How far will work roles change, as new technologies and service delivery patterns take shape? One trust came up with some radical ideas. John Langan and John Rogers explain

Kingston Hospital, Surrey, has pioneered new approaches to work, roles and ways of delivering patient care since the early 1990s. These include a patient hotel, a maternity unit with single rooms where mothers give birth without going to a delivery suite, and 80 per cent of elective surgery performed on a day-case basis.

We have come to realise that we need to think more radically still if we are to meet the challenges of providing highquality healthcare in the 21st century.

We decided, as part of the national Future Healthcare Workforce project, to explore what the nature of work roles will be in 10 years' time in the hospital's medical unit. We were not interested in an exercise in futurology by experts, but rather in harnessing the ideas of staff within the unit.

What they came up with may sound radical and is untried, but it reflects the reality of the way professional practice and service delivery is going in an other - wise fairly standard urban district general hospital.

We began in April 1998 by looking at the future pattern of services, which we were sure would be dramatically affected by changes in technology and in the balance between primary and secondary care.

Technological changes

We thought the following developments were likely in technology and drug therapies:

Dramatic changes in diagnostic tests which would facilitate near-patient testing in many areas, with equipment which was simpler and more userfriendly.

The results of the human genome project will be available in the early years of the 21st century, enabling better targeting of drugs.

An increase in replacement of organs and joints, with artificial organs being used extensively.

More extensive use of robotic surgery.

More non-invasive surgery.

'Intelligent' tablets and tracer drugs would reduce the need for some surgery.

X-rays will be gradually phased out and replaced by ultrasound and scanning equipment, which will be easier to use and interpret.

Pharmacology will change. Real-time monitors using biological feedback mechanisms will have a major impact on many of the endocrinological diseases.

Developments in information technology will allow the creation of electronic patient records. The electronic transmission of images and notes should free time for direct patient care.

Future patterns of service delivery

We thought that a more active approach to case management, a greater role for primary care and some of the technological changes outlined above would reduce inappropriate admissions;

cut length of stay and the number of acute beds; mean faster throughput; and more highly dependent patients. Our predictions for a service scenario for asthma, for example, are shown in the box (right).

A new workforce structure

We were clear that the existing pattern of healthcare staffing - even if we could actually recruit the people needed - was unlikely to be adequate to meet these challenges.

We wanted to build on our experience with patient-focused care to improve the continuity and personalisation of patient care and to reduce delays and unnecessary paperwork.

Our criteria for the future workforce were that it would have to cope with technological change and meet new patterns of service delivery. We needed to:

for emergency admissions to the medical assessment unit - the care process is regularly delayed as different professions contribute to patient assessment;

improve continuity of care for patients;

increase the proportion of time spent on direct patient care; and

increase efficiency by reducing delays attributable to prescribing or testing.

We think that the distinction between staff who care and those who cure will be increasingly untenable in the future.

We concluded that the healthcare workforce of the future - at least in the area of care we were looking at - should be composed of three broad groups. We envisaged that the existing support workforce - healthcare assistants, nursing and therapy assistants and auxiliaries - should play a greater role in the provision of care.

The new role of healthcare attendant would include the undertaking of a comprehensive range of observations, diagnostic tests, assessments and clinical interventions, as well as personal care and administration.

We estimate that the new role represents an enhancement of approximately 30 per cent on the current support role in the unit. Trainee healthcare professionals would fill a significant proportion of such posts.

There would be a new professional role - that of the healthcare practitioner - covering much of the current workload of junior doctors, nurses and therapists and with an extended role in diagnostic tests and their interpretation.

The role would include patient assessment and case history; physical examinations; diagnostic tests (deciding, ordering, undertaking and interpreting);

provisional diagnosis and initiation of treatment; prescription of medication within agreed protocols; development and initiation of treatment plans;

continuing assessment and patient management, including advanced lifesupport; and admission and discharge (within an agreed scoring system). The healthcare practitioner role is explained in more detail in the flowchart overleaf.

There would also be a range of specialists - consultants, specialist registrars, therapists, nurses, pharmacists and scientific staff.

We propose that the healthcare practitioner should prescribe within agreed protocols and refer to pharmacists where there are queries or if there is a need for change. We suggest that pharmacists should, in future, be allowed to prescribe in order to improve response times and reduce the need for referrals to medical staff.

Our project team also gave thought to how a workforce structured as described would affect career structures. There could be much greater flexibility in future, along the lines of, but going further than, the government's proposals in its nursing strategy Making a Difference. The way we described the workforce earlier represents a compromise with the status quo. Most staff educated, prepared and practising via existing routes would require additional training and experience to function as healthcare practitioners or healthcare attendants. But it is possible to conceive of education and training from scratch for these two roles, with direct entry. In this scenario, virtually all our specialists of the future could be drawn from the ranks of healthcare practitioners with additional training. It should also be possible for healthcare attendants who have the desire and ability to undertake shortened training as a practitioner, with credit for existing skills and knowledge.

There would be advantages to a revised career structure:

We could defer the time at which decisions as to long-term career choice have to be made. Young people would not have to decide at 18 which profession they wish to join.

A change of career in later life would be made much easier.

It would be easier to opt out of, and back in to, the career ladder.

We would have a better framework for maximising everyone's potential.

Next steps

We believe we have developed a new level of detail for future roles, putting flesh on the bones of concepts which have been more talked about than acted upon in the past. We accept that, at present, these are just words on paper but we need to assess how they could be turned into reality quickly, as far as legal and other constraints allow.

The first step is to turn the role specifications into detailed competency frameworks on which we can, with our academic partners, base training programmes for our existing staff.

We will need to invest in new equipment and new technology over time to enable new ways of working, but we would need to do that anyway. The difference is that we should have a workforce capable of taking advantage from the beginning, rather than playing 'catch-up' healthcare.

At the same time, we want to continue to work with the national Future Healthcare Workforce project. The project's second report describes local projects in other areas of care and it has been useful to be able to pick up on ideas and approaches in other fields.

We have found this a fascinating exercise for a number of reasons. In presenting our work to different audiences, we have been surprised by the strength of agreement that the current structure of the workforce is unsustainable.

There may be disagreement about the extent of change required, but little about its direction. Change shaped by current practitioners of all disciplines is more powerful than that imposed by outside experts.