The Department of Health’s strategic vision for the NHS presents several workforce planning challenges for the service to tackle. Dulani Mendis suggests strategy tips for creating a culture of long-term improvement.
The Department of Health’s strategic vision for the NHS based on Lord Darzi’s next stage review attempts to promote a world-class, safe and accountable patient-centred service which is fair and allows equal access to health.
The workforce challenges our health service continues to encounter has included: changes to the vision for service delivery, with implications on workforce demand; and changes to the structure of workforce supply, including increased feminisation and the move to a more de-centralised service with a plurality of providers.
General drivers of labour supply
Common factors that affect the supply and demand for labour include influences from society, changing demographics, politics and legislation,market competition as well as industrial and technological advances.
The individualistic nature of our society compels us to address the employment demands of the entire workforce whether it be for those wanting rapid career progression, short-term employment as a stop-gap for more permanent opportunities and those wanting flexible hours and a better work-life balance.
The ageing population and a reduced fertility rate has prompted an increase in the retirement age in the UK for both sexes to boost the declining workforce. The split labour market characterised by high levels of unemployment for low-skilled workers and the shortage of skilled workers has also prompted action by changing immigration policies to attract flexible skilled foreign workers to re-energise the labour market.
In relation to medicine, globalisation will be a key driver of change; the movement of people and the skills shortages in Western nations have previously led to an influx of foreign doctors and nurses, with as many as 70 per cent being born outside the country they are currently working in.
Politics and legislation
Changing political alliances and legislation have also affected workforce trends such as the introduction of government initiatives to attract people back to work through training schemes, welfare to work programmes and the allocation of workforce grants to underdeveloped regeneration zones.
Rising public expectations due to the availability of new technology and medical advances has prompted service providers to ensure that the workforce is adequately trained to face these challenges.
Competition from the private health sector has encouraged the NHS to promote an equally cost-effective, quality service with its incumbent workforce implications.
National drivers for change
A number of government policy initiatives have had and will continue to have a significant impact on shaping our future service and workforce. These include:
- Commissioning a Patient-Led NHS (2005)
- National Public Service Agreement (PSA) targets (2003)
- 18-week Patient Pathway (2004)
- Independent Sector Treatment Centres (ISTCs), (2003)
- Payment By Result (2002)
- Impact of Technology and Research (1999)
- National Service Frameworks (2008)
- Our Health, Our Care, Our Say: A New Direction for Community Services (2006)
- Agenda for Change and Implementation of the Knowledge Skills Framework (2004)
- EU Working Time Directive (EWTD), (1993)
- Improving Working Lives (2000)
- Modernising Clinical Careers (2003)
- The NHS Plan (2000)
- The Vital Connection: An Equalities Framework for the NHS (2000)
- Working Together, Learning Together (2001)
Summary of trends and policy implications on workforce
In developing a strategy the NHS will have to take into account:
- An ageing workforce
- Choice and personalised care – promoting workforce diversity
- Delivering efficiency requirements (Independent Review of Public Sector Efficiency) – encouraging workforce productivity and efficiency
- Employment legislation – e.g. age discrimination
- EWTD and MMC – major workforce redesign, reducing service input from doctors and encouraging allied health professionals to take on new roles and responsibilities
- Feminisation of medicine – capacity for flexible training/career breaks
- Increasing use of technology (National Programme for Information Technology)
- National health improvement policies and managing chronic conditions – driving new roles for staff, increasing flexibility and communication between primary and secondary care
- Plurality of provision (ISTCs working alongside NHS hospitals) – increasing numbers of NHS staff working in or alongside private sector staff (staff secondments)
- Reductions in waiting times
- Speciality skills shortages
- Staff retention – identifying reasons for exit, promoting people management policies to encourage team-working, staff involvement and clinical leadership
- Workforce re-design for service delivery – promoting flexibility across organisations and within professional boundaries
- Work-life balance – part-time and flexible working, demanding good communication and effective hand-over
Strategies to ensure capacity: better recruitment
The performance of health services delivery systems is dependent on the performance of its health workers. An ideal situation for a performing health workforce would be one that is: “sufficient in number, distributed equitably in terms of skills mix, levels of care and geographical area, and one that is adequately trained and motivated to produce effective services in an efficient manner”. 
While the exponential increase in funding for the NHS has helped to achieve target by reducing waiting lists and waiting times a number of trusts continue to experience financial deficits and some patients are still experiencing delays. To maintain capacity in line with budgetary constraints, alternative methods of improving quality and productivity are being identified in parallel with reducing wastage and excessive costs through better human resource management, which represents the NHS’s greatest asset as well as its greatest cost.
Effective workforce planning involves (i) defining a plan based on the service and workforce drivers for change; (ii) estimating the current workforce supply by analysing workforce demographics, exit, retirement and retention rates; (iii) assessing service demands such as the required capacity to achieve 18-week waits, EWTD and work-life balances; (iv) and finally analysing the short-fall in capacity (a gap analysis) between the present workforce and our future needs. From this an NHS action plan would need to be developed with strategies for workforce transition with an inherent responsive audit (review) facility.
National and International Recruitment
In response to workforce trends, the recruitment and retention of a skilled/dedicated workforce maybe encouraged by promoting a learning environment, supporting personal and professional development to make the NHS an employer of choice within the local community and beyond. Seeking international recruitment after other less costly and time consuming initiatives have been exhausted, has also been explored.
Recruitment methods of job analysis, person specification and job description have been enhanced through the use of technology allowing for cost-effective and timely short-listing processes, possibly improving patient care as vacancies are filled from a wide applicant pool.
In response to the current challenges health authorities have also endeavoured to work in collaboration with external organisations such as further and higher educational institutions as well as employment agencies and the local community, to develop new working relationships and proactively seek new recruits. To intentionally develop a workforce that is representative of each local community, enhancing trust among patients and ultimately providing a better quality of care by encouraging diversity at every level.
Strategies to Ensure Capacity: Workforce Development and Retention
The changing demands of our service and the continual advances in medicine commit the NHS to encourage life-long learning and development for employees. The goal being to improve employee job-related competencies as a means of increasing employee confidence, motivation and performance.
Learning, training and development
Essential components of a training policy within a progressive learning organisation may consist of:
- the view that continuous training is the norm;
- the assumption that training is life-long;
- recognition of the need to update existing skills, replace redundant skills and train for new skills;
- the need for multi-skilling to cope with change.
However, whilst one can develop a capable workforce through increased training opportunities, retention strategies such as rewards schemes and flexible working have also been proven to encourage further commitment in industry examples.
In-order to continue to deliver and sustain local and national performance targets role re-design presents itself as a solution in managing the variation in capacity caused by skills shortages and medical workforce issues concerning implementation of the EWTD.
To address this, areas where service bottlenecks exists are identified and managed with the introduction of a new/amended role at that point, to allow release of clinical capacity enabling health providers to concentrate on providing direct patient care. The three main roles developed have been to extend administrative and clerical roles, develop assistant practitioner roles and create advanced practitioner roles from pre-existing experienced clinical professionals. For example, nurses and allied health professionals undertaking tasks previously assigned to doctors.
Development of leadership
Leadership is recognised as a key determinant in the success of an organisation and is particularly relevant to the public sector, which is under constant pressure to improve service delivery and cooperate more effectively.
The development of clinical leadership is likely to flourish by (i) setting clear goals on what kind of leadership qualities are needed in accordance with the goals and vision of the NHS; (ii) establishing a scheme to fund appropriate leadership training courses, to fund secondments and exchanges for varied work-experience within the region and (iii) to improve support for those clinical/non-clinical leaders currently in place.
Promoting a work-life balance
The key to attracting and retaining staff is to develop and promote flexible ways of working within an organisation, in tandem with the improving working lives strategy within the NHS plan.
Flexible working options, includes part-time working, flexitime, job share, term-time working, career breaks and flexible retirement schemes. The aim being to attract new staff and enhance the working lives of existing staff. As well as encouraging flexible working patterns, it is envisaged that the development of flexible working careers will assist in the retention of skilled, experienced staff by introducing secondments and role re-design.
The expectation being that these schemes will support the NHS in maintaining a work life balance which is right for the individual, will improve staff morale and ultimately maintain staff commitment to the service.
As forecast the health worker of tomorrow is likely to be older and female. Recruitment may become more difficult as the spectrum of opportunities for younger people grows, workers will have higher professional and economic expectations and so more labour conflicts may occur. Finally, as public expectations increases educational and training requirements will be higher and health workers will be held more accountable for the quality of services they deliver.
To ensure workforce capacity for increasing service demands in the face of an ageing population and to comply with EU legislation widespread role re-design and the development of a broad skill-mix will be sought after to substitute for the shortfalls in medical staffing making the previous historical roles between practitioners particularly doctors and nurses less distinct.
Further advances in technology and automation may partially solve the shortfall in staff, however greater expansion of technology and developments in remote monitoring and wireless communication is likely to create more of an emphasis on telemedicine with home-based monitoring, diagnosis and treatment bringing medicine back into our local communities.
Whilst the future for healthcare may look promising, our current goals within the NHS should be to smoothly ride the wave of change and in the process to create a long-term improvement culture that will improve patient flow, recruit and retain staff appropriately and embrace new technology in the face of unremitting service transformation.
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