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Nursing and midwifery staff make up by far the largest portion of the workforce in NHS Scotland. Data at 30th September 2004, show that nurses and midwives (headcount) accounted for 43.3% of the NHS workforce.

Figure 29: Breakdown of nursing and midwifery workforce in NHS Scotland

Of the total Nursing and Midwifery workforce in 2004, 71.3% are registered nurses and midwives. Of those, 7.35% are registered midwives. The numbers working in care homes (see previous section) are additional to these numbers.

3.5.10 Gender mix

The nursing and midwifery workforce is predominantly female, with only 10% of the workforce represented by male staff in 2004. The following graph shows the breakdown in gender across the total nursing and midwifery workforce in Scotland.

Figure 30: Gender mix - nursing and midwifery staff as at 30 September 2004

3.5.11 Age profile

The age profile of this workforce has been ageing. At 30th September 2004, 23.0% of the total workforce were aged 50 and over while only 11.9% of the workforce were aged less than 30 years.

Figure 31: Age profile - all nursing and midwifery staff as at 30 September 2004

Note: Numbers for age groups in the chart have been rounded up to one decimal place.

The changes in age profile for both registered and non-registered staff since 1998 are highlighted in the graph below:

Figure 32: Registered and non-registered age profile (1998 and 2004)

However given the record number of students in training since the introduction of the Student Nurse Intake Planning process in 1996, one would expect the age profile to begin to fall again.

3.5.12 Flexible working

The proportion of those who work part time in nursing and midwifery categories, among all registered staff, and among all non-registered staff is presented in Figure 33. This shows that while overall the majority of staff work full-time, a significant proportion work part-time and a majority of non-registered staff work part-time.

Figure 33: Registered and non-registered flexible working

The proportion of the workforce that is part time is increasing slightly, as demonstrated in Figure 34.

Figure 34: Contract type for nursing and midwifery staff (1999 and 2004)

The above shows only a slight increase in the proportion of the workforce working on a part time basis, a trend confirmed in the average contracted hours worked by part time nurses and midwives (Figure 35).

Figure 35: Average contracted hours of part time staff

3.5.13 Vacancy rates

Nursing and midwifery vacancies have remained fairly stable, although there has been an increase since the particularly low rate in 2000. The following table shows the vacancy trends for all nursing and midwifery staff as well as showing rates for registered and non-registered staff.

Figure 36: Vacancies as a percentage of establishment at 31st March 2005

Long term vacancies (over 3 months), indicate where there has been difficulty in recruiting to certain posts. The most recent statistics show that while there has been an increase in 2005, these rates remain comparatively low.

Figure 37: Long term vacancies as a percentage of establishment at 31st March 2005

3.5.14 Leavers and Joiners

The leaving and joining rates associated with registered nurses and midwives are shown in Figure 38.

Figure 38: Movements of registered nurses and midwives (joiners, leavers and net gain)

This demonstrates that there has been in excess of 3,000 registered nurses/midwives joining the NHS in Scotland in each year since 2000/01 and a net gain in numbers in every year since 1998.

'All joiners' are mostly made up of newly qualified nurses entering the workplace for the first time and re-joiners who have previously worked within the NHS but have returned after a break. Those joining from the nurse bank, that is nurses and midwives who have taken up a substantive post having previously held a bank-only contract, are also included.

As well as joiners from the newly qualified group, there are joiners obtained through international recruitment. Work is currently underway developing Partnership Information Network Guidelines on best practice for recruiting from overseas. The Nursing and Midwifery Council ( NMC) have set new requirements for the programme which allows overseas nurses entry to the UK Register. NHS Education for Scotland is currently leading the development of suitable programmes in Scotland which will meet the NMC standard. The number of admissions from overseas (non- EU) to the UK Register in the year to March 2004 was 14,122. In addition there were 1,030 from EU countries.

'All leavers' includes those leaving NHS Scotland as well as those who have left to take up bank-only contracts.

Statistics show that as a percentage of the workforce the number of registered staff leaving NHS Scotland has dropped from 7.4% in 1997/98 to 6.1% in 2003/04. Similarly, the percentage of registered staff entering the workforce has increased since 1997/98 from 7.3% to 8.4% in 2003/04 (the latest available data).

3.5.15 Student intakes

The number of pre-registration nursing and midwifery students has increased significantly over the last few years. Student numbers have increased by 40.1% since 1996/7 and there are record numbers in place with 9,264 students in 2004/5. Figure 39 plots the increase since 1996.

Figure 39: Total pre-registration students in training

Figure 40 offers a breakdown of the total pre-registration student population for each of the five individual training categories since 1996.

Figure 40: Pre-registration students in training by category

The Student Nurse Intake Planning ( SNIP) exercise has been running for several years and is a well recognised process for determining the number of pre-registration nurses and midwives (students) required to meet future service demand. The SNIP process looks beyond the 'here and now' and considers matching demand with supply projected over a five year period. SNIP is updated on an annual basis in light of new and emerging pressures and is undertaken in partnership with a range of healthcare partners including the Royal College of Nursing, Royal College of Midwives and Unison. The outcomes help inform the commissioning process with Higher Education Institutions.

The SNIP process takes a bottom-up approach, using intelligence gathered from Boards and others, and results in recommended intake figures for 5 categories of student nurses and midwives. In providing this, employers are asked to consider the main drivers on future demand, and how these will impact on their overall demand forecasts. These include the impact of service change, as well as the impact of the Pay Modernisation agenda, in particular Agenda for Change.

During the SNIP 2004 exercise further analysis on future demand was undertaken in respect of:

• The recommendations emanating from the Nursing and Midwifery Workload and Workforce Planning Project;

• The GMS Contract and Out of Hours requirements;

• The Care Home sector workforce.

This additional demand was factored into the model to form the basis of the emerging figures this year. The workforce dynamics around supply suggest that recruitment and retention initiatives have been successful in more effectively aligning supply with demand. Due to large increases in previous years' intakes, more students are in the system and the supply to NHS of newly qualified nurses and midwives has increased.

The emerging figure of 3,500 intake for 2005/06 is slightly higher than the figure suggested by the model and reflects that element of professional judgement taken during considerable discussions by the SNIP Reference Group. The recommended intakes are similar to the actual number that Higher Education Institutions have been able to recruit to in recent years. The agreed number of places to be commissioned from Higher Education Institutions in 2005/06 and the breakdown across the categories are shown in Figure 41.

Figure 41: Recommended pre-registration student intakes 2005/06

Student attrition rates will have an impact on the final output figures. Latest available figures suggest an average attrition rate of 22.9% taken over 3 year cohorts (latest full data held for cohorts 1998/99, 1999/00 and 2000/01). The average attrition rate for individual categories are shown below:

Figure 42: Student attrition rates (Diploma courses)

Furthermore, following the completion of their pre-registration training, not all nurses and midwives choose to enter directly into employment. This 'non-practice' rate therefore has a bearing on the supply of newly qualified nurses and midwives. Latest figures gathered during the SNIP 2004 exercise suggest an average non practice rate of 14.8%.

PARTNERSHIP AGREEMENT UPDATE

3.5.16 Bank and Agency staff (Complementary Staffing)

The Scottish Executive's Partnership Agreement ³⁷ sets out a range of commitments to improving health services in Scotland. One of the commitments is to implement nationally co-ordinated nursing bank arrangements that assist with nurse placement, improve patient services and help curb expenditure on agency staffing.

Two recent reports provide recommendations to NHS Boards on nurse bank and agency usage. Collectively they support the implementation of co-ordinated nurse bank arrangements and help cut the costs of agency nursing. These are the report of the Nursing and Midwifery Workload and Workforce Planning Project³⁸ and the Nationally Co-ordinated Nurse Bank Arrangements: Report and Action Plan. ³⁹

NHS Scotland is working to reduce its reliance on agency nurses and the related annual spend. This is being done primarily by converting agency spend into increased establishment and thus increasing overall capacity. It is also leading to an increased number working on nurse banks across NHS Scotland. In the year to March 2005:

• Agency usage decreased by 12.4% compared with a rise of 13.7% for bank usage over the same period.

• The average WTE number of bank staff used by NHS Scotland increased from 2,279 WTE to 2,592 WTE.

• The average WTE number of agency staff used by NHS Scotland decreased from 739.4 WTE to 648 WTE.

Whilst the majority of nurses and midwives will hold substantive contracts, there will always be a need for complementary staffing to cover short term absences. The services that the NHS provides are based on good team work and staff from nurse banks form part of those teams.

There are some highly specialised clinical areas where there are not enough skilled nurses within the service and agency staff are the main source of supply. NHS Boards' workforce planning must include taking a longer term view of how to provide the correct skill mix for these areas in the future.

3.5.17 Nursing and Midwifery workforce targets

Further Partnership Agreement commitments include a commitment to treble the number of nurse consultants as well as to train, recruit and retain more nurses and midwives, bringing 12,000 into the NHS by 2007.

Against a target of attaining 54 approved Nurse Consultant posts, there are currently 49 approved nurse consultant posts in Scotland covering a number of fields of practice. These include cancer care, child protection, public health, learning disabilities, older people's services, perinatal mental illness, family planning and sexual health, epidemiology and infection control.

We conservatively estimate at least 3,000 qualified nurses will join NHS Scotland each year. The actual figures since September 2002 have been and are likely to continue to be higher - there has been a total of 7,923 joiners in the two years to March 2004 - given the investment in the nursing and midwifery workforce to date. This has been largely through initiatives launched under the banner of Facing the Future, such as increased student intakes, Return to Practice programmes, the review of nurse workload as well as support for new role development. This suggests that we are well on track to achieve and surpass the recruitment target of attracting 12,000 qualified nurses and midwives to NHS Scotland by 2007.

CONSIDERATIONS FOR WORKFORCE PLANNING

The changing face of the health service in Scotland provides many opportunities for service redesign and the nursing profession has been at the forefront in implementing new and extended roles to deliver care. Increased demand in condition specific areas, such as long term conditions, has led to demand for and the creation of specialist and new nursing roles. Further opportunities are anticipated as a result of the Working Time Regulations and MMC. NHS Boards need to consider all the options available to them in staffing redesigned services particularly in relation to nursing, the largest staff group and to build this into their workforce plans. It is important too that NHS Boards assess the 'knock on' effect of staff taking on new roles and what that may mean for backfilling posts. The increase in students numbers will mean a greater supply of newly qualified nurses and midwives. But not all vacancies or new posts will be suitable for those who are newly qualified. NHS Boards will therefore have to look at their requirements across the career grades and ensure there is development of existing staff for career progression. This will assist both retention and succession planning for backfilling posts.

The support worker cohort is also changing within its existing roles and moving into new roles. NHS Boards will wish to build on the skills of the non-registered element of the workforce offering development opportunities within support worker roles but also development towards possible training for a registered profession. NHS Boards should build in support worker participation in their workforce plans and engage with initiatives such as the Scottish Executive's programme 'Closing the Opportunity Gap'.

Improvements in and consistent use of tools and methodologies for workload measurement will allow for more accurate workforce planning at local level across all areas of the nursing and midwifery professions. There is also scope for improving workforce information and planning for the nursing and midwifery workforce operating in primary care services. This is particularly relevant where the nursing and midwifery workforce are delivering health services that are closely integrated with other services such as social care. NHS Boards should engage with their partner agencies when considering workforce planning for these services. The successful approach established through the annual SNIP process offers a useful model and NHS Boards and regions will be able to develop and refine this for their own local requirements.

3.6 HEALTHCARE SCIENTISTS

Healthcare Science was identified as a coherent group in the workforce with the publication of Making the Change, A Strategy for the Professions in Healthcare Science. ⁴⁰ Following a conference entitled "Healthcare Scientists in Scotland: Shaping the Future", organised by SEHD in September 2002 it was agreed to set up an overarching body in Scotland, known as the Scottish Forum for Healthcare Science ( SFHS) to facilitate the development of the Healthcare Science workforce in Scotland.

While the SFHS represents a significant step towards addressing issues in this part of the workforce, it is recognised that workforce planning for Healthcare Scientists is at the earliest stages of development. The Forum has highlighted issues for workforce development, specifically the need to identify and profile the Healthcare Science workforce in Scotland. This has been welcomed by the Scottish Executive which has provided funding for such a project to improve baseline intelligence, map current data to the provision of services and provide information on supply routes into the healthcare science group.

Healthcare Science encompasses at least 46 professional roles across the full spectrum of healthcare. These are grouped into three broad divisions:

• Life Sciences

• Physiological Sciences

• Physical Sciences & Engineering

Within these professional roles, Healthcare Scientists undertake a wide range of different functions, for example Clinical Biochemistry, Molecular Genetics, Audiology and Biomechanical Engineering to name a few. In general, staff in this group are trained to honours degree level, with some staff holding masters level and doctorate level training. Those groups that are registered achieve this through the Health Professions Council. Healthcare Science staff support a broad range of healthcare services in NHS Scotland. However due to their relative small numbers, they remain susceptible to changes in service demand and to new service delivery.

DEMAND

3.6.1 Workload

Increasing workload is an acknowledged reality for healthcare scientists within the NHS in Scotland particularly as they are closely involved in the introduction of new technology. In clinical biochemistry, for example, the rise in the primary care workload is reportedly far higher than that in secondary care.

The introduction of evidence-based clinical guidelines and national strategies also impacts on the workload of laboratory medicine. For example the national priority given to cancer services has reportedly increased demands on histopathology and there are pressures facing the future provision of physics services for radiotherapy. Likewise, initiatives on diabetes, cardiovascular disease and renal disease affect the workload of clinical biochemistry. Increases in demand for diagnostic services also mean increased demand for areas of healthcare science such as nuclear medicine and radiation protection services.

Any marked increase in workload has the potential to impact on services and the ability to meet patient needs if the required scientific staff are not in place to support increased throughput. Effective workforce planning is therefore inextricably linked with effective management of workload.

3.6.2 Waiting Times

There are a large number of areas of Healthcare Science that contribute significantly to improving waiting times. For example, histopathology and cytopathology in the laboratory sciences, nuclear medicine and radiotherapy in the physical sciences, and audiology and cardiography in the physiological sciences.

Other disciplines such as clinical biochemistry and haematology contribute significantly to decisions on discharge of patients from hospital and can therefore have a considerable impact on the efficiency of bed occupancy. In today's environment there are greater expectations of the service with increased pressure for faster turnaround of results and a wider repertoire of services to be available on a 24/7 basis. NHS Boards will have to assess the implications across the healthcare science professions of the waiting time standards and targets.

3.6.3 Service Development

As Healthcare Scientists generally work in a high technology environment, they are very much affected by innovative service developments. There are a number of recent examples where the introduction of new services and new ways of working has had a direct impact on the workforce.

The introduction of molecular diagnostics has an effect across the field of laboratory medicine and molecular testing is now mainstream in virology and in cancer diagnosis. The concept of managed service provision is being introduced into the highly automated areas of laboratory medicine which may result in the need for new roles and new ways of working for Healthcare Scientists.

3.6.4 New Role Development

Developments in technology are leading to increased point of care testing ( POCT). This may require expanded and new higher profile roles for Healthcare Scientists outside laboratories.

Building a Health Service Fit for the Future acknowledges that shorter waiting times will be achieved partly through better access to diagnostic services. The use of advanced information, communication and engineering technologies will allow diagnostic methods to be accessed and delivered in the community. This will undoubtedly lead to an increase in locally delivered services as well as a demand for more specialised treatment to be available in the community. This increased access by primary care teams to investigations and tests as well as heightened demand for information will require a suitably skilled and competent workforce, deployed in a manner that can meet patient expectations and the overall needs of the community.

3.6.5 Impact of technology

The development of new technologies clearly has a significant impact on the demand for Healthcare Scientists and on the generation of new roles. For example:

• the introduction of robotics and tracking into laboratory medicine is bringing about high level automation. This new technology can remove some of the workload pressures on biomedical scientists but it also creates the need for high level technology experts.

• developments in technology are likely to increase the use of POCT to provide rapid near patient testing by non-laboratory personnel in a wide range of clinical settings. This is likely to place different demands on Healthcare Scientists who will be responsible for the quality management of the POCT.

• the quality and turnaround times of cervical cytology are being improved due to developments in liquid based cytology. The introduction of immunisation programmes will further affect this service in the years ahead.

• of particular value to remote and rural practice will be developments such as telemedicine and the electronic transmission of high quality digital images. These are expected to impact on the practice of histopathology, including quality control and second opinions.

• digital technology has increased demands on Healthcare Scientists in many areas, ranging from the introduction of Picture Archiving and Communications systems ( PACs) in radiology to the demand for digital hearing aids in audiology.

3.6.6 Pay Modernisation

The Agenda for Change pay system for healthcare scientists 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 the following impact on available capacity is indicated:

Figure 43: Immediate impact of Agenda for Change on capacity

The new consultant contract may mean laboratories having to extend 'normal working hours'. Taken in conjunction with the Working Time Regulations (see below) this may in turn lead to a need for increased numbers of Healthcare Scientists. It is also recognised that Healthcare Scientists are reporting significant increases in workload as a result of the new GMS contract where GP practices are extending the range of services they provide to patients, including those that call on the services of healthcare scientists.

3.6.7 Working Time Regulations

Healthcare Scientists provide a 24/7 service in many areas, for example in providing equipment repair services (medical physics technologists), laboratory analytical service (biomedical scientists) and advisory service (clinical scientists). However, in delivering these services, the Working Time Regulations need to be accommodated, often by 'on-call' and shift working. The combination of achieving rotas that meet the WTR requirements and the increasing volume and scope of activity demanded of a 24/7 service is anticipated to impact on the number of healthcare scientists required.

3.6.8 Training and Continuing Professional Development

Healthcare Scientists are trained in clinically related science which is undertaken across a wide variety of settings. This is usually to BSc level or above. Currently the provision of education, training and development is variable. Some groups, such as Clinical Scientists and Biomedical Scientists, have developed training programmes that lead to registration, followed by continuing professional development. In the case of MTOs the mechanisms for registration are being put in place but the arrangements for administering and funding this training are currently under development.

The introduction of registration with the Health Professions Council for medical technologists is envisaged as requiring all registrants to obtain a vocational degree in medical technology. This creates a number of challenges regarding the provision of appropriate training, some of which is peculiar to Scotland. Also, the introduction of limited site-based training (such as SVQs and foundation degrees) and the support required for assistant grades in laboratories needs to be considered as part of workforce planning, as does the need for backfill to cover compulsory CPD for registered Healthcare Scientists.

SUPPLY

Statistical data for Healthcare Science staff is currently collected by ISD as part of the Scientific, Therapeutic and Technical group. This includes Allied Health Professionals, Ambulance Staff, Clinical Psychologists, Optometrists and Pharmacists as well as data on Clinical Scientists and those affiliated to Biomedical Science.

The 3 broad divisions of Healthcare Science - Life Sciences, Physiological Sciences and Physical Sciences & Engineering - cut across the headings currently used for the collection of data for healthcare scientist staff. These are Scientific & Professional staff (includes data on Clinical Scientists) and Technical staff (includes Biomedical Scientists and Medical Technical Officers). Scientific and Professional staff account for 1.7% of the NHS Scotland workforce while Technical staff account for 5.1% (headcount).

While the Healthcare Science workforce is wide and diverse, the remaining part of this section reflects the current picture of data coverage - in particular Biomedical Scientists and Clinical Scientists who are the cohorts about which we have the best intelligence. The lack of robust detailed information for all Healthcare Science staff prevents a full analysis at this time of the current supply of all healthcare scientists. However, as already mentioned, a project to improve workforce information is being supported by SEHD in conjunction with the Scottish Forum for Healthcare Scientists. Also, specific work is underway to review the current Biomedical Science workforce - a large cohort and a crucial group in supporting the broader clinical team.

3.6.9 Biomedical Scientists

Biomedical Scientists, formerly referred to as Medical Laboratory Scientific Officers ( MLSOs), provide an essential role in interpreting investigations for the diagnosis, management and early detection of disease through specimen examination and clinical interpretation. They work mainly within laboratory settings but also in near-patient settings such as wards and clinics.

Baseline intelligence on Biomedical Scientists in Scotland indicates the following:

Figure 44: Number of staff in post ( WTE) - Biomedical Scientists ( MLSOs)

In its report Another Step Forward⁴¹ (2002) the Scottish Medical and Scientific Advisory Committee ( SMASAC) identified further information relating to the recruitment, training and retention of Biomedical Scientists. The Advisory Committee concluded that:

• main laboratory disciplines are Clinical Chemistry; Blood Transfusion; Haematology; Cellular Pathology; Histopathology; Cytology; Autopsy; Medical Microbiology; Virology; Immunology; Histocompatibility/Tissue Typing.

• Medical Laboratory services provide much of the diagnostic evidence that is crucial to the delivery of modern healthcare in NHS Scotland. Approximately 50% of patient diagnosis depends on laboratory tests.

• laboratory services are consultant led, employing medical staff; clinical scientists, Biomedical Scientists, Laboratory Assistants, Medical Technical Officers and Cytology Screeners amongst others.

• approximately 21% of Biomedical Scientists are aged 50+ (Figure 45)

Figure 45: Age profile of Biomedical Scientists

Source: Another Step Forward ( SMASAC, 2002)

• Approximately 35 Biomedical Scientists will retire each year for the next 10 years (Figure 46)

Figure 46: Biomedical Scientists ( MLSOs) approaching retirement

Source: Another Step Forward ( SMASAC, 2002)

• Overall, approximately 3 out of 5 staff are females. However the gender mix varies dramatically across the different grades with the majority of staff in the higher grades being male.

• Biomedical Scientists are required to be state registered with the Health Professions Council ( HPC).

• Biomedical Scientists have to undergo further post-graduate training and receive further qualifications to progress in their careers.

The current available data indicates that numbers in post have been rising steadily although not dramatically. Training numbers will be factored in once better data is established. Information on Biomedical Scientists will be updated as part of the project to improve data and intelligence on all Healthcare Scientists for workforce planning purposes.

3.6.10 Clinical Scientists

Although Clinical Scientists are a relatively small professional group within the NHS, they are critical to the provision of health services in Scotland. Most patients' diagnosis depends on laboratory tests and laboratories are largely staffed by healthcare scientists overseen by clinical scientists.

Clinical scientists pose a particular challenge for workforce planning as in many areas they are small in number and have specialist skills. In some areas, such as physics and engineering, only small numbers of graduates are trained and the sustainability of some courses could become vulnerable.

The current 'Grade A' training scheme for clinical scientists has operated successfully since 1994 and is funded through National Services Division ( NSD) of NHS National Services Scotland. Trainees are appointed to supernumerary posts based in centres around Scotland that are approved for training purposes by the appropriate professional bodies.

Figure 47: Clinical Scientist training scheme

Total numbers in training in recent years are set out in the table below. All schemes now last 4 years to state registration.

Figure 48: Numbers in training

Scientists are also able to enter the profession, and achieve registration, by routes other than the formal training scheme. This is viewed within the healthcare science arena as essential, not only for scientists but also for technologists, if the health service is to take maximum advantage of the availability of specialist skills in the scientific community.

Increased specialisation within laboratory science has implications for career advancement. For example in the delivery of reference laboratory services in areas such as microbiology, it is reportedly becoming increasingly difficult for post holders to achieve MRCpath (Member of the Royal College of Pathology) and to secure effective career progression. National Services Division advise that there is therefore a need to provide opportunities for clinical scientists at a higher specialist training level to have general attachments in a wider laboratory setting, whilst retaining part of the job in their specialist area. A proposal for a small number of Higher Specialist training slots is currently being developed for Scotland by the National Services Division.

CONSIDERATIONS FOR WORKFORCE PLANNING

Healthcare Scientists undertake key roles in NHS Scotland providing a diverse range of services such as genetics and rehabilitation engineering. In doing so they are crucial in helping to reduce waiting times. While Healthcare Science collectively accounts for some 46 different professions, it is important that the role each play is recognised even although they may not always be visible.

The information contained within this section highlights some of the main challenges that lie ahead in order to plan effectively for the Healthcare Science workforce in Scotland. This will require a better understanding of the dynamics affecting the workforce both in terms of supply and demand. In addition, consideration must be given to how traditional roles will develop and expand in light of technological advances and service demand.

As a first step, it is important to build upon and improve the level of data and intelligence available for the purposes of effective workforce planning. Through the Scottish Forum for Healthcare Science ( SFHS), a project to achieve this has been sponsored by the Scottish Executive. In taking this forward through the SFHS it will be important that there is full involvement and participation from each of the individual professions within Healthcare Science and from NHS Boards and regions.

3.7 ALLIED HEALTH PROFESSIONALS ( AHPs)

The nine Allied Health Professions ( AHP) are as described in the strategy document Building on Success: Future Directions for the Allied Health Professions in Scotland; ⁴²

• Arts Therapists (Art, Music, Drama)

• Podiatrists

• Dietitians

• Occupational Therapists

• Orthoptists

• Physiotherapists

• Radiographers

• Speech and Language Therapists

• Prosthetists/Orthotists

(It should be noted that in this section data on Prosthetists and Orthotists has been excluded, except where stated, as there are discrepancies with the data which are undergoing reconciliation at present.)

DEMAND

Over the last 10 years demand for the Allied Health Professions has been increasing, primarily because of service delivery changes.

3.7.1 Changing Demography

A growing elderly population and a growing number of patients with chronic conditions, often with complex co-morbidity, has driven an increased need for Allied Health Professionals who can provide a wide range of skills in both the acute and chronic care of patients.

3.7.2 Waiting Times

As patients are treated more quickly with improved journey times through the NHS system enhanced clinical teams are needed to support the additional activity. This has an impact on Allied Health Professionals, in particular: radiographers, who support hospital treatment across a number of specialties and are key to faster access to diagnostic tests; and physiotherapists, who provide rehabilitation services to patients who have undergone acute treatments, such as hip and knee surgery. Some of this additional demand will also be met by new and more efficient ways of working and by AHPs taking on new roles.

3.7.3 Working Time Regulations

The Working Time Regulations impact some of the AHPs providing care in acute settings on a 24 hour 7 day a week basis. Much of this is managed by on-call and shift working arrangements. New limits on hours require a reassessment of the number of staff required.

3.7.4 Workload

Work is currently underway through a 12 month project to establish how workload is measured and whether recognised measurement systems or tools are being used to allocate resources across the AHPs in Scotland. A project officer has been appointed by the Scottish Executive Health Department to take forward a programme of targeted activity at local level and to link with workforce planning development. The work is expected to complete in December 2005 with the publication of a report on the findings and an action plan to be taken forward. It is clear that no one solution in terms of workload measurement will suffice for the 9 different professions in the Allied Health Professions and it is envisaged that a range of workload measurement tools or processes to support and contribute to the development of the workforce will be considered.

3.7.5 Pay Modernisation

Since October 2004 all Allied Health Professions have been subject to the Agenda for Change pay agreement. This changes their terms and conditions of service and affects capacity. Taking into account changes in annual leave entitlement, contracted hours and overtime, the effect on the AHP workforce will be a gain of 2.4% on the current WTE establishment once the new pay system has been fully implemented. This is an average figure which covers a range from 0.7% to 6.1% as shown below in Figure 49.

Figure 49: Impact on capacity of Agenda for Change

3.7.6 New Roles

There is increasing opportunity for Allied Health Professionals to develop their roles and scope of practice. Building a Health Service Fit for the Future emphasises the need to maximise the skills of those who are not doctors in the provision of services being reconfigured for the future. AHPs have a wider role to play in preventative intervention, in unscheduled care and in remote and rural healthcare in both specialist practitioner and consultant allied health professional remits. The Framework for Role Development in the Allied Health Professions⁴³ is intended as a tool to assist in adopting a consistent approach to developing roles within services thus enabling AHPs to realise their full potential for health services in NHS Scotland. For example, the emergence of Community Health Partnerships which are more accountable to local communities and better linked with social work services present fresh opportunities for developing new roles.

3.7.7 Health Improvement

A cross-governmental approach is driving health improvement and helping to ensure effective delivery. Along with other health care workers, AHPs have a pivotal role to play in this important area, working on a broad front to improve physical, mental and social well being, fitness and quality of life. The contribution of AHPs to an increasing focus on health promotion in schools, and the work of dietitians with families, are two examples of this.

3.7.8 Additional Support for Learning Needs

The Education (Additional Support for Learning) (Scotland) Act 2004 ( ASL Act) introduces a new framework to support children and young people who face barriers to learning. Under the ASL Act appropriate agencies, including NHS Scotland, have a duty to comply with requests for help from education authorities unless to do so would be incompatible with their own statutory or other duties or would unduly prejudice their ability to carry out their functions. For NHS Scotland the ASL Act is likely to have resource implications, including a higher number of requests for assessment from parents and local authorities and a greater number of education staff to train and collaborate within an increased number of mainstream schools. £3 million has been allocated in 2004/05 and again in 2005/06 to NHS Boards to assist preparation for NHS obligations under the ASL Act. The key AHPs involved in meeting the demands of the ASL Act include speech and language therapists, physiotherapists and occupational therapists, although orthoptists, orthotists and dietitians also have a specialist role to contribute.

SUPPLY

The chart below shows the proportionate split of the 8 Allied Health Professions, excluding Prosthetists and Orthotists, incorporating registered and non-registered staff (in head count). Physiotherapists are the largest profession at 29% of the total, while Arts Therapists are the smallest with under 1%.

Figure 50: Registered and assistants as at 30 September 2004, by profession

Figure 51 shows headcount and whole time equivalent ( WTE) of Registered AHP staff employed at 30 September 2004.

Figure 51: Staff in post as at 30 September 2004

At 30 September 2004 there were 1,789 headcount and 1,383.7 WTE non-registered AHPs in post, a rise of nearly 70% over the past decade (headcount). In 1994 non-registered AHPs were 15.7 % of the total AHP workforce rising to 17.8% in 2004 (headcount).

3.7.9 Trends

Figure 52 shows the trend in WTE of registered staff employed in each of the professions since 1994. For all professions there was an increase in staff employed. The largest percentage increases were for dietitians (87%), occupational therapists (70.9%), and speech and language therapists (47.4%).

Figure 52: Staff in post trends by profession as at 30 September ( WTE)

Looking back over the past decade there has been an average 43.9% rise in WTE over all the registered Allied Health Professions with the rate of increase slowing over the last 5 years to 17.7%. The professions all showed growth over the period, as can be seen from the table below.

Figure 53: Rate of growth (based on WTE changes)

3.7.10 Gender Balance

Qualified AHPs are predominantly female with little change in the last 5 years (92.3% in 1999 to 91.6% in 2004).

3.7.11 Age Profile

Qualified AHPs are generally young professionals with over half of staff under 39 (57.4%). This is so for each separate profession apart from arts therapists and radiographers where the percentages of the workforce under 39 are 16% and 45% respectively.

Figure 54: Age profile of AHPs by profession as at 30 September 2004

3.7.12 Flexible Working

Nearly 40% of qualified AHPs work part-time, an increase over the last 5 years from 36%. All professions have seen an increase in part-time working apart from dietetics, which has decreased from 43% to 39%. The average number of part-time hours worked by AHPs has also increased in the last 5 years.

Figure 55: Average contracted hours of part time qualified AHPs: by profession

3.7.13 Turnover

The average turnover rate for all qualified AHP professions is 7.1% over the last five years. The professions with the highest average turnover rates are occupational therapists (8.7%), physiotherapists (8.2%) and speech and language therapists and arts therapists (7.1%).

3.7.14 Vacancies

AHP vacancies between 1996 and 2004 are shown at Figure 56. Currently this data includes prosthetists and orthotists for 2003 and 2004.

Figure 56: AHP vacancies as at 31 March 2004

Note: Estimated figures for establishment and vacancies are used at Scotland level, to compensate for under-reporting.

3.7.15 Student Intakes

Pre-registration training courses are available in Scotland for all the Allied Health Professions with the exception of Orthoptists. The demand for training places is buoyant although the ratio of applicants to places varies from 11:1 for physiotherapy to 2:1 for podiatry.

In general, the number of places in pre-registration courses is determined by Higher Education Institutes. However, there has been specific action in 2002/3 to fund an additional 65 undergraduate students in the key priority areas of radiography, physiotherapy, occupational therapy and speech and language therapy. There is also a fast track pilot 2-year postgraduate diploma in therapeutic radiotherapy which aims to produce 30 therapy radiographers by 2006.

For the longer term, SEHD are working with NHS Education for Scotland to develop a Commissioning Plan for Education and Training which will provide a strategic co-ordinated strategy and process for commissioning the education and training required to produce a workforce fit for the future. This will take account of the pre-registration and CPD needs of AHPs.

Figure 57 shows the number of commencements in pre-registration training for the Allied Health Professions from 1998 to 2004.

Figure 57: Commencements in AHP courses

Figure 58 shows the number of AHP graduates there were in Scotland in 2003 and 2004 and the number expected to graduate from 2005 to 2006.

Figure 58: Number of AHP graduates

3.7.16 Skill mix changes in registered and non-registered staff

In the last 10 years there has been a 2% increase in the proportion of the AHP workforce made up of non-registered staff. As at September 2004 this ratio was approximately 80:20, registered:non-registered staff. With improved competency training for the non-registered staff and the possibility of regulation for this staff group in the future the opportunities for their roles to change and enhance are considerable. This in turn would free up the registered staff to undertake their core duties in patient care. The resultant skill mix change could follow a number of scenarios with two shown in the chart below changing the skill mix to 60:40 (blue lines) and 70:30 (red lines).

Figure 59: Projected skill mix changes to the AHP workforce

PARTNERSHIP AGREEMENT UPDATE

The Partnership Agreement commitment regarding target numbers for the Allied Health Professionals is to ensure a total of 1,500 extra Allied Health Professionals, such as radiographers, physiotherapists, dietitians and chiropodists and is due for delivery by September 2007. The target is based on an increase in headcount to 9231 from a baseline of 7731 at September 2002. Figure 60 shows good progress over two years with an extra 606 AHPs being brought into the NHS Scotland workforce. To achieve the target growth for AHPs, NHS Boards need to maintain a similar level of recruitment as they have done to date.

Figure 60: Partnership agreement target - AHPs

Note: This data includes prosthetists and orthotists.

CONSIDERATIONS FOR WORKFORCE PLANNING

Allied Health Professionals have expertise in a range of assessment, diagnosis, treatment and rehabilitation interventions which to date have not been fully exploited in health terms. Maximising their contributions to new patient pathways to secure improved outcomes for patients will require a focused approach to key care groups and engagement with other health and social care professions as part of the redesign process and NHS Boards will wish to consider this in their workforce plans as they look to multi-disciplinary and multi-professional teams in delivering patient care.

A wide range of initiatives is underway to support recruitment and retention of AHPs within NHS Scotland, recognising that retention of staff is a key factor in maximising capacity. This can be further enhanced if practitioners have the opportunity to develop their careers to their full potential.

It will be important to consider the career structure of AHPs with more flexible career pathways. The creation of specialist practitioner posts will provide opportunities for retaining AHP expertise and enhancing role development. A mentoring and support programme has been provided for AHPs moving into new AHP leadership roles, along with career-long learning to ensure AHPs meet re-registration conditions, are more effective in their work and have greater job satisfaction and organisational commitment.

NHS Boards must take account of the non registered support staff that form part of the AHP workforce and factor in their future contribution to service delivery. This will also require consideration of development opportunities towards registration for one of the professions.

NHS Boards need to consider the widening role of AHPs within primary care and ensure that their workforce plans take account of this and other sections of healthcare where roles may develop.

3.8 CLINICAL PSYCHOLOGISTS

The information in this section is derived from work being undertaken at present by NHS Education for Scotland and ISD on the psychology workforce. Workforce Planning for this staff group is still in the early stages, with the emphasis on supply at the present time.

Clinical Psychologists are the largest group of applied psychologists employed in the NHS. (There are a number of other branches of Applied Psychology also relevant to the healthcare agenda, including Counselling Psychologists, Health Psychologists, Assistant Psychologists and also Counsellors and Cognitive Behaviour Therapists, who may or may not be psychologists.)

DEMAND

In the absence of comprehensive data across Scotland and, for the purposes of early work being done by NES, an estimate has been drawn up by adopting a population-based approach using published reference data. On this basis, an initial estimate suggests that a minimum establishment of 1,025 posts may be needed. This equates to 1 WTE clinical psychologist per 5,000 of the population.

Demand for psychology services may change under the influence of a number of factors. All of the following will need to be considered by NHS Boards in their workforce plans.

3.8.1 Changing demography

Clinical Psychologists provide services across the life span and across a range of services from health improvement to chronic disease management. However, with the increasing emphasis on the latter, especially because of Scotland's ageing population, demand for clinical psychology services is anticipated to grow.

3.8.2 Service development

The development of the Scottish Intercollegiate Guideline Network guidelines and Clinical Standards as well as the expectations of multidisciplinary and multi-agency teams, have led to service developments which are tending to increase the demand for Clinical Psychologists. The future shape of psychology services in NHS Scotland will be discussed at a two day conference in October 2005, arranged by NHS Education for Scotland and this should offer an indication of future workforce needs.

3.8.3 Workload

Recognition of the importance of psychological factors to achieving objectives for physical and mental health and well-being, particularly for those with chronic conditions, will impact the demand for clinical psychologists' services.

3.8.4 Waiting times

Along with the increasing public expectation of psychological care there is scope for improving service delivery, for example in the length of wait for patients accessing the services they require.

SUPPLY

Data shows that at 2004 there were 437 qualified Clinical Psychologists (389.13 WTE) in NHS Scotland. That amounts to 1 WTE per 12,997 of the population. (In addition there were 29.5 WTE Applied Psychologists; 67.1 WTE Assistant Psychologists; 21.3 WTE Counsellors; 16.9 WTE Cognitive Behaviour Therapists; and 8.9 WTE other clinical staff.) We also know that at this time 73% of the workforce were female and 38% worked less than full-time, on average 0.7 WTE.

NHS Education for Scotland and Information Services Division ( ISD) have been working to develop a data collection system, modelled on the ISD survey of medical staff, to provide intelligence about the skill-mix employed in psychology services across NHS Scotland. This system was piloted in 2001 and, with modifications, the survey has been repeated annually from 2002 to 2004.

This data gives the following picture of the specialties which Clinical Psychologists were working in at 2004.

Figure 61: Distribution of Clinical Psychologists across specialties at 2004

Training to be a Clinical Psychologist takes three years (following graduation from a degree course recognised by the British Psychological Society). Clinical Psychologists are unique among healthcare professionals in that their pre-registration training, funded by the NHS, is undertaken as a postgraduate practitioner doctorate. Clinical Psychology trainees are NHS employees who spend more than half of their time in training in supervised practice.

The intake to Clinical Psychology training courses in Scotland has increased from 32 in 2001 to 61 in 2004. In October 2004 there were 161 Clinical Psychologists in training compared with 96 in 2001. In Scotland the expansion rate in the workforce is currently estimated at 5%. The expansion in training capacity began in 2002. The number of trainees in training has increased by 61% since then.

New provision for a 1-year Masters level training has been introduced this year. This equips graduate psychologists with the competencies to deliver interventions for common mental health problems presenting in adults in primary care. The course was developed in consultation with the service and designed to improve waiting times in the primary care setting. There are plans to develop a parallel programme to equip graduate psychologists to contribute to services for children and young people. These are being developed in consultation with the Child & Adolescent Mental Health Services Workforce Group and the Child Health Support Group.

CONSIDERATIONS FOR WORKFORCE PLANNING

As NHS Boards redesign services, there is an opportunity with the supply of psychologist improving for consideration to be given to the wider as well as specialist role that psychologists play in healthcare services.

Psychology is undergoing a programme of expansion and modernisation of pre-registered clinical psychology training. There is inevitably a time lag between the start of training and the production of health care professionals such as psychologists. However, the skill mix of psychologists in Scotland is also being extended by the introduction of a new grade of psychologists in primary care to help provide care for those with common mental health problems. (The first cohort will complete their training and enter the workforce in January 2006.)

Workforce planning needs to recognise these changes in psychology training and NHS Boards should ensure that they can realise the benefits this increase in supply offers them. In particular NHS Boards should consider the maximisation of clinical psychologists' skills within primary care teams which provide patient care, at local level, across a wide spectrum of needs.

3.9 PHARMACISTS

The Pharmacy workforce includes those directly employed by the NHS (managed service) and those independent pharmacists providing community services and contracted by the NHS.

The Right Medicine: A Strategy for Pharmaceutical Care in Scotland⁴⁴ set out a modernisation plan for pharmacy services in NHS Scotland. In order to underpin this, it was recognised that reviewing skill mix within hospital and community pharmacy and examining how to fully utilise the skills of pharmacy technicians, dispensers and assistants was required. NHS Education for Scotland have taken a lead role in the workforce development aspects, initially for technicians and pre-registration pharmacists. There is also a national consultation about community pharmacy and skill mix underway, Making the Best Use of the Pharmacy Workforce. ⁴⁵ Current roles are in many cases dictated by the traditional structure of service delivery existing within the NHS. It is recognised however that the skills of the full pharmacy family could be put to better use to meet the challenges in delivering a modern, 21st century NHS. A new Pharmacy contract is currently under consultation and this may have an impact on workforce planning in the future although, at present, this cannot be assessed.

3.9.1 Managed service

The managed service workforce consists of pharmacists, pharmacists in training, pharmacy technicians, technicians in training and pharmacy assistants. In September 2004, the pharmacy workforce totalled 1,703.1 WTE, or 1,936 headcount. This is a staff group dominated by females as demonstrated in Figure 62.

Figure 62: Gender mix statistics for September 2004 (Headcount)

The predominant work pattern is full time (71%). However, during the period from 1999 to 2004, there has been a trend towards more part-time working (21% of the workforce, increasing to 27%). The age distribution for qualified pharmacists is relatively stable as indicated below.

Figure 63: Age profile of qualified pharmacists

Compared to the wider Scientific and Professional Staff Group, qualified pharmacists are younger.

Figure 64: Age profile of qualified pharmacists & all other qualified scientific and professional staff at September 2004

In the context of the pharmacy team, pharmacy technicians tend to be younger while pharmacy assistants generally span the full age range.

Figure 65: Age profile of pharmacists, technicians and assistants as at 30 September 2004

Pharmacists in Training are, as expected, a younger group of staff with 89% aged 25 years or younger in September 2004. Very few individuals are taking up training in this profession after age 25. Historical trends are similar when comparing 1999 to 2004. Likewise, in-training pharmacy technicians are a younger group with 62% aged 25 years or younger and all individuals aged 50 years or younger.

3.9.2 Contracted service

The Scottish population is served by 1,148 pharmacies. Little information is currently known about the pharmacy workforce delivering community pharmacy services. However under the new Pharmacy Contract, more information will be available and will assist in ensuring the training and development considerations of the contracted service are taken into consideration.

3.9.3 Future roles

Future enhanced roles will see pharmacists, technicians and other support staff integrated into the multi-professional team with pharmacists focusing on the clinical and professional aspects of medicine use and technicians leading on the technical aspects of medicine use, e.g. preparation and supply. Further work is required to determine how new roles will impact on demand for both pharmacists and pharmacy support staff.

CONSIDERATIONS FOR WORKFORCE PLANNING

The new Pharmacy contract, which is currently under consultation, will have an impact on how we workforce plan for pharmacy services in the future although this cannot be assessed yet.

Currently we are working to overcome knowledge gaps to improve our ability to workforce plan for pharmacy. The national consultation on community pharmacy and the data gathered from the implementation of the Pharmacy contract will go some way towards completing the information needed on this vital group of the health workforce, particularly with regard to independent pharmacists. This information will provide a more solid base for analysis and in the future allow more specialised and detailed studies to direct the action that must taken to sustain the pharmacy workforce.

It is widely recognised that the skills of the full pharmacy family including pharmacy technicians, dispensers and assistants, can be put to better use to meet the challenges in delivering a modern, 21st century NHS. This means that current roles can be developed as the traditional structure of pharmacy is challenged and service improvements to patients are realised.

NHS Boards should ensure that they consider the role of the pharmacy workforce within the primary care setting and factor the need for their skills into the wider primary care workforce planning developments.

3.10 CONCLUSIONS

The analyses contained in this Chapter, draw a 'top-down' picture of the many factors that will influence the future demand and supply of the healthcare workforce in Scotland. In this initial year of operation of the workforce planning framework for NHS Scotland, this National Workforce Planning Framework 2005 comes before any bottom-up assessments of demand from NHS Boards and regions (other than short-term demand for consultants). Once NHS Boards and regions have produced their workforce plans that will complete the workforce planning cycle set in train by this report.

In future years, as described in Chapter 5, this planning framework will deliver Board plans first, followed by regional plans and these will inform national projections of future demand against which supply can be assessed and adjusted.

The NHS cannot function without its workforce. It is also true that the workforce is the most costly recurring element of healthcare provision. NHS Scotland must therefore aim to maximise its use of the workforce in the most efficient way. That means adopting a continuous improvement approach to achieve better retention, better productivity, better use of skills, better conditions. Pay modernisation, Building a Health Service Fit for the Future, the extension of current roles, the creation of new roles - these and other initiatives all provide opportunities for creating and maintaining a modern workforce for a modern NHS.

In an environment that is changing as rapidly and as frequently as healthcare, the workforce needs to be highly flexible. It cannot remain stuck in the past in traditional roles, protecting traditional professional boundaries or inefficient working practices. Patient care needs to be delivered through a team-working approach which simplifies and smooths the patient's path through the healthcare system, rather than subjecting him or her to unresponsive procedures simply because they are convenient to the provider. That means forging multi-disciplinary, multi-skilled and multi-professional working - stretching across primary, secondary and tertiary care and other sectors, such as social work and education, and oriented around seamless and efficient service provision at the 'front-end', rather than staff demarcations. This is a challenging change to make, but much is already happening to make it a reality.

It is clear from the analyses that significant investment is made in training the healthcare workforce of the future. This is particularly evident for initial training. The public rightly expect a good return from this investment of public funds. Yet, many of those who are trained in Scotland do not stay in the NHS in Scotland, and many leave Scotland altogether. We need to rectify this and make the NHS in Scotland a place where more of our trainees want to develop their careers after they qualify. If we could improve retention our workforce pressures would quickly reduce. Otherwise there is a temptation to keep pouring more trainees in, with a poor return on the investment made.

There are a number of initiatives which we are supporting at national level to improve retention rates, such as in the medical workforce where we are keen to see the universities improve the number of Scottish-domiciled students going into medicine, and therefore more likely to stay on in Scotland; and in the nursing workforce where we are supporting qualified nurses to return to practice. We look also to the workforce regions and NHS Boards to outline in their workforce plans their ideas for improving retention of their staff and how those will impact on their future staffing needs.

There is also a need to take stock on the extent to which we aim to 'grow our own' in Scotland and be self-sufficient, particularly in highly qualified professions. This will become more and more relevant in a shrinking world with growing global economies. Scotland has traditionally trained large numbers of doctors. There have been benefits in this: not just to Scotland's reputation but to the increased capacity for service delivery which historically predominantly rested with junior doctors. That reliance on doctors-in-training to deliver service is now changing with the reduction in working hours, the move to care delivered by trained doctors and with the advent of MMC. In other parts of the workforce, whether for initial training or continuing professional development, extending roles or newly emerging professions it is vital that throughout the training period the demand for staff with those skills and competencies is continually monitored.

A modern workforce should also reflect the community it serves. Diversity across all staff groups is a positive indicator of the NHS as an exemplar employer and jobs and careers should be designed to be attractive to all members of the community. This will ensure that NHS Scotland does not miss out on all the possible avenues from which to source staff or trainees into healthcare services. That will be important as the NHS faces significant change and competes for skilled staff with other employers and other healthcare systems worldwide.

All groups of staff are affected - some directly as a result of change, others indirectly as the consequences of change mean new roles, new ways of working and new technology for them. These opportunities will take the NHS into a new future of better services for patients and better opportunities for staff.

It is clear, however, that we need to improve our knowledge of the workforce - its configuration and composition. NHS Scotland has the largest workforce in Scotland. And it is a complex workforce. Better intelligence is needed on all its elements, not just the staff groups identified in this chapter. However, we flag two areas where the need for a better evidence base is particularly apparent:

• our knowledge of the healthcare scientists' group is limited and there is a need to develop our understanding of that cohort and to protect future capacity in the various sub-specialties that comprise vulnerably small numbers;

• there is a prominent gap in the information required to undertake effective workforce planning for primary care, including GP practices. This is an urgent priority and particularly relevant in light of the emphasis placed on local care by Building a Health Service Fit for the Future. If 90% of healthcare takes place in the community we should be workforce planning for these services as much as for those in the acute sector. A clearer picture of the size and shape of the primary care workforce will support 'whole systems' planning and delivery of services and recognise the contribution made by all groups from GPs to community pharmacists.

3.10.1 Principles underpinning the workforce planning framework

In considering this framework for workforce planning the Workforce Numbers Group established three principles that any assessment of the future workforce should meet in order to be credible and fit for purpose. These are Affordability, Availability and Adaptability. Forecasting future staff requirements counts for little if the means are not there to convert these predictions into the appropriate number of suitably trained and accredited staff, in an affordable and timely manner.

3.10.2 Affordability

The vast majority of spend in the NHS is on staffing which is understandable since the NHS relies on its staffing to deliver health care services to patients. Funding for health care is increasing year on year by over £700 million and will be almost £10.3 billion by 2007/08. However, we must acknowledge that the overall amount of resource will always have a limit. Workforce planning must therefore recognise this. There is little use in producing significant extra numbers of staff if the NHS cannot afford to employ them, or if services have been redesigned in such a way that their skills are no longer required as forecast. At national level, increases in staffing and pay modernisation are recognised in the Executive's overall spending plans. At local level, workforce planning and service planning must both inform and reflect local financial planning to ensure affordability. Long term plans must be realistic and refined year on year as the previous horizon comes closer and the picture is clearer.

It is also important to bear in mind the broader context of the Scottish labour market beyond the health sector. Affordability is not just about cash funds for health, but also the size of the public sector workforce in Scotland and the impact that has on the economy. A persistently growing health care workforce is not sustainable. We have already seen since 1997 very significant increases in many staff groups in the healthcare sector - 12% more non-medical staff, 30% more AHPs, 6% more nurses and midwives, 21% more consultants. The non-medical workforce amounts to 15% of all those with NVQ Level 4 qualifications in the Scottish workforce. Clearly an increase in any of these numbers and proportions will have a sizeable impact on the labour market, particularly given the expectation of a shrinkage in the size of the working-age population in Scotland over the long-term.

3.10.3 Availability

Any assessment of future workforce must be tested against the availability of candidates to populate that workforce. The demographic changes and competition for potential and existing employees make it vital that we are alert to wider labour market forces and actively monitor and compare turnover rates with other sectors of the labour market. The NHS must be aware of its position in the market place and recognise that global economies reach into Scotland. Given the shrinkage in Scotland's working population we may not be able to source a constantly growing workforce from a purely Scottish pool. This means working harder at retaining the staff we already have, looking more energetically at recruitment from beyond Scotland, and continuing to work with staff to maximise current capacity.

Work is underway at national level to analyse how the broader Scottish labour market will influence the healthcare sector workforce in the future and inform NHS Scotland's workforce planning. Equally, it is important for regions and NHS Boards to factor in regional and local labour market dynamics to their workforce planning.

Availability is also about the right numbers of staff being available with the right skill sets. This requires a coherent and strategic approach to the commissioning of training and education of NHS staff, ensuring that the right training is being commissioned to serve the needs of future services. NHS Education for Scotland ( NES) is responsible for overseeing this area of work and is currently drawing up a national commissioning plan for education. This will cover all of NHS Scotland's education and training needs and ensure there are no gaps in the agreements that the NHS and the Scottish Executive make with the higher and further education sectors for the production of suitably trained people to serve the needs of NHS Scotland.

It will also be important for NHS Boards and regions to outline in their plans how local education and training arrangements may impact on the availability of suitable staff and how these are influencing their future staff projections.

3.10.4 Adaptability

If the workforce continues to grow, the capacity of NHS Scotland to absorb more and more staff must be carefully considered. The workforce planning underway for the introduction of MMC has identified that there is capacity in the training infrastructure to expand training numbers but this must be balanced with the pressures placed on other parts of the workforce, for example on those who are required to carry out supervision and assessment. In nursing and midwifery the use of mentors is reportedly at full capacity dealing with the current levels of students. This indicates that adjustments to supply should be gradual and managed to ensure the system can expand and contract in a timely and effective manner.

The NHS will need to improve its 'swiftness of foot' to respond to changes in service delivery that are set to accelerate in the immediate and medium-term future. Its capacity to redesign and adapt services, to introduce new roles and to have the infrastructures in place to train current staff with the new skills and competencies they will need, must be planned for and managed. There is a massive change agenda to be delivered following the vision provided by Building a Health Service Fit for the Future and the Executive's response to that report. There is equally an opportunity to stimulate innovation and inspire a culture of patient-focussed continuous improvement. This is a crucial moment on which we must all capitalise and we will wish to work with regions and NHS Boards to realise that ambition in the initial and future workforce plans which they develop.

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