Health and Social Care Committee workforce inquiry: recruitment, training and retention in health and social care

This content relates to the following topics:

The 2019 Conservative Party manifesto included pledges to deliver 50,000 more nurses, 6,000 GPs and 6,000 other primary care professionals. Two years on, no plan to address workforce shortages has been published, funding for the training and development of staff was conspicuous by its absence from the Spending Review and the measures in the Bill relating to workforce remain weak. 

Summary

  • The Covid-19 pandemic has exacerbated an existing workforce crisis in the NHS and social care. Significant workforce shortages and rates of turnover pose a grave risk to the recovery of services and quality of care, as well as the health and wellbeing of staff. Many staff will emerge from the pandemic in need of time and support to recover.
  • High levels of staff vacancies, sickness absence, turnover and work-related stress are having a damaging impact on staff. There is an urgent need to develop and sustain compassionate and inclusive workplace cultures that protect staff wellbeing and attract, retain, and sustain staff in their vocation to provide high-quality care. 
  • The NHS People Plan was the latest in a series of stop-gap measures that have failed to address the NHS workforce crisis. The case for a fully funded, multi-year health and social care workforce plan is overwhelming. 
  • The Health and Care Bill provides an opportunity to require the publication of regular, independently verified workforce projections to enable better workforce planning.
  • Manifesto pledges to recruit more GPs and primary care professionals are unlikely to be met. The key to addressing staff shortages in primary care is to move to a new model of general practice in which multidisciplinary teams draw on a range of health care professionals alongside GPs. This requires investment in capacity and leadership to support change.
  • Addressing workforce shortages in the NHS must not come at the expense of other parts of the system, including social care. Comprehensive reforms are needed to improve pay, terms and conditions in social care in order to overcome the current social care workforce crisis.

Comments

Madeleine St Clair

Position
Retired, patient,
Comment date
01 June 2022

I wrote a paper ‘Primary care and multimorbidity - my thoughts’, below, for my local GP practice last year because I was so exhausted by negative experiences and by what seemed a lack of willingness to change or explore solutions. ( please note formatting has been lost, and I have replaced the name of the practice with an X)

I have multimorbidity and complex health needs. I have a rare, fluctuating and deteriorating neurological condition, and multiple neurodisabilities. I am under the care of 9 specialists including 3 professors who review me regularly.

I was struck by your statement
“ The key to addressing staff shortages in primary care is to move to a new model of general practice in which multidisciplinary teams draw on a range of health care professionals alongside GPs.” Not dissimilar to my solutions point 6 below.

Has any more work been done on this?

Primary care and multimorbidity- my thoughts

In general, I feel the current system is not geared up to deal with multimorbidity, people with complex needs, or people with disabilities. The structure, culture and attitudes need to change, as currently the system fails patients.

Contrary to the government’s latest intervention I don’t believe doing more of same is the answer. The old and existing ways of doing things just don’t work anymore. I feel doing things differently is the way forward.

My perception of the current system
At practice level:
This is a brief summary of my experience of X overall, and just to give examples as symptoms of a failing system, I don’t want get into the blame game here. Focussing on solutions is what is required
- GPs do not take responsibility for overseeing my care
- Multiple failed consultations and home visits
- Home visits offered very reluctantly
- Fragmented and at times chaotic care, that lacks follow up
- Reactive, single issue and task focussed approach to my care
- Shortcomings concerning basic health needs
- Signs and symptoms outside the main reason for consultation are often ignored, to my detriment
- Other than my lead GP, other GPs seem unaware of my condition and problems
- Random referrals that don’t always consider where most of my care is delivered
- Other than my lead GP, little sense of partnership, respect for me as an individual, or respect for my knowledge or experience
- Information held by x can be contradictory, inconsistent, out of date, or inaccurate

Wider issues:
- Along with an increasing population, the number of patients considered clinically complex is growing, resulting in increased complexity of consultations
- Increase in need and demand isn’t matched by an increase in resources
- Research and guidelines are lagging behind. Overall, guideline and study design do not accommodate multimorbidity:
- Single speciality single problem focus
- Multiple different disease guidelines
- Guideline design tend to be based on RCTs, which exclude people with multimorbidity
- Current systems are not well suited to managing complexity, issues include:
- Multiple different information sources, referral letters, test results and so on, often resulting in contradictory, inconsistent, out of date, or inaccurate information
- Communication challenges as a consequence of involvement of multiple different specialists and healthcare professionals. No standard format for referral letters
- There is an over reliance on algorithms being used on an increasing scale to diagnose and manage health problems

So what needs to change within X?
Agree that things need to be done differently
This is a critical first step. The current organisation of services and care delivery revolves around an outdated model, which needs a radical overhaul. Doing things the way they have always been done doesn’t work any longer

Identify what needs to done at practice level and act
Whilst a growing population, increased complexity of consultations and underinvestment in resources are significant factors, these are not the only issues and together with the COVID pandemic should not be used as excuses for local inaction. X partners need to determine:
- factors that may be beyond their control (eg growing population), but agree how to respond to these
- factors that they can influence at PCN level and beyond (eg investment in resources, guideline development) and agree how they will do that, and
- factors within their control and act (see below)

Possible practice level solutions and actions:
1. Recognise multimorbidity
- Agree a definition for complex need/multimorbidity, including disability. Quantify the number of people with complex need/multimorbidity the practice sees per year. Agree how the practice will flag people with complex need/multimorbidity, ahead of each contact
- Recognise it is not possible to follow multiple different disease guidelines, GPs need to work in partnership with patients and exercise oversight and clinical judgement

2. Lead GP and teamwork
- Reduce fragmentation of care by assigning an individual GP to look after patients with complex needs
- Other GPs need to ‘check in’ with the lead GP to ensure ongoing coordinated care
- Make sure the lead GP is known, and flagged on various practice systems
- GPs need to work as team and not as separate practitioners

3. Shared decision-making, empowering patients
- Shared decision-making. Organising care that is really patient centred. Accept you need to work in partnership with the patient and specialists - many patients (but not all) will know a lot about their condition and the outcome of recent consultations, so use their knowledge and experience, but they are not doctors and will need GP clinical judgement. Agree templates for patients and GPs to use to make consultations more efficient and effective
- Help patients help themselves. I thought about buddy schemes and blogs, but these could be very limited and open to abuse. Online/Zoom tutorials could be really useful. Tutorials could include how to search, how to identify trusted sites, how to recognise and avoid misinformation and disinformation
- At consultations tell the patient the correct medical term so they can go away and look it up, point them to trusted sites. For example, telling a patient with BPPV that they have grit in their ear is inaccurate, confusing and misleading. When first diagnosed, I didn’t exactly know what hypogammaglobulinaemia was, I do now, but only because I was given the correct term and was able to go away and read about. I know how to access academic and trusted sites

4. Improve access to information for staff within X
- Link information, identify someone within the practice to do this, ensure information, including that from the patient, is captured in one place
- One clinical record that the health teams can use. I produce my own because I feel there is nothing comparable available in primary or secondary care

5. Be proactive and make appointments, routine, non-urgent, and urgent, more efficient and effective
- Extended consultation times for all appointments for pts with multimorbidity
- Routine annual appointments. Determine schedule, and pre-book these (they can be by phone!)
- Structured annual review, agree information requirements and format
- Structured medicines annual review, agree information requirements and format
- Agree consultation template
- Agree overarching priorities rather than goals within a particular condition (what really matters to the patient), agree broad management plan.
- Could a patient generated medical record be reviewed at the annual review meeting? Should specialists be asked to comment, sign it off?
- Non-urgent appointments. Pre consultation preparation, both patients and GP, for non-urgent appointments is key; but will depend upon information being readily available
- Are structured email updates readily available and used? Where are they? Do GPs know about them, can they access them?
- Urgent appointments and home visits. Determine structure for urgent appointments and home visits, most likely to respond to acute issues. Don’t assume acute issues are always linked to underlying chronic conditions. An urgent consultation/home visit template might include (in no particular order):
- Priorities for this consultation
- Prompts
- Differentials?
- Possible links to other diagnoses or active problems, or independent of?
- Have you checked recent test test results?
- Have you checked recent referral letters?
- Is specialist input needed?
- Have you read the patient summary, have you spoken to the patient about it?
- Have you spoken to lead GP?
- Discussion with lead GP - key points
- Discussion with patient - key points
- Impression
- Plan

6. Identify what other resources in primary and secondary care can be used
- Appoint a complex needs specialist (could be a nurse specialist), responsible for booking routine appointments, routine screening, pre consultation preparation, phoning the patient ahead of consultation, complete template (to be agreed), bring information together in one place and make sure it’s all up to date? Lead patient discussion groups? Lead development of online resources?
-Routine screening
What, who e.g for me, bloods and DN
- General hospital physicians that can provide support to people with multimorbidity?
- Standard referral and follow up letter format? Even if it’s just GP actions right at the top as standard to start with?

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