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Scottish Health Workforce Plan - 2004 Baseline
4 Redesigning the clinical workforce: Why change is needed
The forces affecting the workforce are numerous and the relationships between them are complex. Nevertheless, to manage workforce planning and development effectively it is essential that we understand and respond to these dynamics.
In order to develop a framework that is manageable and understandable, it is helpful to streamline the issues and variables. The following diagram outlines the various drivers, in three key clusters: Quality, Capacity, and Resource.
The relationship between the three key components can be expressed as:
We can expect pressures to increase service quality to continue and to result in further pressure on capacity, including the size and composition of the workforce. This in turn is subject to the overall availability of resource and affordability.
In this environment, success in the future for NHSScotland depends not only the total resource available, but also on gaining the best value from the use of those resources, including optimal use of skill and better use of information, communication and technology.
Redesigning the clinical workforce: optimising capacity
Safe and effective care is dependent upon staff who are equipped to deliver high quality care. The New Deal and European Working Time Directive are two key drivers which assist in achieving this end, but not without an impact on capacity. In Chapter 2, the various challenges the NHS workforce faces were described. Skill mix is one means of managing these challenges: developing the skills of staff so that they can contribute to service as flexible members of integrated, multi-disciplinary teams.
This section has three objectives:
it quantifies the historical effect of the New Deal on doctors-in-training hours and service capacity;
it defines skill mix and describes different skill mix change options; and
it provides some preliminary analysis exploring some of the implications of skill mix and shift, looking across traditional professional boundaries.
The shift of the balance of care from hospital to primary and community based services will require more detailed analysis of the workforce requirement. This will assist in evaluating options for the provision of seamless, integrated services.
Workforce capacity has been defined in terms of total available hours.
4 Since 1998, the European Working Time Directive (WTD) has applied to all staff, excluding doctors-in-training who are currently covered under the New Deal. The following tables summarise the working time rights and protections for staff.
All Staff (excluding Doctors-in-Training):
Table 14: Summary of Working Time Rights and Protections
a limit of an average of 48 hours per week which a worker can be required to work; a limit of an average of 8 hours work in 24 hours which night workers can be
required to work; a limit of an absolute 8 hours where the work has been risk assessed to identify
special hazards; a right for night workers to receive free health assessments; a right to 11 hours rest per day; a right to a day off every week; a right to a rest break if the working day is longer than 6 hours; and a right to 4 weeks paid leave per annum.
|
Doctors-in-Training: Working Time Regulations Timeline
Table 15
Date | Average Weekly Working Hours |
August 2004 | 58, New Deal contract limit of 56 applies |
August 2007 | 56 |
August 2009 | 48, European WTD applies |
To introduce an element of forward focus, we provide a simple view of future capacity taking into consideration some of what we know today, such as the implementation of the European WTD for doctors-in-training (limiting the work week to 48 hours), the commitment to increase Specialist Registar (SpR) numbers and the Partnership Agreements for increased nurses, doctors and AHPs.
The Effect of the New Deal on Capacity in Terms of Hours
The hours limits imposed by the Working Time Regulations and the New Deal contract are reducing the amount of service provided by hospital-based doctors-in-training and have redefined average weekly hours per junior doctor over the last 10 years.
The following graph indicates that while there was an increase in total available hours provided by doctors-in-training between 1993 and 2000,
5 total available hours remained stable between 2000 and 2003.
Estimates for 2006 and 2009 have been provided and reflect the Executives continuing commitment to increase the SpR headcount by 375 and the effect of Working Time Directive when the 48-hour limit applies in August 2009. For this simple forward view, all other variables remain constant.
Chart 17: Total Available Weekly Hours from Doctors-in-Training
Understanding What is Driving the Trend
There are two key drivers of the historical trend: average weekly hours per junior doctor and headcount. The following two graphs show that while average weekly hours per training doctor have declined consistently for all doctor-in-training
6 grades over the period, headcount increases vary depending on the training doctor grade and rates of change vary over the 10-year period.
Chart 18: Average Weekly Hours per Doctor-in-Training by Grade
Chart 19: Headcount by Grade Over Time
What is the Effect on the Doctors-in-Training Mix?
As a result of the historical trends in these two variables (average weekly hours per training doctor and head count), the mix of total hours has also changed.
Initially, there has been an increase in the total hours provided by the registrar group
7 while hours provided by the SHO grade are reduced. Latterly, there has been a dominant increase in SHO hours while hours provided by PRHOs have reduced.
Chart 20: Mix of Hours by Grade Over Time
Chart 21: Change in Total Weekly Hours by Grade
The following two graphs separate out the respective contributions of each factor (reduction in average weekly hours per training doctor or change in headcount) and show which factor is driving the change in mix referred to above.
Chart 22: Change in Total Weekly Hours 93 to 00 by Grade
Chart 23: Change in Total Weekly Hours 00 to 03 by Grade
As a result of implementing the New Deal for doctor-in-training hours, the previous trend of increasing total hours demonstrated in the earlier half of the decade stabilised. However, recent strategies to reduce average weekly hours per training doctor have focused on recruiting to the SHO group.
What Other Factors Play a Part in Defining Training Doctor Capacity in the Future?
The potential effect of the EWTD is to reduce junior doctor total available hours further when the 48 hour per week rule is implemented. Modernisation of Medical Careers (MMC) may also influence training doctor contribution to service delivery.
The NHS has traditionally relied on doctors-in-training for day-to-day delivery of service; the training of junior doctors has been a practical working apprenticeship over long hours with relatively little supervision.
The objective of Modernising Medical Careers (MMC) is to improve the quality of services by improving the quality of training. An effect of the MMC initiatives may be to further reduce the training doctor time available for service delivery. This, coupled with the effect of the New Deal implementation previously discussed presents an opportunity to explore new ways of working.
The potential for other healthcare professionals developing their roles to encompass responsibilities traditionally considered the role of doctors-in-training can be explored. Likewise, clinical support staff
8 may take on responsibilities that will release the other healthcare professionals to take on the new duties. These shifts of responsibilities and duties must be reinforced and supported by the professions, regulatory developments, suitable training and development and ongoing clinical governance. Skill mix change and multidisciplinary working are complementary. Both are supported by addressing the specialist/generalist mix, defining new roles and new types of workers with clarity about who does what in the process of care, and inter-professional training.
Defining Skill Mix Change
Skill mix change can be defined as change in the mix of staff employed, the tasks allocated to each worker and the skills possessed by those staff. One way to measure skill mix change is to monitor changing staff inputs used to produce services over time.
The following table defines skill mix change options and provides some examples. The seven different types of skill mix change are identified as either having a shorter or longer implementation timescale. Typically, substitution and delegation can be achieved in a shorter timescale as the activities and staff involved are already defined and existing; the boundary between each role requires to shift. The other skill mix change options involve a greater degree of development and therefore require more implementation time.
SKILL MIX CHANGE OPTIONS
Timing of Impact | Type | Definition | Example |
Shorter Term | Substitution | Expanding the breadth of a job by working across professional divides or exchanging one type of worker for another | |
Delegation | Moving a task up or down traditional uni-disciplinary ladder, change ratio of junior to senior staff mix | |
Longer Term | Expansion | Increasing the depth of a job by extending the role of skills of a particular group of workers | |
Innovation | Creating new jobs, introducing new type of worker | |
Transfer | Moving the provision of the service from one health sector to another | |
Relocation | Shifting the venue from which service is provided from one health care sector to another without changing the people who deliver the services | |
Liaison | Using specialists in one health care sector to educate and support staff working in another sector | |
Analysis of Skill Mix Across Professional Boundaries
The following analysis reviews the available weekly hours for nursing and midwifery staff (N&M) and clinical support staff
9 as well as doctors-in-training. Total N&M and clinical support hours have been used including contracted hours, bank, overtime and agency hours in order to present total registered nursing and midwifery or clinical support staff time.
10
Over the period between 1993 and 2000, total available weekly hours remained constant and increased in the period from 2000 to 2003 (see chart 24). The increases from 2003 to 2009 reflect the effect of following:
partnership agreement increase in registered nurses
11
commitment to deliver the balance of 375 additional SpRs and
reduction in doctors-in-training hours to 48 hours in 2009.
Throughout the time period, the skill mix remained largely constant with a shift latterly to more hours provided by the registered nursing and midwifery group (see chart 26).
Chart 24: Total Available Weekly Hours (000s): Training Doctors, Registered N&M and Clinical Support Staff
Chart 25: Total Available Weekly Hours (000s): Training Doctors, Registered N&M and Clinical Support Staff
Changes in the available mix from 1993 to 2000 (see chart 26) were driven by the following factors:
a reduction in clinical support staff
an increase in doctors-in-training hours due primarily to increases in registrar group headcount as previously demonstrated and
an increase in registered nurse and midwifery hours driven by increased headcount.
In the following period (2000 to 2003) we have already demonstrated that total training doctor hours remained constant through high recruitment to the SHO grade. Registered nurse hours increased primarily through increased head count and clinical support staff increased reversing the trend from 1993 to 2000. The shift to a greater mix of registered nurse hours continues beyond 2003.
Chart 26: Change in Total Available Hours (000s) by Skill Group
Chart 27: Change in Registered Nurses Total Substantive Weekly Hours (000s)
The above analysis suggests that skill mix shift is already taking place: registered nurses are expanding their role to include duties traditionally considered the responsibility of doctors-in-training and clinical support staff are taking on some responsibilities previously assumed by registered nursing staff.
Widening the concept of Skill Mix to all Staff Groups in the Hospital and Community Sector
Traditionally, skill mix has been considered in terms of one profession largely reflecting the grade mix within that profession. The previous analysis explored the opportunity to look across professional boundaries and specifically looked at doctors-in-training and nursing and midwifery and clinical support staff.
Given the move to delivering high quality care through an integrated team, it is important to consider the full workforce skill mix. As a result, consultant and non consultant career grade doctors (NCCG) as well as allied health professional hours should also be included in this skill mix analysis, as the challenge of increasing the capacity of the consultant and NCCG skill pool is likely to present opportunities to share duties between consultants, senior nurses, and senior allied health professionals.
MMC is considering proposals that NCCG doctors can re-enter training to become a consultant. The full implications of MMC require to be modelled, however for this example of skill mix analysis, we will assume that 50% of the NCCG doctors return to training to become a consultant. This along with grouping all health care clinical support staff
12 together allows an evaluation of skill group
13 mix historically.
The following radar graph (chart 28) and bar graph (chart 29) demonstrate historical and future trends for skill group mix and change for three points in time: 1993, 2003 and 2006. 1993 is used as the baseline for comparison for the skill mix change radar graph.
Over the past 10 years, the radar graph indicates that the skill groups with the greatest change relative to the 1993 baseline are: the consultants and NCCG doctors and qualified scientific and professional staff. The health care clinical support staff group and registered nursing and midwifery remain virtually unchanged over the period.
Taking into consideration the Partnership Agreement commitments for consultants, registered nurses and qualified allied health professionals, the skill mix and change position is presented for 2006.
The radar graph indicates that the 1993 to 2000 trend is continued: the greatest changes occur for the consultant and NCCG group and the qualified scientific and professional skill group. Over the 1993 to 2006 period, the change results in a slight shift in the total mix as demonstrated in the total mix bar graphs for the three reference dates: 1993, 2000,
and 2006.
Chart 28: Change in Skill Group Relative to 1993 Baseline
Chart 29: Mix of Skill Group Relative to Total over Time
Conclusion
This analysis has investigated skill mix changes within the Hospital and Community Sector from 1993 to 2003 and has projected forward, on the basis of some known changes, to 2006 and 2009.
This analysis provides evidence for the skill mix change we understand is already occurring. It also provides an approach for understanding the effect of these changes and projecting them forward. Overall, the skill mix shifts are significant, but complex. The value, however, of multi-professional analysis is clear.
The challenge for NHS workforce planners is to establish the relevant mix for the next
10 years and to establish the plan to achieve that mix. Ideally, we should define the target mix and monitor our progress towards that target over time. To establish this target will require engagement of staff and management at all levels. The target definition will also require answers to a number of questions, including the following:
What is the long-term service vision?
What is the impact of Pay modernisation (GMS, consultant contracts and Agenda for Change) on employee behaviour, e.g. productivity, effectiveness, recruitment, retention, returning to work, work-life balance, career progress, career flexibility?
What is the impact on Modernisation of Medical Careers on the medical skill mix, workforce mix, specialist and generalist balance, primary care or secondary care career choice decisions?
What is the impact of Partnership Implementation Network (PIN) guidelines covering various topics such as family-friendly policies on employee behaviour, e.g. recruitment, retention, work life balance?
What is the impact of new ways of working on the workforce in terms of recruitment, retention, workforce, life balance, contribution, career progress, career flexibility, productivity and effectiveness?
What has been, and will be, the impact of the recruitment incentives put in place?
What is the impact of the workforce dynamics increasing and relieving pressure outlined in Chapter 2?
Achievement of future skill mix targets will require support and acceptance by many stakeholders, including the professional bodies and the public.
In the next section, The Way Forward, the proposed approach and timescales for addressing these questions are set out.
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