The Minister for Health and Social Services Mark Drakeford said: “Our destiny really does lie in the skill, the experience, and the commitment of staff at all levels in the NHS.”
The NHS Wales workforce is both a key enabler and driver for change and must be integral to all planning and investment decisions if the opportunities to improve care are to be realised.
The best innovations and ideas for improvement come from those who understand and deliver health services together with service users. Imagine the influence and impact the 73,197 (whole time equivalent) people who work in the NHS in Wales could have if they work collectively to achieve a shared vision of securing the Minister’s stated aim of implementing the principles of prudent healthcare fully across the health service:
- Do no harm
- Carry out the minimum appropriate intervention
- Organise work around the only do what only you can do principle
- Promote equity
- Remodel the relationship between user and provider on the basis of co-production.
Future demand for health and social care will not be met unless we plan, develop and use the workforce differently. The prudent healthcare approach provides a real opportunity to consider how the workforce is used and deployed. This article focuses on:
- The healthcare challenges the workforce needs to respond to;
- The design of the current workforce and its ability to respond to challenges;
- What the future workforce could look like if the principles of prudent healthcare are applied;
- The tools and resources available to support workforce development and redesign.
The healthcare challenges the workforce needs to respond to
The service and workforce challenges facing health and social care are well documented1 and have informed the Welsh Government’s strategies for health and social care services.2 Working Differently Working Together3 is the latest Welsh Government workforce strategy supporting NHS Wales to manage the complex agenda of workforce reform.
A highly-skilled and experienced workforce is needed to ensure healthcare is of the highest quality, is safe and provides value for money. The following is a summary of the key challenges:
The Nuffield Trust report A Decade of Austerity in Wales?4 estimates there could be a £2.5bn gap in funding for health in Wales by 2025-26 if funding is flat in real terms. To meet this financial challenge the NHS would need to make efficiency savings of 3.7% a year after 2015-16. The economic challenge will mean NHS Wales will continue to need to do more with less, as well as continuing to make transformational changes, including moving more care out of hospitals into the community – the Nuffield Trust report highlights a series of examples of where this is already happening in Wales.
The pay bill accounts for 75% of the total NHS budget and therefore will need to demonstrate value for money.
Demographic and social changes
The demand for care services is anticipated to increase, in part due to a predicted 4% increase in the Welsh population by 2022 and a further anticipated increase of 8% by 2037. Wales’ demographic profile is predicted to change too, with a 3% decrease in the 16 to 24 age group by 2037 and a 50% increase in people aged 65 and over by 2037. Wales has a higher proportion of people aged 85-plus compared to the rest of the UK and higher deprivation rates.5
A changing demographic profile means an increase in age-related conditions, such as dementia and cancer. In addition, the consequences of behavioural and lifestyle choices, including alcohol consumption, sedentary lifestyles, persistently high smoking rates in some parts of Wales and rising obesity rates across the country will result in an increased prevalence of a range of chronic and potentially life-limiting conditions.
The pressures on the healthcare system from an increase in chronic conditions and co-morbidity resulting in complex healthcare needs will be significant. Changes to the retirement age also mean the NHS workforce will have to work longer and many may have healthcare needs of their own.
Innovation and technology
Skills for Health (2009) identified the main skills and employment challenges facing the health sector. Candice Imison has stated:
“The health sector is in constant evolution as medical science advances and new technologies are adopted. The surprise over the past 50 years is how little traditional patterns of working and service provision have changed in this context. Twenty-first century medicine is being delivered using structures and processes that have changed little since 1948 and the inception of the NHS.” 6
The public is increasingly accessing technology and becoming more knowledgeable, which is increasing expectations and changing relationships with health professionals. Self-diagnosis and treatments have become as common as online shopping and are widely available.
Digital imaging, stem cell therapy, genetic screening, robotic surgery and tissue regeneration are just some of the innovations in treatments and developments in technology which will continue to transform care services and influence working practices.7 The use of technology to redesign NHS systems and processes to support medical science advances will be a challenge.
The design of the current workforce and its ability to respond to the challenges
The NHS is the largest employer in Wales. It is a labour-intensive public service with staff drawn from many professions and occupational groups working in a variety of settings. Staff are directly employed by the NHS and there are also a range of contractor professions providing NHS services, including dentists, opticians, pharmacists and more than 2,000 GPs.5
Figure one shows the increase in the workforce over the last seven years. Despite current difficulties in recruiting doctors in certain specialties, there has been growth in overall numbers of consultant medical staff. At the same time as the increase in consultant numbers (+25%) there has been an increase in the number of GPs (+4%) working in Wales.
The NHS in Wales invests around £350m to support approximately 15,000 students and trainees undertaking health-related education programmes. It is estimated that 60% of the total training budget (including continuing professional education) is spent on doctors, who make up just 12% of the workforce and 35% on nurses and allied health professionals who together make up 40% of the workforce.
Medical training is undergoing a significant review across the UK – the Shape of Training review – and there are substantial areas of shortage and risk providing opportunities to drive development of other professions and staff groups. The Health Professional Education Investment Review, commissioned by the Minister for Health and Social Services, will report during February 2015 and is likely to have significant implications for the future provision of education for the healthcare workforce. The review will consider how the Welsh Government obtains value for money and a secure supply of staff for the NHS. The outcome will support NHS Wales in planning, developing and providing the workforce required to meet the needs of the citizens of Wales.
The education and training of the healthcare workforce has been the foundation on which the NHS is built and will continue to be a critical component in the drive to raise standards of care. The workforce is trained and educated around current organisational and professional structures, which inhibits flexibility and creates professional silo-working. This approach may have been appropriate for the models of care when the NHS was originally established however, it is no longer suitable to meet the needs of today’s patients or health service.
Eighty per cent of the staff NHS Wales will need for the next decade are already working in the service, therefore the need for training and skills development is essential.
It is not known how much is spent on the social care workforce and the number of volunteers and family members who provide some form of care is greater than all the professionals combined and yet there is little or no investment in their training.
While there are many examples of workforce redesign, these are usually ad-hoc and reactive to either local or national pressures. New roles have been introduced and yet the old roles have remained, resulting in increased costs and confusion; new categories of workers with poorly-defined roles, especially in relation to the roles of others have sprung up, resulting in the duplication of functions or services.
Over the years, the drive worldwide in health has been for an increase in specialist roles rather generalist roles. This has limited the flexibility of the workforce and, in some cases, career development for individual practitioners. In many cases, highly-educated and skilled health professionals spend significant amounts of their time undertaking aspects of care, which could more appropriately be undertaken by others with different skills who may be less expensive to employ. The reasons for this are multi-factorial but must be resolved if we are to succeed in modernising the workforce and achieving a prudent healthcare approach to workforce and service delivery.
Delivery of services
The majority of NHS staff work in hospital settings, often isolated from other sectors, in contrast to the policy requirement for more integration across secondary care and primary/community settings. The medical workforce – doctors – are the critical decision makers who influence what interventions are implemented. However, this medical model of healthcare is becoming increasingly difficult to sustain because of the difficulties in recruiting sufficient doctors in certain specialties.
The majority of care is currently delivered on a see-and-treat basis, following an episode of ill health and, to a lesser degree, a rehabilitate model. In the future, the balance will need to shift towards an active preventative and maintenance model.
Given Wales’ changing demographics and health needs the workforce of the future will therefore need to be different. The Horizon 2035 work being undertaken by CfWI8 provides an example of a different way of thinking about the workforce and how the workforce and healthcare is designed via a skills and competencies lens to meet this future challenge.
The NHS is data rich but information poor. Getting the right workforce information to the right people is crucial to support decision making. Current systems of workforce and service continue to be fragmented and are not fully integrated for planning and delivery purposes. Nationally, tools designed to help managers look at their data alongside other NHS organisations to enable easy analysis and benchmarking are not routinely used.9
The workforce planning process has tended to focus on the numbers of regulated professions required to inform education commissioning rather than on the needs of patients and the skills and competencies required to support independence. The design of the workforce around the key decision points in patient pathways will need to underpin future workforce planning.
What the future workforce will look like if the principles of prudent healthcare are applied?
The future workforce may not look very different to that of today, in terms of the broad professional groups – doctors, allied health professionals, nurses and support roles will always be needed. However, the skills of these individuals; where services are delivered in the future and the workforce model and makeup of clinical teams, will need to be very different.
Service and workforce planners will work with clinical leaders to agree who is best placed to provide care at a particular time in a patient’s journey, enabling skill mix changes and integration between professions. This will ensure that individual staff only do what only they can do. Professional demarcations and boundaries will be redefined resulting in less duplication of, improved continuity of care and reduced risk to patients.
Improved integration will mean that staff from different disciplines and services are working together more effectively in multi-disciplinary and multi-agency teams. This will mean the skills, competencies and experience of staff are being used in the most effective and efficient way resulting in a more prudent use of the workforce.
To support the delivery of high-quality care across a wide range of different settings investment in the education and development of the workforce is imperative. This will include initial preparation for roles, at whatever level and whether regulatory requirements exist or not. Investment and development of the workforce will not stop once initial preparation has been completed and all staff will keep themselves updated and abreast of the latest evidence, whatever their role in NHS Wales.
Education programmes leading to professional registration will have curriculum and specific outcomes set by regulatory bodies, however there will remain scope for the Welsh Government and NHS Wales to identify specific requirements to be included in the programmes. Not only will the principles of prudent healthcare be embedded within the curriculum of the future but the principles will be applied across the delivery of the education provision. This will result in:
- An increase in inter-professional education;
- Greater collaboration across education providers;
- An increase in education delivered across health, social care and third sectors;
- Education delivered in targeted ways for specific staff impacting on the patient pathway;
- Education developed once for the whole of Wales (where appropriate);
- Common education frameworks developed to support new and extended roles across different staff groups;
- All training delivered in Wales having a firm evidence base.
Medical training is undergoing a significant review across the UK (Shape of Training review) and there are substantial areas of shortage and risk and this provides opportunities to drive development of other professions and staff groups. The Nursing Midwifery Council will report on its review of nurse training in 2015 and the review of education provision in Wales will report in February 2015.
he Welsh Government’s national plan for primary care10 highlights that primary care is the first point of care for 90% of people’s contact with the NHS in Wales. Development of a skilled local workforce is one of the five priority areas for action. We need to plan for a sustainable GP workforce to meet population need and focus on ensuring the wider primary care team who provide care around the individual patient is right, supporting an increase in numbers and skill mix of all professionals. Developments could include 24-hour GP practices in emergency hospital departments; new roles, such as community link workers supporting people experiencing poverty or hard-to-reach groups. Systems will be redesigned and consultants will work beyond traditional boundaries in delivering care outside of hospitals as suggested in the Kings Fund report Specialists in Out-of-Hospital Settings.12
Heath and social care will increasingly work together and will have to continue to re-examine the content of work and re-design care pathways to ensure seamless care is delivered across the sectors. There will be agreement between the sectors to ensure there is no duplication, harm is reduced and continuity of care maximised. Team roles will be clearly identified, care will be based on available evidence and staff will be working to the top of their competencies. New roles have and are being developed to align the workforce to the service needs, this will continue. Examples include volunteers providing befriending services to the elderly to reduce loneliness and depression and life coaches to support the public health agenda.
Most information systems will be fully integrated with the new electronic staff record (ESR) and are providing a more detailed national picture of the workforce to inform decision making about future planning and design of the workforce. Intelligence about the skills, competencies and qualifications of the workforce is also captured to enable greater workforce flexibility and adaptability.
To support practice, it will increasing become important for staff to be trained and educated to maximise the use of technology. The use of technology will increasingly become core a skill for the workforce of the future and will enable service users to make informed choices and be involved in the delivery of their care, thereby supporting the co-production agenda.
Tools and resources to support workforce change
A number of tools and resources have been developed to support service change and the development and re-design of the workforce in NHS Wales. Many of these resources have been developed by the Workforce Education and Development Services (WEDS). 9 Figure two identifies the tools available and how they support the prudent healthcare approach to healthcare delivery.
In planning for the future Welsh health workforce, it is recognised that 80% of NHS Wales’ staff needed for the next 10 years or more are already working for the service. The redesign, development and deployment of the existing workforce and the modelling of it to meet future service needs is therefore critical.
Workforce development and redesign cannot be separated from the organisational context in which staff work and practice. The quality of a service depends on the personnel performing it but also on the settings in which it develops.13 Organisations will make the resources needed to provide the service and support the re-design of the workforce available.
The drive for efficiency and improvement, which underpins all the prudent healthcare principles means that “in a system with limited resources, health professionals have a duty to establish not only that they are doing good, but that they are doing more good than anything else that could be done with the same resources”.14
In 2014-15, the NHS Wales workforce and organisation directors commissioned WEDS to undertake work on the strategic, system-wide workforce planning issues for the NHS workforce.15 The report highlights the need for the following:
- Develop workforce planning and workforce redesign skills within organisations and supporting clinical leaders and managers to deliver this agenda;
- Develop clear strategies for training and development of the existing core workforce in addition to the education commissioning of new staff;
- Develop organisation development and workforce (HR) strategies to support redesign;
- Address the needs of the support workforce across both health and social care;
- Prioritise planning which addresses the need to deliver care closer to patients homes and maximising opportunities to:
- Develop skills to support this in primary care and community services
- Spreading the use of supporting technologies
- Develop roles around clinical teams with:
- Clear roles and accountabilities
- Identified career progression.
In summary, NHS Wales will need to achieve the following if the workforce is to be fit for the future:
Design the future workforce – ensuring that the future workforce is in line with service and financial planning.
Develop the future workforce – includes education commissioning, staff development, and recruitment and retention process.
Deliver the future workforce – ensuring plans are delivered, processes are effective, clinicians are engaged and best practice is shared.
1 Imison, C. et al. NHS Workforce Planning: Limitations and Possibilities; 2009 [Accessed 5 Jan 2015]. Available from http://bit.ly/1s4zPtc
- NHS Confederation, Urgent and Emergency Care Forum. A workforce fit for the future: Working together to improve the delivery of urgent and emergency care; August 2014 Briefing. [Accessed 5 Jan 2015]. Available from http://bit.ly/1AEkMYZ
- Centre for Workforce Intelligence (CfWI). Big picture challenges for health and social care: Implications for workforce planning, education, training and development; [Accessed 5 Jan 2015]. Available from http://bit.ly/1tIPCsZ
- Wanless D. Securing our future health: taking a long-term view; 2002 [Accessed 5 Jan 2015]. Available from http://bit.ly/1IpmqOA
2 Welsh Government. Together for Health: A Five Year Vision for the NHS in Wales; [Accessed 5 Jan 2015]. Available from http://bit.ly/1xDZRV6
3 Welsh Government. Working Differently – Working Together: A Workforce & Organisational Development Framework; 2012 [Accessed 5 Jan 2015]. Available from http://bit.ly/1tOdNvY
4 The Nuffield Trust. A decade of austerity in Wales? 2014 [Accessed 5 Jan 2015]. Available from http://bit.ly/1pfTLow
5 Statistics for Wales. 2012-based National Population Projections for Wales; November 2013 Bulletin [Accessed 5 Jan 2015]. Available from http://bit.ly/1AElkOy
6 Imison, C. Tomorrow’s workforce? A perspective on employment and skills in the United Kingdom’s health sector. In Skills for Health. Tomorrow’s workforce: Commentaries on the future of skills and employment in the UK’s health sector; 2009. p. 29-34 [Accessed 5 Jan 2015]. Available from http://bit.ly/1tIRl1H
7 Health Education England (HEE). The Delivery of 21st Century Services – The Implications for the Evolution of the Healthcare Science Workforce; 2014 [Accessed 5 Jan 2015]. Available from http://bit.ly/1HLQt4C
8 CfWI 2035 Horizon Scanning [Accessed 5 Jan 2015]. Available from: www.horizonscanning.org.uk
9 Workforce, Education & Development Services [Accessed 5 Jan 2015]. Available from: www.wales.nhs.uk/sitesplus/955/page/65980
10 Welsh Government. Our plan for a primary care service for Wales up to March 2018 [Accessed 5 Jan 2015]. Available from: www.wales.nhs.uk/sitesplus/986/opendoc/252458
11 The King’s Fund. Specialists in out-of-hospital settings: finding from six case studies; 2014 [Accessed 5 Jan 2015] Available from: http://bit.ly/1Dk0Htj
12 Skills for Health [Accessed 5 Jan 2015] Available from: http://www.skillsforhealth.org.uk/
13 Bevan Commission. Simply Prudent Healthcare; 2013 [Accessed 5 Jan 2015] Available from: http://bit.ly/1pYu0XR
14 Workforce, Education & Development Services; 2014 [Accessed 5 Jan 2015] Available from: http://www.wales.nhs.uk/sitesplus/866/opendoc/240621