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3 Workforce Planning by Staff Group

3.1 Introduction

This chapter describes the outcome of the national workforce planning analysis undertaken for the following staff groups:

• Consultants, Staff and Associate Specialists, Doctors in training

• General Practitioners

• Dentists

• Nurses and midwives

• Healthcare Scientists

• Allied Health Professionals

• Clinical Psychologists

• Pharmacists

A Workforce Numbers Group was established in 2004 to consider and advise on the development of workforce planning for healthcare (with representatives from across the service and other interested parties). Other staff groups including administrative and clerical staff, ancillary staff, ambulance service staff, senior management, trades and works staff, have not been prioritised by the Workforce Numbers Group for assessment in this year's national publication. The vital contribution these groups make in NHS Scotland should form part of NHS Board and regional workforce plans. In addition work is currently taking place regarding the widening of the healthcare support workers agenda, both in NHS Scotland and on a UK basis within the Foster Review Group. ¹⁹ The Review group is looking at regulation of non-medical healthcare professionals and support workers, including staff working in new roles and support staff not regulated at present. These staff will play an increasingly important role in the clinical team as the work of nurses, midwives and doctors is redesigned. In the chapters in Section 2 of this report we describe how we are building capacity for workforce planning to expand to all staff groups and professions.

For each of the staff groups/professions we provide an assessment of:

• the demands for that part of the workforce;

• the supply and the current shape of the workforce.

3.2 The Medical Workforce - Consultants, staff and associate specialists, doctors-in-training

DEMAND

3.2.1 Waiting times targets and standards

To meet existing waiting times guarantees and achieve the shorter times announced in Fair to All - Personal to EachNHS Scotland will need to increase outpatient and inpatient activity beyond previous levels. Productivity gains will produce extra activity but additional staff resources are also likely to be required. This section on waiting times provides estimates of the additional consultant capacity required to meet waiting time targets, using historic productivity rates. This does not take account of new ways of working nor service redesign and improvements in productivity rates. It is important to note, however, that productivity improvements may lead to an improved quality of service rather than increased throughput, and therefore may not directly reduce the demand for workforce. This reflects the fact that consultant productivity is a function of complexity as well as volume of treatment - a relatively low throughput of complex treatments may demonstrate a higher level of productivity than a higher throughput of simpler cases.

There are two workforce demands arising from waiting times targets: one to bring them down to the target level and the other to maintain them at that level. Staffing requirements are therefore assessed as a non-recurring need to tackle the initial bulge, and a recurring need to maintain the required standard once it has been reached.

The following table provides an estimate of non-recurring and recurring demand for consultant time across Scotland (in extra whole time equivalent ( WTE)) to achieve and maintain the 18-week (16 weeks for cardiology) general and condition-specific targets announced in Fair to All - Personal to Each. This total WTE demand is also presented in terms of total headcount requirement. The baseline for this assessment is activity information as at December 2004 and staffing data as at 30 September 2004 and the 'high' and 'low' estimates stem from variations in activity levels across units and specialties. Those specialties featuring in Fair to All - Personal to Each are presented below. Anaesthetics has also been included given its supporting role in meeting the new targets.

Figure 7: Non-recurring and recurring consultant demand to meet waiting times targets

Not all of this demand will necessarily need to be met from within the NHS. Use of the independent sector to deliver waiting list activity will reduce the requirement for consultant time in the NHS to achieve these targets. In determining their consultant recruitment plans for the period to September 2006, NHS Boards have reflected initial assessments of waiting list demand for consultants in these specialties. These recruitment plans support progress towards the Partnership Agreement aim and are discussed later in this section.

Further detail on the methodology used here can be found in the Background Annex (see www.workinginhealth.com). It should be stressed that the above assessment assumes the nature of NHS services will stand still with no change in the design of services, working patterns or productivity - something which past experience suggests will not be the case.

Modernising Medical Careers is a specific dynamic which will need to be factored into this modelling as the content and nature of the MMC programme are decided. A Solutions Group has been established to work with the Service in assessing the impact MMC will have on service delivery and the workforce implications. As conclusions from this work are reached these will be incorporated in future iterations assessing the waiting times workforce capacity.

NHS Boards and regions will need to further assess in their workforce plans the consultant workforce required to meet the waiting times targets (including those for diagnostic standards), taking account of service and workforce redesign and the potential for productivity gains. This should also include consideration of regional working. The focus here has been on consultants who are considered to be most affected by the waiting time targets in Fair to All - Personal to Each. However NHS Boards should consider also the implications for other doctors, as well as for other staff groups.

3.2.2 Working Time Regulations

The Working Time Regulations ( WTR) require a phased reduction in worked hours by junior doctors to 48 hours a week by 2009. The current WTR requirement is 58 hours per week but under the junior doctors' New Deal Contract doctors in training are already required to work a maximum of 56 hours per week. Considerable progress continues to be made in reducing junior doctors' hours. Almost 99% of junior doctors now work 56 hours or less a week and NHS Boards have started the process of moving towards a 48 hour week.

Figure 8 quantifies the impact on the junior doctor workforce of reducing to 48 hours per week by 2009. This assessment is based on the monitored actual hours for the period August 2004 to January 2005, using as a baseline the number of whole time equivalent junior doctors at 30 September 2004.

Figure 8: Implications on junior doctor workforce of reducing to 48 hours per week in 2009

The 'Difference in WTE' column shows the projected change in junior doctor capacity resulting from the reduction in working hours to 48 per week, assuming standstill in the Service and in all other factors affecting the workforce. It is unlikely that simply increasing medical training grades will be the solution for educational reasons and in terms of service sustainability. This challenge is more likely to be met through deploying a combination of medical and clinical staff and new roles.

3.2.3 Clinical governance

The development of clinical governance in recent years has brought with it higher levels of quality patient care and a more thorough governance of clinical practice. This is set to develop further as a key priority for the NHS. As standards rise there may be an impact on capacity as consultants and clinical colleagues devote more time to delivering higher quality standards and carrying out the clinical audit and personal development required to do so.

3.2.4 Mental Health Act

Implementation of the Mental Health (Care &Treatment) (Scotland) Act 2003 is expected to have implications for the number of psychiatrists required in the future. As a result of the Act psychiatrists have the additional duties of more in-depth assessment and attendance and membership of tribunals. The National Mental Health Workforce Group has prioritised the workforce implications of the Act in its action plan and is estimating the impact on the premise of a stable system after a transitional period as the Act is implemented. Two scenarios (high and low) indicate that between 16.2 and 39.7 WTE additional psychiatrists may be required on a recurring basis. A midway position of 28 WTE has been assumed as the additional psychiatrist requirement from 2005. However account needs to be taken of new roles, team working, service redesign and how these factors will affect the demand for more psychiatrists. NHS Boards' consultant recruitment plans for the period to September 2006 have incorporated the implications locally for the psychiatry specialties resulting from implementation of the Act in October 2005.

3.2.5 Pay modernisation

The new Consultant Contract provides more transparent scheduling and organisation of consultants' activity. This is giving NHS Boards valuable data on which to base their consultant planning for the future and with which they will be able to inform their workforce plans. The ability under the contract to better manage consultants' time should lead to increased efficiencies and facilitate service redesign that maximise capacity.

Under the new contract, it is possible to identify clearly and comprehensively the total commitment which is being made by a consultant to the NHS. This data will ensure that NHS Boards can plan the use of consultant time more accurately to meet their needs. The average number of weekly programmed activities across NHS Scotland worked by consultants as at October 2004 was 11.5.

It is also worth noting that terms and conditions for Staff and Associate Specialist doctors are currently being reviewed. These doctors, who currently comprise 17.3% of the WTE medical workforce, make a vital contribution to service delivery. The future demand for this cohort may change, depending on approaches taken to meet other pressures on the medical workforce and the impact of whatever new contractual arrangements are agreed for this group. The implementation later this year of Article 14 of the Order establishing the Postgraduate Medical Education and Training Board ( PMETB) will enable Associate Specialists and others to apply for acceptance onto the Specialist Register. Where this opportunity is used there may be a need to backfill posts to sustain activity being carried out in those roles. This development will need to be monitored to address whatever consequences there may be for planning the medical workforce of the future.

3.2.6 Modernising Medical Careers

Modernising Medical Careers ( MMC) aims to improve patient care by delivering a modernised and focused career structure for doctors through a major reform of postgraduate medical education and training. It is expected to reduce the capacity for service delivery by doctors in training and potentially increase the requirement for supervision of training and assessment by consultants and others.

Work is ongoing to assess the capacity implications of MMC, both in the short term for transition to the new arrangements, and in the longer term once MMC is embedded. As already mentioned, a Solutions Group has been established and NHS Boards are quantifying the impact of the changes MMC will bring about.

3.2.7 Balance of trained doctors to doctors-in-training

Scotland currently relies heavily on its doctors-in-training for the delivery of service to patients. The ratio of doctors-in-training to trained doctors is relatively high compared to the rest of the UK. The vital role of doctors-in-training in delivering clinical care will continue but, as Professor Sir John Temple's recent reviews of the medical workforce ²⁰ have made clear, Scotland will see a major shift towards delivering more care from trained doctors, for a combination of reasons ranging from MMC to the impact of the working time limits and increased standards of care.

3.2.8 Age profile and potential for early retirement

Currently 15.1% of all consultants are within the 55-59 age group and could choose to retire early over the next few years. This is a factor which NHS Boards and regions should consider in their workforce plans, particularly in light of the new consultant contract and current proposals for a new NHS pension scheme.

3.2.9 Service redesign and new roles

The key role of the doctor is to diagnose illness and determine suitable treatment. The number of patients presenting is forecast to increase and the way in which they are cared for is likely to change. The role of the doctor will remain as pivotal as ever in terms of diagnosis but other practitioners will become more involved in the prescribing and delivery of patient treatment in the future. For example surgical practitioner nurses now assist consultants with certain surgical procedures. The role of the doctor within the wider clinical team and the ways in which the skills of the whole team can be enhanced and deployed to deliver the services required by the general public will shape the number and type of doctors required in the future.

Building a Health Service Fit for the Future clearly states that NHS Scotland needs to change because the healthcare needs of Scotland are changing and the service must change in order to meet these new demands. The medical workforce will be shaped by the need to deliver sustainable and safe local services and the Scottish Executive's response to Building a Health Service Fit for the Future will give direction on this. Professor Kerr found that the public are willing to travel for highly specialised treatment but want as many "core" services as possible close to home. This vision - generalists as well as specialists, whole team working, increased use of technology and extended primary care services - will all impact on the skills required by the medical workforce.

3.2.10 Independent/voluntary sector

Once trained there is no requirement on doctors to work for the NHS: they may decide to work in the independent sector, abroad or in a career outwith medicine. The medical workforce (in whole time equivalents) currently employed in the independent sector in Scotland is relatively small:

Figure 9: Independent sector medical workforce

However the number of consultants who hold 'practising privileges' (a contract between the doctor and the independent healthcare provider), enabling them to work part of their time in the independent sector is 1605. ²¹ The demand for the medical workforce by the independent sector in Scotland is not large in comparison to the NHS but requires monitoring.

SUPPLY

The number of trained doctors (consultants, Staff and Associate Specialists ( SAS)) and doctors-in-training has increased by 18% between 1999 and 2004.

Figure 10: Medical staff in post

NOTE: ¹HCHS refers to the Hospital, Community and Public Health Services of the NHS. It excludes the HCHS dental specialties.

The number of consultants has increased by an average of 2.9% each year over the last 5 years. Consultant vacancies have also increased since 2001 although the rate for those vacant more than 6 months has dropped in the last year. Figure 11 shows the vacancy trends for medical consultants working in hospital, community and public health medicine specialties.

Figure 11: Hospital, community and public health medical consultant vacancies ( WTE as at 30 September)

The numbers of Senior House Officers ( SHOs) and Specialist Registrars (SpRs) have steadily risen in recent years. The latter have increased by 30% from 2001 as a result of a Ministerial commitment to increase the number of training posts by 375. All these extra posts were in place by August 2005. The following table shows the specialties where the extra 375 SpR places are allocated.

Figure 12: Allocation of extra 375 SpR places

Source: NHS Education for Scotland

Between 1997 and 2004, on average 235 SpRs in Scotland obtained their Certificate of Completion of Specialist Training ( CCST) each year. From 2005 to 2014 this is expected to increase to 287 SpRs per year, reflecting the investment of 375 additional SpRs in recent years. This supply is fed from 834 funded medical school places within the five medical schools in Scotland: Aberdeen, Dundee, Edinburgh, Glasgow and St Andrews. These figures show that Scotland is producing a healthy supply of doctors, in excess of its needs and proportionately more than currently provided elsewhere in the UK. However, as highlighted in Professor Sir John Temple's report Securing Future Practice, ²² a significant proportion of these medical students and trainees choose to leave Scotland at some point during their training.

This may in part be because of the high levels of non-Scots domiciled students and trainees who come to Scotland. The proportion of those who are Scots-domiciled stood at 53.9% in 2004/05 (a slight improvement from 51% in 2001/02). The Calman Review ²³ noted that overall just over 1 in 2 of the graduates of Scottish medical schools (including those from overseas) are working in Scotland 5 years after graduating. Retention of medical students and trainees, therefore, has a significant effect on the supply of doctors in Scotland.

3.2.11 Medical Undergraduate places

A key recommendation in the Calman Review proposed an increase in the number of medical undergraduate places. This has been accepted ²⁴ and implementation will take a phased approach to allow, as part of workforce planning, for alignment of supply with future needs. It will lead to an increase in output from Scottish medical schools of 100 graduates as the medical students at University of St. Andrews will no longer be sent to Manchester to complete their clinical training. The Scottish Executive will also provide pump-priming funding to support the establishment of an accelerated four year course in medicine for graduate entrants. Furthermore, the universities and a newly-established Board of Medical Education in Scotland will review admissions arrangements for broadening access and to ensure that applicants from Scotland are not disadvantaged. These actions will increase and improve the supply of Scots-domiciled medical students in Scotland and as a consequence the numbers likely to qualify and remain as consultants in NHS Scotland.

3.2.12 Modernising Medical Careers

One of the benefits of MMC will be the faster supply of doctors qualified to apply for consultant posts. The PRHO, SHO and SpR years are being replaced by a 2 year Foundation Programme followed by on average 6 years of specialist training (compared to an average of 11 years in total now). MMC changes the structure of training for junior doctors and work is ongoing to establish the number of training places required across the specialities to supply the consultant (and SAS) workforce that Scotland requires. Places in the first year of the MMC Foundation Programme, which commenced this August, have been set at 800 to match the existing funded places in Scotland's medical schools.

3.2.13 Article 14 of the PMETB Order

As already described under Pay Modernisation, the implementation of Article 14 of the Order establishing the Postgraduate Medical Education and Training Board ( PMETB) will offer Associate Specialist doctors and others a route to apply for entry to the Specialist Register of the GMC and thereby gain eligibility to apply for consultant positions. PMETB is currently accepting applications from doctors seeking inclusion on the Specialist Register of the GMC. Decisions on applications will be made after 30th September 2005 when PMETB is expected to assume its statutory powers. This is a potential additional source of consultants in Scotland and initial estimates indicate it could yield between 25 and 50 consultants in the short term although clearly arrangements would be required to backfill the existing Associate Specialist posts being vacated.

3.2.14 Gender mix

The proportion of females among doctors has increased by almost 7 percentage points since 1993. In 2004, 41.1% of all doctors were female compared to 38.8% in 1999. There are more female SAS doctors than males, while the proportion of females among consultants has increased from 22% in 1999 to 28% in 2004. Among junior doctors the proportion increased from 38.7% in 1993 to 46.9% in 2004.

Figure 13: Proportion of medical staff workforce that is female

3.2.15 Age profile

The consultant workforce is slightly older compared to 1999, with more consultants over the age of 50 than before. The average age in 2004 was 47.1, compared to 46.4 in 1999.

Figure 14: Age profile of consultants - all medical specialties (headcount)

The average age of the consultant workforce will eventually be affected by the shorter training offered by MMC, allowing many SpRs to obtain their CCST at a younger age than at present.

3.2.16 Flexible working

The percentage of medical staff engaged in part-time working has reduced since 1999 from 16.4% to 8.3% in 2004. However, there are fluctuations by grade: the proportion has reduced within the Specialist Registrar and SAS categories, but increased among consultants.

PARTNERSHIP AGREEMENT UPDATE

3.2.17 Planned consultant expansion to September 2006

In the short term, the Scottish Executive has committed to aim to increase the number of consultants by 600 ²⁵ by September 2006. This target is based on an increase in headcount to 3,903 from a baseline of 3,303 at September 2002. The consultant headcount at September 2004 was 3,483, leaving a remaining requirement of 420 consultants to aim towards.

3.2.18 Projected recruitment

NHS Boards have planned their recruitment for consultants for the period from October 2004 to September 2006 taking into consideration the various drivers of demand such as the waiting times targets. This totals 479 (headcount) and is for new posts as well as to fill existing vacancies.

Figure 15: Consultant expansion - NHS Boards' projected recruitment to September 2006

3.2.19 Supply

The total number of SpRs expected to receive a CCST before September 2006 is 539. The 'home grown' supply available to meet this demand is estimated at 391. This excludes those SpRs who are expected to leave Scotland to take up a consultant post elsewhere and takes into account average attrition rates. The following specialties are the ones we have identified as having supply pressures for the Boards' immediate recruitment plans and Boards should factor this into the action they take: general medicine (acute medicine), general psychiatry, clinical radiology, accident and emergency medicine, anaesthetics, general surgery, trauma and orthopaedic surgery, and urology. However, these are all specialties where additional SpR places (as part of the extra 375 SpR posts) have been allocated and will over time provide an increase in supply of newly qualified consultants.

We can also be more proactive in attracting SpRs, who have newly qualified, into Scottish posts. NHS Education for Scotland has already begun to identify the intentions of current SpRs in terms of seeking employment in Scotland. NHS Education for Scotland will also help SpRs to career plan and will offer guidance on careers in Scotland. In the longer term, planning for MMC will take account of any misalignment of SpR specialties with predicted consultant demand.

Supply will be further boosted by existing consultants or SpRs with a CCST coming from outside Scotland. Based on historical patterns this supply source could amount to 201 consultants between October 2004 and September 2006. It includes those coming to Scotland as consultants for the first time as well as those who have worked previously in Scotland, either as consultants or SpRs, returning to take up a consultant post. Additional action by NHS Boards to attract more of these consultants to Scotland could increase this supply source. Initial estimates suggest that this assertive action could result in around 75 additional or retained consultants. Furthermore, a conservative estimate suggests that the new arrangements (Article 14 of the PMETB Order) to facilitate Associate Specialists and others to become consultants could yield around 25 consultants over the period.

Figure 16 presents the position:

Figure 16: Projected supply of consultants

Figures 15 and 16 indicate that there is sufficient supply (692) to meet Boards' expansion plans and fill existing vacancies (479). However, we cannot assume that there will be no new vacancies between now and September 2006 and it is reasonable to expect that there will always be vacancies that will be unfilled at any one time. That is part of normal turnover for any workforce. New recruitment demand for consultants to September 2006 will be created by existing consultants retiring or leaving the service. From historical patterns this could total 323 (of which 210 would be leavers under 60 years of age and 113 would be 60 and over). Improving retention will ease this pressure and NHS Boards should consider what steps they can take to achieve this - for example, flexible working practices and the creation of part-time consultant posts could assist in improving retention.

Figure 17: Potential consultant headcount at September 2006

This analysis is illustrative but it suggests a potential September 2006 headcount (3,852) which compared to the September 2002 headcount shows an expansion of 549, close to the aspiration to expand by 600 and, given the inevitability of there being vacancies, broadly in line with NHS Boards' projected recruitment. A more proactive approach from NHS Boards in filling vacancies, retaining current consultants and recruiting from external sources should increase this figure further in striving to meet the aim in the Partnership Agreement commitment.

CONSIDERATIONS FOR WORKFORCE PLANNING

The next few years will present a number of challenges in planning the medical workforce. Services will change as the NHS in Scotland is modernised and the shift continues from provision of care by doctors-in-training to provision of care by trained doctors. Planning will have to take account of this as best it can, recognising that workforce planning is an iterative process that must be refined year on year. However, with the long lead time to produce a fully trained consultant it is imperative that future demand is considered and action taken to prepare for the services and workforce required.

The factors highlighted in this section, for example waiting times standards, working time regulations and MMC, will need careful assessment by NHS Boards to determine the local implications. The Executive's response to Building a Health Service Fit for the Future will also need to be considered and workforce plans should reflect changes to services that will take place over time.

In the short term, a proactive approach to increasing the consultant workforce will take us closer to the aim in the Partnership Agreement to reach 600. NHS Boards have already planned ahead their recruitment of consultants and NHS Education for Scotland is supporting qualifying SpRs to take up consultant posts in Scotland. NHS Boards are encouraged to be proactive in recruitment to consultant posts by advancing appointments where vacancies are identified early. Real-time workforce information, on key aspects such as vacancies, should be monitored by NHS Boards so they can identify where specific pressure points may arise and take early action.

There is generally a good level of alignment between medical training grade numbers and future consultant requirements across most of the medical specialties, but this will require adjustment year-on-year. This is especially so with the implementation of MMC and the Executive's response to the Calman Review. It also needs to be examined not just in the Scottish context but across the UK and globally, especially for those specialties where there may be worldwide pressures. The balance of the numbers of doctors in training with the fully-qualified workforce also needs to be considered on an on-going basis, to take account of service delivery requirements and capacity within the system to sustain training numbers. Scotland trains a large number of doctors but many of them leave either during their training or once they have qualified to be a consultant. Improving the retention of these doctors would greatly increase the supply of doctors into the consultant and SAS workforce.

3.3 The Medical Workforce - General Practitioners

The provision of services by GPs and their teams is largely, although not exclusively, based on the 'independent contractor' model, which is in contrast to the medical staffing arrangement seen elsewhere in the NHS, where doctors hold contracts of employment with an employing organisation.

As part of the implementation of a new contract for GP practices (the GMS contract), on 1 April 2004 geographical NHS Boards were placed under a new duty to provide or secure the provision of primary medical services for their populations. This can be achieved either by providing services directly, by way of NHS salaried employees including primary care doctors, or by independent contractors entering into a contract for services with their local Health Board to be 'providers' of primary medical services.

This has fundamentally changed the way in which services delivered by GP practices are contracted for. NHS Boards now contract with GPpractices (not individual GPs) to provide a set of services for an agreed value, rather than reimbursing individual GPs for specific items of service through a range of separate fees and allowances. Furthermore, remuneration is no longer driven by the number of GP principals in each practice.

An immediate effect of this change is to encourage a team-based approach to the GP practice workforce. Practices now have every motivation to deploy their resources across the whole practice team as they feel best fits the required delivery of services to patients. This is leading them to think in terms of the extended practice team rather than GPs alone when, for example, they are thinking about replacements for retiring or departing GP partners. In these circumstances, they can instead choose to employ other health professionals such as nurses or AHPs, or use sessional doctors (for example, locums) as required. A further important area to consider in workforce planning terms is the way in which doctors are engaged or employed in other ways outwith the traditional practice based model. This approach clearly chimes with the emphasis placed by Building a Health Service Fit for the Future on the extended primary care team.

From April 2004, ISD have published figures for the number of GPs using the new terms of the GMS contract. These cover performers working in different capacities and are aligned to categories such as performers who are independent contractors; salaried doctors; locums; registrars; retainees; or armed forces. It is possible for doctors to perform primary medical services in more than one of these categories. The analysis described here uses data from the period 1998-2003 and is therefore based on the original terminology such as 'principal'. However, where possible, the new terms have been used.

DEMAND

3.3.1 Service redesign

Ninety percent of patient contacts with health care services are in the community with members of the practice team - the GP practice is the central interface between the health service and the vast majority of patients. However, we are seeing developments in the way in which services are offered and the nature of practice models, reflecting the move to a broader diversity of primary medical services provision.

Demand for GPs in the future will fundamentally be driven by the shift to a service model which promotes care in community settings. This is a key pillar of the vision for the NHS recommended in Building a Health Service Fit for the Future. This will mean that patients are treated increasingly by a health and social care workforce which is community-based and less focused than at present on acute and unscheduled care to address the major healthcare challenge facing Scotland - the needs of the elderly population with long term conditions. This will mean focusing hospital acute services on planned elective and highly specialised care, while placing a far greater emphasis on developing effective managed care in local settings, whether delivered through GP surgeries, local pharmacies or local hospitals.

Building a Health Service Fit for the Future points a way forward which will have a profound effect on the shape of locally-delivered services and, in turn, on the contribution and role of general practitioners. It looks towards enhanced roles for GPs themselves which will see GPs working increasingly across the secondary/primary care interface (for example, see the section on GPs with special interests below) and towards a development of GP-led services operating out of community hospitals, as well as GP input into the concept of a rural general hospital.

The emerging Community Health Partnerships ( CHPs) will be pivotal to taking forward the range of local care which we want to see delivered in community settings. The workforce planning which we undertake to address this development in locally provided care will need to take account of the role of CHPs in co-ordinating patient-centred care across both the acute/primary care interface and the primary/social care divide. We will therefore look to NHS Boards and regions to work closely with their CHPs as they develop their workforce plans.

Care during the out of hours ( OOH) period is a prominent example of a recent shift in the model of service provision. Under the new contractual terms, most GP practices have opted out of responsibility for providing OOH cover except in a few remote areas and the Islands. NHS Boards now have this responsibility but Board-provided OOH services still rely heavily on GPs - some working solely in OOH but many also working full-time in daytime general practice or as sessional doctors. In future years we can expect an increased role for nurses, AHPs and paramedics in OOH services moving to a more multi-disciplinary team approach. Building a Health Service Fit for the Future flags the importance of developing multi-disciplinary community casualty facilities as the "lynchpin of the unscheduled care framework" ²⁶ delivering the majority of the care currently available in Accident and Emergency services. We will need to assess the implications of these drivers in the light of the Board workforce plans to be produced in April 2006.

A model based on GPs working in professional teams will be pivotal to achieving this vision, whether in practices or in services delivered directly by NHS Boards. They will also contribute increasingly to work in the acute sector. For example, those with a special interest will work more and more in A&E and outpatient clinics and in areas such as endoscopy, minor surgery and dermatology. This ability of GPs to work as generalists in a number of acute care settings will dovetail with the specialisation of consultants.

The flexibility in skill mix within practices and the team-based approach may lead to an increase in the use of sessional and salaried GPs as well as to greater numbers of practice nurses and AHPs. It may be argued that enhanced roles for nurses, pharmacists and paramedics in primary care will decrease the demand for GPs. However, these changes have been taking place for several years without a significant drop in activity for GPs. The historic evidence therefore suggests that further enhanced roles for primary care staff in the future will not significantly decrease the demand for GPs.

This is a key question which we will wish regional and Board workforce plans to address - that is the degree to which the shift to managed care in local settings will be met by GPs and the degree to which it will be met by the wider clinical team around the GP. It is crucial that we get this balance right.

3.3.2 Tackling health inequalities

Scotland continues to suffer from health inequalities - the gap between the best and worst areas of Scotland is substantial. Building a Health Service Fit for the Future recommends adoption of the principles of anticipatory care and preventive medicine by especially targeting resources at deprived areas. It suggests that this will involve more GPs but also, perhaps more crucially, the expansion of capacity in the wider primary care team, through the extended role of nurses, AHPs and other staff. Tackling health inequalities will clearly be a key area for planning the future workforce.

3.3.3 48-hour access

As part of the Scottish Executive's Partnership Agreement, ²⁷ patients with a clinical need have guaranteed access to a primary care health professional within 48 hours should they request it. Meeting the 48-hour access target is rewarded in the Quality and Outcomes Framework ( QOF) of the new GMS contract. Initial indications from QOF achievement data and from the Performance Assessment Framework ( PAF) on the ability of practices to meet this guarantee suggest that compliance is already very high, well above 95%. It is therefore unlikely that more GPs would be needed in the future to help meet this target.

3.3.4 GPs with special interests (GPwSIs)

Building a Health Service Fit for the Future emphasises the potential for developing the role of GPs with Special Interests (GPwSI) and the contribution they can make to enhancing services at a local level, supporting the more efficient and effective delivery of planned care, and adding a valuable dimension to rural healthcare. The Centre for Change and Innovation ( CCI) is already overseeing a programme training up to 40 GPs across Scotland to take on GPwSI roles.

This work needs to be carefully managed and developed in a way which ensures robust training and underpinning in terms of regulatory requirements and standards and accreditation of quality care. It also needs to guard against inadvertent erosion of the generalist values which imbue much of what we should treasure about the general practitioner role. However given these caveats, we foresee further development of this model and, at national level, will be taking forward discussions on GP career development, including GPwSIs, with NES, the Royal College of General Practitioners, NHS Boards, the universities, CCI and the relevant regulatory bodies, to develop this agenda.

3.3.5 Non-clinical work by GPs

GPs contribute to Board primary care management in a variety of roles including appraisal, service re-design, involvement in Community Health Partnerships, GPIT facilitation, audit and OOH service management. They are also active in training and teaching, both post- and under-graduates, academic work and research. GPs also require continuous professional development which needs protected time away from clinical work and they have a contractual requirement to participate in annual appraisal. These pressures take GPs away from clinical work and increase the demand for back fill.

3.3.6 Demographic changes

While the overall population of Scotland is projected to decline over the next 10 years, the number of older people is projected to increase, particularly those over 85 years. Older people generally have greater healthcare needs and these impact particularly primary care services, where effective management of long term conditions, often with co-morbidity in elderly people, is most required.

Based on data from the Practice Team Information ( PTI) system at ISD for 2003-4 (the most recent data available) it is estimated that both males and females aged over 85 years contact a member of the practice team about 15 times per year. For most other age groups females tend to have higher contact rates than males, with for example females aged 45-64 years likely to contact their general practice around twice as often during a year compared to similar aged males. Different members of the practice team see a different age profile of patients - for example PTI data show that the elderly are mainly seen by practice nurses or district nurses rather than GPs.

Figure 18 shows the projected increase in demand for the services of different members of the practice team assuming that the average contact rates by each age and gender group remain as they were in 2003-4. Service demand here means the total number of patient contacts that would be necessary to treat the future population assuming the average number of contacts per person remained the same as they were in 2003-4. This is shown alongside the actual growth in workforce during the previous ten years.

Figure 18: Projected growth in patient contacts based on projected populations changes only

Source: Government Actuarial Department.

The approach taken here looks at the effects of population change in isolation and does not take into account other drivers of service demand such as changing prevalence of disease and co-morbidity in the population, future service re-design and contractual changes. However it is informative to note that in Figure 18 projected demand for GPs (and practice nurses) is less than workforce growth experienced in the ten years to 2003. Projected growth in demand for district nurses is highest and is similar to the growth already experienced in the ten years to 2003. Most district nurse patient contacts are with the oldest, homebound proportion of the population whose numbers are predicted to rise most sharply in the coming years. The demand for health visitors is projected to continue to fall, in line with falling numbers of young children.

3.3.7 Patterns of ill health

As identified in Building a Health Service Fit for the Future the incidence of chronic conditions will increase, particularly as the numbers of elderly in the population increase. Conditions such as diabetes, asthma, obesity, mental health, and some of the more traditionally 'acute' conditions such as cancer and coronary heart disease will need more systematic and careful management in primary care settings. Health improvement services such as smoking cessation and well man clinics will also continue to place demands on the primary care team, including an element of the GP's time.

Much chronic disease management has been undertaken by practice nurses since 1990 and contacts with these professionals have risen sharply. However this has not led to a decrease in GP contacts, suggesting that nurses are filling an unmet need rather than taking over work previously done by GPs. Increasing co-morbidity and a drive to manage chronic illness and serious conditions in a more sophisticated manner closer to people's homes may also lead to the need for more GP intervention.

Furthermore, Building a Health Service Fit for the Future recommends a more proactive targeting of deprived areas to reach out with anticipatory care to prevent future ill-health and help tackle health inequality. Depending on the design of such services there is likely to be some impact on GPs.

SUPPLY

Official figures on the numbers of GPs working in NHS Scotland show a relatively modest but consistent year-on-year increase in numbers over the 10 years to 2004. The WTE number of GPs (excluding registrars, retainees and sessional GPs) increased from 3417 in 1994 to 3663 in 2004, an average increase of 0.7% per annum. These GPs were distributed among 1046 practices across Scotland giving an average of around 3.5 GPs per practice. This average has been rising in recent years, mostly due to the steady decrease in the number of smaller and single-handed practices.

3.3.8 GP Registrar Training Numbers

GP Registrar places are administered by NHS Education for Scotland. For the period 2003/4 to 2005/6 additional funding has been made available to increase the annual number of GP registrar places to 280, up 30 places per annum from the previous complement of 250 places.

The annual output of trained GPs from this cohort is lower than the total number of funded places due to some doctors training less than full-time and to others taking more than a year to complete their training (for reasons ranging from sick leave and maternity leave to failure of summative assessment). Based on data for 2003/4, the destination of GP Registrars after one year can be estimated as follows:

Figure 19: Estimated destination of GP Registrars after one year

This suggests that around 20% of trained GP Registrars leave Scotland upon completion of training (although some of these may return to Scotland later), with a further 10% returning to the acute sector. This leaves at least 70% remaining in Scotland in primary care.

3.3.9 Sessional GPs

Sessional doctors are freelance and are employed by practices on a regular or occasional basis, including for maternity or sickness cover. Based on numbers on the Performers' List ²⁸ we estimate upwards of 800 sessional GPs are working in general practice, which represents a significant proportion, in the region of 15-20%, of the overall GP workforce.

There is evidence that newly-trained GPs are more likely to take up posts as sessional doctors rather than as principals or salaried doctors. Recent analysis using 2003 data suggests that while only 10% of registrars became principals (now called performers) one year after training, over 60% were working in general practice. The vast majority of these will be working as sessional doctors rather than as salaried doctors, largely due to a mixture of opportunity and choice.

Even though we know that many GPRs work as sessional doctors immediately after completion of training, the lack of data on the subsequent career flows of such doctors makes assessment of the contribution of sessional GPs difficult. It is important that this 'hidden' element of the workforce is measured to allow us to make an assessment as to whether the supply of GPRs requires adjustment in order to meet future demand.

3.3.10 Age profile

Figure 20 shows how the age distribution of GPs has changed over the last 10 years, with more GPs aged over 40 in 2004 compared to 1994, and fewer aged less than 40. This means we can expect a greater number of retirals over the next 10 years than there has been in the past.

Figure 20: Age profile of GPs*

* Includes GP Performers in 2004 and GP Principals in 1994

3.3.11 Gender mix

Figure 21 shows that while the number of male GPs has decreased in the last 10 years the number of female GPs has increased by 47% and they now constitute over 40% of the workforce. This proportion is likely to continue to rise in future years since the proportion of Registrars that are female has risen from 59% in 1994 to 66% in 2004.

3.3.12 Flexible working

Figure 21 also shows that female GPs are much more likely to work part-time than male GPs. However over the last ten years the proportion of GPs working part-time has increased among both male and female GPs. A significant proportion of female GP registrars also now train part-time.

Figure 21: Gender and contract type profile of GP workforce as at 30 September 2004

n.a. not available
* Excludes salaried GPs; data not available.
§ Excludes Retainees and sessional GPs.

3.3.13 Modernising Medical Careers ( MMC)

MMC is set to change the way that all doctors, including future GPs, are trained. Under MMC there are plans to increase the exposure to general practice among trainee doctors by offering 4 month rotation periods during the two year Foundation Programme. This will give those potentially interested in pursuing a career as a GP more relevant experience on which to base their decisions.

After the Foundation Programme trainees will apply to join a Specialist General Practice Training Programme which will involve a period in general practice and a period in a hospital-based setting gaining appropriate experience. The precise arrangements are still in the process of being finalised but it is envisaged that the period spent in general practice will be longer than the current 12 month registrar period. This could potentially have implications for the supply of GPs if, on implementation, there is a year when a cohort of Registrars do not enter the trained GP workforce. However the overall impact will not be known until arrangements are agreed on how MMC will be phased in to replace the current structure, and in particular how existing Senior House Officers will slot in to the new training programmes.

CONSIDERATIONS FOR WORKFORCE PLANNING

The analyses described in this section highlight some of the challenges to be faced in planning the future GP workforce. In order to achieve an effective alignment between supply and demand we must build a better evidence base around the dynamics which impact on the GP workforce so that we can take decisions on GP registrar numbers which are properly informed by a clear understanding of the future requirement for GPs, whether sessional or non-sessional. That requires also a full understanding of how the role of the GP will change in relation to the wider primary care team, and the future direction of primary care services in the wake of Building a Health Service Fit for the Future.

More information is needed on the contribution and work patterns of sessional GPs who provide a significant proportion of medical services to the population, especially in the south of Scotland and the Central Belt. More precise planning of the future workforce and the number of training places requires a more detailed picture of the size and shape of the entire pool of GPs providing services to the NHS. Practices themselves are in the best position to provide information on their use of sessional GPs.

This data collection should be part of a wider process for collecting robust data on the whole of the practice-based workforce. Doctors, nurses, administrative, managerial and clerical workers, AHPs and other ancillary healthcare workers are all employed by practices at an unknown level. It is vital for workforce planning that a routine, accurate and inclusive method for such data collection is established.

The effect of the new contractual arrangements on GP recruitment and retention also needs to be monitored to allow projections of the future supply of GPs to be more accurately estimated. MMC may also have an effect on the supply and demand for GPs and up-to-date information will be essential to allow accurate projections of future GP needs. By comparison with hospital specialty training programmes the lead time for an increased yield from GPR training is relatively short at 3 years. This allows for a swifter response to be made to change in future GP requirements through adjustments to the number of GPR places.

We will also work with NHS Boards and regions and with other key stakeholders to assess the role of the wider primary care team, within and beyond GP practices, and the contribution which can be made by expanded and new roles carried out by non- GP members of the team, including the scope for introducing a 'physician assistant' role.

3.4 THE DENTAL WORKFORCE

DEMAND

There have been a number of projects undertaken and publications released recently about the demand and supply factors affecting the dental workforce. These include An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland²⁹ which provided the Scottish Executive response to the consultation on modernising dental services that took place in 2004. The Action Plan recognises that dental service provision is not just about the dentist but the whole dental team, including the Professions Complementary to Dentistry ( PCDs) such as hygienists, therapists, nurses, technicians and administrative practice staff. Access to Dental Health Services in Scotland, ³⁰ commissioned by the Scottish Parliament's Health Committee and published in February 2005, includes information on areas where the availability of NHS dental services is reported as insufficient to meet need or demand. Workforce Planning for Dentistry in Scotland, ³¹ the fourth in a series of workforce planning reports, provides both a context for the development of dental services in Scotland and detailed workforce information on which to base decisions about the future configuration of the workforce in order to meet demand.

3.4.1 The impact of team working

Dentistry is provided within NHS Scotland under General Dental, Community Dental and Hospital Services with input from a range of dental team members including dentists, hygienists and therapists, dental nurses, administrative staff and technicians. Each has a key role to play in the delivery of patient care and there is agreement that maximising the potential of the whole team is critically important.

The General Dental Service provides the majority of dental services (accounting for approximately 75% of the costs of all NHS dental services in Scotland). General Dental Practitioners ( GDPs) are independent contractors who, while working under existing NHS arrangements, treat children and adults under a hybrid capitation and continuing care arrangement, supported by an item of service fee structure. While some practitioners undertake only private work, many GDPs undertake a mixture of private and NHS treatment.

General Dental Practitioners will need to become fully involved in developing a comprehensive approach to maximise the contribution and skills of all dental professionals. There will be implications in terms of the service being able to absorb the additional training places in training practices with the additional workload that this brings.

The use of salaried dentists to improve accessibility has been relatively successful in some remote and rural areas and these will have an increasingly vital role to play in meeting the need of disadvantaged groups and those with special needs. The pressure will come in terms of improving efficiency relating to the availability of evening and weekend appointments and waiting times for routine treatments. From April 1 2005 NHS Boards can commission salaried services in accordance with their resources to meet local priorities, including the need to complement GDS provision, as defined within the SEHD primary care letter of 13 April 2005. ³²

3.4.2 Demographic changes, pattern of dental health, public demand, policy priorities

Currently, 49% of Scottish adults and 66% of children are registered with an NHS dentist, with additional numbers of children and adults accessing primary care services through the Community Dental Service and under private arrangements.

As the demographics within Scotland change so the nature of NHS dentistry will have to adapt to meet the changing demands. Projections show that the proportion of edentulous people (those without teeth) over 65 years of age is expected to reduce from 55% in 1998 to 20% in 2028. There is an implication that such improvements in oral health tend to be associated with an increased use of dental services, but what these services are and how they are used (for example expanded cosmetic utilisation) is difficult to predict.

Overall the dental health of Scotland's children has improved over the last 30 years. However well over half of five year olds in Scotland in 2003 had some dental decay, with those from deprived communities bearing the greatest burden. Likewise, the oral health of adults in Scotland has markedly improved over the same period and this is likely to continue. In the future, fewer adults will be edentulous and more will retain more teeth as they grow older.

Patient expectations are changing in terms of what they demand of dental services and this will have a bearing on the number of dentists and the Professions Complementary to Dentistry. The Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland highlights a number of ways in which the Scottish Executive aims to tackle such situations. There is a shifting emphasis in dental care towards improving oral health by prevention rather than treatment. This shift will also have an impact on what a dentist does and how services are delivered.

Currently, there are a number of Scottish Executive policies which will affect the level of demand placed upon the dental services. These include:

• Partnership Agreement commitments - to systematically introduce free eye and dental checks for all before 2007. From April 2005 an oral examination will be free for those aged 60 and over.

• Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland - a number of commitments and targets are included in that document, which are aimed at taking a co-ordinated approach to health improvement and dental services and working in partnership with the key professions and agencies in health and education to transform oral health in Scotland by the end of the decade and make NHS dental services available to all who need them.

3.4.3 Independent sector

Workforce Planning for Dentistry in Scotland reported that across Scotland there are significant variations in the provision of NHS and private care. No restriction can be placed on an individual GDP who may wish to work within the independent sector. This has and will continue to have a bearing on the number of dentists within NHS Scotland and the associated geographical coverage. Private sector services are not evenly distributed geographically with a greater proportion in Aberdeen, Edinburgh and Inverness. Although use of public sector dental services has remained constant, the private sector dental services has increased significantly in recent years. Consequently, 350,000 additional patients have obtained dental care.

The Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland focuses on ensuring that those independent contractor dentists who have been or continue to be either wholly or partly committed to NHS Scotland dental services are suitably rewarded. However, the independent sector will continue to feature in the provision of dental services in the future.

SUPPLY

The number of dentists in Scotland has increased by 70% since 1975, and continues to rise steadily. Figure 22 shows that consistently over the last 10 years joiners have outstripped leavers, giving a net growth year on year.

Figure 22: Joiners and leavers

Data from ISD indicates that, at September 2004, there was a total of 2,161 dentists working in General Dental Services in Scotland, including salaried and non-salaried principals, assistants and vocational trainees, up by 2% from the same point in 2003. All the dentists in the table above provide NHS services. Any dentist who provides a wholly private service has not been included.

3.4.4 Gender Mix

The proportion of females has increased from 31% in 2000 to 34% of GDPs in 2004 and this is an ongoing trend.

3.4.5 Age Profile

Female dentists tend to be younger than male dentists: at 31 March 2004, 64% of female dentists were aged 39 or under, compared with just 38% of male dentists. Figure 23 shows the number, age profile and gender of non salaried principles only.

Figure 23: Age profile by gender

Figure 24: Age of dentists as at 31 March 2004

In 2004 there were 81 salaried dentists employed within NHS Scotland, an increase of 53% from the 53 employed in 2001. It is anticipated that this number will increase in light of NHS Boards being given authority to appoint to areas where the existing NHS service is either stretched or lacking.

In 2004, 91 graduates from Scottish dental schools entered vocational training in NHS Scotland by 30 September of their graduation year, which equated to 79% of the total number of graduates. This compares to the previously available data, covering the years from 1995 to 1999 which indicated that, on average, only 58% of dental graduates started their vocational training in NHS Scotland. This trend indicates that the level of retention is improving significantly.

This trend is supported by an increase in the number of vocational training places in order to match the annual dental graduate output.

3.4.6 Dental Students

In Scotland, Dundee and Glasgow Dental Schools train all dental students, the number of which has traditionally been set as a student intake target.

In 2000, to better plan the number of postgraduate places for dentists in Scotland, an output graduate target was set at 120. The dental student attrition rate for the full 5 years of dental school varies considerably from 5% to 12%, dependent on each cohort of students. The Scottish Higher Education Funding Council ( SHEFC), with the Universities, is tasked with ensuring that the output is as consistent as possible and to adjust the intake yearly.

The graduate target has been increased from 120 to a target of 136 per year by 2006, and 143 per year by 2008.

PARTNERSHIP AGREEMENT UPDATE

In the Partnership Agreement the Scottish Executive recognised the need for an increase in the number of dentists and dental graduates in Scotland and committed to undertake an assessment of the reasons for the shortfall in the number of dentists in some areas and the options for addressing that. It was agreed that this work would be completed by April 2005. This was achieved through publication of An Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland in March. The Action Plan recognises that over the next two to three years an increase in the number of dentists is needed. Measures to address this are outlined in the report and are set out elsewhere in this section.

Looking towards the future the Scottish Executive, in partnership with NHS Scotland, will publish annual reports on progress on implementing the action plan including the increases in the numbers of dental students, dentists and dental professionals.

CONSIDERATIONS FOR WORKFORCE PLANNING

Modernising NHS dental services in Scotland presents a number of challenges, one of which is around the workforce. The Action Plan for Improving Oral Health and Modernising NHS Dental Services in Scotland states "it is essential that if we are to achieve our aim of securing improvements in oral health and health services, we must act now to ensure that current workforce issues do not restrict our ability to deliver the comprehensive service to which we aspire". The Action Plan sets the targets of increasing the number of dentists by at least 200 over the present number, at an average rate of 50 per year and raising dental student numbers to achieve a dental graduate increase of 136 by 2006 and 143 by 2008. It also recommends the introduction of Vocational Training posts for all dental graduates and of a bursary scheme for dental students linked to NHS commitment.

Planning for the dental workforce needs to be developed in line with other developments for primary care services. NHS Boards should begin to consider dental services as part of their workforce plans taking account of the Action Plan and its implications at local levels.

3.5 NURSES AND MIDWIVES

Nursing and midwifery staff are the main care givers in the NHS; they number over 54,000 and represent 43.3% of the whole workforce. They are therefore crucial to the delivery of effective health services in Scotland. Furthermore, the role of the nurse/midwife will change in the future as the NHS is modernised. We are set to witness a shift to community based services and more working in multi-disciplinary and multi-professional teams which will bring to the fore the contribution of the general, specialist and extended scope nurse. New roles and responsibilities are already extending and changing the traditional definition of the nurse/midwife as changes in the medical workforce and redesign of health services underscore their increasingly pivotal role.

DEMAND

3.5.1 Waiting Times

As described in Chapter 2 new waiting times targets and standards will require increased inpatient and outpatient activity. While increases in productivity and redesign of services will contribute to meeting this demand, there will still be a need for additional staff. As before, there are two workforce demands arising from waiting times targets: one is the initial push to bring current times down to the target level and the other is the on-going activity to maintain them at that level. Staffing estimates are therefore made for non-recurring and recurring needs.

Figure 25: Demand for extra nursing capacity to meet waiting times targets ( WTE)

Detail on methodology used can be found in the supplementary Annex. It should be stressed that the above assessment assumes that the way in which NHS services are delivered will stand still, with no change in the design of services, working patterns or productivity - past experience suggests this will not be the case. And not all of this demand will necessarily need to be met from within the NHS. Use of the independent sector to deliver waiting list activity will reduce the requirement for extra nursing capacity in the NHS to achieve these targets. NHS Boards and regions will need to assess in their workforce plans the workforce required to meet the waiting times targets and standards, taking account of service redesign and the potential for productivity gains in their area.

3.5.2 Working Time Regulations

Working Time Regulations, as they apply to nurses and midwives, have been in effect since 1998. However the application of regulations on working time to junior doctors will have a further knock-on effect for nurses and midwives. As explained in the earlier section on the medical workforce, the service delivery capacity of junior doctors will reduce by 2009 as a result of the regulations. There will be a variety of solutions to address that reduction in capacity and it is likely that some will result in an increase in demand for the nursing and midwifery workforce.

3.5.3 Regulatory Changes

The UK-wide Nursing and Midwifery Council ( NMC), which regulates the nursing and midwifery professions, is undertaking major reviews and consultations on a number of issues which could have a wide ranging effect on the nursing and midwifery workforce. For example they are beginning a review of pre-registration nursing (including registration of overseas professionals) and the possibility of a four-year training programme. They have just completed a consultation on a framework for standards of post-registration nursing. They are also setting new standards for mentors and teachers.

A Review of Non-Medical Regulation (looking at regulation of all non-medical clinical staff in the light of Shipman enquiry) being undertaken by the Department of Health in England (Foster Review) may also have implications for the nursing and midwifery workforce. The review is considering, among other things, regulation of existing roles, new roles and support workers as well as matters affecting Continuing Professional Development and re-validation. Their report is due by the end of 2005.

3.5.4 Mental Health

The Mental Health (Care and Treatment) (Scotland) Act 2003 will come into effect in October 2005. The Act signposts the start of new era in mental health practice in Scotland and will require a comprehensive range of provision as the foundation on which to build new services and approaches that will enhance mental health and mental health services, including:

• the need to develop, extend and deliver models of service within the community, for example 24/7 crisis intervention, home treatment and assertive outreach.

• the need to ensure access to appropriate inpatient facilities for young people, mothers with perinatal illness and their babies, and to provide the least restrictive environments possible for people with mental health problems who have committed criminal offences.

• the need to ensure the provision of a range of therapies including psychosocial interventions, meaningful activity, employment and support for recovery.

• the need to expand and deliver wide access to different levels of psychological interventions in mental health services and primary care.

While the exact workforce implications of these changes are not yet clear, they will require a flexible, skilled and experienced nursing resource. Judgements on their impact on the nursing workforce have been taken into consideration as part of the general assessment of future demand from NHS Boards used in the annual Student Nurse Intake Planning ( SNIP) exercise.

A review of mental health nursing is also being undertaken reporting in March 2006. Demographic challenges, changes in the roles of other mental healthcare professionals and the need to develop workforce capacity, skills and roles to enhance the provision of primary and community-based services are issues that will be highly pertinent to that review.

3.5.5 Demographic changes, patterns of ill health and public demand

As the largest part of the NHS workforce, increased demand for healthcare services will be reflected in an increased demand for nurses, although the roles and proportion of registered and non-registered nurses will change. Increased chronic disease management may lead to more nurse-led services and likewise more proactive public health promotion services could be predominantly delivered by nurses. With regard to midwifery, a falling birth rate in Scotland might be thought to indicate a fall in demand. However, if midwifery-led maternity services increase, as indicated by the Expert Group on Acute Maternity Services, ³³ then this will not necessarily be the case. These are dynamic areas and NHS Boards will need to monitor developments carefully to accommodate them in their workforce plans.

3.5.6 Pay Modernisation

The Agenda for Change pay system for nursing and other non-medical staff came into effect on 1st October 2004, introducing 3 pay spines and 9 new pay bands to which staff are matched on the outcome of a job evaluation process. In the medium to longer term Agenda for Change will be a key lever for facilitating redesign of services that maximise existing capacity and allow for more responsive services to patients. In the immediate term there are three elements that have a direct impact on workforce capacity:

(i) Annual Leave / Public Holiday entitlement are harmonised under Agenda for Change. Where staff had previously been entitled to a higher rate of annual leave, this entitlement is protected for five years. The new harmonised Agenda for Change rates are-

• On appointment - 27 days annual leave and 8 days public holidays

• After 5 years service - 29 days annual leave and 8 days public holidays

• After 10 years service - 33 days annual leave and 8 days public holidays.

(ii) Contracted Hours: the full time working week is now standardised at 37 ¹/ ₂ hours. Transitional arrangements have been put in place for those working more or less than that prior to Agenda for Change. Part time staff may opt to either remain on their current arrangements or reflect pro rata the new full time arrangements.

(iii) Overtime: Staff in pay bands 1 - 7 who work beyond the standard 37 ¹/ ₂ hour week will be paid overtime at a rate of one and a half times basic pay plus any long term recruitment and retention premia. Staff in pay bands 8-9 will not be eligible for overtime payments.

In analysing the combined impact of these changes a reduction in capacity is indicated as follows:

Figure 26: Immediate impact of Agenda for Change on capacity

Although this shows a reduction in capacity equivalent to 648 WTE nurses and midwives, this does not translate into a requirement to recruit an extra 648 staff, given the scope for managing change in leave and weekly hours through modifications to working patterns and other approaches to backfilling absences.

New GMS Contract - The new GMS contract deliberately focuses the contractual relationship on the whole practice team and provides a platform for more practices to extend the range of services they provide to patients. These developments will increase the demand for nursing staff, such as practice nurses. A strategy was published in 2004 ³⁴ which will help develop practice nursing in new ways, for example by introducing a skill mix model in the form of healthcare assistants, staff nurses, specialist practise nurses and advanced practitioners.

As part of the SNIP exercise for determining nursing intakes in 2005/06 a 15% increase in demand for newly qualified staff over the next 5 years was factored into the modelling process in anticipation of the impact of the new GMS contract.

Out of Hours provision across NHS Boards in Scotland is changing as GPs opt out of this service under the new GMS contract. In a recent national survey on Out of Hours services, data was collected during the period November 2004 - January 2005 on Boards' plans for future out-of-hours services. Most NHS Boards anticipate a move towards a multi-professional service with a greater proportion of services delivered by non- GPs (including nurses, paramedics and AHPs) over the next two years. Figure 27 indicates the anticipated increase in nursing and total non-medical capacity required to deliver these services.

Figure 27: Anticipated required hours for Out of Hours services

3.5.7 Productivity and Workload

The Facing the Future group was established in 2001 to take forward work on a number of key themes to improve recruitment and retention within the nursing and midwifery workforce. As part of this work the group commissioned research into nursing and midwifery workload and workforce planning. The resulting report, Nursing and Midwifery Workload and Workforce Planning Project, ³⁵ made two recommendations that affect capacity and how that capacity should be measured. Recommendation 17 advised that establishments should ensure that nurses and midwives who have overall team leadership responsibility in the direct care area have a minimum of 7.5 hours per week of protected time to enable them to focus on leadership, managerial, education and clinical governance-related aspects of their role. Recommendation 18 stated the predictable absence allowance should be a minimum of 21%, with a proportion (recommended as 1 of 21%) defined to support systematic management of maternity leave. These recommendations, along with the other eighteen, are now being implemented across NHS Boards.

During the 2004/05 SNIP exercise, workload and its likely effect on future demand was taken into consideration for the first time. The resulting increase in demand, estimated at 2.1%, was then applied to the modelling process for arriving at recommended student intakes for 2005/06.

3.5.8 Service redesign and new roles

The nursing profession has been at the forefront of developing new and extended roles. More than ever before, nurses are being encouraged to develop in new ways to provide more patient focused and effective delivery of care. A new roles Framework for Developing Nursing Roles³⁶ has been published, by the Scottish Executive following extensive consultation with service providers. This framework will allow new roles to be developed in a clear and systematic manner.

Increased demand in disease-specific areas (for example long term conditions, patient rehabilitation) has led to the creation of specialist and new nursing roles, and sub-specialisation across medicine has spawned the development of generalist and specialist roles to support specialist doctors. New roles have been created by merging advanced nursing roles with traditional medical roles, such as Anaesthetic and Critical Care Practitioners ( ACCPs). Further developments are anticipated as a result of the changes facing the medical workforce.

The advent of NHS 24 has created a further demand on the nursing workforce and staffing pressures have been experienced as a result. These are being considered by a review of NHS 24 which is currently underway, and on which an interim report was recently published. ³⁷ While the National Workforce Plan 2005 - A Framework for NHS Scotland considers workforce planning in the long term to 2015, demand over a shorter period for nursing staff from organisations such as NHS 24 is taken into consideration at national level as part of the annual SNIP exercise.

The development of diagnostic treatment centres and developments in ambulatory care and intermediate care will also impact on the nursing and midwifery workforce. Building a Health Service Fit for the Future puts greater emphasis on more care being delivered and managed by healthcare professionals who are not doctors. Nurses are already extending current roles and developing new ones. This will continue as further opportunities become available across the healthcare delivery field from additional preventative intervention, extended primary care services, specialist work in unscheduled and planned acute care and also in rural healthcare.

Through the development of Community Health Partnerships ( CHPs) joint working with other key partners in community settings such as social care providers and the voluntary and independent sector are set to become more prevalent. Nurses and other occupational groups will be required to work across organisational boundaries to provide integrated and improved services to their local communities.

3.5.9 Care Homes

The collection of current workforce data and demand forecasts across the care home sector for registered staff is difficult to achieve, mainly because of the large number of independent organisations involved. Therefore three censuses run by Information Services Division of NHS National Services Scotland ( ISD), in March 2002, September 2003 and March 2004 have been used collectively to calculate an estimate of the number of nursing staff employed by care homes. As Figure 28 shows, this amounts to a considerable number of registered nurses and has the potential to rise over the next decade as the elderly population in Scotland increases.

Figure 28: Breakdown of registered nurse numbers across care homes

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