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Recasting the NHS workforce

Recasting the NHS workforce

Carolyn Wickware investigates how NHS England’s new care model vanguards are reshaping the workforce nearly two years after they were launched
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The events of recent months in London and Manchester have shown the bravery and dedication of NHS staff. When Jane Cummings, chief nursing officer, and Sir Bruce Keogh, national medical director for NHS England, offered their thanks to doctors and nurses for their ‘tireless efforts’ after the London terrorist attack in June, they noted that NHS staff volunteered to work extra shifts to help with the emergency response.

But these acts of goodwill aren’t limited to the times when tragedy strikes and increasing patient demand is stretching staff to breaking point. Ahead of Labour’s failed attempt to remove the 1% pay cap for NHS staff, MPs were told by doctor-turned-MP Andrew Murrison that they are ‘risking that the well of goodwill will not just get low but run completely dry’.

As demand on the NHS shows no sign of slowing, a robust NHS workforce is needed now more than ever.

Yet the Five-Year Forward View paints a picture of a lopsided and compartmentalised workforce in primary and secondary care that risks leaving the health service ill prepared for the future.

The number of hospital consultants, it says, has increased faster than the number of GPs ‘even though patients with multiple conditions would benefit from a more holistic clinical approach’.

That was in 2014, when NHS England published the document outlining its action plan for the next five years.

Since then, official statistics show the situation has become worse. Between September 2015 and March 2017, the NHS has lost 220 full-time equivalent (FTE) GPs but gained 2,193 FTE hospital consultants.

The Royal College of Nursing has reported 40,000 nurse vacancies across the UK, while a survey by Pulse magazine found that 12.5% of GP positions are vacant – nearly twice as many as in 2014.

Despite the worsening national workforce picture, new care models were given £101m at the beginning of this year to press on with changing how care is delivered.

While much of the national focus was on recruitment to fill workforce gaps, local healthcare leaders in charge of their vanguards have been focusing their resources on retaining and retraining staff to make the best use of the personnel they have to hand. How have the new care models changed the workforce, and the way they work, on a local level, in the two years since the new care models were announced?

‘Preparing the troops to fight the last war’

All 50 new care model sites were announced by September 2015, with the aim of redesigning care to bring it out of hospitals and closer to patients and to act as models for how the NHS will work in the future.

In many cases, redesigning care has also meant redesigning the local workforce to provide the new ways of working – all while the NHS is in the grip of a workforce shortage.

Speaking at NHS Confederation’s annual conference this year, Niall Dickson, chair of the organisation, described workforce as a ‘major challenge’ facing the NHS.

He said the NHS is running the risk of ‘preparing the troops to fight the last war’ when it should be moving towards building a workforce with ‘permeable’ and ‘flexible’ professional boundaries.

‘It means training and retraining our existing workforce for new roles and new challenges,’ he said.

This is reflected in the guidelines for setting up three of the five vanguards that focus on care integration across primary, secondary and social care boundaries.

The framework documents – which act as a blueprint for a successful vanguard – for integrated primary and acute care systems, multispecialty community providers and enhanced health in care homes, all describe the absolute necessity of a ‘flexible’ workforce model with opportunities for career development.

The enhanced health in care homes vanguard set up by NHS East and North Hertfordshire clinical commissioning group (CCG), the local county council and the local care home providers association, built on this by training their care home staff to recognise certain medical issues in their patients before calling 999 in an effort to take pressure off their local A&E and primary care.

A spokesperson for the vanguard said the aim was to skill the staff ‘so that they didn’t automatically dial 999’ when a resident had breathing difficulties or a fall. Instead they are encouraged to talk to other relevant clinicians about the situation first (see case study box 1).

The extra training has cut A&E attendances and hospital admissions by 45%, while improving relationships with GPs and other clinicians outside of the care homes.

But the benefits weren’t just for the healthcare system outside of the care home, as the vanguard said by giving the staff new skills, managers reported an increase in staff retention within the homes.

‘A rewarding and varied career’

According to Professor Ian Cumming, chief executive of Health Education England, retention is ‘the biggest challenge’ facing the NHS workforce.

In a recent interview with Healthcare Leader, he said: ‘It’s not just what’s coming though the training pipeline but what’s happening with people retiring or leaving for other reasons.’

‘We know that people who we invest in become very loyal members of staff within the NHS,’ he added.

‘We need to give people who are joining us through the professional route a rewarding and varied career, opportunities to pursue specialty interests, to grow and develop in leadership and management roles.’

Much of this is being addressed by initiatives within the vanguards. Northumbria Healthcare, part of the integrated primary and acute care system in Northumberland, is giving its hospital employees the chance to experience different ways of working.

Dr Jane Weatherstone, associate medical director of primary and community care at Northumbria Healthcare, said integrating primary and secondary care has given members of the trust a chance to see different ways of working.

She said: ‘Lots of people may be coming to organisations such as ours at the start of their career and they stay in that organisation and they only see one side of healthcare provision.

‘Primary and secondary care integration allows managers to work out in primary care and get a really good understanding of how it works.’

Meanwhile, in Gosport, Hampshire, the local multispecialty community provider, Better Local Care, recruited a GP from a practice 30 miles away based on a special interest he has in elderly care and nursing home medicine.

The GP, who was hired to work in one of the multispecialty community provider (MCP)’s practices as an additional GP, is also overseeing and working with four district nurses to take on all of the home visits for GPs across seven practices (see case study box 2).

By accommodating a GP’s special interest, giving him management responsibility and a varied day-to-day job, the MCP has increased job satisfaction and added to the local workforce, while easing pressure on A&E and primary care services.

‘This is a bit chicken and egg’

While many of the vanguards are developing similarly grassroots-level workforce changes, widescale development to incorporate new roles and recruitment is proving a challenge, with new models of care still in development and other national initiatives being pushed to top priority.

Mark Warner, the workforce lead for Developing One NHS in Dorset, an acute care collaboration vanguard covering 766,000 patients, said: ‘Our demands are constantly changing and evolving and growing so we have seen a growth in our clinicians.

‘We have more consultants at Dorset County Hospital than we did five years ago, but a lot of that is just to deliver a growth in demand.’

He added that Dorset is coping with the same workforce shortages being seen at a national level but ‘it’s going to take some time to develop a workforce and recruit them and train them.

‘We are having to work with our education providers, to make them aware of what we’re trying to do and to line them up for the new care models, but I think it’s fair to say this is a bit chicken and egg,’
he said.

‘What you can’t do is develop the new care pathways in isolation of what your workforce supply will be and when it will be available because the two things are so closely linked,’ he said.

The vanguard, he said, has started the process of developing a ‘high-level macro’ workforce plan, including use of new roles like physician associates and nursing associates, which will then need to be tested ‘at an individual service by service level and that will inevitably be iterative’.

Despite the challenges, an NHS England spokesperson told Healthcare Leader that the vanguards are helping the NHS ‘better understand some of the key characteristics behind properly joined-up workforce models’.

The spokesperson said: ‘These sites have been leading the way on workforce redesign and have shown the true value of multidisciplinary teams – staff from health, social care, pharmacy and voluntary organisations – working together to improve the care patients receive. ‘Vanguards have found this collaborative way of working has improved staff satisfaction as well as patient care.’

Case study 1 Enhanced health in care homes – East and North Hertfordshire CCG

The enhanced health in care homes vanguard has cut A&E attendances and hospital admissions nearly in half by equipping care home staff with new skills.

The CCG trained care home staff in handling dementia patients, falls, wounds and other neurological and respiratory conditions so that when a patient has
a medical problem, the care home is able to better assess the situation and only dial 999 when absolutely necessary.

A spokesperson for the vanguard said the core reason for the project ‘was to keep elderly care home residents out of hospital as much as possible because pressure on the ambulance service and on acute hospitals was quite critical’.

To ease the pressure and develop better relationships with clinical staff outside the care home, the CCG launched a nine-month specialist-training programme called ‘Complex Care Champions’.

The programme saw the CCG give £2,000 to care homes per staff member trained. According to the vanguard, the money can be used however the care home wants, with some paying it to staff as a bonus, or paying some to the staff and using the rest to buy extra facilities.

Since the programme was launched late last year, the vanguard has trained 213 staff in care homes and cut the number of hospital admissions and A&E attendances by half. The programme has also seen a 57% reduction in pressure ulcers.

The spokesperson added that the job satisfaction among the trained care home workers ‘has improved tremendously’, as has staff retention.

Case study 2 MCP – Better Local Care, South Hampshire

The MCP vanguard in South Hampshire is reshaping how the workforce operates by using primary care staff with special interests to take the burden off other areas of the local healthcare system.

Better Local Care hired a GP and four district nurses to take on all of the home visiting appointments for seven practices in the town, freeing up 200 extra appointments for GPs.

Dr Donal Collins, GP lead for the vanguard, told Healthcare Leader that the GP, who lives 30 miles away, ‘had an interest in elderly care’ and saw the opportunity to work with the MCP. 

Dr Collins said the five-month pilot programme, which launched in early May, has already given GPs back an hour every week, while the nurses have identified several new patients who required care from an occupational therapist or physiotherapist.

The service isn’t just a help to the overburdened primary care staff taking part, it has eased pressure on hospitals.

Dr Collins said that before the pilot, GPs in the area tended to complete their home visits by 3pm, meaning any hospital admissions usually happened around 6pm.

He said: ‘So no matter what was wrong with them, the hospital really couldn’t get them home again, so that would involve an overnight stay in hospital.’ 

By sending the patient to the hospital by lunch time, Dr Collins said the hospital has ‘a much better chance of turning them around and getting them back to their own home’ in the same day, reducing pressure on hospital staff.

Carolyn Wickware is a reporter at Healthcare Leader

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