Workforce planning in the healthcare system

Victoria Vaughan (VV): What is the role of ICBs in workforce planning and development? And what’s your top priority in meeting the workforce challenge for the future population?

Fiona Grove (FG): From a workforce planning perspective, the main job we do with ICBs at Arden and GEM is to help them understand their data. We work with ICBs and systems to pull the data from all their constituent parts and providers together – health, social care, primary care, even the voluntary and independent sector – to get a holistic picture of the whole workforce.

Quite often systems as a whole may have more of the right number of staff than they think – they’re just not necessarily in the right places. You could have an oversupply in one area and an undersupply in another, but if you used people across whole pathways or shared across organisations, you’d get much better coverage.

We work with people to understand and interrogate their data and then to ask the right questions. That enables them to start looking at how they can deploy that workforce more effectively – how they can utilise people across the system and whole pathways, rather than just looking at an individual organisational group of staff.

We have electronic staff record (ESR) data within mainstream healthcare, which is fairly straightforward, and you can run reports that are set nationally. It becomes slightly more complicated when you start looking beyond trusts and ICBs, but in my experience, social care will have the data. They may have it on multiple systems, but they do have it, and we can develop templates that broadly mirror what’s on ESR to pull that data through. Primary care pretty well now completes a national minimum data set. It’s not as rich as the ESR and the social care workforce databases, but it does give us a good overview and the quality of it has improved dramatically over the last few years.

Quite often systems as a whole may have more of the right number of staff than they think – they’re just not necessarily in the right places.
Fiona Grove

Sarah Green (SG): It’s been a key piece of work since ICB inception to gather and harness data to get a more comprehensive picture of our workforce. There’s still more to be done in terms of data variation, but we’re getting there. We’ve got to a pretty good foundation.

The other important point is how we reflect that business intelligence alongside our population health data. We look at what our demographics are showing around our communities, our population, and this is where our workforce is – and then ask if they tally and think about how we begin to map it. In terms of the ICB role, it’s about oversight, convening, coordination and collaboration – and then pulling it together into one workforce strategy.

I think about it as a helicopter view of planning. It’s being able to coordinate and have a strategic overview of the needs of our workforce and population and being able to plan and build our workforce in response to those clear oversights. Central to all of that is building really effective relationships.

Our top priority is to make sure that we have the workforce in the right places. The ICB needs the ability to move the workforce so you’ve got the right people, the right skills in the right place, creating inclusive and compassionate workplaces. If we want reform, ICBs need to be supported to do that.

Jayde Robinson (JR): I echo what Sarah said with regard to the strategic role, but my team provides operational support as well. My role is to represent primary care and we align with the ICB. I’ve got a primary care workforce strategy very much aligned to the long-term workforce plan and we’re working together to achieve the best outcomes for our patients and our workforce. I think a clear focus on train, retain and reform helps to do that because we’ve got some really clear, defined goals that we want to achieve as part of that.

In primary care, we’re focused on nine areas in particular, looking at sustainability, growth, clinical leadership, and how we actually mobilise our staff in the best possible way. We need systems to come together, to work as part of the integrated care system, to meet the needs of our patients and grow that workforce.

Obviously, the additional roles are under my portfolio, so I lead that on behalf of the system. We work with all the PCNs across Norfolk and Waveney to understand their recruitment requirements for the additional roles reimbursement scheme (ARRS) and, indeed, all roles. We support them in their planning, as well as development and overall view.

In terms of data, we have some limitations in the information that we have in Norfolk and Waveney. General practice – PCNs in particular – are very good in terms of their staff reporting because they need to do that as part of their contract. Pharmacy is also very good, and we can pull that as frequently as within general practice.

Dental is now on a yearly basis reporting and that’s something that’s pulled then published nationally. But unfortunately, it hasn’t been released yet so we’ve only got data until 2022 at the moment. The optometry data we can access is 2019 data.

I’ve worked closely with our business intelligence team to pull together the kind of dashboards that Fiona is talking about, so I’ve got a good idea of where roles are placed, whole-time equivalents and being able to see some of the demographics that we’ve got across the system. We can see that by practice and by PCN. So, we’ve got a starting point.

As a system, we’re looking at the numbers coming through and we want to understand the reasons behind them. We know, for example, our physician associate (PA) numbers, in particular, are down probably because of the national coverage of PAs. Our nursing numbers are also down this year. But interestingly, our GP training numbers are increasing, so we are now looking for more places across our system, though estates is a significant challenge. We’re looking at our clinical space to utilise it in the best way and also thinking about supervision.

So, there are some challenges with increasing numbers, but then in other areas, we’re depleted in our numbers.

VV: How do you solve the challenge of having the right number of staff but in the wrong place? Moving staff between social care and health care is challenging. How can an ICB work on this with partner organisations?

SG: Primary care is such an important role for us in the system, and it’s no mean feat to manage those relationships when practices are sovereign in their own right, and we’re trying to bring them on board. It’s about relationships and understanding each other’s perspectives.

Staff being able to move freely across the system and not being defined by organisational boundaries is one of the driving forces of the ICB. But it’s taken a long time to build up organisations with strong organisational boundaries – different terms and conditions, pay differentials, and different ways to roster staff – so it’s going to take quite a while for us to unpick it. That’s not to say it’s unachievable, but that’s the reality when you’re looking at the movement of staff.

We’re moving away from historic competition and towards an adult conversation. It’s a cultural shift for everybody. That’s the reality because everybody’s working with the best intent in really complex and challenging situations.

We’re moving away from historic competition and towards an adult conversation. It’s a cultural shift for everybody.
Sarah Green

The thing that cuts through the culture shift for me is that we’re all in it, everybody’s in it, from the lens of wanting to improve the population care that we deliver. That’s our North Star that we talk about – it helps bring people together. It’s about finding that mutual point of collaboration that people coalesce around rather than focusing on all the reasons why not and the differences.

We’re working on ways that enable earlier mobilisation across the system, which might be a passport, mandatory training or alignment of employment policies. It’s enabling pathways of care for our staff, to have those career opportunities and being upskilled in a different area so they no longer need to think they have to leave one organisation for another.

JR: It is a journey. There are some barriers that we can’t shift. Each primary care sector is a small business in its own right, and obviously, those settings don’t have the same pay and conditions as Agenda for Change, for example. So, there are some technical difficulties that we have to navigate through.

But actually, we are working collectively as a system. A really good example of that is looking at fellowship programmes working with system partners, either in the secondary care or social care settings. So that creates a development opportunity to specialise in a particular area and look at what the system needs as a whole. We are in the early stages of developing a passport across Norfolk.

And when we talk about workforce planning and programmes, primary care is front and centre. So, it’s really good that primary care now has a voice at the table in terms of the people directorate and the function.

Norfolk and Waveney has been really successful in the recruitment of ARRS roles and we’ve tailored the workforce in line with long-term conditions – linking business intelligence with a population health management approach. We’re looking at what that means for the training and educational needs for our staff and GP retention. My team’s role is really to focus on retention for our primary care staff, as well as the development and growth.

Like many ICBs, we have a training hub in place and a number of programmes to get new talent into the system. One is a volunteer career pathway – working with the voluntary sector to entice them into primary care roles. They go through a voluntary programme first, and it can lead to recruitment for those individuals.

FG: In terms of the culture shift needed for a more system way of working, I’ve seen a couple of different methods.

One is for organisations across systems to start with a mutual support agreement where people within different disciplines agree that in an emergency or times of pressure, they can support each other. That started during the pandemic and has continued, and it seems to work well. It’s meant that where they’ve had episodes of sickness or high levels of absence, for whatever reason, people from nearby organisations have offered support to step in, and from that, people are moving into much more integrated working agreements.

The other approach that I’ve seen work across systems is to start looking at care pathways. There are risks – I’m not saying that they’re a panacea – but once you start working across a pathway where you’re offering people opportunities to grow and to develop around the whole system, people are less likely to move for 50p more an hour or whatever.

We’ve seen rotational opportunities work well, especially for junior posts. For instance, people can get a chance to work in stroke services, high dependency, acute community rehab, and so on. They get a whole range of experiences, and then make decisions about specialising. In doing that, they also build relationships and gain a really good understanding of the skills of the other people around them, which leads to greater respect. And it means that when you come across a problem or a challenge, you know who to contact and some of those barriers start coming down naturally.

VV: In terms of recruitment and retention, what are the challenges and how can they be overcome?

FG: Retention has been an ongoing problem for a number of years, both in primary care, secondary care and the community.

There are pockets where we need to consider how to get better at retaining people in the middle of their careers. Not all organisations use family-friendly policies, and this can make returning to work following family breaks and caring leave really quite difficult for some. We see pockets of this across the whole country where policy could probably actually make that a lot easier.

And we have a lot of staff groups who feel undervalued and that always leads to retention issues. We hear a lot in the press and from Government that the NHS is broken. I’m not saying I entirely disagree with that statement, but I think that constantly hitting people with a big stick makes them feel undervalued.

In specific areas of the workforce – midwifery, for example – where there has been a lot of public criticism then it can be tough because it’s tarring everyone with the same brush. It means that the people who are good and effective in their roles feel they are being criticised and undervalued.

And because there are very high levels of vacancies within the NHS, people feel the pressure of not having full teams and of having to do extra. Then there are other pressures, which may be around development and career progression, that add to it.

There isn’t a magic bullet, but I think we can work with people to help them develop and feel more secure in their roles and in their competence. And, of course, we are not pulling enough people through the pipeline to replace those people who are leaving and retiring.

SG: For a pipeline of people, we don’t have one university that’s responsible for all of our training within our footprint. The University of Bath provides outstanding education for pharmacy, but we don’t have a local uni for a lot of our other undergraduate workforce.

We maximise the opportunity to reach out into the communities as a pipeline. There are pathways where people can come in for work experience to get a taste of health and care or come in as support workers and progress. We know that if we grow our own workforce, people are more likely to stay because they live locally and they’re committed to our communities.

We’re really keen to do apprenticeships, but that’s still a challenge because of the affordability of the backfill. Everybody is keen to use apprenticeships and they’re incredibly popular with young people – whenever we do advertise apprenticeships, they’re filled – but they’re not an inexpensive fix.

And on retention, the Darzi report talks extensively about reform. As everybody knows, you don’t transform organisations, you transform people. So the focus has to be around how we enable people to do the job they’ve been employed to do and do it well.

An example would be funding for clinical staff development but not much clarity about how we enable capacity. Yet quite often, when you talk to staff, they mention the amount of paperwork or administration – so how can we take some of that heavy lifting away from people in different ways? Perhaps that’s through development programmes or digital solutions. That’s all part of retaining people because actually, if you’ve got the infrastructure right, then clinical people can do what they need to do.

Some parts of our system are doing well. When I look at our acute organisations, there is a really low vacancy rate at the moment, and the retention programmes are really strong. The workplace has been encouraged to be accessible – through flexible working requests and learning development, for example.

But in other parts – social care, for example – there’s high turnover. There are differences in pay and there are different ways of working. So we’ve been working closely with our local authorities, looking at how to share some of our assets around our training and development funds so that they are spread across the system.

People want access to good career development, and they want a great line manager who understands them and values them. To me, those are the two factors that retain people. So being able to have some consistency in how we address that is helpful. And that’s the beauty. When you start joining up, you can start addressing some of the variations.

There’s a lot about ensuring our middle managers have the tools and skills to effectively lead and manage people. I don’t know about you, but I’ve kept in a job because I’ve had an amazing line manager – someone who’s made me fly and flourish and feel valued. We talk about setting the tone; how do we enable all of our leaders and our managers to encourage that intent?

Equality, diversity and inclusion is a really big piece of work that we’re doing…There’s a long way to go, but we’ve got the foundations to build on to make us the inclusive culture that we want to be
Jayde Robinson

JR: It’s for ICBs and ICSs to think about how we can enable development across all areas. Some national funding is sector-specific. General practice receives funding, but dental, optometry and community pharmacy do not receive any funding in terms of their workforce development. So, we need to support them with that. All the programmes we put in are to support all four primary care sectors.

The approach we have taken is to look at continuous professional development and make sure all sectors are represented in terms of our system priorities and linking to our long-term planning.

The culture piece is integral. It’s making sure we’ve got an environment where development shows from start to finish of someone’s professional career, either in clinical or non-clinical settings. And it’s making sure that we’ve embedded the compassionate leadership approach in all we’re doing.

Equality, diversity and inclusion is a really big piece of work that we’re doing after we recognised that we could do more based on the staff survey results. There’s a long way to go, but we’ve got the foundations that we need to build upon to make us the inclusive culture that we want to be.

In terms of a pipeline, we work with a number of colleges within the system, but also outside. There are a number of challenges that are not unique to Norfolk and Waveney – pretty much the bottom half of the UK also experiences the same issues. We don’t have a dental school within Norfolk – there’s nothing in the East of England, actually – so for dental, we get a lot of our students coming from London and Sheffield. It’s about thinking how we’ll retain them once they’ve done their post-foundation qualifications.

With apprenticeships, we’ve had really good collaborative work where a system partner hasn’t used all their apprenticeship levy and we’ve been able to transfer it within primary care settings.

VV: When it comes to training and developing the primary care workforce, what’s the approach given that ICBs are not the direct employers?

SG: It’s a challenge like no other, I’d say. It’s a different type of leadership and management. It’s not leadership through authority; the future is about collaboration.

The challenge is to be constantly influencing without having direct authority. It’s having a collective oversight and being able to influence when you’re working with multiple organisations that have their own boards and their own sovereignty.

However, the beauty of being in an almost slightly independent role and having a helicopter view is that we can be the ambassador. We can galvanize efforts to address health inequalities and to ensure there is a greater focus on prevention and care closer to home. We can shift and move things that way.

JR: Being separate can be helpful, actually, because PCNs and practices see us as an advocate for primary care across the system. They use us to help support communication with the regional and national team and look to us for local programmes that can be put in place to enable them.

Working across different areas does help, I think, because there are similarities in each of the primary care sectors – the same challenges, maybe just a slightly different dynamic. We are well-connected across the system. We go to primary care network (PCN) team meetings and practice managers meetings, so they see us as a point of contact.

It gives them a sense of perspective as well. We’ve got that system piece to introduce elements that they haven’t considered before. We can say: ‘Another primary care network or practice is doing this – have you thought about that?’

We’ve visually mapped out where we’ve assisted practices. So, I can see at higher level where we’ve engaged and the practices that we haven’t engaged. And, of course, that’s the important part because then we can say to them: ‘Are you aware of what we could offer you? Are you aware of how we can help you build this or reduce that gap?’

If we stretch ourselves and work at the top of our competence, we become more effective, give better patient care and we develop other people
Fiona Grove

FG: You ask about the primary care workforce but I think focusing entirely on health is probably the wrong way to do it. We need to think across health and social care. If we can support colleagues in social care and use integrated care as a means of doing that, we will massively free up capacity in health. It then becomes a symbiotic relationship.

The secret to ensuring that we’ve got a workforce fit for the future is that we all work together. By ‘all’, I mean our hospital trusts, our ICBs, our Commissioning Support Units, NHS England, social care and the voluntary sector. We must all work together to develop career pathways and career opportunities that can meet the needs of a wide range of people. And to do that, I think we have to be flexible in our approaches.

We need to utilise our higher education institutes, apprenticeships, and volunteering. We also need to enable mentoring, preceptorship and all those support mechanisms that help people learn. If we can do all of that, we’ve got a real opportunity to grow our workforce and strengthen them as individuals and offer them opportunities.

The other thing that we have to do is encouraging everybody – regardless of their role – to work in the top 30% of their competence. We tend to work in the bottom 30 to 40% of our comfort zone – we do the things that come to us naturally and that are easy for us. Whereas, if we stretch ourselves and work at the top of our competence, we become more effective, give better patient care and we develop other people.

When I say that, I am talking about competence. I’m not suggesting that people do things that they’re not competent to do. But if we could all work in the top 30% of our competence, we would gain a lot. We’d address some of the productivity problem, it would make people’s jobs more interesting, and therefore, retention and recruitment would be better.