How will we staff new models of care in the NHS?

This was the first thing on my mind as I read the NHS five year forward view. According to Simon Stevens’ vision, the NHS in 2020 will have a greater focus on prevention and there will be fewer barriers between GPs and hospitals, mental and physical health, and health and social care. More patients will be treated outside hospital, often by multi-specialty teams in the community.

These ideas were positively received. But as people analyse the details of the plan, many are asking exactly how the ambitious agenda will be delivered. At the core of this question is whether the NHS has the right staff available to support these new models of care.

This workforce challenge was the subject of a recent conference held at The King’s Fund. Professor Ian Cumming, Chief Executive of Health Education England, kicked off the event with striking figures on workforce trends. These showed that the training pipeline for health care workers is not delivering the right staff to meet patients’ needs. While the number of consultants increased by more than 50 per cent between 2002 and 2012, the number of registered nurses grew by just 13 per cent. This has produced an oversupply of doctors in certain specialties and a huge undersupply of nurses.

I was particularly struck by facts I heard about district nurses during the event. Only five district nurses were due to qualify in London in 2013 and there are now around half as many in the NHS compared to a decade ago. These trends lay behind one speaker’s description of community services as a ‘forgotten tribe’. As more than £5 billion of the NHS budget moves out of hospital via the Better Care Fund in 2015/16, surely these trends need to be reversed.

Workforce development is not all about crystal ball-gazing. Most of the people who will staff the NHS in 10 years’ time are already working within it now. However, Professor Cumming revealed that just 5 per cent of his £4.8 billion budget is spent on developing and retraining the current workforce.  New skills and job roles are needed now, but organisations across the NHS are struggling to fill vacancies.

One strategy to help NHS staff meet growing demands from patients outside hospital is for consultants to take on new roles in the community. I launched The King’s Fund’s new report on specialists in out-of-hospital settings at the conference. It describes six services in which consultants are supporting community and primary care staff to treat patients with more complex conditions closer to home. Two of the hospital consultants who featured in our research, Louise Restrick and Myra Stern from the Whittington respiratory service in London, spoke about their fantastic work leading a community team that focuses as much on prevention as treatment.

The day finished with some practical tips on workforce redesign from Candace Imison and Richard Bohmer. They emphasised the need to redesign the work that needs to be done in the NHS before redesigning the workforce arrangements. At the moment, that relationship is often working in reverse. They outlined some key characteristics of successful workforce redesigns: old roles must be decommissioned as new ones are developed to avoid costly duplication; roles must be clearly defined; and we must not forget the benefits of seniority – senior clinicians, although more expensive, tend to order fewer tests and utilise fewer bed days, admissions and procedures.

The health service is facing a huge workforce challenge. NHS providers spend seven in every ten pounds on staff costs, but the structure of the NHS workforce is not aligned to meet the complex needs of an ageing population at home and in the community. While many policy-makers focus on organisational structures, it is clear that successful implementation of the NHS five year forward view will hinge on getting the staffing right.

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#252883 E Pek
Deputy Clinical Quality Lead for Therapies
Hertfordshire Community NHS Trust

We overlook staff groups beyond medicine and nursing at our peril: occupational therapists for example are trained to work with people across the health and social care spectrum. They are to be found in acute hospitals, community trusts, mental health and learning disabilities and social care. They are waiting for integration and will be a ready-made section of the workforce waiting to deliver new models of healthcare and prevention work.

#252977 Ruth Robertson
Fellow in Health Policy
The King's Fund

Thank you for you comment. I couldn't agree more. Although I focused on nursing staff in the blog - allied health professionals will also be key to delivering these new models of care. You might be interested to read the Haywood rheumatology centre case study that was part of our specialists out of hospital project - they have developed extended roles for AHPs such as a consultant physiotherapist - a key part of their service. If you're interested, you can find more information about what they're doing here:

#253228 Susanna Malkakorpi
Student Nurse

I felt compelled to comment and agree with you on the idea of planning for services before workforce planning and training. Being a "mature" student nurse few months away from qualifying, I often find our nurse education very focused purely on caring and clinical skills. This in itself is, of course, the core of our role, yet I have been left with a feeling I wish we would have had more focus on leadership and innovation. I wish I would have had a chance to get my "teeth into something" and participate in real life change projects on our placements, with the third sector, community organisations etc rather than just have a theoretical essay to write on the subject. I often have felt there is a contradiction in our role - on one hand we are expected to do the caring role only (albeit this is, ward depending, mostly done by the healthcare assistants), do as the doctors tell us and never complain. On the other hand there is a big rhetoric promoting innovation, leadership and courage as most important aspects of nurses, yet this aspect felt very ignored during my course.
I personally feel a bit lost on what to do with my qualification. I want to get more involved in the above matters, yet it appears the only route is via working your way into a ward management over the next several years. Maybe someone else here might be able to give me (and few of my close colleagues on the same course) some further advice? We are out here, us more mature students with often a career already behind us, keen to move on and take part!

#253455 Michelle

You dont have to be a ward manager to be a leader this can occur at any level. Whilst i can see your point about more leadership and change management being in nurse education it should also be promoted more in the NHS. In terms ofyour comment about mature students wanting to be involved in bigger things again change management isnt about age however i do believe that anyone wanting to promote change must be involved in care on the ground at some point in their career and not go straight into decision and policy making. As for you feel lost what to do with your qualification go and do what you hopefully went into nursing for to nurse. Too many times i see people wanting the bigger exciting jobs when what we need is nurses on the wards and departments delivering high quality care with compassion whilst also leading and developing services . We need a balance in nursing of exellent nursing skills as well the williness to push for change and developments.

#260218 Anne Hickley

I'm attending the Future of Health Conference on Friday as an RA patient part of the 'people's panel' and each of us was asked to put a question to Simon S in advance. Mine was closely related to this so I'll be very interested to see whether he tackles it or not! :-) interesting article - thank you!

#260355 Lynn Ash

There is a year on year increase in demand on ultrasound services both in the acute and community setting yet there is a major national shortage of Sonographers. Many Trusts are running on several vacancies and may be forced into using costly agency staff. A significant percentage of sonographers are over the age of 50. Where is the national strategic workforce planning?

#267484 david oliver
Visiting Fellow
King's Fund

I think Lynee's advice to Susanna is spot on. It is great for clinicians to be interested in leadership, innovation and quality improvement. However, your credibility as a clinical leader depends on a solid grounding in the clinical role you trained to do. For instance (In common with many doctors in such roles), I have played many national clinical leadership roles but throughout have been doing several on calls a month and regular ward rounds and clinics. I would go as far as to say that leadership in nursing and allied health professions is greatly enhanced when it is clear that the leader in question knows the job inside out and still keeps their hand in. So my advice, like Susanna's is effectively not to run before you can walk. Do the job you trained to do, learn by doing and from more experienced colleagues, but don't wait to become a ward manager or nurse practitioner or equivalent community nursing role before leading local quality improvement projects or developing your own leadership skills perhaps by getting further qualifications. Well, you did ask for advice...


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