Equipping NHS nursing, community and support staff with additional skills to deliver care is the best way to develop the capacity of the health service workforce, and will be vital to enable the NHS to cope with changed patient demand in the future. However, expanding the skills of the non-medical workforce in this way also presents big organisational challenges for NHS Trusts, and will not be easy to achieve in the current financial context. Despite this, changing staffing should be considered an urgent, ‘must-do’ priority for Trusts.
These are the conclusions of a new report, ‘Reshaping the workforce to deliver the care patients need’, published by the Nuffield Trust health think-tank today. The Trust was commissioned by NHS Employers to examine how best NHS staffing can be reorganised to support new ways of delivering care to patients – the authors conducted a survey of local Health Education England (HEE) leaders, examined a number of case studies around the country, convened an expert seminar, interviewed a wide range of stakeholders, and carried out a review of relevant literature.
The starting point for the report was the recognition there is a growing gap between what patients need and the skills and knowledge of the workforce that cares for them. When the health service was created in 1948, its role was largely to treat patients for one-off episodes of illness such as infectious diseases, and get them fit to return as quickly as possible to their daily lives and jobs. But the typical NHS patient in the 21st century is much older, frailer and sicker, often with multiple co-existing conditions, and likely to return numerous times to hospital. From the Five Year Forward View downwards, all agree that the NHS needs new and different models to deliver care to these patients – but how can we best reshape the workforce to do this?
The authors point out that there are three routes to workforce change:
- producing larger numbers of the same types of staff;
- developing the skills of the existing workforce;
- producing new types of workers
Traditional workforce planning, they observe, has focused on the first of these routes – but the long training times of the professional healthcare workforce mean that this is a costly, inflexible and slow solution. In addition, they argue that as doctors only make up 10 per cent of the more than 1.3 million-strong NHS workforce, the solution does not lie in changing medical school curricula.
Instead, they conclude that the best way to ‘grow’ the workforce is by expanding the skills of the existing non-medical workforce, in four main categories:
Firstly, the authors point out that the support workforce, which includes healthcare assistants, is large and highly flexible, while short training times mean that numbers can be expanded relatively quickly. There is good evidence that support workers can provide good-quality, patient-focussed care, as well as reduce the workload of more highly qualified staff. For example, Bradford District Care NHS Foundation Trust created the new role of ‘assistant practitioner’ in 2014 to carry out vital physical health checks, such as ECGs, on patients with mental illness, having realised they did not need qualified nurses to do this, but people who were competent to carry out physical assessments.
Secondly, the report argues that extending the skills of registered healthcare professionals, such as nurses, pharmacists, physiotherapists and paramedics, provides opportunities to manage the growing burden of chronic disease more effectively. The authors say there is some evidence that these new ways of working could release some savings and help bridge the workforce gaps that are forecast, particularly in primary care. For example, South East Coast Ambulance Service created a new role of ‘paramedic practitioner’ (PP) in 2006, after observing a significant shift in its workload from providing solely an emergency service to mainly dealing with patients with long-term conditions. The PPs train on an 18-month part-time course and an eight-week GP placement, assess and treat patients with chronic illness, and treat patients with minor illness and injury – often in their own homes.
Thirdly, the report concludes that advanced practice roles for nurses, ie those that require a further period of study, typically a two year Masters qualification, offer opportunities to fill gaps in the medical workforce; provide mentoring and training for less experienced staff; and offer a clinically-facing career option for experienced nursing staff. For example, Sheffield Teaching Hospitals NHS Foundation Trust developed the role of Advanced Clinical Practitioner (ACP) in 2006 to help fill growing gaps in junior doctor rotas. The Trust’s 70-80 ACPs work across a range of services, including critical care, operating theatres, A&E, renal and haematology services, and are expected to use expert knowledge for complex decision-making.
Finally, the authors examine the new role of physician associate , where non-medical staff who have studied on a two-year postgraduate degree programme work under the supervision of doctors and surgeons. They say that such staff open up a new workforce pool to the NHS – but that their potential numbers in the immediate future are small, and their impact is limited by lack of a regulatory framework, which prevents physician associates from prescribing and ordering tests.
However, the authors warn that reshaping the NHS workforce also carries risks. For example, they say that there is evidence that without careful role and service redesign, new and extended roles can increase patient demand, and cost money rather than save it.
They therefore identify 10 important lessons for organisations seeking to redesign their workforce, such as being realistic about the time and capacity needed to support change. In addition, the authors argue that the Health Education England (HEE) budget and specialist workforce planning expertise should be protected by ring-fencing monies to support local workforce design.
Launching the report, Candace Imison, report author and Nuffield Trust Director of Policy, said:
“Our research shows that reshaping the NHS workforce can offer huge opportunities – for patients, through improved health outcomes, and for staff, through more rewarding roles and better career pathways. But we stress in our report that this is not simply a ‘nice to do’ – it is urgent, and essential if the Health Service is to find a sustainable balance between available funding, patient needs and staff needs, and deliver services fit for the 21st century”.
Daniel Mortimer, Chief Executive, NHS Employers said:
“As the voice of workforce leaders in the NHS, NHS Employers commissioned the Nuffield Trust to have a thorough look at where we are in terms of workforce development, drawing on the already strong practice across the NHS. I am delighted with the final report, which explores where we can further develop our workforce to get the greatest benefit for patients and clients. Our challenge now is to take forward the learning and recommendations in the report.”