning links between national and regional activity and offer frameworks for practical workforce planning in both the NHS and providers of social care services.

23. The Plan will also be influenced by:

• public service reform and integration of health and social care, allowing space for NHS Boards, Local Authorities and IJBs to plan for the workforce for the health and social care system that Scotland needs, now and in future;
• the need to recognise the challenges in bringing together a workforce plan for a social service sector made up of approximately 2,600 separate employers from the public, private and voluntary sectors, alongside an NHS which is effectively a single organisation with 22 employers working with numerous independent contractors in primary care.
• The need to take account of the Public Health workforce, emerging roles in health protection and health improvement, and development of those roles via NHS Health Scotland and NHS Education for Scotland ( NES).
• Within NHS Scotland, the progressing plans for elective centres; recommendations on workforce planning from Audit Scotland; the NHS Scotland Workforce 2020 Vision, Everyone Matters; within social care, the Scottish Government's Vision and Strategy for Social Services; and within primary care, the workforce recommendations from Pulling Together, the report of the independent review of primary care Out of Hours Services; and
• approaches and methodologies in use which support development of services delivered by multi-disciplinary teams - for example, the Workforce Planning Guide by the Scottish Social Services Council, the NHS Scotland 6 Step Model, and local authority tools and guidance. Integrating elements from these methodologies in a proportionate and sensible way, and setting them out in clear and understandable guidance, will help to define workforce needs for the future.

24. The issues on which the Plan will need to focus will require careful consideration to ensure the health and social care workforce has all the support it needs.