Coronary Heart Disease and Stroke: STRATEGY FOR SCOTLAND
4 Workforce Issues
43. The effective implementation of the CHD/Stroke Task Force recommendations will require a substantial increase in the numbers of specialist nurses, Allied Health Professions (AHPs), technicians, pharmacists, intermediate specialists, cardiologists and cardiac surgeons who deliver cardiac services. The Reference Group believes that this will be difficult because there are currently very few suitable people in Scotland
with the appropriate training to fill such new posts. The recruitment and retention of consultant cardiologists is already creating problems for the service; for example, four Trusts have recently advertised for, but have been unable to appoint, a new consultant cardiologist, while three senior cardiologists have left to work abroad. Implementing the Task Force recommendation to appoint an additional 30 consultant cardiologists throughout Scotland will therefore be extremely difficult in the short term.
44. For nurses, opportunities in postgraduate training in the care of those with CHD are limited, and the development of local training programmes would support basic CHD care skills as well as specialist skills. The development of nurse and AHP consultant posts would support local initiatives, and could be pivotal in developing the non-medical contribution to CHD service developments.
45. Clinical Perfusion Scientists ('perfusionists') are blood circulation specialists who fulfil a unique role in cardiac surgery. S/he controls cardiopulmonary bypass equipment that replaces the functions of the heart and lungs during surgery, maintaining the patient's circulation. As Clinical Perfusion is a distinct discipline, one of SCIN's responsibilities will be to ensure appropriate training opportunities, and that existing perfusionists are optimally deployed within the Network.
46. The CHD/Stroke Task Force Report was clear that stroke units had to be adequately staffed with appropriately trained health professionals. Currently there are not enough stroke physicians to lead services, and maintaining these depends on borrowing sessions from other specialties. In the interests of patients, there need to be at least two individuals in each district if proper cover is to be provided.
47. There are at present only four or five designated stroke physicians in Scotland, located in the teaching hospitals, who provide dedicated services. The majority of sessions elsewhere are provided by geriatricians and neurologists who have an interest in stroke. While there is a need to increase the number of physicians with an interest in stroke, particularly because of the need to develop stroke unit care, increasing the numbers alone will not address issues such as cross cover between sites, or cover for periods of sickness and annual leave. It is clearly in the interests of patients that this situation should be ended. One possible solution is to increase the number of sessions clinicians undertake, but it is not clear who would provide these extra sessions. The first tasks of the National Advisory Committee on Stroke should therefore be to:
establish the current position in terms of who is contributing how many sessions to stroke care;
clarify the total number of sessions needed overall;
quantify the impact on other services of providing the number of sessions required for stroke care; and
to make recommendations on how these issues should be addressed.
48. An increase in the number of Stroke Medicine Specialist Registrar training posts will allow sub-specialty training and expansion of consultant posts. This will ensure clinical leadership for development of local stroke services, effective service delivery in terms of the health gains from stroke unit care, and the appropriate introduction of secondary prevention measures for transient ischaemic attack (TIA) and stroke. The shortages in overall numbers of trained nurses, AHPs and clinical psychologists available in Scotland must be addressed. There needs to be a particular emphasis on the post-graduate development of competencies and education.
49. Opportunities in postgraduate training in stroke care are limited, and development of local training programmes would support basic stroke care skills as well as specialist skills. The development of nurse and therapy consultant posts would support local initiatives, and, as in the case of CHD, could be pivotal in developing the non-medical contribution to stroke service developments.
50. Initial work arising from the AHP Framework, Building on Success (June 2002), includes the funding of additional student places for four priority areas (physiotherapy, occupational therapy, radiography, and speech and language therapy). Helpful developments include a career convention in the autumn of 2002 to promote AHPs, and the appointment by the Department of an AHP professional officer.
51. The Reference Group recognises that much of NHSScotland faces similar problems in terms of workforce numbers, and that introducing initiatives that are designed to attract healthcare workers to the fields of CHD and stroke may create grave staffing problems in other parts of the service. At the same time, though, one of the principal attractions of MCNs is their potential to make more efficient use of the workforce generally. The wider issues of healthcare workforce planning in Scotland are being actively addressed, in particular through the recent publication Future Practice - A Review of the Scottish Medical Workforce and Working for Health - the Workforce Development Action Plan for NHSScotland. This follows on from the Executive's response to the report of the Scottish Integrated Workforce Planning Group, Planning Together, and outlines a series of actions to be undertaken to make workforce development more effective, including the establishment of a new National Workforce Committee and National Workforce Unit within the Health Department.
52. The Reference Group believes that implementation of the following will be key to successful workforce planning for CHD and stroke, and recommends that:
SEHD/NHS Education for Scotland introduce an immediate and substantial increase in the number of training posts so that by December 2003 there are:
there is further development of multi-disciplinary working:
for multi-disciplinary team working to progress, all staff will be required to have the relevant competencies, skills and knowledge. NHS Education for Scotland should therefore establish core competencies for all professions dealing with CHD and stroke by December 2003;
MCNs should consider the creation of consultant therapist and specialist nursing posts to promote cardiac and stroke services in line with evolving service developments;
NHS Education for Scotland should ensure that by December 2003 there are organised training schemes for non-medical staff to develop both general and specialist skills in CHD and stroke care.
53. There should be links between all MCNs and the new machinery being set up to promote workforce developments:
the Regional Workforce Groups (which will relate closely to Regional Service Planning arrangements), covering the North, East and West, which will provide a crucial direct link to service planning; and
the National Workforce Committee, which will oversee planning of numbers for all professional staff groups, based on evidence gleaned through Regional Workforce activity.
54. The Reference Group notes that in taking forward implementation of The Right Medicine, the strategy for pharmaceutical care in Scotland, the Scottish Executive Health Department will, during 2004, create Clinical Pharmacy Leaders to support the extension of pharmaceutical care in the priority areas of CHD and stroke.
55. The new contract framework for general practice, currently subject to national negotiation, proposes a quality and outcomes scheme which is likely to include quality programmes for CHD and stroke. The objective of these programmes is to enable and encourage practices to assess and improve quality of care in the secondary prevention of CHD and stroke. Criteria developed relate to all patients with CHD and stroke, whatever their age.
56. The draft scheme outlines a series of phased clinical quality markers that can be achieved by practices. These will progress from the entry level of building and maintaining an accurate computerised disease register of patients with CHD and stroke through successively more demanding standards until the premium level is achieved by the delivery of every standard to the highest possible level. Standards will relate to appropriate drug therapy (aspirin, beta blockers, ACE inhibitors and statins), lifestyle modification (smoking, diet, alcohol and physical activity) and risk factor management (cholesterol, hypertension and obesity). A very similar programme has been developed independently as a component of 'Have a Heart Paisley'.
57. While recognising that the new general practice contract is still subject to negotiation, the Reference Group endorses its proposals for secondary prevention of CHD and stroke, since these are consistent with, and underpin, a number of the Reference Group's key aims:
filling the gap in data about management of patients in the community;
helping to roll-out the lessons from 'Have a Heart Paisley';
paving the way for practices' participation in local Managed Clinical Networks; and
promoting the roll-out into primary care of the standards developed by CSBS for secondary prevention following AMI.