NHS STAFFING: The NHS could benefit from forging closer links with public health policy. But it needs to adopt a more strategic approach, argue Ros Levenson and Teresa Edmans

Imagine this. Somewhere, in a health authority or trust near you, a group is discussing a serious problem for the NHS: how to fill essential staff vacancies in order to offer a safe and effective service. Down the corridor, another group is discussing an equally important issue: the links between unemployment and health.

The first group may be noting that the NHS often struggles to fill vacancies, including vital posts in medicine, nursing and therapies. An NHS Confederation survey found 78 per cent of trusts had difficulty recruiting nurses and turnover was high.

1The Department of Health reports that in the latter part of 2000 there were over 10,000 more qualified nurses, midwives and health visitors in the UK than in 1997.

2But a major overseas recruitment drive has been necessary to make up the shortfall in UK staff, with an agreement signed last year to recruit up to 5,000 Spanish nurses to the NHS.

Extensive recruitment has also taken place within countries outside the European Union, such as the Philippines.

So while the first group is deliberating the staffing crisis, the other is considering the proven link between unemployment and poor health. Saving Lives - Our Healthier Nation states that mortality from all major causes has been found to be consistently higher than average among unemployed men, while unemployed women have higher mortality from coronary heart disease and suicide.

3In other words, communities where people have jobs are likely to have better health.

So what are the chances of these two groups getting together? If it happens at all, it is likely that links are made in the context of small-scale initiatives, often championed by individuals with a particular personal commitment.

Yet both groups might find their problems could be addressed more effectively if the NHS made more systematic attempts at using its might as a major employer to encourage people to train for and work in the NHS locally.

The health service would benefit from being able to employ more skilled staff and having more staff at all levels who understood the issues facing the local community. There would also be environmental benefits of employing local labour:

less pressure on transport, for example.

The King's Fund has been working on these issues as part of its health and regeneration programme.

It has carried out research and run a seminar with the London Regeneration Network, which was attended by 70 participants across a range of health and local authorities, trusts, primary care groups, NHS education consortia, regeneration bodies, voluntary and government organisations, among others.

4Some common themes emerged.

There was widespread agreement that a strategic approach was needed. This would be much more effective than the fragmented efforts made so far.

Although local efforts to make links between NHS organisations and local regeneration schemes must be unreservedly applauded where this has occurred, the lack of an integrated and strategic approach has led to numerous short-term projects that have proved difficult to sustain when specific funding opportunities came to an end.

There is, as yet, little sign that the experience gained within specific communities has had much influence outside these areas.

It is to be hoped the situation might change as a result of a House of Commons health select committee report, which recommends giving urgent consideration to developing a pro-active role for the NHS in area-based regeneration and neighbourhood renewal.

5Specifically, it says: 'We recommend that the substantial resources of the NHS at all levels are used, as far as is practicable, to improve health through direct and indirect employment and through its procurement and planning functions. '

In addition to developing a more strategic approach, there is much the NHS and its partners can do to move forward on the issues.

What is required is a cultural shift, a change of thinking to raised the profile of employment, work-related training opportunities and regeneration.

The role of the chief executive is important, as is the support of the board. All too often individuals are left to make the running, and initiatives can be blocked simply by a lack of enthusiasm or commitment from middle managers who may not be convinced of the potential their organisation has for improving people's lives and making the NHS itself better able to function by being actively involved in regeneration partnerships.

It is important to learn from initiatives around the country. Different parts of the NHS are engaging in regeneration schemes involving hospitals, community nursing, general practice and mental health services. They have secured financial support from many sources, such as local statutory sector investment, the European Social Fund, Single Regeneration Budget Programme and the Higher Education Funding Skills Council.

Some schemes have targeted long-term unemployed people, others have focused on recruiting people from ethnic-minority communities to the NHS. In some areas, the projects have concentrated on school leavers, and in others on people with mental health problems. In all instances, people have been offered training and employment opportunities, with ensuing benefits to both their communities and the NHS, which has gained skilled staff.

Without a major shift from short-term project funding, it will remain difficult to make any sustainable progress. The need for the NHS and its partners to find ways of supporting training opportunities and developing the workforce should an integral part of its strategy.

The new workforce development confederations will help by bringing together funding streams for both medical and non-medical education and training at local level. Integration can also be achieved through better use of existing funds, by the health service, the employment service and learning and skills councils pooling their budgets.

The health sector should work with a wide range of organisations to develop new ways to enable people to access employment and training opportunities locally. It needs to be more proactive and outward looking, and to value the contribution of voluntary groups, local government and the private sector.

This may not be easy, as effective partnerships can take time to develop. There may well be suspicion about whether health agencies are genuinely open to new ways of working or are simply seeking back-door supplements to their core funding from regeneration funds, while continuing with their old functions.

Community groups may have unrealistic expectations about extra funding from regeneration schemes, which can cause tensions.

These can be generally eased through honesty on all sides and by the NHS being willing to partner local communities at grass-roots level. It can do so by joining existing employment, volunteering and mentoring schemes.

It can learn more about existing voluntary-sector projects, schools and colleges, and help facilitate community events.

Local managers can support regeneration by working across agency boundaries. All too often, departments within one agency see their own recruitment issues in isolation and fail to put them in the context of the wider health economy.

The small scale of employment vacancies in some fields makes co-operation essential. For example, there may be many jobs available regularly in a single education confederation area, but only a few in a particular trust.

With goodwill and a bit of creative thinking, several agencies could pool their vacancies and advertise them as a group. Applicants could be recruited, trained and supported as a group, with the benefits of peer support.

All these efforts will be more effective if the NHS can be seen to be a good employer. In a time of almost full employment, it is not enough to say 'come and work for us'.

The NHS needs to demonstrate that it can offer benefits such as childcare, flexible working, respect for staff, and good training and development opportunities for all staff.

It also needs to offer imaginative stepping stones into NHS employment for people who may not have considered it. Cadet schemes, volunteering opportunities, work with schools and colleges and mentoring can play a part.

The NHS plan makes many references to changes that require growth in the NHS workforce. This, together with a more patient-centred NHS, provides a top-level imperative for the NHS to address long-standing workforce issues.

It is up to the government to provide the framework, and for local NHS organisations to provide the commitment.

Key points

The NHS needs to fill vacancies; the need to regenerate communities should be addressed jointly with local groups and organisations.

There is much that can be done now by the NHS and its partners.

A strategicapproach and sustainable funding are necessary to ensure permanent change.