Liberating the NHS: developing the healthcare workforce

COMMENTS ON DEPARTMENT OF HEALTH
LIBERATING THE NHS: DEVELOPING THE HEALTHCARE WORKFORCE

The Royal College of Physicians of Edinburgh is pleased to respond to this important consultation on developing the healthcare workforce in England.  The College has a number of important comments and concerns about the proposed changes; these include:

1. The rapid implementation time-table risks major disruption to the training of the current cohort of trainees.  The short term de-stabilisation of medical training rotas and clinical placements may jeopardise young careers and compromise service delivery with the changes in boundaries and responsibilities.  Transition arrangements will be crucial, and the College foresees a major risk of training disruption if existing Deanery structures and processes are dismantled before the Skills Networks are fully established and seen to be working effectively.
2. The lack of evidence, through pilots, for some of the radical structural changes proposed – no robust argument has been presented for not building on the experience and expertise within the existing postgraduate Deaneries.  Similarly, there is no evidence that these changes will generate efficiency savings, particularly given the proportion of the medical education and training budgets that are taken up by salaries of trainees who also deliver services.
3. The great potential for conflict between the competition ethos required of providers and their need to co-operate through the new Skills Networks.  This generates serious concerns about the priority that will be given to training responsibilities by providers who are accountable to GP commissioners for the delivery of services.
4. The need to ensure that private provision of NHS funded services is not subsidised by allowing private providers to avoid training responsibilities and/or levies.
5. None of the urgent improvements in medical education and training called for in recent reports by Temple and Collins are addressed by these changes eg serious supervision gaps.
6. The extension of MEE to HEE is welcome, provided that the quality of medical education and training provision and support is not diluted as a result of expanding the remit.
7. There is no real clarity on the co-ordinating mechanisms that will be required to ensure (the independent) HEE, CfWI, Skills Networks and professional regulators work together to develop, deliver and quality assure education and training and workforce planning.
8. Achieving medical engagement with these reforms will be particularly challenging as the national networks established by the postgraduate Deaneries and Colleges are broken up into smaller Skills Networks.
9. The consultation is silent on the question of national recruitment procedures for medical trainees and the College is concerned how recruitment can continue to achieve the necessary standards of fairness, transparency and efficiency once the Deanery networks are removed, particularly in the short term.
10. The College believes that it is imperative that standards are maintained across the UK and that training arrangements are coordinated to ensure freedom of movement between countries.  Scotland, Wales and Northern Ireland will maintain Deanery structures to coordinate and deliver training.  The developments in England threaten this coordination through the ill-defined structure for Skills Networks.

Responses to specific questions included in the consultation document follow:

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Q1. Are these the right high-level objectives? If not, why not?

The objectives proposed are satisfactory, but the College is clear that the current system is capable of achieving many without the radical changes proposed eg high quality medical education and training.  In terms of the specific objective of value for money, the proposals offer no data or evidence to support the achievability of this objective through the proposed changes.  However, the commitment to transparency in funding flows is welcome.

Q2.  Are these the right design principles? If not, why not?

The design principles are satisfactory but should also include that it is ensured that all members of the workforce meet UK agreed standards of competence in any particular skill or knowledge base for their profession, and that these standards are accepted by the various independent regulators.

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Q3. In developing the new system, what are the key strengths of the existing arrangements that we need to build on?

Strengths of the present system are that there are established national standards, competences and curricula in medical training with robust quality assurance systems that allow a certified doctor to work safely anywhere in the UK.  This is achieved by close working between Medical Royal Colleges, Deaneries and the regulator, and will be very difficult to maintain within the new system.  A further strength is the engagement of the overall medical workforce who perceive education and training as part of everyday work, many of whom are frustrated by the lack of local employer support for education.

The consultation document makes much of the apprenticeship model, and the College believes the benefits of apprenticeship rely on the support of a national educational and assessment framework, but this can also bring the risk of unfair patronage at the end of training.

The emerging strategy towards multi-disciplinary education brings significant opportunities for improved team working, but the College believes that skill mix changes within teams must be subjected to a robust economic evaluation.  Multi-disciplinary working must recognise the place of specialist skills, given the emerging evidence demonstrating improved patient outcomes and often increased efficiency resulting from specialist consultant input.

Q4. What are the key opportunities in developing a new approach?

These include:

• Increasing the flexibility and breadth of experience in the early years of postgraduate medical training.
• Upskilling nurses in basic medical tasks and documentation.
• Better planning of undergraduate numbers - an over-supply is imminent with insufficient Foundation posts for all graduates.
• Better workforce data acquisition.
• Appropriate expansion in the number of consultants to deliver a safe service and ensure adequate training and supervision of trainees within the EWTD.
• Providing opportunities for those with exceptional aptitude to develop fully and quickly.

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Although no questions are asked within this chapter, the College wishes to draw attention to the role of the regulator and the absence of references to the Medical Royal Colleges whose work provides the essential professional input referenced earlier into curricula development, assessment of medical trainees and quality assurance of local postgraduate training arrangements.  The independence of the Colleges provides reassurance to trainees and to the public that training is being delivered effectively and safely, and this input must be preserved within the new arrangements.

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Q5. Should all healthcare providers have a duty to consult patients, local communities, staff and commissioners of services about how they plan to develop the healthcare workforce?

Healthcare providers should be consulted, but this needs to avoid being cumbersome and unwieldy.  Healthcare staff are cynical about consultations from past experience of their views being ignored and with the process seeming no more than a paper exercise; the healthcare provider must demonstrate a willingness to make changes in light of the responses received.

At a national level, the expertise and experience of professional associations (including the Medical Royal Colleges) must be sought to future-proof workforce plans against changes in specialist practice.  If the views of different groups conflict, healthcare providers must have transparent pathways to resolve this.

Q6.  Should healthcare providers have a duty to provide data about their current workforce?

For workforce planning to work, it is essential that accurate data on local and national numbers and trends is shared openly.  Availability of reliable data will be a challenge in the short term.

Q7. Should healthcare providers have a duty to provide data on their future workforce needs?

Healthcare providers should have a duty to provide data about their current and future workforce needs.  While healthcare providers are expected to create their own workforce plans, the Centre for Workforce Intelligence (CfWI) has still to develop a national plan.  If this differs from local plans, it is unclear how this will be resolved.

Q8. Should healthcare providers have a duty to cooperate on planning the healthcare workforce and planning and providing professional education and training?

Employers have never had total autonomy over medical development given the requirements of the specialist register and the need for regulator approval.  This is protective of patients by ensuring that doctors are trained fully for their specialist practice.  The emergence of revalidation will place more emphasis on formal accreditation of new skills and areas of work.

Healthcare providers will clearly have to cooperate on planning the healthcare workforce. However, if healthcare providers propose addressing skills gaps in different ways, how will this be resolved nationally?  It is of paramount importance that there is cooperation on planning and providing professional education and training for all staff, but particularly for smaller medical specialties and professions.  This will need carefully monitoring by Medical Royal Colleges on behalf of the GMC, especially as it is provided across a network of healthcare providers.

It is not at all clear why clinical placements would be best managed ‘multi-professionally’, as stated.

It is also important that GP Commissioners are well informed and committed to workforce development and the training standards required of providers.  This must be reflected in the commissioning arrangements and contracts for services.

The proposals to require healthcare providers to establish Skills Networks lacks impartiality and risks conflict in situations where education and service needs clash.  Clear accountability arrangements must be in place to protect training responsibilities in the face of increasing financial pressure for service delivery and in situations where the survival of a healthcare provider may be in question under the new commissioning arrangements.

Q9. Are there other or different functions that healthcare providers working together would need to provide?

Leaving groups of health care providers to establish Skills Networks in the absence of a statutory framework is a very high risk strategy.  The NHS reforms put providers in a competitive market and this will conflict with the requirement for cooperation over workforce planning and development, particularly for rare skills and/or smaller disciplines.  The College is concerned that the training programmes for smaller specialities will suffer under the new regimes, and the role of HEE in terms of direct commissioning of training for smaller medical specialties requires clarity.

National coordination is essential to ensure local Skills Networks operate effectively and that education and training is seen as a priority alongside healthcare provision.  As regards the functions of the networks, these should include the need to work with Medical Royal Colleges (as highlighted in para 6.28) and professional regulators such as the GMC, GDC and NMC, as Deaneries currently do.

Q10. Should all healthcare providers be expected to work within a local networking arrangement?

All NHS healthcare providers should be expected or possibly required to work within a Skills Network.  The position of private healthcare providers is unclear, and the governance and accountability issues of organisations that may be both commissioners and providers of education and training are unclear.

No questions are asked about the section on Setting up local ‘Skills Networks’, and the College has significant concerns about the achievability of this within the proposed timescale in the absence of piloting of the new structures before the existing Deaneries are abolished.  It would be much more practical to expand and amend the role and remit of Deaneries to cover the entire local workforce (in the same way that MEE is being expanded to HEE), retaining the expertise and well-founded working relationships already within these organisations, and addressing the funding arrangements through a local education levy on healthcare providers. No arguments are presented against this.

Q11.  Do these duties provide the right foundation for healthcare providers to take on greater ownership and responsibility for planning and developing the healthcare workforce?

The duties laid down for healthcare providers place greater ownership and responsibility with them but more detail is needed on the position of private healthcare providers, the need to meet national standards for training and education (as set out by professional regulators), and much greater emphasis on quality management and assurance.  No mention is made about responsibilities for revalidation of the medical profession.  In the absence of piloting, there is a significant risk that these radical changes may fail against such a tight implementation schedule.

It is unclear how HEE (a “… lean and expert organisation …”) will be able to achieve the necessary national coordination to ensure equity of provision and quality of training across all healthcare providers and their Skills Networks

Q12.   Are there other incentives and ways in which we could ensure that there is an appropriate degree of cooperation, coherence and consultation in the system?

Other incentives and ways of ensuring cooperation include more specific duties for Skills Networks for clinical engagement with professional regulators and Medical Royal Colleges. In terms of coherence, there is a need for greater detail on the structure, operating practices and accountability of Skills Networks given the proposed speed of their introduction.  It will be difficult for national bodies such as HEE and CfWI (and Medical Royal Colleges) to engage with networks if they have widely varying structures and operational frameworks. Ensuring effective consultation will require evidence not only that this has taken place, but that plans are altered in response.

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Q13. Are these the right functions that should be assigned to the Health Education England Board?

There is significant overlap/duplication with the professional regulators’ current role (particularly the GMC’s) with respect to standard-setting, quality assurance and curricula development that needs further discussion and clarity.  Liaison with the devolved administrations in the rest of the UK will be an increasing challenge, given the widening differences in NHS structures.  Training standards for doctors must be maintained as UK standards; it is important to avoid unintentional barriers to the cross border flow of trainee doctors as a consequence of training differences.

Q14. How should the accountability framework between healthcare provider skills networks and HEE be developed?

The College is concerned that the removal of regional oversight (currently provided by the Deaneries within the SHA structures) will result in less effective national accountability of healthcare providers’ education and training responsibilities.  Healthcare providers will be individually accountable to their local commissioning consortia for services and collectively accountable to HEE for their skills networks.  This conflict between competition and cooperation at a local level requires a clear accountability framework that will be challenging to create at a national level and will require some regional scrutiny.

The College is also concerned that a single national HEE will be in a position to fully discharge the quality assurance responsibilities of the current postgraduate Deaneries, and that a regional structure may be required to manage this task efficiently.  The College is particularly concerned about the ability of HEE to directly manage the 12 smaller medical specialties.  Well established relationships will be severed and the short term potential for disruption is huge.

Q15: How do we ensure the right checks and balances throughout all levels of the system?

For medical training and Continuing Professional Development (CPD), the regulator (GMC) will require clear quality management systems in place locally to demonstrate compliance with national standards for the training and revalidation of doctors.  Skills Networks must be required to put in place effective local QM systems and HEE will require objective evidence of achieving the required standards.  As in question 14 (above), a sub-national structure may be inevitable to manage this work effectively.  The Medical Royal Colleges are responsible for the national curricula, CPD standards and specialist input into revalidation and, being independent of the providers of healthcare and the new Skills Networks, are best placed to support this work.

Q16: How should the governance of HEE be established so that it has the confidence of the public, professions, healthcare providers, commissioners of services and higher education institutions?

If HEE is to be the guardian of the quality of healthcare education and training, it has to satisfy the regulators and the professions and have the authority to hold the Skills Networks and their healthcare provider owners to account for the safe and effective delivery of training and the delivery of accurate workforce data.  There should be a statutory duty to consult with the profession and the regulators and to publish their plans and annual reports.

The particular needs of academic trainees do not appear to be addressed, and universities should be included in local Skills Networks.

Work is clearly needed as to the evidence required to demonstrate effective workforce planning, and clarity about the relationship between regulators and the skills networks eg will the GMC quality assure the quality management systems in place within the Skills Networks, replacing the current activity at a  Deanery level?  This may increase the burden of QA on the regulator and/or dilute their impact.

HEE will require wide representation if it is to achieve the confidence of the bodies described, and would do well to consider devolving some of its functions to others such as the GMC and other professional organisations.

Q17.  How should we ensure that the Centre for Workforce Intelligence is effective improving the evidence base for workforce planning and supports both local healthcare providers and HEE?

Accuracy of baseline information and strategic trends in service delivery and professional practice is critical if CfWI is to succeed in the long term national planning, which should drive local workforce plans.  Much of the strategic input could be achieved nationally rather than locally to avoid duplication, but implementation plans will require clear local advice and input – challenging in the absence of a sub-regional structure.  The CfWI must continue to be led by experienced healthcare professionals to ensure the impact of workforce plans reflect high quality, cost effective and sustainable clinical care.

Q18. How should we ensure that sector-wide education and training plans are responsive to the strategic commissioning intentions of the NHS Commissioning Board?

It will be difficult to ensure that sector-wide education and training plans are responsive to the strategy of the NHS Commissioning Board in the face of so many bodies with an interest.  The White Paper delivers a very mixed message with respect to locally responsive planning and the need to meet national strategy.  It is not clear how this will be balanced, it is likely to lead to much duplication of effort and could lead to significant local frustration.  It is important that national commissioning objectives are, in turn, influenced by clinical developments that will also drive workforce plans – to imply that the relationship between CfWI/HEE and the NHS Commissioning Board is one way would be a mistake.  National standards must drive planning for both service and education/training.

Q19. Who should have responsibility for enforcing the duties on providers in relation to consultation, the provision of workforce information, and cooperation in planning the workforce and in the planning and provision of professional education and training?

None of the bodies have the necessary authority and expertise to discharge all these functions, but certainly HEE and the GMC should retain responsibility for the quality of education and training for doctors.  The NHS Commissioning Board and Monitor should have a statutory duty to take account of the output from HEE and GMC in terms of their own monitoring of the effectiveness of commissioning and the economic evaluation of healthcare providers.

Q20. What support should Skills for Health offer healthcare providers during transition?

Skills for Health is a provider of training and as such has no specific role during transition.

Q21. What is the role for a sector skills council in the new framework?

A separate sector skills council does not seem necessary – consideration should be given to subsuming its work into HEE.

Q22. How can the healthcare provider skills networks and HEE best secure clinical leadership locally and nationally?

Nationally, the Medical Royal Colleges and the Academy of Medical Royal Colleges are a clear source of leadership for doctors, and HEE should seek representation from them in their decision taking and development mechanisms.  Fellows and Members will provide local expertise within Skills Networks and in provider units with the benefit of support from their national College. Much of this will be available from doctors currently employed in Postgraduate Deanery roles.  On a more practical level, commissioning consortia must require providers to value time devoted to training and create time in the job plans of selected doctors to discharge leadership roles locally.

All professional groups should have similar access to national leaders and time to discharge their education responsibilities.

Q23. In developing the new system, what are the responsibilities that need to be in place for the development of leadership and management skills amongst professionals?   

For doctors, the new Academy Faculty of Clinical Leadership provides a ready made vehicle for the delivery of clinical leadership skills now embedded in each medical curricula.  Other healthcare professions may require a new focus for leadership training, and HEE would provide a valuable coordinating function to encourage cross sector development, including that of non-clinical managers. 

Q24.   Should HEE have responsibilities for the leadership development framework for managers as well as clinicians?

Yes – see above.

Q25.   What are the key opportunities for developing clinicians and managers in an integrated way both across health and social care and across undergraduate and postgraduate programmes?

Leadership development: it would be beneficial for HEE to combine a leadership development framework for clinicians and managers as it would promote better mutual understanding and some joint learning.  Multi-professional skills networks will be well placed to deliver this to their current workforce.  It will be more challenging for educational providers to deliver this to undergraduates, but could be commissioned by Skills Networks or HEE.

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Q26. How should Public Health England, and its partners in public health delivery, be integrated within the new framework for planning and developing the healthcare workforce?

Public Health England should contribute through HEE and the professional regulators in planning and developing the healthcare workforce. There does not appear to be any mechanism for local involvement by Public Health England in the Skills Networks of public health professionals who are employed by local authorities; skills networks are created by healthcare providers and this needs consideration.

Q27. Should Local Authorities become members of the healthcare provider skills network arrangements, including their associated responsibilities; and what funding mechanisms should be employed with regard to the public health workforce?

Yes, Local Authority involvement should be assured for defined health professions and specific disciplines.  However, the resulting organisations will be large and cumbersome with too many parental bodies and risk becoming ineffective and inefficient unless carefully structured and managed.

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Q28: What are the key issues that need to be addressed to enable a strategic, provider-led and multi-professional approach to funding education and training, which drives excellence, equity and value for money?

It is unclear why the strategy for effective funding of education and training should be provider-led - this should be standards-led as defined by the professions and the regulators, appropriately informed by long term service needs through the NHS Commissioning Board.

Q29: What should be the scope for central investment through the Multi-Professional Education and Training budget?

Central investment should be linked to clearly defined education contracts with healthcare providers and cover all trainee posts.  New requirements from regulators or commissioners must be balanced against available funding.

Q30: How can we ensure funding streams do not act as a disincentive to innovation and are able to support changes in skill mix?

Funding may also be available centrally (perhaps by bids) to support innovation in terms of new roles.  Such investment must be coordinated to protect standards.

Q31 How can we manage the transition to tariffs for clinical education and training in a way that provides stability, is fair and minimises the risks to providers?

The immediate risk to providers may be in terms of clinical services rather than training as efficiency savings are required, and it is important that identified training and education funds are protected.

Q 32: If tariffs are introduced, should the determination of the costs and tariffs for education and training be part of the same framework as service tariffs?

Not all providers may be required or allowed to deliver education and training.  Therefore, tariffs for education and training should be separated from service tariffs, albeit difficult in medicine where education and clinical service are so closely bound together.  However, separation will reinforce the importance of delivering against clearly defined (separate) contracts and quality standards for education and training.

Q 33: Are there alternative ways to determine the education and training tariffs other than based on the average national cost?

Average cost could create a rather blunt instrument in terms of tariffs for all education providers.  Large teaching hospitals in London will already have very different cost structures to smaller district general hospitals, but both may be commissioned to deliver training and education of the same quality.  National tariffs should reflect a range of providers in the samples used to define levels.

Q 34: Are there alternative ways to determine these costs other than by a detailed bottom-up costing exercise?

Surely this will be undertaken for service tariffs, and no less attention should be given to training and education equivalents.

Q 35: What is the appropriate pace to progress a levy?

Creating a training levy to effectively ‘top slice’ funds from providers to support training must wait for the new system to settle and for confirmation of service tariffs.  Progressing this too early risks setting an inappropriate levy that cannot deliver education and training to the required quality standards.  When under pressure, it will be all too easy for hard-pressed managers to compromise on training to meet their financial objectives.

Q36: Which organisations should be covered by the levy? Should it include healthcare providers that do not provide services to the NHS but deliver their services using staff trained by the public purse?

All organisations delivering services paid for by the NHS should contribute to the training levy.  This should include local authority and private providers.  However, this will be particularly difficult for any services (or training) provided outwith England.

Q37: How should a levy be structured so that it gives the right incentives for investment in education and training in the public interest?

The levy should be challenged regularly through benchmarking of costs between different providers who achieve the required quality standards.

Q38: How can we introduce greater transparency in the short to medium term?

The total investment in and funding of education and training should be identified within provider annual returns to ensure those responsible for standards monitoring can challenge the cost effectiveness of such funds.

Q40: What are the key quality metrics for education and training?

It is critical that the metrics selected satisfy all interested parties and do not impose a disproportionate burden on providers.  MEE has produced draft proposals for these for the medical profession, although they duplicate many already in use by the GMC. 

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Q41. What are the challenges of transition?

The challenges of the transition are primarily the speed at which changes are required to take place, that they are wide-ranging, untested, not standardised across the country and may well prove costly at time of national austerity.  They take place at a time when there is already significant change and upheaval in all other English NHS systems.  Local workforces with appropriate expertise to set up and run Skills Networks may not be in place, particularly if key staff leave the current SHAs, PCTs and Deaneries in advance of the establishment of Skills Networks.

Q42. What impact will the proposals have on staff who work in the current system? AND
Q43. What support systems might they need?

There is a high risk of disruption to current medical trainees’ programmes, support, recruitment and assessment with the dissolution of the Deaneries and potential changes to training programme boundaries with the move to Skills Networks.  MTAS is still fresh in the minds of many, and the proposals and speed of transition risks chaos of similar proportions. Deanery staff are faced with an uncertain future, and low morale will de-motivate trainers already currently unrewarded for their input.  The recent successes in terms of the development of local Schools of Medicine and sub-specialty training leads should be transferred to the new structures, and the arbitration role of the Postgraduate Deans requires careful consideration.  All of these issues could be addressed by having the Skills Networks shadow the Deaneries until the former are operating effectively or, alternatively, using the Deaneries as a basis for expansion into multi-professional Skills Networks.

Funding uncertainty will discourage longer term recruitment in providers as staff leave, resulting in gaps in service provision that will affect quality of education, supervision and, potentially, patient care and safety.  Staff approaching retirement may choose to go early, losing valuable experience.

Q44. What support should the Centre for Workforce Intelligence provide to enable a smooth transition?

CfWI can only provide limited support until Skills Networks are in place, but could then share their methodology for data collection and analysis that could be applied locally.

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Q45. Will these proposals meet these aims and enable the development of a more diverse workforce?

A full Equality Impact Assessment is needed to identify whether the proposals will enable the development of a more diverse workforce and the risks in the short term of undertaking such a radical programme of change.

Q 46. Do you think any groups or individuals (including those of different age, ethnic groups, sexual orientation, gender, gender identity (including transgender people), religions or belief; pregnant women, people who are married or in a civil partnership, or disabled people) will be advantaged or disadvantaged by these proposals or have greater difficulties than others in taking part in them? If so, what should be done to address these difficulties to remove the disadvantage?

The proposals are unlikely to have a systematic negative impact on any one group, although medical trainees about to the enter the system as new recruits in the next 2-3 years may experience significant chaos as they plan their careers in a new and untested system.