Building a Health Service Fit for the Future1 highlights workforce pressures as one of the drivers that will determine the shape of health care in Scotland over the next 20 years. The composition and skills of the workforce, the report states, will be 'the major determinant of how we are able to respond to…changes in demand'.
Great strides have been made in workforce planning in Scotland in recent years. Examples of progress include:
all NHS Boards now have a statutory duty to have arrangements for workforce planning in place and to collaborate across boundaries where appropriate
workforce development regions have been set up, with regional leads appointed to work with NHS Boards in the North, West and South-East of Scotland
a national lead for workforce planning has been provided through the National Workforce Numbers Group
a comprehensive NHS Scotland workforce information system has been developed to generate workforce data.
Workforce planning at NHS Board and Regional levels defines not only the nature of the workforce necessary to deliver high-quality services, but also informs national assessments for the supply of trainees. It ensures that any changes to numbers of under-graduate and pre-registration places on health professional training courses in Scotland are based on evidence from the NHS on its future workforce needs.
A range of initiatives has been developed to attract people into the NHS, including 'return to practice' schemes, incentive packages to encourage GPs to work in rural and remote areas and to attract dentists to work for the NHS, and fast-track pilot training schemes for radiographers. Once in the service, education, training and development opportunities are being supplied to give staff the support they need.
Significant investment has been made in pay modernisation initiatives, reflecting the Scottish Executive's commitment to rewarding staff fairly for the contribution they make. And care delivery is being redesigned through the development of new and extended roles for clinical staff. Non-doctor endoscopists, nurse-led cardiology clinics, minor surgery nurses, extended-scope physiotherapists and radiographers - these and many other roles are transforming the way in which services are delivered to patients, forging redesign of the clinical workforce and providing great opportunities for NHS staff to develop their skills and enhance their careers.
All this activity has played its part in securing an 11% increase in NHS staff numbers in Scotland since 1997.
The National Workforce Planning Framework 2005
The framework has been designed to take the work forward. It provides a template for developing the NHS workforce to meet the expectations set out in the Scottish Health Workforce Plan 2004 Baseline2 and the Scottish Executive's response to Building a Health Service Fit for the Future.
The framework is published in three parts:
this document, which provides an overview and outlines the future direction of travel
a Full Report, with greater detail on specific staff groups
a Background and Methodologies Annex, explaining what is behind the analysis; the annex is accessible on the internet at www.workinginhealth.com
The framework is not a recruitment and retention plan designed to meet immediate staffing pressures. Instead, it looks to the longer term, aiming to ensure that we can avoid in future the staffing pressures experienced all too frequently in the past.
It also recognises that perfectly aligning the future supply of staff with demand isn't possible, given constant developments in service provision and a mobile labour market. It therefore seeks to build mechanisms that will allow services to anticipate and respond effectively and quickly to changes in supply and demand.
2. Framework drivers and principles
The drivers for the framework can be split into three kinds - short-term, long-term and general. They give us a picture of the kind of workforce required for the future, and are shown in Table 1.
Table 1. Framework drivers
Targets and standards - the need to meet waiting times targets and standards.
Legislation - requirement to comply with new legislation such as the Mental Health (Scotland) Act 2003.
Training and redesign - the impact of Modernising Medical Careers, 3 a new set of training arrangements for the medical workforce, which will drive redesign of the whole clinical workforce.
Demographic changes - the greater proportion of older people in the population means a smaller pool from which to source the future workforce and an increased demand for care.
Changes in patterns of ill health - we can expect an increase in the incidence of long-term conditions.
Patient expectations - patients expect swifter access to services and more flexible, responsive services provided close to their homes.
Clinical standards - an increased emphasis on quality as well as volume of services.
Staff aspirations - staff want better working conditions to allow them to provide higher-quality care and secure a better work/life balance.
These drive evolutionary change and have impacts in the short, medium and longer term. They include:
pay modernisation - affects recruitment and retention, capacity and the design of services
service redesign - including new and developed roles for staff.
The framework adopts three principles against which to test judgements on supplying the future workforce:
affordability - we need to ensure that workforce planning projections are affordable and offer value for money.
availability - we need to ensure adequate sources of supply for the planned workforce, taking account of the overall labour market, competition for scarce skills and opportunities for inward recruitment; careers and posts must seem sufficiently attractive to people with the skills we require.
adaptability - we must ensure the planned workforce is trained and supported and that our workforce plans fit with those for service redesign.
3. Staff group assessments
The Full Report 4 offers detailed workforce analysis of different staff groups. Ambulance staff group were not analysed because that would duplicate the workforce planning being done by the Scottish Ambulance Service. Healthcare workers such as administrative and clerical staff, ancillary staff, senior management and trades and works staff are also not included as yet. We value the vital contribution these staff make to NHS Scotland and all these groups will form part of NHS Board and Regional Workforce Plans.
Changes to one set of staff may have knock-on effects on the roles played by others, and this should be factored into workforce planning and redesign at all levels.
Key conclusions are summarised here, with required actions.
Consultants, Staff and Associate Specialists, Doctors-in-Training
There will be a continuing shift from provision of care by doctors-in-training to provision of care by trained doctors.
Analyses show a generally good level of alignment between medical training-grade numbers and future consultant requirements across most medical specialties, but this will require adjustment year-on-year. Extra training-grade places have been targeted at specialties where an increased supply of consultants is needed and the Scottish Executive Health Department ( SEHD) is working with NHS Boards to support their plans for expanding the number of consultants.
Training-grade numbers have risen by 21% for specialist registrars and 28% for SHOs since 1997. The need to improve retention of training-grade doctors is being addressed by SEHD and NHS Education for Scotland ( NES). Modernising Medical Careers5 ( MMC), the major reform of post-graduate medical education, will have a significant impact on training-grade numbers and on the balance of the medical and non-medical workforce required in the future. This will need to be factored into Regional and NHS Board Workforce Plans later in 2005/06.
The Scottish Executive's response 6 to the Calman Review 7 confirms that it will provide for an extra 100 medical school places per annum by retaining medical students from St Andrews in Scotland.
General Practitioners ( GPs)
Building a Health Service Fit for the Future8 points to a shift in focus from acute care to community-based services that must be reflected in service and workforce planning.
The General Medical Services ( GMS) contract has changed fundamentally the way the workforce is deployed within GP practices by encouraging the development of multidisciplinary practice teams and looking towards an expanding contribution from non- GP members of the team.
Since 2003/04, the supply of GP registrars has been adjusted from 250 to 280 training places per annum. Further adjustments will be made in future years.
The Dental Workforce
The Scottish Executive has published an Action Plan9 for dental services and its action points, including those affecting the workforce, are being taken forward. Planning for the dental workforce needs to be developed in line with that for primary care services in general.
The target output from Scottish dental schools has been increased from 120 to 136 per year by 2006, with 143 per year anticipated by 2008 to improve the supply into vocational training for general dental practitioners.
In recognition of the important role of the wider dental team, courses have been funded to prepare a new professional role - the combined Dental Therapist/Hygienist. Numbers qualifying in Scotland will increase from 8 to 45 per year by 2010. Dental nurses and their training will be regulated for the first time from 2006, with initial target numbers set at 250 qualifying annually.
Nurses and Midwives
Great opportunities exist for the nursing and midwifery workforce to continue to develop clinical roles in the interests of better patient care and this must be reflected in service and workforce planning.
The Student Nurse Intake Planning ( SNIP) process provides a robust, bottom-up approach to projecting future demands for nursing and midwifery staffing. The number of students in training is now at an all-time high of almost 9,000. The intake figure of 3,500 for 2005/06 reflects the actual number that Higher Education Institutions have been able to recruit to in recent years.
The Scottish Forum for Healthcare Science provides a collective body for this workforce, which consists of some 46 sub-specialties. SEHD has funded a project that will include reviewing education and training routes into healthcare science to ensure future needs are met.
Allied Health Professionals ( AHPs)
The AHP workforce has grown by 27% since 1997, in line with increased demand. Supply is being supported by initiatives to retain existing experienced staff, including the development of a 'return to practice' scheme, provision of development opportunities for support staff and the development of advanced practice and consultant roles.
Steps have been taken to increase the supply of clinical psychologists and develop new roles for trained psychology graduates in response to increased demand. Clinical psychology training course intakes have increased from 32 in 2001 to 61 in 2005. There are now 161 clinical psychologists in training, compared to 96 in 2001.
SEHD is now working with the pharmacy profession, Schools of Pharmacy and Colleges of Further Education to ensure that sufficient numbers of registered pharmacists and qualified pharmacy technicians are available to meet NHS Scotland's needs. This includes reviewing skill-mix requirements in hospital and community pharmacy and examining how to use fully the skills of pharmacy technicians, dispensers and assistants.
4. Making it happen
Our vision is a patient-centred NHS that offers seamless services. This means making changes to fit around patients' priorities, rather than bending patients' needs and wishes to existing structures and systems.
Building a Health Service Fit for the Future10 approaches services by looking at patients' dominant needs over the next 20 years. It focuses on:
We need to plan the workforce to ensure it can meet the challenges this vision of NHS services presents. Workforce planning flows from service planning and must be fully integrated with it.
The importance of an integrated framework for workforce planning at National, Regional and NHS Board level is clear. The National Workforce Planning Framework 2005 is one element in a workforce planning cycle that will involve:
Regional Workforce Plans being produced by January 2006; NHS Boards in each region will be expected to work together and with their regional workforce leads to produce a Regional Workforce Plan that addresses work to be undertaken collaboratively across the region
NHS Board Workforce Plans being produced by April 2006; these will be part of local health planning processes and will provide assessments of the workforce NHS Boards need to underpin strategic service planning, in alignment with the relevant Regional Workforce Plan.
Regional and NHS Board Workforce Plans will provide projections of the workforce required to deliver services over the next 10 years. They will also offer proposals for relevant training packages, new and extended role developments and options for addressing misalignments between workforce projections and available supply.
Guidance will be issued to NHS Boards and workforce regions on the preparation of Regional and NHS Board Workforce Plans. From 2006, these plans will inform the production of the National Workforce Plan in December of each year.
5. Key actions
This National Workforce Planning Framework 2005 has set up a cycle of workforce planning to be undertaken at National, Regional and NHS Board level year-on-year. Action is now needed to make that happen - locally, regionally and nationally.
Actions will be monitored and reported in subsequent workforce plans at National, Regional and NHS Board level.
National level actions
1 SEHD will ensure that the workforce planning implications of the Scottish Executive's response to Building a Health Service Fit for the Future11 are taken forward with regional workforce leads, NHS Boards and stakeholders such as staff organisations.
2 The National Workforce Unit will oversee development of a robust evidence base for the primary care workforce and further develop workforce planning capacity. It will:
improve the collection of data on the whole primary care workforce
secure better intelligence on the contribution and work patterns of sessional GPs
align workforce planning for primary care with the Scottish Executive's response to Building a Health Service Fit for the Future.
3 The National Workforce Unit will continue to build capacity and capability for workforce planning in NHS Scotland. This will include roll-out of the Scottish Workforce Information Standard System ( SWISS) 12 in autumn 2005, promotion of a UK-wide competency framework for workforce planning, and an audit of training arrangements for workforce planning.
4 The National Workforce Unit will issue guidance in summer 2005 for the preparation of Regional and NHS Board Workforce Plans. It will also work with NHS Boards and regions to develop models and toolkits for workforce planning.
5 The National Workforce Unit will produce a National Workforce Plan by December 2006, informed by Regional and NHS Board Workforce Plans and reporting progress against actions.
6 SEHD will determine specialist medical training numbers (including GP registrar numbers), reflecting future consultant and GP requirements and the implementation of Modernising Medical Careers. 13
7 SEHD will address the workforce planning implications of developing new and extended roles in the workforce, taking into account published frameworks for role development 14 and evidence from Regional and NHS Board Workforce Plans on new roles.
8 The National Workforce Unit, working in conjunction with the Scottish Forum for Healthcare Science, will work to safeguard future capacity in smaller sub-specialties among the healthcare scientist workforce. They will also ensure that effective planning is in place to meet projected demand from regions and NHS Boards for larger sub-specialties.
9 SEHD will performance-manage delivery of NHS Boards' recruitment plans for their consultant workforce and will continue to support NHS Boards, where necessary, in recruiting to hard-to-fill posts and redesigning posts to ease recruitment and retention pressures.
10 SEHD will develop a better national evidence base to inform policies and strategies on improving retention of staff. This will include efforts to improve the retention of doctors-in-training and ensure a healthy supply of future consultants and GPs.
11 SEHD will explore developments and practice in workforce planning (clinical and non- clinical) outwith Scotland and will disseminate innovative approaches and solutions that will add value in NHS Scotland and, where appropriate, other areas of the public sector.
NHS Scotland actions
12 Each NHS Board and Region will produce a Workforce Plan to timetable and in line with guidance to be issued by SEHD.
13 NHS Boards and Regions should apply solutions to future staffing pressures identified through their workforce planning, including action on education and staff development and recruitment and retention.
14 NHS Boards and Regions should develop capacity by investing in dedicated workforce planning expertise, supported by the UK Competency Framework for workforce planning.
15 NHS Boards and Regions should ensure that workforce planning is effectively integrated with arrangements for service planning (and redesign), and financial planning, and that it links appropriately with arrangements for planning education and development of staff. The integration betweeen these elements should be demonstrated in NHS Boards' and regions' workforce plans.
16 NHS Boards should have effective local functionality for their workforce information requirements and should commit fully to inputting and maintaining workforce data for SWISS. Information should include real-time workforce data on issues such as vacancies, specific pressure points, turnover, stability and recruitment rates, and should be regularly monitored by senior management. Interim arrangements may be required by NHS Boards' prior to the full development of SWISS.
17 NHS Boards must monitor vacancies in all staff groups and take action on long-term vacancies through, for example, redesign of posts and/or services. This is a key priority which will be actively performance-managed by SEHD.
18 NHS Boards should ensure that work on improving absence rates and increasing productivity levels is factored into their workforce planning, along with other actions aimed at improving efficiency and effectiveness of services.
19 NHS Boards should continue to contribute to meeting Partnership Agreement commitments for consultants, dentists, nurses and allied health professionals. Specifically, NHS Boards should deliver on agreed recruitment targets for consultant expansion.
20 NHS Boards should continue to plan and prepare for the full implementation of the Working Time Regulations in 2009, taking action where necessary by, for example, using solutions such as the 'Hospital at Night' initiative.
Much has happened in taking forward workforce planning for the healthcare workforce since the launch of the Scottish Health Workforce Plan 2004 Baseline15 in April 2004. There is still much to do.
NHS Scotland's key asset is its staff. It is vital that we use effective strategic workforce planning, fully integrated with service planning, to ensure that the service has the right people, with the right skills, in the right place, at the right time.
The National Workforce Planning Framework 2005 will enable NHS Scotland to anticipate movements in the workforce and respond quickly and flexibly to complex changes in workforce supply and demand. In so doing, it will play a vital role in providing a modern workforce, in a modern NHS, for a modern Scotland.