Workforce is a top concern for integrated care boards (ICBs). As part of our focus on workforce Victoria Vaughan, editor of Healthcare Leader, talked to Felicity Cox, chief executive of Bedfordshire, Luton and Milton Keynes ICB, Jonathan Higman, chief executive of Somerset ICB, and Marzena Nieroda, deputy director of partnerships and enterprise at UCL Global Business School for Health about how ICBs can approach this issue.
Victoria Vaughan: Felicity and Jonathan, could you give an overview on what you think the ICB’s role is in workforce?
Jonathan Higman: Our position is that we need a local workforce strategy – one that reflects what’s coming out nationally but is aligned with our integrated care strategy and the delivery of services. At the moment, we’ve got expectations around how we want to deliver services differently but a workforce that’s not necessarily configured to do that. So, we’re developing a strategic workforce function that is joining up the system. We’re working collaboratively with the local authority to consider how the future workforce will look and how we’ll get there locally. From 1 April , we have a single unitary authority and a single foundation trust with two acute sites, community and mental health all under one umbrella.
Felicity Cox: I have the situation where I have three providers who come from out of patch, and then, within patch, I’ve got two acutes and then 96 practices. So one of the ICB’s roles is coordination and collaboration across the system. There is a tendency, particularly amongst the NHS bodies, to recruit from each other, which is a complete waste of money. For example, it costs £3,000 to recruit a band five nurse from one trust to another. So, creating consistency in the terms and conditions is essential. My system is not yet at a passport stage, but I’d like to be.
It’s about looking at the health and care workforce as a totality. Rather than becoming a healthcare assistant in a care home and then you’re nicked by the NHS, how can we work that through so that we give some continuity and some opportunity? And equally, how do we recognise the differences in our staff groups? For example, care home staff often leave in teams because they’re friends and all move together, which is an interesting dynamic we don’t have in the NHS.
There is a tendency, particularly amongst the NHS bodies, to recruit from each other, which is a complete waste of money.
VV: Jonathan, where are you in putting the strategy into action? Given that you’re a neat system, do you have areas of focus?
JH: Within Somerset, we’ve got a particular issue because there is no university. That means there is an outflow of young people who go elsewhere to pursue their education and degrees, and we don’t get them back until later in life when they want to settle down. So, we’ve done a couple of things to address that – we’re getting a local provision of degree-level education and training.
We have developed a university centre in Taunton that now delivers nurse degrees and nurse degree apprenticeships accredited by the University of the West of England and the Nursing and Midwifery Council. So it was quite a big step to get accredited delivery.
It’s also doing social work degrees locally for people, and we’ve trained our first 15 social workers who have now come into the system in Somerset.
We’ve also put together a programme to help people who have said they want to be part of the NHS – volunteers who came forward during the pandemic and unemployed people too. It’s for those who might have found it difficult to access careers in the NHS. We’ve effectively said, ‘We’re going to give you a range of experiences around certain roles in the NHS and we will guarantee you an interview at the end of it for a substantive role.’
That programme is now up and running, and nearly 200 people have come into Somerset’s workforce as a result. And the retention rates are really good.
VV: Do you feel like it’s the ICB’s responsibility to have this workforce across your system and ensure you have enough people to provide the care?
JH: The neatness of our system means that we have one foundation trust that employs 15,000 people. Obviously, they have a big responsibility in terms of being able to fill their vacancies, and we don’t want to get in the way of them doing that. But there are some strategic issues that we haven’t tackled at a system level, so I see us in a place where we’re doing that.
I also see us working much more collaboratively with the council to have one workforce across health and social care and offer training and development opportunities. Some of it will come down to standardisation of terms and conditions, which we’re a way away from at the moment, but also, how do we come up with models of care where you can incentivise people to be a care worker?
We are the pin between the providers… So we need to try and broker passports that enable us to have one workforce.
We are the pin between the providers, the foundation trusts, the local authority, and the providers of domiciliary home care and nursing home care. So we need to try and broker passports that enable us to have one workforce.
VV: Felicity, would that be similar for you? To have one workforce with things standardised across health and social care?
FC: That’s exactly what we’re trying to do so that we can offer people continuing employment and opportunities. In our part of the world, if you go into care work, you’re stuck, whereas there are lots of other options. We have a huge Amazon warehouse and a Lidl warehouse. We have a huge number of Aldis and Lidls opening what feels like almost weekly. We’re also an area of full employment so we really have to think about being an attractive employer in a competitive market.
We’ve put a lot of energy into our various training offers. We’ve been fortunate in that we offer the primary care hub for our system. So, we do lots of primary care training for general practitioners, practice nurses and others. We also offer health and wellbeing, and we’ve put a lot into the ShinyMinds app to support nurses. So, we’ve got a whole range of things to support people to stay with us. And actually, across our region, we’re the best at retention.
But it’s tricky when the easy commuting distance to London means that, for more junior staff, you’re competing with shops and warehouses that include discounts as part of the employment package.
Talking to our schools, we also have found that kids are not considering health and care as a career. That’s partly because we’ve not reached out to them in the right way. So we’re having to rethink our recruitment and careers advice so that it appeals to younger people. We need to talk about the varying opportunities there are in the NHS and across our local authority providers because, between all of us, there is probably not a career you can’t pursue. But people tend to think of it in terms of doctors, nurses and maybe care assistants if you’re lucky.
VV: Marzena, as you’re in education, do you have thoughts on how to engage young people so they want to pursue a career in healthcare?
MN: It might be simply changing how some of those roles are described and bringing in more innovative aspects. Our students love those topics, you know – they really want to see the opportunities that change the world. It’s also important to bring technology into this and the value of changing public health perceptions and getting people more engaged with preventative health behaviours.
I find it amazing that most of our students want to change the world, and they look at it in this very positive way. They see so many opportunities to make a change – and they’re looking at this from multiple angles, and it really brings out the best in them.
Of course, we need more nurses and care staff, but there is scope to work on perceptions. For instance, it’s very difficult to start reading about healthcare and not see something about the shortages and negative experiences with GPs. We need to do much more work to bring out the positive aspect.
It’s difficult to read about healthcare and not see something about the shortages and negative experiences…we need to do more to bring out the positives.
VV: How will this idea of one workforce – going between care and health job roles in a sustainable way become a reality?
FC: We’re working on that in joint recruitment approaches with our colleagues in social care, and we’ve got some rotational roles through the ARRS roles, but it’s quite tricky at the moment.
One of the areas that are ripe for a big re-look is skill mix in primary care. There’s an assumption in primary care that they have to employ everyone for it to work. But actually, you’re also seeing people in some of the additional role reimbursement scheme (ARRS) roles where they are directly employed starting to leave again because they’re not keeping their skills levels up. Even in the middle of their licence, they’re not being appropriately used. And yet, in other practices – perhaps larger practices with better infrastructure and more opportunity – they can manage that.
So, there’s something about our models that we need to look at because paramedics or pharmacists or other people who want to work at the top of their licence and maintain their skills can’t do that in a small practice. The partnership model of general practice has served people very well – and could continue to – but not in very small partnerships anymore. They just can’t provide the level of infrastructure and development that people need.
JH: We’ve got some experience of this with Symphony – an organisation which is a subsidiary of one of the foundation trusts and is running 16 GP practices. In Somerset, we’ve got 63 practices.
One of the things that they’ve done is to change the workforce model. So you’ve got GPs who are almost like GP consultants – it’s that point about everybody working to the top of their licence. The practice model is supported by extended scope – physios, paramedics, and nurse practitioners, all working within the practice but under the direction of the GP.
We’ve also developed health coach roles. Again, they’re working both in the practice and across PCNs to support those people who are identified as being the most vulnerable and linking them up to communities and the voluntary sector. It’s taking forward social prescribing. It is seeing that individual and saying, ‘What is it that you need to keep you well in the community that means your condition doesn’t escalate and we don’t end up having a whole lot of crisis intervention?’
We’ve been thinking quite differently about some of those roles. And there is a role for the ICBs in articulating that to communities. It’s the point that was made about people wanting to change the world and still thinking that health and care is a place where they can do that.
There are such a variety of different roles that people could go into, and we aren’t particularly good at providing people with opportunities to try them. My wife’s a careers advisor, and one of the things she says to me all the time is, ‘There is still a sizeable number of young people who want a career in health and care.’ But she says it is so difficult for people to get experience in those sectors.
VV: Does there need to be a work experience programme?
JH: Yes. We love a work experience programme, then we limit it and say we can only take 10 people on it. Or, you know, just trying to apply for a job or find a place where you can get that experience. And how do people find out what it would be like to be a health visitor or a health coach? Who do I connect them with to enable them to experience this and see whether it is right for them?
So, there’s a lot of that basic level entry stuff we don’t do well. You can go on the website and apply to be a nurse – that’s fairly clear. But if you want to do some of these other things, it is much more difficult to work out how on earth do you get into it. So, as an ICB, we’ve got to change the narrative about the opportunities in the health service.
VV: Could ICBs directly hire primary care teams or will your work focus on passing funds down?
FC: I definitely don’t think ICBs should be recruiting practice teams or primary care teams. We can’t be direct providers of care within our licence, so I don’t think that’s part of our remit. But we should be creating the right environment and enabling other people to do that, and that’s where we’ve got to concentrate our efforts. We want to connect people and build our neighbourhood teams around the place and the population.
VV: Is it about bringing people together so that they can develop services and then devolve budget to them?
JH: Yes, and part of that is being very clear about our strategy and our plans for delivery. What is the set of principles that we would want around, for example, on the day primary care access? How do you wrap that around anticipatory care and being able to support people in communities by working with the voluntary sector? So, we’re working on defining how those things come together and what that should look like.
And then we’d ask neighbourhoods and communities, how do you deliver that within your community and what workforce do you need to enable that to happen?
VV: How do you ensure you’ve got that strategy right? Who are you bringing in from the coalface to the ICB level to ensure you’ve got the strategy right for those local areas?
JH: It might be slightly easier for us. This is the key function of the integrated care partnership from a statutory perspective – it is about having a real proper engagement process. So, at the moment, we’re working with a voluntary sector assembly where we’re trying to hear the voices of a whole range of voluntary sector people. That broadens the perspective. In the past, we’ve heard voices that are self-selecting in terms of the people who have had the time and interest to get involved. It’s a challenge because the people you want to hear from are those who historically don’t come forward.
FC: We’re using our strategy as the launch pad and then saying to the ICP, ‘Right, now, are we doing the right things? Help us to connect and network into communities so that we can see how it would work.’ Our ICP is full of councillors, members of the public, some police and fire service personnel, and some voluntary sector personnel – and they have much deeper connections to communities than we do. So, it’s using them to test and strengthen. Over time they will take responsibility, but we’re not asking them to write a strategy from a blank sheet of paper or produce a traditional NHS strategy. It’s a hybrid; it’s something in between.
VV: The Devon ICB tried to suspend QOF to help the local GPs in winter but were blocked by NHS England and the current primary care network (PCN) contract will end in a year, so are you lobbying NHS England to ensure that you’ve got some flexibility to support your local primary care in the way that works for them?
FC: Yes, we are doing that. And the other big lobby for us is primary care estates, capital for estates, because it’s all very well announcing new additional roles but, for as long as we’re in tight buildings with odd historical arrangements, we have a hand tied behind our back.
The estates issue is significant. So much of the capital monies we get are focused on building the estates on the acute hospital site, and there isn’t a clear mechanism for that within primary care
JH: Yes, the estates issue is significant. So much of the capital monies we get are focused on building the estates on the acute hospital site, and there isn’t a clear mechanism for that within primary care. We’re doing some work with external providers looking at whether there’s an opportunity to leverage capital differently to support primary care.
We have done some stuff with primary care locally in Somerset to support the pressures at the moment. It’s not gone as far as Devon, but basically saying that we’ll support primary care to do the right thing over the next few months, and if money is the issue, then we need to have that conversation.
VV: Do you mean that they can come to you for extra funding for extra clinics or locums?
JH: A bit of that, but it’s more about saying, ‘We’ll work with you around your level of income that you’ve had previously, so don’t worry about losing stuff by doing the right thing for your patients effectively’.
VV: In terms of the estates, do you have an idea of how much more you need?
FC: Yes, absolutely. I’m about to be in the middle of a maelstrom where we’re saying we can support these estates changes in primary care, but we can’t support a whole heap of others that need to happen. As you start to prioritise your estates piece, you think you can only do this much when the demand is this much.
VV: The acute sector has its own workforce function and looks after itself in terms of who they’re hiring, we hear about ‘Peter robbing Paul’ and that NHS in some cases can offer better terms than the care sector. But you’re a system now, so how do you negotiate that?
JH: That is part of having one plan. We shouldn’t be putting blocks and bureaucracy in place – we should enable the acutes to develop their own workforce – but it needs to be done within the context of a strategy we’ve all agreed on.
VV: You said you’re looking at the future workforce, so what will that look like in your strategy? Will the plans articulate job roles you need to see within five years or ten years?
FC: Our part of the world will have a huge population explosion because of house building and expansion. So, we need to plan for how our demography will change – how our population makeup will change. We need to make sure that we don’t become one giant commuter belt for London. Our local authorities plan on a 20-year time horizon. If your plans are too short, you will solve yesterday’s problem but not tomorrow’s.
JH: We’re looking at something like a 16% population growth over the next 20 years, but to a point where 50% of the population is aged over 75 within the context of young people leaving Somerset. So who’s going to care for those people who are over 75 if we don’t do something very different?
The challenge in the NHS has always been that we’ve never looked quite far enough into the future. A one-year plan won’t get you to a point where you’re ahead – you’re trying to fill the gaps you’ve got rather than looking to the future.
VV: Is there a feeling of working together? Do you feel that there’s this understanding around everyone trying to pull in the same direction of a healthier population, less burdened NHS, and better quality of life for residents?
FC: Partnership working at a strategic level is good, but it’s very hard to make sure it cuts through all the layers of the different organisations. It also happens in my own organisation where you’ve got finance saying no to something that’s one of our new statutory responsibilities. It’s getting everyone to understand that we are greater than the sum of our parts when we work together.
JH: It’s a benefit of a neat system that there is an alignment in recognising the issues and an agreement about where we should prioritise our effort. The point for me now is: what does that mean on the ground? At a strategic level, yes, there’s an alignment around it. We’re not there yet in terms of working out what that looks like, and that’s what we need to do over the next six months.
One of the challenges of a system with a smaller number of partners is that you have nowhere to go if those relationships start to break down. Or, if you don’t have an alignment in thinking, it’s much more difficult to influence that when you’ve got a smaller number of people around the table. There’s some room for manoeuvre in a bigger system where you can work around people and influence in a different way.
VV: What are you expecting from your primary care staff in terms of the future of working in a collaborative way? What would you like them to think about and do, and how are you getting two-way communication going?
JH: We’re trying to get to a point where we are strengthening the GP provider voice within the system so that we can hear their views and their thoughts about how we can solve issues.
The challenge is that the people you’re talking to are the people who just need to do their job every day. It’s about people being able to step away from the day job for five minutes.
We’ve got a structure where we’ve got a GP provider board and a PCN clinical director’s group, and we’re saying to them, ‘We want to invest some money in you being able to have a voice as a set of providers, and some of that is about creating time’.
FC: There is a huge organisational development programme that needs to go behind all of this, and it would really be helpful to work that through with GPs to help us understand how we can do it in a way that works for them. At the moment, we’re not having the right conversations. And we’re not putting the right level of energy behind supporting practices to change.
MN: The discussion on partnerships is critical for this kind of change. You have doctors and management – very often, there are different agendas. We really need to work with compassion to understand.
For instance, you don’t have someone reacting with anger just because something doesn’t work the way they think it will work. You have an overworked workforce, patients who are stressed for all sorts of reasons, and different staff at various places when they support this patient’s journey. We need to foster empathy and understanding to make some of those partnerships more meaningful.
This Healthcare Leader roundtable took place in January.