BGS response to consultation on workforce strategy

02 May 2018

BGS recently responded to the public consultation by Health Education England with input from NHS England and other bodies, on its draft health and care workforce strategy for England to 2027. The focus was on the development of the strategy, which will be published in July 2018 to coincide with the NHS 70th anniversary. In our response we welcome the commitment to a free, universal healthcare system but state that we would like to have seen a greater recognition of and commitment to person-centred care being placed at the heart of the strategy.

BGS supports the six principles in so far as they have the potential to address some of the workforce issues that are a challenge at present, for example, workforce supply and the level of unfilled vacancies in some specialties and parts of the country.  In some areas this is a particular problem for our specialty; where local services have recognised that the demands of demographic change require a greater number of Geriatricians and specialist nurses and AHPs with expertise in the care of older people. Currently demand frequently outstrips supply.

However, we would like to have seen a more explicit recognition of and commitment to person-centred care being placed at the heart of the strategy.  Whilst this is important for everyone, it is particularly important for older people, especially those who are beginning to develop cognitive problems.

We welcome especially principle 6. Ensuring that service, financial and workforce planning are intertwined, so that every significant policy change has workforce implications thought through and tested.  This is essential if changes are to be meaningful and lasting.  We recognise the challenges involved in adhering to this principle and hope that it will have buy-in at the right level in order to build political consensus that this is the only way that a sustainable system can be delivered effectively. 

What measures are needed to secure the staff the system needs for the future; and how can actions already under way be made more effective?
Accelerate system reform and investment. 

Our view is that education, training and recruitment must be more closely aligned to the rapidly increasing population of older people, with full account taken of the increasingly levels of frailty that people are living with.  While system reform is already underway, we need greater investment to accelerate reform.  Ensuring that there is capacity to address the challenges involved in better meeting the health and care needs of older people, at a scale that fully recognises population growth requires significant reform and investment over time; a workforce strategy that builds this in is key.

In-built flexibility in place of care.

Ensuring timely access to allied health professionals. 
The strategy needs to address the growing trend to move into Advanced Clinical Practitioner roles; for example this is a common career path for physiotherapists.  The potential for a reduction in numbers of AHPs as a consequence doesn’t appear to have been considered, yet physios and other therapists play a critical role in supporting older people to maintain as much independence as possible, both physically and in their work with older people with dementia and other mental health issues. Similar concerns about the impact of extended roles for nurses on the supply of nurses in non-extended roles have been more widely acknowledged and also need to be addressed.

How can we ensure the system more effectively trains, educates and invests in the new and current workforce?

Developing expertise in older people’s healthcare throughout the system. 
Demographic change means that all health and care professionals will be working mostly with older people.  Increased education and training in frailty as a specific medical condition, and enhanced knowledge and expertise in treating people living with multiple long term conditions are essential if we are to have a workforce that can meet the healthcare needs of our changing and ageing society.  We were surprised that the draft strategy makes so little reference to demographic change (it is only referred to in the section on dentistry). 

Changes to undergraduate training across healthcare professions.
A focus on older people should be fully embedded in the core curriculum for all professions.  This means not just developing strong clinical knowledge and expertise in ageing, frailty and long term conditions, but also receiving more training to understand and navigate the whole system of support for older people.  For example, someone who wants to become a General Practitioner will need to know more about new models of integrated care in order to know where they can best refer their older patients.  Developing a wider, more holistic understanding of health and social care systems is going to be essential in creating a future workforce that is equipped to provide high quality care for our ageing population.  We recognise the introduction in some areas, for some topics, of interdisciplinary undergraduate learning, with an appreciation of the positive impact this can have for learners and support the extension of this approach.

Joined-up and long-term planning for geriatric medicine. 
We have concerns about the risks of decisions that focus on addressing short-term issues only.  A joined-up approach to planning across all the relevant bodies is essential.  Our understanding is that Shape of Training is going to lead to an overall reduction in training numbers in geriatric medicine, whereas we had previously been assured that we would keep the same number of training posts.  Condensing these into four rather than five years would have meant a net increase, and would therefore have begun to address the shortfall in numbers of Geriatricians.  This is an issue which will impact significantly on the capacity of the future workforce if it is not addressed.

Technological skills.  While there is reference to staff having technological skills it is mainly in relation to genomics.  There are a lot of other technological innovations that are already being used to strengthen the quality of healthcare for older people and improve health outcomes.  It would be helpful to include in the strategy recognition of the use of technological solutions as part of a holistic approach to skills development and training for health professionals.    An example we recently highlighted in a report we jointly published with the Royal College of GPs showed staff working in an urgent care team in Merseyside who are equipped with tele-video technology for remote assessment and support which enables the majority of cases referred by GPs to be reviewed within an hour.  Only 10% of the cases then seen by the urgent care team need to be transferred to hospital and the patient reported satisfaction for this service consistently exceeds 95%[i].  

Evolving models of care.  The consultation document does not include anything on the benefits of a mix of healthcare professionals all being trained to develop the same core competencies, for example competencies in care of ortho-geriatric patients.  We see this as key.  It would also support the work being done through the Getting it Right First Time (GIRFT) programme on identifying and reducing unwarranted variation in practice.  It would be helpful to have some read across to this in the workforce strategy. 

What more can be done to ensure all staff, starting from the lowest paid, see a valid and attractive career in the NHS, with identifiable paths and multiple points of entry and choice?

One of the things that would help, especially for those considering medicine as a career, is in planning that recognises the need for career breaks while on maternity or paternity leave, very often at the same time in their lives that doctors are in training and on route to becoming a consultant.  Creating more posts which are less than full time would help to address this and ensure that the investment in education and training is not lost. 

Those planning medical training numbers have been very slow to recognise that the growing number of women training as consultants requires a change in the way training posts are counted and allocated.  In specialties such as Geriatric medicine, which attract a high proportion of female applicants, the lack of clear advice from the centre regarding such matters as whether or not “numbers” can be filled when the current incumbent is on maternity leave, and whether more than one trainee can use a training number where two trainees are both working flexibly, is problematic. The lack of recognition that those working flexibly as trainees are likely to work flexibly in consultant posts, with a requirement to adjust training numbers accordingly, is problematic and leads to an imbalance between supply and demand.

How can we better ensure the health system meets the needs and aspirations of all communities in England

Public health and social determinants of health.  We need a workforce strategy that fully encompasses public health issues, and the wider social determinants of health.  Ensuring that more people are able to experience healthy ageing requires the promotion of better health from childhood onwards.  The interdependent nature of health on other factors is shown clearly in the regional variations in the average number of disability-free years people experience, depending on where they live.  We believe a greater focus on the health impacts of housing, education, employment and economic policy is the only way to ensuring that avoidable pressures on the health system are addressed, and that better health into old age is promoted on an equitable basis.  

What does being a modern, model employer mean to you and how can we ensure the NHS meets those ambitions?

Flexibility in employment contracts.  The nature of the training that doctors undergo on route to becoming a consultant currently mitigates against a work-life balance that is family friendly.  We know that some people are attracted to the specialty of geriatrics because there is more flexibility in working hours than in some other specialities. However, it is impossible to ignore the need for financial investment in training more doctors if more flexible working is to be a feasible option. Given the rapidly increasing pressures on the health system we believe this is a fundamental aspect of the workforce strategy that must be addressed if it is to be a meaningful strategy that is fit for the future. 

Career development opportunities.  All healthcare staff need to know that there are opportunities for progression.  This is especially important for those in junior and low paid roles.  In particular we believe the lack of career progression opportunities for the low paid social care workforce needs to be addressed urgently in order to improve recruitment and retention and provide a more skilled workforce. 

Better recognition of the impact of healthcare work on individual wellbeing.  At present staff are working under enormous pressures without the time and space for support and recognition of the issues that are part of day to day work; for example we believe that much more could be done to recognise the impact of professional bereavement that healthcare staff routinely experience. 

At present our members, working with older people and their families, are acutely aware of the difficulties in accessing both intermediate care, and social care.  Urgently addressing the need for an integrated system with adequate levels of financial investment would make a huge difference to the ability of Geriatricians and other healthcare professionals specialising in older people’s healthcare to deliver excellent care. 

What policy options could most effectively address the current and future challenges for the adult social care workforce?

The plans for the integration of NHS and social care present a challenge but also a great opportunity for thinking imaginatively about the future workforce. Greater use of apprenticeships across the sector, and opportunities for those who may enter the workforce with relatively few formal qualifications to develop their skills and expertise may help recruitment and retention. Clearly paying social care staff the living wage, paying for travel time between visits to service users and the removal of “zero hours” contracts are all obvious and important changes to improve recruitment and retention in the sector.

Greater investment in prevention strategies also has a bearing on the pressure that the social care workforce is under.  The roles of community Geriatricians, community nurses and other specialist health professionals are key to enabling people to remain independent and living in their own homes for as long as possible.  Prevention strategies can reduce (but not remove) the risks of falls and fractures.  The benefits of helping people to re-gain previous levels of mobility following a fracture are essential in enabling older people to maintaining independence.  We highlight this here as an example of the interdependence between health and social care and the need to consider the two systems together in order to build long term sustainability in the health and care system for older people. 

[i] Integrated care for older people with frailty.  Innovative approaches in practice.  BGS/RCGP 2016