Workforce Planning

19. Workforce planning in the NHS is notoriously problematic. The Government acknowledged this in its memorandum:

 "Successive governments have tried to achieve better planning of the workforce....Workforce planning is not an exact science, and is subject to complex variables...there are information gaps...The timescales are challenging... approaches to healthcare are changing and it is difficult to forecast with accuracy the long-term implications of skill mix and productivity changes, shifts in clinical care, technological advances or changes in patterns of disease."[19]

20. The Director of Human Resources at NHSE reminded us of the gap between the introduction of changes in the workplace and their inclusion in workforce planning mechanisms:

 "changes that are happening in the Service are moving ahead of the formal workforce planning mechanisms that we have.....There is always ...bound to be some sort of gap between innovation and development on the ground and the extent to which that is captured effectively within formal workforce machinery."[20]

Workforce calculations are further complicated by the long training periods required and the need to take account of drop out rates and retirement.

Workforce Planning Mechanisms

   21. There are a number of bodies which contribute to the overall NHS workforce planning process. On the medical side there is the Advisory Group in Medical and Dental Education, Training and Staffing (AGMETS), the Medical Workforce Standing Advisory Committee (MWSAC), the Specialty Workforce Advisory Group (SWAG), the Medical Practices Committee (MPC), and Local Medical Workforce Advisory Groups (LMWAGs). The function of these groups is described in the DoH memorandum.[21]

22. Workforce planning for non-medical groups is employer-led through education consortia which bring together representatives of health authorities, trusts, GPs, social services and the independent sector to estimate their workforce planning needs and to plan the necessary education and training. The efforts of consortia are distilled through Regional Education and Development Groups (REDGs) who advise NHSE regional offices on the acceptability and coherence of consortia workforce plans and on the strategic direction of education and development.

23. A sub-group of the NHS Executive provides a national overview, advises on education and workforce issues and makes recommendations about necessary changes and their implementation.

24. The present planning arrangements have been subject to some criticism. The NHS Confederation acknowledged that there needed to be "integration between medical and non-medical workforce planning and the other aspects of [the] system that do not work so effectively should be reviewed."[22] It believed that:

 "systems for identifying future requirements do not currently look across all healthcare professions, but work in a fragmented manner"[23] and that "workforce planning would be improved by streamlining the current complexity of mechanisms and systems, in particular integrating medical and non-medical healthcare professionals within healthcare workforce planning against current and future service delivery needs."[24]

25. The King's Fund recognised the need for increased staff flexibility in terms of the roles performed, but identified obstacles to such a development. It believed that growth in clinical care and increased specialisation reduced flexibility by creating the need for additional training whilst making it difficult, if not impossible to switch specialties in mid-career.[25] The King's Fund also drew attention to the impact of professional barriers which, it argued, inhibited progress towards a more integrated approach to planning.

 "Flexibility is further reduced by deep-seated institutional factors within the NHS workforce, particularly its division into different professions, between which there is very little movement. Furthermore the Service has largely worked with the specific 'skill bundles' that have emerged from the professions themselves and these in turn have not been devised with flexibility in mind nor indeed with the needs of the Service. As a result, roles and training programmes cutting across existing professional boundaries have proved very hard to develop."[26]

26. Mr Bob Abberley, Head of Health at UNISON told the Committee that:

 "workforce planning needs to be across the workforce as a whole, and involving all organisations delivering care ...The problem is the NHS is compartmentalised...[27] we have to have a training and qualification system which allows people to move up through from virtually the cleaner to the doctor."[28]

   27. Miss Christine Hancock, General Secretary of the RCN considered that the Government had not got the figures right:

 "because I do not think they know where they come from, and workforce information, workforce planning...is incredibly poor in the Health Service."[29]

 Mr Roger Kline of MSF suggested that:

 "if you do not employ [staff] in the right numbers and with the right training, it actually costs the Health Service lots and lots of money."[30]

28. The Royal College of General Practitioners believed that LMWAGs and consortia were taking time to work together with health authorities and Trusts[31] and the RCN thought that greater dialogue was needed between consortia and universities. Education consortia are still relatively young and with the spread of good practice we believe they can be expected to develop and improve. It will be their task to ensure that they are representative of all the staff who come within their remit.

   29. Another problem with the current workforce planning system was put to us by the British Psychological Society who said that :

 " The recent devolution of workforce planning to local education and training consortia gives rise to anxieties about a loss of national perspective and strategic direction."[32]

30. This was a concern shared by clinical scientists who, for workforce planning purposes, currently fall under the auspices of education consortia. They argued that because of the numbers involved manpower planning for them should be carried out centrally and devolution to consortia would be ineffective.[33] In its memorandum DoH explained that it had introduced:

 "New arrangements to develop a strategic overview for smaller sections of [the]

workforce with their specific problems and characteristics"[34]

The point was underlined by the Head of Workforce Planning and Education at NHSE :

"There are some very small groups which benefit from national workforce planning...We have set up an advisory group for scientists and technicians which is going to commission a major workforce planning and recruitment retention survey, and take that forward during the next year."[35]

31. We welcome the establishment of this body, the National Advisory Group for Scientists and Technicians (NAGST). Its work should go a long way towards overcoming some of the fears of clinical scientists and others that they were not being properly considered in the planning process. At the moment membership of NAGST is confined to representatives nominated by NHS regional offices. Both the Conference of Clinical Scientists' Organisations[36] and the Council of Science and Technology Institutes, Health Care Scientific Advisory Committee[37] told us that stronger formal links are required between NAGST and national professional bodies. We recommend that the Government takes steps to introduce such links.

32. Whilst we heard oral evidence from the Chairman of MWSAC and from representatives of local education consortia, we did not undertake a systematic study of the whole range of workforce planning mechanisms. We accept the premise that there should be national policies that are delivered locally and monitored externally. Nevertheless we have come to the conclusion that workforce planning process is overcrowded with contributing forces and current arrangements would benefit from some streamlining. Mr Andrew Foster, Chairman of the NHS Human Resources Committee of the NHS Confederation said:

"The system does not hang together. It is not integrated between medical workforce and non-medical workforce planning. Private care is not properly integrated into it; primary care is not; taking into account service planning is not. The way that the consortia can produce a workforce plan and then people cannot be recruited into training is not addressed."[38]

A related point concerning community children's nurse education was provided during our predecessor Committee's inquiry into Health Services for Children and Young People in the Community: Home and School.[39]

33. Mr Foster also believed that the system "has evolved as a set of parts rather than as a whole."[40] One of the effects of this development process is the lack of consistency between the various 'parts'. Mr Nigel Turner of the NHS Confederation commented:

"Different assumptions are used in different consortia and potentially interpreted in different ways by the different institutions within these consortia."[41]

34. A concerted effort towards the development of an integrated planning body allowing for significant areas of appropriate joint training clearly needs to be made. Methods of introducing changes in approach and technological developments swiftly into the planning mechanisms must also be devised. This might not be easy to bring about in the short term. But a start should be made. At the very least we consider that with immediate effect there should be improved interaction between the medical and non- medical planning bodies.

35. The DoH memorandum informed us that:

"Education consortia, REDGs and LMWAGs liaise closely...this is reinforced by cross-membership between the various groups."[42]

 We believe that this should extend to regular meetings between MWSAC and REDGs, who should exchange information, discuss new ideas and develop plans. In an environment of rapidly changing technology and working practices this would seem to be a vital step.

36. In the longer term we recommend a major review of current planning procedures which should pay particular regard to their rationalisation and eventual replacement by an integrated planning system. We think it necessary that any new system should not only incorporate the national overview currently provided by the sub-group of the NHSE, but also actively promote a national strategy for workforce planning which, allowing for local conditions, brings a sense of consistency and cohesion at present notable for its absence.

37. The budgets for local education consortia come in two parts. There is a core budget used for basic and first registration training and a development budget for post-registration and financing new types of training.[43] Some education consortia have used the latter in an enlightened way. The Chair of the Inner London Education Consortia explained:

"there are now different types of training, training in teams, training in new roles, training in dual roles, that we can now develop and speak to education providers about what we want and how they can design education courses which meet our needs."[44]

The Chair of the South Essex Education Consortia made the same point.[45]

38. The issue of the provision of appropriate joint training throughout the UK should feature largely in the major review of current planning procedures that we have recommended.

39. We also believe that there would be considerable benefit in a close study of how doctors are currently trained. The Chairman of MWSAC advocated courses for science graduates that would turn them into "a special new sort of doctor."[46] Graduate entry might be a cost-effective way of broadening the recruitment base for medicine and expanding the total intake. In post-graduate education there is need for a system more in tune with rapidly changing health service demands. We suggest that DoH should ask the MWSAC to look in more detail at the balance between specialist and generalist training for doctors in achieving a flexible medical workforce.

Skill Mix

40. Current or future planning mechanisms will increasingly need to consider the matter of skill mix. MWSAC has made reference to skill mix in each of its three reports. Its Chairman told us:

"We have in our earlier reports hammered on about skill mix and my personal observation is that the country has not made as much progress as one might wish."[47]

41. We would like to see the NHS undertake further research on the issue of skill mix. In an article discussing substitution of staff, Gerald Richardson and others agreed that:

"To estimate the level at which doctors can be substituted with other health professionals in the UK would require a multi-centre randomised controlled trial with careful measurement of costs and patients' outcomes and an adequate follow-up period."[48]

This would be a complex and expensive exercise, but:

"These costs may be small when compared to the potential savings available from substituting other health professionals for doctors and the potential costs (including damage to patients) of changing skill mix in the absence of a sufficient knowledge base. It is surprising that such evaluations have been absent when skill mix in many countries has been altered radically."[49]

42. We further believe that alterations in the skill mix might have benefits beyond simple value for money savings. In their analysis of the UK nursing market, James Buchan and others contend that:

"In the absence of agreed and robust outcome measures, decisions on staffing mix are being based primarily on considerations of cost...Some research suggests that there is a direct relationship between the grade mix of nursing staff used and measures of the quality of care, with a 'richer' skill mix leading to higher quality of care."[50]

43. Some education consortia have anticipated the trend and commissioned research. The Chair of the Isle of Wight Local Education Consortia told us:

"Our consortium is trying to undertake some visioning on what the future educational development needs of nursing in primary care are going to be from a five year perspective, particularly taking into account the information we have had about the lowering numbers of GPs in the future. We have commissioned that research."[51]

44. In 1997 the Audit Commission recommended the instigation of pilot schemes to assess the feasibility of nurse anaesthetists.[52] We believe it is high time that a major evaluation of all the potential areas that might benefit from skill mix and substitution was undertaken in the UK. The exercise should not rely on the initiative and innovation of individual education consortia.

45. We recognise that the Government is not solely responsible for the inflexible roles of the various professions staff in the NHS. We believe that the Government's work could be greatly assisted by dialogue between groups representing staff in the NHS aimed at removing entrenched professional boundaries and 'territorial power rivalries' which even today inhibit progress and change.

46. It appears that skill mix reviews are driven by local management initiatives which result in local and parochial solutions some of which are contingent on other factors such as shortages in the labour markets, budget pressures and establishment costs. This does not lead to a co-ordinated strategic approach to assess the impact of these local approaches on the overall impact on the workforce requirements.

47. Responsibility for organisational development within the NHS is blurred. There is a need for health professionals along with the NHSE, Health Authorities, and trusts to design, implement and evaluate new patterns of service provision including ones that entail significant changes in skill mix. We welcome the development of a flexible workforce, so long as 'flexibility' does not become an arbitrary tool in the hands of employers. An appropriate strategy acceptable to patients, staff and employers must be worked out. We recommend that efforts are made to co-ordinate local initiatives and assess their strategic impact on the future workforce numbers. We further recommend that co-ordinated pilot studies are undertaken to assess the impact of altering the skill mix.

Doctor Numbers

48. The Government has accepted the recommendation contained in MWSAC's Third Report that intake into medical schools be increased by 1,000 per annum. This amounts to a 20 per cent rise.[53] A major factor in medical workforce planning is the extent to which the UK has become dependent on overseas qualified doctors.

49. In its memorandum to us the Joint Consultants Committee noted that:

"The General Medical Council reports that the majority of new registrations last year [1997] were from overseas."[54]

It pointed out that EU countries plan to reduce their current overproduction of doctors, thereby limiting the numbers available for recruitment to the UK from Europe.

50. The British Medical Association (BMA) believed that the UK:

"Must aim towards self-sufficiency in medical staffing; reliance on doctors from overseas, particularly from developing countries which need their expertise, is not an acceptable strategy."[55]

The BMA also argued that there has been inadequate consultant expansion following on from a change in training programmes and increased patient throughput:

"The problem is compounded by an increase in the number of consultants seeking early retirement from the NHS."[56]

51. The recruitment of doctors into general practice is also not without its problems.[57] DoH officials were confident that matters here were improving,[58] although the full impact on GPs of the development of Primary Care Groups remains uncertain.

52. A recent article in the British Medical Journal drew attention to the impact over the next decade of the retirement of general practitioners who qualified in South Asia,[59] a source of recruitment not likely to be available in the future.[60] This group represents one in six practising GPs of whom two-thirds are likely to retire by 2007. The distribution of these doctors varies. The greatest number are in some of the most deprived areas of the UK, where filling vacancies can be difficult. The authors of the article concluded:

"Various responses will be required by workforce planners to mitigate the impact of these retirements."[61]

53. In a supplementary memorandum the BMA analysed trends pointing to a potential future and accelerating shortfall of doctors. The immediate past Chairman of the BMA told us that his organisation had :

"Thought we honestly needed 2,000 more [medical students] per annum. Campbell [Chairman of MWSAC] said 1,000...our reply was 'that will be a lot better than nothing'."[62]

54. The MWSAC based its recommendation on an anticipated annual wastage rate of 3.3 per cent and a growth demand of 1.7 per cent of doctors in the NHS. Past figures are in excess of these percentages and achieving this wastage rate is regarded by MWSAC itself as challenging.[63] We do not believe that this will be achieved given the expected demographic changes in the profession. If current trends continue, and if a progressive impact is to be made on reducing dependency on overseas qualified doctors, the increase in the intake to medical schools will need to be in excess of 1,000.

55. The MWSAC calculated that the cost of increasing the annual intake of medical students by 1,000 would be around £200 million a year.[64] The Chairman of MWSAC told us candidly:

"There is no point writing a report which cannot be afforded in any sector in this country."[65]

56. We recognise that, ultimately, the terms of reference of MWSAC require it to take account of resource implications.[66] Affordability is a political decision. We firmly believe it is in this country's best interest to pursue a more ambitious path towards greater self-sufficiency in doctors and to ensure that expanding demand for medical services, including the appropriate training and supervision of junior doctors, can be met. MWSAC too were of the same opinion.

"We favour self-reliance as a long term goal, that is relying largely upon UK doctors although not aiming for a workforce comprised entirely of UK doctors."[67]

57. The MWSAC gave careful consideration to the risks associated with under and over-supply. An increase of 1,000 in the annual medical school intake, in the view of MWSAC, would not produce a domestic over-supply by the year 2020 under any realistic scenario. It should be noted that past predictions and actual increases in medical student intakes have consistently fallen below demand for doctors in the UK. The consequence is the current need for a substantial increase in medical student numbers. Because small percentage point shifts in wastage and growth rates over time have large effects on the number of medical graduates required these indices need to be kept under constant review.

58. We believe existing medical schools may have difficulties in accommodating the minimum extra intake of 1,000 medical students. There may be a need for new medical schools and new types of graduate courses and this need will become urgent as the expansion in intake exceeds 1,000.[68]

   59. We recommend that the proposed number of medical students be increased by a minimum of 1,000 per year. This increase should be accompanied by a commensurate expansion in the number of senior doctors and consultants in order to provide for the necessary career opportunities and supervisory roles.

Nurse Numbers

60. In a memorandum to us on medical and nursing staff in the NHS the DoH said:

"With the extra money that is being made available, the NHS will be able to take on more doctors and more nurses - up to 7,000 more doctors and 15,000 more nurses over the next three years."[69]

This suggests that the numbers are cost derived rather than service driven. The DoH later informed us that in their view there was a scientific approach to the figures based on present assumptions of current and future needs, bed activity, waiting lists, participation rates, vacancy levels and trends in healthcare.[70]

61. The Secretary of State for Health told us:

"Taken nationally...looking at various figures from various sources...there are probably 9,000 or so nursing vacancies which have been vacancies for three months or more - in other words, serious vacancies and not just turnover."[71]

Others have calculated that the figure is higher.[72]

62. The written evidence we received, the oral evidence we took from staff representative groups and our informal discussions all revealed disturbing staff shortages in the NHS.[73] Mr Andrew Foster of the NHS Confederation told us:

"It is undoubtedly the case that in all areas at the moment the ratio of staff to patients has declined substantially over the years and that is a significant cause of the problems and stresses that are faced by the system at the moment."[74]

63. Miss Christine Hancock of the RCN explained some of the causes of NHS nurses moving into the private sector:

"Most nurses believe passionately in the Health Service. In my experience, the private sector does not have a labour market of nurses who like private medicine but they drift into it for a variety of reasons, hours, accessibility, a job going...and when they get there one of the things they always say is that they are able to nurse patients properly...what they can do is they can give the patient care that they trained for and they believed in...One of the biggest things...that drives clinical staff out of the NHS is the feeling that they are not able to care for patients properly and they are not able to do their job properly."[75]

64. The decrease in training places for nurses over recent years has caused the number of qualified nurses registering to reduce from 32,143 in 1993-94 to 26,465 in 1997-98.[76] The midwifery statistics for the same period show a decline in the number of midwives re-registering on an annual basis from 105,723 in 1993-94 to 93,776 in 1997-98.[77] The Government's proposed reforms, and a reduction in doctors' hours, will increase both the demands on staff and the numbers needed to deal with the changes in approach that will result. The evidence we have received leads us to conclude that on current trends the projected increases in the number of nurses and other clinical staff fall well short of what is required to deal with current shortages and future developments in the NHS. We hope that recent Government initiatives will reverse these trends, but we suggest that the Government urgently reassesses its staffing figures to ensure an NHS workforce that is sufficient for requirements.

20   Q12. Back

21   Ev. p34, Annex D. Back

22   Ev. p161. Back

23   Ibid, para 2.7. Back

24   Ibid, para 6.3. Back

25   Appendix 68. Back

26   Ibid. See also Ev. p108, para 66; Q118; Ev. p74 ; Appendix 67, para 6.5 Back

27  Q127. Back

28  Q129. Back

29  Q123. Back

30  Q214. Back

31   Appendix 15. Back

32   Appendix 51. Back

33   See, for example, Appendix 16 and Appendix 63. Back

34   Ev. p9, para 5.3. Back

35   Q25. Back

36   Appendix 16, para 6(d). Back

37   Appendix 63, para 4.2.1. Back

38   Q227. Back

39   Third Report (HC 314, Session 1996-97). We noted that: "Although the English National Board had approved institutions for community children's nurse education, most of the places could not be taken up because education consortia had not commissioned places for community children's nurses, despite their being plenty of candidates for such places." (pl). Back

40   Q228. Back

41   Q237. Back

42   Ev. p 16, Annex D. Back

43   Q305. Back

44   Ibid. Back

45   Q314. Back

46   Q99. Back

47   Q75. Back

48   Skill mix changes: substitution or service development?: Gerald Richardson, Alan Maynard, Nicky Cullum and David Kindig, Health Policy 45 (1998), p127. Back

49   Ibid. Back

50   Nurses Work : An Analysis of the UK Nursing Labour Market: (Developments in Nursing and Health Care 18), James Buchan et al. Back

51   Q304. Back

52   Anaesthesia Under Examination: Audit Commission, 1997. Back

53   Ev. p5, para 4.5. Back

54   Appendix 28. Back

55   Ev. p 63. Back

56   Ibid. Back

57   Ibid. See also Appendix 15. Back

58   Q60. Back

59   Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?, by Donald H Taylor Jr and Aneez Esmail, BMJ, No. 7179, 30 January 1999, pp 306-310. Back

60   Ibid, p310. Back

61   Ibid, p306. Back

62   Q114. Back

63   Planning the Medical Workforce ,Medical Workforce Standing Advisory Committee: Third Report, December 1997, p3. Back

64   Ibid, p40. Back

65   Q84. Back

66   Q83. Back

67   MWSAC: Third Report, p3. Back

68   This was an option put forward by MWSAC, ibid, p4. Back

69   Ev. p26, para 6.3. Back

70   Appendix 71. Back

71   Q322. Back

72   The RCN believes there are 12,000 vacancies. Back

73   See, for example, ev. p69. Back

74   Q251. Back

75   Q144. Back

76   UKCC Annual Statistics 97/98. Back

77   Ibid. Back