Background

We are committed to making the NHS Plan work and are encouraged by the budget settlement for the NHS.

We know that there are plans in the medium term to meet the shortfall of NHS clinical (and other) staff to deliver the NHS Plan. The Government has also said that changes in working practices will be fundamental to delivering these improvements.

The SofS has stated that the biggest problem in the short term is shortage of capacity. In response to this there are plans for visiting teams from overseas to provide elective services. However, this only applies to elective services. We need to deliver and improve the performance of other services.

Questions for discussion:

• What positive steps could be taken if the NHS cannot recruit and retain enough clinical staff in primary care in the shorter term?
• What positive steps could be taken if the NHS cannot recruit and retain enough clinical staff in hospital care in the shorter term?
• What imaginative solutions, including changes in working practices, can we as doctors and nurses, suggest?
• What can we do to help these to happen?

Approach

After initial introduction, members were split into two groups to consider the questions for discussion. The groups rejoined to summarise key points.

Output

Advice, using key points, follows.

ADVICE

1. Managing public expectation

It is clear that public expectation of the NHS is rising in a way that demand will exceed what can be provided within finite resources. Many initiatives established by the Government (e.g. NHS Direct and NHS Direct On-line) have enabled patients to receive appropriate healthcare advice. However, public education, whilst beneficial and empowering, can itself lead to increased demand on services. Wanless proposed that health promotion should be a central part of in managing demand and recommend increased emphasis be given to prevention.

• We believe that schools offer the best opportunity for laying the foundations of health, self-care and using the NHS appropriately. Whilst we understand that the National Curriculum Guidelines for PSHE already includes some teaching on aspects of health services these should be expanded.

• We believe that the Expert Patients Programme will, if pursued vigorously, empower patients with chronic disease to be more self-reliant, confident and independent.

• We believe that it is important that Ministerial and Departmental Statements encourage responsible, appropriate and deliverable use of the NHS.

2. Maintaining standards and quality of care

Staff shortages threaten clinical governance and quality of care in all sectors and settings. Much of the national debate has been about substitution of one profession for another in delivering a task and we are aware of work going on in some areas of the NHS (the National Occupational Standards group looking at health care scientists, for example). Members found this approach limiting through focusing on existing professions rather than ensuring that the right skills and competencies are available. The object is to provide a workforce with the skills needed rather than one delineated by professional boundaries. Recruitment should not be broadened at the expense of maintaining appropriate standards for patient care.

• There is a need to move towards a wholly trained workforce with integrated career pathways. This must be supported by rigorous attention to maintaining standards.

 

3. Better targeting and use of resources for recruitment and retention

Members are very aware that we must maximise the time that clinicians spend on clinical activity. Providing adequate support from properly resourced and trained clerical and secretarial staff with the appropriate skill mix is key to achieving this. Their support is vital and currently undervalued.

A core group of highly skilled NHS staff are currently expected to spend valuable clinical time and energy, co-ordinating temporary staff cover. Supervising and supporting temporary staff can be very stressful and time consuming and contributes to sickness absences and resignations.

We therefore believe that there is a need to recalculate staffing levels to reflect demographic and case-mix changes. This must include administrative staff – since too much clinical time is currently wasted on administration because of a lack of such posts. Such an emphasis would be more cost effective than simply providing locum cover and benefits from subsequently greater continuity of care. This, in turn, will help achieve the health outcomes that the public, professions and government wish to see. This may address problems of retention and could encourage both nurses and doctors to stay in the NHS.

The European Working Time Directive and changes in the pattern, and probably geographical configuration, of services this will create also needs consideration.

Members support all that the Government is doing with its childcare strategy, but would wish it to be accelerated, to align it with shift working and include after-school provision. This should be available across all specialities, especially for primary care, at reasonable costs. To encourage trained staff back into healthcare, and to recruit and retain staff an attractive employment package needs to be developed.

We are supportive of the targeted approach that the government has taken toward the implementation of various National Service Frameworks.

• Childcare availability needs to be improved and to include primary care.

• There is a need to provide well-trained, properly remunerated, clerical and secretarial administrative support to clinicians to maximise clinical time

• A revision of optimum staffing levels through a centrally co-ordinated research programme is needed to establish accurate base staffing levels. The research should take into account current and projected dependency levels, capacity and technology usage in different care settings and include an allowance to ensure that sickness; absences (such as maternity leave) and study leave are incorporated into workforce projections. If the base staffing level is realistic then the impact of short-term absence could be absorbed reducing the need for locum cover and increase continuity of care.

4. Investing in training capacity and recruitment of trainers

Training is a vital function and must be undertaken by those with sufficient experience, not by locum staff or those with short-term experience and added on to a burgeoning workload. Administrative support could provide greater capacity for professionals to also be trainers in work-based practice. Members would be supportive of a scheme to retain staff approaching retirement to shift greater proportions of their time to training or to continue part-time without affecting their pension entitlement. This would keep valuable expertise in the NHS for longer and enable our most experienced staff to pass on their skills rather than retire. This is a role many would welcome.

• A scheme needs to be developed to enable those who wish to change their career focus, perhaps through a reduction in clinical commitment to enhance training time, to be able to do so. We welcome the inclusion of such ideas as part of the new GP contract and look forward to supporting implementation.

• Consideration would need to be given to pension planning.

5. Greater focus on the ‘D’ in R&D

The NHS Plan is moving from a vision to a reality, with already visible improvements in some areas of health in our populations. We welcome the recommendations produced by the National Institute for Clinical Effectiveness (NICE) however, we are aware that in many areas of clinical intervention and practice, evidence exists that is not implemented or promoted.

One of the major problems is the volume of paper to sift through. Without the provision of time for consideration many important points may be missed. Guidance should be prioritised on the basis of what produces good outcomes. Practical evidence-based care models, made accessible to clinicians, may encourage them to abandon custom and practice. Further work is needed to establish criteria for disseminating only essential information to NHS.

• Care Models and Pathways that are recognised as examples of excellence and establish an evidence base, should be centrally recognised by the DoH and promoted throughout the NHS in an easily digestible and co-ordinated format.

We recommend:

• An education programme for schools should be developed, that includes lessons from the Expert Patients Programme, particularly with regard to the management of health and health services.

• The Department of Health should commission scoping work to explore the competencies required to deliver care. A workforce plan encompassing career pathways should be developed.

• Arrangements for the provision of childcare need to be improved and to cover primary care.

• Staffing levels should be re-assessed to include administrative support as part of the clinical team.

• The Department of Health should consider the feasibility of a scheme which would retain staff in a teaching /training role, that is not restricted to teaching/university hospitals.

• Consideration should be given to reviewing NHS pension arrangements in order to encourage retention.

• Commissioned research should focus on the key factors of implementation of care models. Potential improvements in patient care should include attention to the steps needed for their practical implementation into practice, and an assessment of the resources needed to achieve this.

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copyright: © | published January 2003