Nigel Crisp writes exclusively for HSJ about an All Party Parliamentary Groups review that recognises the importance of a highly and varied skill mix among health professionals.
There is an urgent need to redesign roles in healthcare, break down traditional demarcations and develop and extend the skills of all health workers. Health leaders – particularly clinicians – need to be very much bolder in promoting these changes and governments need to do much more to support them. The Millennium Development Goals are not going to be met and improvements will not be made at a time of financial constraint unless these changes are given much higher priority.
These are some of the conclusions from a review conducted by the All Party Parliamentary Groups on Global Health and on Africa which have just published their findings.
There are many successful examples around the world: from nurses undertaking caesareans and cataract operations in Africa to Lady Health Workers in Pakistan and Ashas in India providing basic healthcare after a carefully planned training. In the UK we have seen, for example, the successful introduction of nurse prescribing and the creation of imaging and other technicians. There is good evidence that when these changes are done well they can have an enormous beneficial impact in providing greater access to healthcare, improving quality and reducing costs.
The review also heard of failures and of the risks that untrained people could be placed in situations where they were out of their depth and gave poor and, even, unsafe care to patients. Peter Carter of the Royal College of nursing summed this up for the review well. He noted that: “You don’t need registered nurses to do all of the tasks that historically had been carried out by qualified nurses. Healthcare assistants can do many of those tasks, perfectly satisfactorily, providing they’ve had the proper induction, training, and education. And where it goes wrong, in some parts (and I do stress some parts of the NHS) is where there has been task shifting onto unqualified people who’ve not been given even the most rudimentary induction into the fundamentals of nursing care”.
The review considered his and other evidence and identified the success factors that were involved in the most effective job re-designs and role extensions. The keys to success are good leadership and planning, appropriate job design and recruitment, formal training and scope for progression, supervision and referral systems, and recognition for health workers and good teamwork. Together they can lead to success.
Equally, the absence of these factors can lead to the sort of failure that Dr Carter has talked about. Poor job design, inadequate training and lack of supervision can all be disastrous for the patient as we as the health worker.
These risks are real. There is also a risk, the Review was told, that such changes will be resisted for the wrong reasons – because of territorialism, worries about job security, professional jealousies and institutional and personal advantage. This is why it is so important that respected clinicians lead these changes and are able to navigate around all these obstacles.
The review also showed very clearly that whilst most of the successful changes were indeed led by individuals – mainly passionate and driven clinicians – they needed governments and national systems to set out the vision and create an enabling environment to make change at scale. Regulation, education, payment systems all need to be aligned and, crucially, a government or national health system needs to set the direction and “approve” or “authorise” the change if it is to have maximum effect. Where this has happened - with Aravindh in India, Mozambique’s Tecnicos di Cirurgia, or Ethiopia’s Health Extension Workers for example – the impact on access, quality and costs has been enormous.
The position in England
The review took a global view but also discussed the position in England noting that, as Mike Farrar of the NHS Confederation told it: ”Throughout the NHS we see many examples of skill mix and substitution handled expertly”.
He went on to explain how the Confederation was carrying out its own studies on the role of pharmacists and on what sort of health workers should be involved in care of people with dementia. Workforce figures bear out the high level of change with, for example, a large increase in Health care assistants in recent years. This has been accompanied by some concern about standards and quality of care with a call for greater regulation.
The Department of Health provided evidence of the work underway in many parts of the new NHS including for example QIPP, the Care Quality Commission and the Centre for Workforce Intelligence. Tellingly it also stated that: “At present it is for local healthcare providers to decide how best to organise the skills mix of their workforce to achieve better outcomes in both patient care and value for money.”
There appears to be no overall vision and incomplete alignment of all the initiatives. The review believes there is scope to provide this through the changes underway in the NHS and urges Clinical commissioning Groups to seize this agenda; Health Education England to set out a vision for the workforce of the future: the UK Sector Skills Council to create programmes to support the vision across health and social care; The Care Quality Commission to inspect the way Healthcare Assistants are trained and developed; and QIPP to give this even more emphasis.
Looking around the world we can see health worker shortages accompanied by growing demand in fast developing economies and by financial constraints in the stalled economies of the West. The time of a skilled health worker is becoming the most precious commodity in health care. I believe that making the best use of that time will be one of the dominant issues for the next 10 years. It is a time for bold leadership – from clinicians to lead the changes and from governments and national organisations to support them.
The All Party Parliamentary Group on Global Health, chaired by Lord Crisp and the Alun Michael MP, and the All Party Parliamentary Group on Africa chaired by Hugh Bayley MP, published All the Talents - how new roles and better teamwork can release potential and improve health services on July 11th. Copies of the full Report and the Executive Summary are available here.