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4 The Way Forward
4.1 Introduction
On 25 May 2005 Professor Kerr delivered Building a Health Service Fit for the Future, outlining a 20-year vision for the future shape of services in Scotland. This vision was broadly welcomed by the Minister for Health and Community Care in the Parliament on 25 May. A detailed implementation plan will be produced in the autumn. To deliver that vision we must ensure that we are able to equip the NHS with the workforce that can make it happen - that means a major shift in the way we plan the future workforce at national, regional and Board level.
It makes it clear that:
change is inevitable
given the complexity of the drivers [for change], planning for change is essential
'more of the same' is not the solution - to meet the challenge of the drivers will require new ways of working, involving the whole healthcare system in the change process. 45
Building a Health Service Fit for the Future makes another telling point. In flagging the key elements identified by a Canadian Health Commission for the provision of sustainable health services - providing services, meeting needs and securing resources (financial, physical and human) - it points out:
"… there is no 'invisible hand' that silently and unobtrusively keeps these elements in balance. Ultimately, the question of whether and how the system is sustained comes down to choices by those involved in the system - by government, by providers, by clinicians and by patients." 46
In other words, it is down to us - at national level in the Scottish Executive and among staff and professional groups, and at regional and Board level among managers and professionals in the NHS family and its partner agencies - to fully commit to working together in an integrated workforce planning framework in order to plan ahead effectively and secure the workforce required by the kind of Service outlined in Building a Health Service Fit for the Future.
In describing the drivers for change in demand for NHS services Professor Kerr highlights workforce pressures as one of the three drivers which will determine the shape of healthcare in Scotland in 2024 47 - these pressures "will be the bottom line in determining how we are able to respond to these changes in demand". All of those with an interest in the healthcare workforce - the Scottish Executive, NHS managers, NHS staff, independent contractors, the voluntary and independent sectors, professional and staff representative groups - share a responsibility in ensuring that we plan effectively to ensure that we have a future workforce which can respond to those changes positively, rather than serving as a constraint on them.
4.2 Changing the way in which we view the workforce
Professor Kerr's report is about making the accelerated step changes required to deliver an NHS which is patient-centred and operates on a continuum of care that provides whole-system care. Planning for a patient-centred service means making the changes to fit future services around patients' priorities, rather than bending patients' needs and wishes to the dictates of existing structures and systems. That means moving to a different way of describing the NHS - as a set of services experienced by patients rather than chunked up according to internal structural divisions that mean little or nothing to the individual's contact with the 'front-end' of delivery.
Building a Health Service Fit for the Future does this by approaching services according to the dominant needs that can be expected from patients over the next 20 years:
- care of older people;
- care in local settings;
- unscheduled care;
- planned care;
- diagnostics;
- specialised care;
- children and young people's services.
It charts a clear direction of travel for these services and flags the need to integrate them across the primary care, secondary care, tertiary care and social care sectors. Scottish Ministers have endorsed this approach and are now preparing a detailed response.
This is therefore the way in which we need to look at the workforce. Workforce planning follows on from service planning and must be fully integrated with it. That means that regional and Board workforce plans will need to look at their workforce not simply in terms of the staff groups outlined in Section One of this document, but in terms of the services listed above and the workforce required to deliver those services. Their point of departure will be the plans they make for their services and the service outcomes they set for themselves - they will then need to map their workforce needs onto those.
We will therefore expect regional and Board plans to begin to categorise their workforce along the lines of the services described above. They will still need to identify specific staff number requirements through accepted staff groupings (x specialised nurses, y AHPs, z hospital consultant specialists) but increasingly these should be clearly tied back in all cases to NHS Boards' and regions' plans for delivering care in the care streams outlined above as information systems become more sophisticated.
4.3 Building the workforce of the future: key themes
Building a Health Service Fit for the Future provides a vision for the Service. The Executive's response to this report will serve as a template from which to plan the workforce of the future. The report briefly describes the workforce implications of each of the changes it proposes. This will help inform regional and Board workforce plans to ensure that we can align workforce supply to the challenge of delivering on the vision that Ministers accept.
It is not for this report to repeat all the messages which have already been well articulated by Professor Kerr's publication. However it seems important to emphasise some of the key themes which flow from Building a Health Service Fit for the Future and which will need to be incorporated, subject to the Scottish Executive's response, into NHS Boards' and regions' workforce planning:
The major burden of ill health facing the health service is increasingly that of chronic disease, primarily among older people. This is happening at a time when the proportion of people in Scotland over 65 will increase to over one in four in the next 25 years or so.
We are currently trying to treat chronic disease through episodic bouts of emergency acute care - 70% of emergency admissions are from people with a long standing illness. A rapid shift in the balance of care needs to take place so that we move to managing chronic disease through safe, effective and sustainable services in primary care as close to the patient's home as possible, reducing pressure on the hospital sector.
People with long standing chronic disease will often have complex co-morbidities. We will need a workforce which can address their needs as close to home as possible by operating a system of care co-ordination for individuals with multiple chronic conditions. They will also need to promote and develop self care and support the vitally important role played by carers and volunteers.
Community Health Partnerships will be the main organisational vehicle for the delivery of care in local settings and the main business of a system of local care will be in the related and overlapping areas of care of older people and support for people with long-term conditions. This will be part of a whole system approach whereby the boundaries between organisations and services are not apparent to users.
If we are to seriously tackle health inequalities we need to enhance the primary care services delivered to the most deprived members of society by expanding the numbers of professionals available to see patients, allowing for earlier intervention and more proactive outreach to individuals (mostly through nurses, AHPs and other non- GP professionals).
The vast majority of unscheduled care contacts do not require on-site medical skills. We need more of a multidisciplinary clinical team approach less reliant on doctors, enabling flexibility to keep minor episodes (70%-80% of the total seen in A&E Units) out of hospital and locally available, linked to local diagnostic services and assessment systems to redirect patients when necessary.
We should look at regional centres for specific waiting time services for elective work. Diagnostic pathways should also be developed, built around clinical teams straddling the primary and secondary care boundaries, and providing direct access to the primary care clinician where care can be managed in primary care. This suggests changes in skill mix and greater flexibility in roles, responsibilities, skills and breadth of care teams. It also suggests an expansion in staffing of diagnostic services, which are currently suffering from a lack of capacity.
Highly specialised care will necessarily be concentrated at regional or national level, based on interlinked tiers of care from basic interventions at local level to highly sophisticated procedures delivered regionally or nationally. These specialised services have to be concentrated in order to group a critical mass of skilled staff in one place with sufficient cover, create satisfying jobs and career opportunities for those staff, and provide a sufficient caseload to maintain skills. This has implications for national and regional workforce planning.
Rural health systems have specific needs involving extended roles, for nurses and AHPs and for GPs with a special interest.
The foregoing points highlight just a few of the themes running through Building a Health Service Fit for the Future which will need to inform and shape Board and regional workforce plans (and the national workforce planning carried out by the Department). These plans will need to project the workforce required to deliver the future design of services envisaged by the Scottish Executive's response to Professor Kerr's report, so that we can ensure the supply is in place to secure that workforce in the years to come.
That will be challenging, given the need to project a major shift of staff to support managed care in the community and away from hospital settings. This presents risks which need to be managed, given that it is based on a predicted but not known resulting reduction in acute care activity. Equally the message is clear that the major challenge for all health systems over the next two decades and beyond must be to shift resource and investment into appropriate and effective management of chronic disease, particularly for the elderly, as close to home as possible. This will demand a different workforce to the one we have today and, if the approach is accepted by Ministers, we need to plan for it now.
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