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Scottish Health Workforce Plan - 2004 Baseline

2 Setting the scene: A changing NHS - a changing workforce

A number of developments have brought workforce issues centre-stage for the NHS in Scotland and across the UK. These are driving current trends on workforce numbers and are creating a number of short- to medium-term pressures on costs and capacity. They have major implications for the way in which services are designed and delivered, and for NHS resourcing given that some 70% of NHS costs are tied up in staff pay.

Demographic and lifestyle Demographic and lifestyle changes

NHSScotland is Scotland's largest employer and is therefore heavily influenced by developments in the labour market and by factors impacting on recruitment and retention of staff. A key shift is the increasing proportion of women in the workforce in areas which have traditionally been male-dominated. Some 60% of the medical student intake in Scotland is now female, and this has major implications for medical workforce numbers, given the greater tendency for women to seek flexible working patterns.

Scotland's population is declining and ageing and, in a shrinking Scottish labour market, attracting staff into the NHS in the face of competing sectors will become increasingly important. Although financial reward is an important factor for individuals joining and staying with NHSScotland, other key factors are: vocational commitment, flexible working conditions, the opportunity for self-development through quality training and learning; employer/employee relations; and a high calibre professional environment.

Demographic and lifestyle changes suggest that flexibility of working patterns and the quality of the working environment will become increasingly prominent factors in recruiting and retaining staff.

Integrated team working and new roles

A central thrust of health policy is the delivery of a patient-centred approach to care - that is, to fit NHS processes and structures around the needs of the patient, rather than fitting the patient around the needs and constraints of existing NHS systems.

This approach seeks to overcome barriers between social, community, primary and acute care sectors, allowing patients a more seamless progression from GP surgery or social work/community setting to acute hospital, or vice versa. It also goes hand in hand with efforts to keep patients as much as possible out of hospitals and in local community settings, extending the ambit of GP practice-led primary care, promoting preventive health strategies, and encouraging the principle of domiciliary care.

That emphasis on integration and community-based care argues for the development of integrated multi-disciplinary teams, covering a variety of new clinical roles that go beyond the traditional reliance on "doctors and nurses". For example, instead of seeing a doctor or dentist a patient may be seen by a nurse endoscopist, a therapy radiographer, a nurse practitioner, a dietician, a physiotherapist or a dental therapist - working as part of a wider team. Or they may be advised by an "NHS24" nurse on the end of a telephone.

Fundamental to maximising the contribution of this multi-disciplinary team is the Health Care Support Worker, a developing role within health and social care. We need to do more nationally to support the emergence, integration and contribution of this new and important role.

Multi-disciplinary teams are best established in line with the patient pathway of care and may be made up of a core team with others inputting when patient need dictates. Such teams are rich in skill and expertise which complement each other and are led by a team leader who is not necessarily a doctor.

This model aids delivery of care in rural and remote settings and is applied increasingly through teams that straddle traditional health sector boundaries - for example, hospital-based geriatricians may link with practice nurses to manage chronic disease in the community.

These developments have significant staffing consequences and raise some challenging issues:

• a need to forge new roles for staff and to increase the numbers of staff in the Allied Health Professions and in primary care;

• multi-disciplinary teams spread responsibility and leadership more widely - this can be culturally and professionally challenging for traditional leaders (such as doctors); and

• gaining public acceptance of new roles and team-based working can be difficult when patients equate quality service with access only to the doctor.

Health and safety and quality care

There has been a major effort in recent years to improve the health and safety of staff and the quality of care provided to patients. Most significantly, the hours limits introduced by the New Deal contract and the Working Time Directive are reducing the amount of service provided by hospital-based doctors-in-training, as well as reducing hours of work, where necessary, for other NHS employees. This leads acute services towards a more consultant-delivered model of care, where the ratio of consultants to doctors-in-training is greater; where consultants are more directly engaged in emergency and routine day-to-day care; and where doctors-in-training develop their skills through more structured, higher quality training, compared to the "on the job" supervision they currently receive. Work traditionally done by doctors-in-training is also now increasingly being carried out by specially trained healthcare professionals operating in more integrated teams. For example the taking of blood is now often carried out by Phlebotomists rather than Pre-Registration House Officers.

Scotland has a higher ratio of doctors-in-training to consultants than England, and our ratio has increased in recent years. The Modernising Medical Careers reforms of doctor training grades will, from August 2005, progressively introduce more structured training pathways for doctors that allow working time compliant training/working patterns, produce trained doctors more quickly, and provide a platform for further specialisation amongst trained doctors. These reforms will have a major impact on the service delivery capacity of doctors-in-training, on the speed of the consultant supply chain, and on the ratio of trained doctors to doctors-in-training.

These developments and others, such as demographic changes and new technology, are driving major service redesign and key changes across the UK:

• An expansion of consultant numbers and non-medical staff (nurses and Allied Health Professionals), as activity traditionally carried out by doctors-in-training is redeployed to those staff groups.

• A continuing increase in doctors-in-training (to ensure continuing supply for an expanding consultant cohort).

• The introduction of new contracts for doctors-in-training, consultants and GPs designed to accommodate the working time limit of 48 hours per week, address the burden of extended out-of-hours/on-call commitments, underpin and extend the role of primary care, and enable more efficient delivery of safe and effective services.

Pay modernisation

Since 1999, pay systems for almost all NHS staff and for many independent providers have been fundamentally reviewed and renegotiated. This programme of pay modernisation, by far the largest change programme for NHS staff ever mounted, is a response to the developments described above and a reflection of the Executive's commitment to recognise the vital contribution made by the workforce. Pay modernisation is a powerful tool to help drive reform of the NHS and to improve its delivery through redesign and better team working. It does this by seeking to invest in NHS staff through better management of workload, greater flexibility, fair reward and opportunities for development, thereby ensuring continuing recruitment and retention of staff, improved morale, and a platform for securing the increased numbers required. It also seeks to promote ways of working which will deliver benefits through more effective patient-centred care, better value for money, and beneficial redesign of services.

The key current strands of pay modernisation are:

• The New Deal contract for doctors-in-training, agreed in 2000 across the UK. This is driving down the working hours of doctors-in-training and having a far-reaching impact on the organisation of hospital services and working patterns.

• The new GMS contract, which introduces a local contract between NHS Boards and each GP practice team, rewarding practices for delivering quality outcomes in their treatment of patients. This will also manage GPs' workload by allowing them to opt out of certain services, including out-of-hours services, if they so wish, and it will introduce salaried GP options.

• The new consultant contract, which will take a more managed approach to the scheduling and organisation of a consultant's activity, through explicit agreement between consultant and manager of all of a consultant's weekly activities. Like the New Deal contract this is designed to accommodate the hours limits set by the Working Time Regulations. For the first time it will link consultants' pay progression to the achievement of objectives agreed with managers, and will fairly recognise the on-call and out-of-hours commitments provided by consultants.

• Agenda for Change is the new UK-wide pay system designed for most NHS staff other than very senior managers and staff within the remit of the Doctors' and Dentists Review Body. This is still subject to further ballots to be held by UNISON, Amicus, Society of Radiographers and the T&GWU later in 2004, following which, if approved, it will be rolled-out across the UK. Agenda for Change introduces a system of job evaluation which rewards staff for the role they are carrying out rather than their job title, and provides an agreed process for assessing the worth of new roles. It also establishes a Knowledge and Skills Framework that allows individuals to extend their skills and design new roles to respond to changes in service delivery. A key aim of the Agenda for Change NHS pay system is to provide - through job evaluation - a platform for developing staff into new roles that aid team-based delivery of care.

Securing and retaining the workforce

At UK level, Scotland is competing in an increasingly tight NHS labour market, with recruitment drives being mounted in England and in other parts of the UK, and more widely in the European Union. We risk losing more healthcare staff south of the Border than we gain. There are particular and perennial challenges in recruiting and retaining staff to work in rural and remote areas.

The NHS uses not only its own facilities for training, but also the independent, private and to some extent the voluntary sectors as well. With its strong medical school/teaching hospital base Scotland generates a healthy supply of doctors-in-training, but does less well in keeping hold of those doctors-in-training as they become consultants. Many are English-domiciled and therefore naturally look south of the Border when they reach consultant grade, or before. NHSScotland needs to capture and better understand cross border flow in securing and retaining not only the medical but other sections of the clinical workforce.

New Nursing and Midwifery access routes are being developed to allow maximum
step-on/step-off options throughout the career path. Scotland has also developed innovative Clinical Psychology training programmes designed to provide flexible options and placement opportunities in order to retain this important section of the workforce. There are also examples of fast track training for Allied Health Professionals where this accredited programme builds on previously gained qualifications.

Scotland's declining population puts extra pressure on recruitment and retention, and while increased pay will provide incentives for working in the health sector, it is arguably more important that NHSScotland employers seek to retain and attract staff by offering leading-edge packages that take into account career development prospects and work-life balance considerations.

Within the framework set out in the Workforce Strategy, a major new Careers for Health initiative is being rolled out. This information campaign promotes the variety of career options available in the NHS. Furthermore, central support is being made available for a programme of retention and recruitment measures.

Partnership Agreement Commitments

Significant increases in the short term are required across all staff groups, and these are reflected in the Executive's Partnership Agreement commitments - see box opposite.

More details on the Partnership Agreement commitments and on progress to date are provided in Appendix A.

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