Preparing the healthcare workforce to meet the challenges of the future will require clear professional development strategies, write Tony Weetman and Steven West
Healthcare workforce planning is notoriously difficult.
Worryingly, workforce planners and commissioners have sometimes failed to engage properly with educators, so proposed solutions have sometimes involved ‘quick fix’ role substitutions that are ideologically rather than evidence driven.
The idea of the healthcare professional as the sum of a series of competencies, as in the concept of the ‘skills escalator', does not recognise the need for people to have certain attributes to pursue particular professional paths.
Each profession has unique values, skills and attributes that distinguish it from other professions and this needs to be recognised.
Increasing longevity and the emergence of chronic disease management are shaping future services, leading to more community-based provision. This is a worthy aspiration but may fail to recognise the uncertain and complex nature of professional practice. Carefully integrated care pathways, designed so that the right patient sees the right healthcare professional at the right point in the illness ‘journey’, are critical.
The problem is that these protocols ignore the fact that most older patients have significant co-morbidity, are on multiple medications and may veer from the proscribed pathway. Initial diagnosis and the capacity for intermediary re-assessment are crucial.
It is also becoming clear to trusts that the relatively expensive specialist nurse and advanced practitioner roles do not appear to have the educational and scientific foundations to operate 'off protocol'. In fact, analyses of doctor role substitution reveal that it is not necessarily cheaper, even for protocol-driven care.
The model of ‘role substitution’ rather than ‘role enhancement’ may be wrong. It is essential that practitioners are fully equipped to deliver safe and effective healthcare in a variety of settings. This means investing in their education and developing their ability to assess, diagnose, solve problems and treat a variety of conditions that do not fit a simple ‘protocol’ approach.
All healthcare professionals should be empathetic, good communicators who are non-judgemental in their approach and function well as part of a healthcare team. These are generic skills all professional educational programmes should cover. Beyond this, there are additional skills and attributes that are essential for individual professional groups.
For medical practitioner roles, knowledge of the scientific basis of medicine, capacity to undertake the clinical reasoning process that underlies diagnosis, and the ability to cope with uncertainty and take responsibility are crucial.
Similarly, a parallel array of essential attributes have been determined for the nursing, midwifery and allied health professions. From an educational perspective, the important point is that developing these competencies requires a particular educational foundation, which builds on key attributes that students must have at entry and develop throughout the education process.
Rather than a skills escalator, the relationship between different professions is best characterised as a multi-sided climbing frame, each side representing a particular professional cluster. Entry attributes determine the side on which you start, but you can change sides if you exhibit attributes required by another profession. You can stop at a variety of levels or aspire to reach the top. Those at the top of each side provide the role models to those in the professional cluster behind them.
Medicine can be complex, uncertain and difficult, and many aspects cannot be provided effectively by adhering to a simple protocol. This is not medical elitism; it is simply confronting the reality of people's differences and the multiple manifestations of illness.
It is crucial that all medical practitioner roles bring to bear diagnostic skills and flexibility at the appropriate point in the care pathway. Service needs to be re-organised to permit this. The complexity of chronic disease management, advances in science and the challenge of clinical reasoning in the context of multiple pathologies requires doctors with an even more profound educational base than ever before.
Nurses and other health professionals’ unique skills and attributes can be enhanced to support diagnosis, care and therapy delivery. The evidence base supporting high-quality care needs to be quickly and effectively used in practice. To do this, practitioners will need appropriate education and career pathways that have been carefully constructed to support high-quality diagnostic, therapeutic and care delivery as well as enhancing patient safety.
This may mean that the underpinning science base, clinical decision-making and therapeutic interventions need to be reviewed in the undergraduate and postgraduate curriculum to ensure the foundations are solid. The basis on which the service can be improved must be around role enhancement and not substitution.
The NHS needs higher education to help develop the educational foundations for the various professional clusters, bringing to bear their educational expertise. Clear articulation of the nature and projected needs of the health service will be crucial. This kind of dialogue should inform the nature of outcome-orientated curricula, developed by educational experts.
But this will only be possible if the current dislocation of the health and education sectors is addressed. With close collaboration, we can re-empower the professions, re-motivate clinicians and create the clinical engagement essential to rise to the formidable health challenges that lie ahead in a more cost-effective manner.