With winter fast approaching, expectations of a new wave of Covid-19 coinciding with the annual ‘flu season, and pressures on the NHS making almost daily headlines; the question of preparedness in frontline public services has never been more salient. The challenge of workforce resilience is discussed here with NPC Executive Director Katie Barnes and Paul Vaughan RN, Deputy Director, Primary Care Nursing & NextGen Nurse, NHS England.
Introduction
Our daily lives are built against a backdrop of public services that support the social contract between citizen and state. Each of these services has evolved over decades to provide a framework for ensuring that support and security are provided for everyone who needs it – within the limitations of budgets and the prevailing policy agenda. Each public service area – education, justice and policing, welfare, health, and social care, defence and security – should function well under normal circumstances, even allowing for the fluctuations and disruptions brought about by political change. The ability to function as needed whilst under stress, and simultaneously to deal with the fallout of that stress, is a hallmark of national preparedness.
Preparedness is a balancing act, and particularly so when viewed through the lens of public services. Their capacity to flex in the face of unexpected demand is a function, not only of adequate funding but also of three other critical elements: an appropriate structure, good management of underlying demand and supply patterns and a resilient workforce (i.e., enough people with the right qualifications to withstand both normal and abnormal requirements). Taking the National Health Service (NHS) as an example, Paul Vaughan (Deputy Director – Primary Care Nursing and NextGen Nurse at NHS England) explores how the NHS Long Term Plan (2019) seeks to address all three of the critical elements:
- Restructuring the supply of healthcare in various settings.
- Changing the approach of primary care towards better support of the public in health management.
- Implications for the already significant challenge of workforce skills supply.
Restructuring the supply of health care
In 2019, the NHS Long Term Plan set out a new vision for the future of the NHS. In the face of rising demand (we are living longer lives, but not necessarily experiencing healthy old age), increasing co-morbidities (meaning one or more chronic diseases such as diabetes or heart disease) and population expansion, the model of universal healthcare free at the point of use is increasingly difficult to finance. One strategy is to free up more expensive GP time by directing patients towards other, equally but differently skilled healthcare professionals. This relies on such professionals being available in sufficient numbers and with appropriate skills where and when they are required. This strategy of substitution sits alongside a set of measures designed to increase overall numbers of healthcare professionals in the system. However, are these measures working well enough?
Some three years on from the publication of the NHS Long Term Plan, it is evident that significant steps have been made on the structural reorganisation of the NHS. It is also evident that cracks in the system remain, and some have been exacerbated by the Covid-19 pandemic and other stressors. Stories of ambulances queuing for hours outside emergency departments are now routine and reflected in the response times. Paramedics cannot hand their patients into the care of hospital staff because patient ‘flow’ through the system is inhibited – partly by lack of available beds elsewhere in the system. The system is not so much broken as unbalanced. If we were to imagine a hierarchy of treatment settings where hospitals are at the top (in terms of both cost of delivery and scale of urgency or specialism in the care needed), we would see far too many patients being passed ‘upwards’ due to lack of capacity rather than clinical need. This is what systems experts term ‘failure demand’ – i.e., demand that is created because of lag or failure elsewhere in the system.
Changing the approach to primary care
In reorganising the delivery model such that patients are treated more effectively lower down the hierarchy, and only the most necessary cases treated in acute settings, the NHS Long Term Plan aims to rebalance the situation as well as creating a layer of resilience. This makes eminently good sense. Taken to its logical conclusion, this approach is designed to ensure that more patients are treated in primary care and community settings (e.g., GP surgeries, and diagnostic and treatment centres). In the case of patients living with long-term conditions such as diabetes or asthma, more effort will be placed on helping them manage their condition effectively at home. It is an approach that sits well with the concepts of preparedness and resilience. A public service which properly supports citizens in managing their own needs as far as possible means less resource needs be committed to episodic or emergency treatment of poorly controlled conditions. Patients are better able to stabilise their conditions and, in many cases, become healthier and more resilient – not only to infections and illness, but to other disruptions in their lives. As a result, the healthcare system has more flexibility to deal with the unexpected without undue ‘legacy’ effects.
To properly manage demand profiles, the newly shaped NHS under the NHS Long Term Plan relies on a foundational layer of holistic primary care. The Clinical Commissioning Groups established following the Health and Care Act (2008) are re-grouping into regional Integrated Care Systems (ICS), with a focus on integrating care, navigating the complexity of multiple waiting lists and early interventions that work to avoid hospital admissions. They are designed to work as person-centric organisations, bringing partners together to manage population health and prevent more individuals from needing NHS support in the first place.
Whilst this is a relatively simple proposition from a purely economic perspective, another key resource – that of skilled staff – is much harder to flex. The integrated model for primary care relies on a supply of suitably-qualified professionals of all types – GPs, nurses, and allied professionals, such as the ‘3 Ps’ (physiotherapists, pharmacists and phlebotomists), and it is this supply of these professionals that is causing concern today. The pipeline of a skilled workforce must be developed well before the need for those skills arises and can make or break the most elegantly engineered strategy. True, the NHS rallied additional staff and hours during the height of the Covid-19 pandemic. All whilst dealing with an unknown virulent disease with little knowledge of how to treat it, and uncertainty as to whether it could be contained and insufficient access to vital equipment.
However, we must face the fact that the effort and resource that went into the fight against Covid-19 is not sustainable long term, and the sheer scale of resource diverted to the Covid-19 pandemic has left deep scars on our NHS. Patients who were asked to stay away during those first dangerous months now take their place in an NHS backlog that needs extra resources to tackle – on top of existing waiting lists and staff shortages. Money can only be one part of the solution.
Workforce skills supply challenges
We can be confident that the NHS Long Term Plan includes proper consideration of two of the three non-financial elements, i.e., structure and balance in supply and demand. The new structure seems more appropriate for the healthcare needs of the future, at least into the medium term. Demand will almost certainly be influenced by supplying care according to the aims of the new model.
But what of workforce skills?: herein lies the greatest challenge. A recent report from the Health and Social Care Select Committee notes significant gaps in the NHS workforce, noting a stark warning from the King’s Fund that ‘The government’s current target of recruiting 50,000 NHS nurses is not having any meaningful impact on the true scale of nursing shortages.’ The report noted that ‘almost every healthcare profession is facing shortages’ Citing the removal of the nursing bursary in 2017, the Committee recommends the reinstatement of this bursary with a condition that ‘nursing and midwifery students who take up this bursary should be guaranteed, where possible, at least 3 years of work in the NHS Trust in which they trained, to eliminate the need for them to seek agency work after graduation.’
Agency and bank workers: agency workers have their own effect on the workforce. In evidence the Nuffield Trust estimated that four in five NHS vacancies were being covered by temporary, bank, or agency staff; most of whom are paid at higher rates than salaried staff. As a means of bringing more part-time workers into the workforce, increased numbers of agency or bank staff could expand both capacity and flexibility within the system. However, this relies on two assumptions: first, that agency and bank staff are willing to work more shifts; second than this cohort of professionals does not significantly overlap with the cohort of permanently employed NHS staff who are seeking extra shifts through bank work, simply to augment their income in the face of a cost of living crisis. In some settings high levels of agency staff introduces serious questions about continuity of care – it is not a silver bullet solution.
Nurse specialism: there is another challenge that is hiding in plain sight here. Agency and bank nurses tend to work mostly in hospitals and other residential settings such as nursing homes. The recommendation for bursaries linked to 3 years’ post-graduate work in an NHS Trust also benefits hospitals primarily. Yet the foundation of the NHS delivery model under the NHS Long Term Plan is in primary care, in GP surgeries and health centres. Here nurses play a vital role that extends into support for patient self-management. In general practice it is often the nurses that coordinate care, liaising with other professionals to ensure a patient’s needs are met. Their role is vital in providing intelligence on population care needs and appropriate delivery models. Nowhere in the Select Committee report is this specialism mentioned, yet it is a part of the workforce that is under immense strain. The recommendation to retain newly-graduated nurses in trusts for 3 years in return for training bursaries will stem the potential supply of nurses in general practice even more – right at the time they are most needed if we are to realise the potential of the new model.
Overseas recruits: a further complication lies in the current reliance on overseas recruits to fill urgent vacancies for healthcare professionals of all types. Whilst professionals trained outside the UK will always be a necessary and welcome part of the skills mix, over-reliance can cause its own resilience issues. We witnessed the loss of European nationals working in the NHS in the wake of Brexit. Overseas recruits need to know that we value them as more than just headcount. Efforts need to be made to understand how to properly integrate nurses and other healthcare professionals into a truly diverse workforce, reflecting the ethnic diversity of the population it cares for.
Recruitment and culture: strategically ‘designing in’ an assumption that significant numbers of our workforce will be supplied (and readily available) from overseas recruits virtually guarantees that significant effort and cost will continue to be apportioned to the recruitment and settlement effort. It also raises the thorny question of why the shortage of UK-trained nurses has arisen in the first place. It is a complex issue – with caps on the numbers of places available meaning that every year large numbers of potential new recruits are turned away, whilst nurses working in an over-stretched system are leaving due to burn-out. Others are finding the role economically challenging. A Nursing and Midwifery Council leaver’s survey showed that the main reasons for nurses and midwives leaving the profession in the year to June 2020 were retirement, a change in personal circumstances and too much pressure. The fourth most common reason was workplace culture having a negative effect; a reason cited by nearly one in five, and this should set alarm bells ringing.
Future considerations
Resilience in the NHS stands or falls on how well the constituent parts work together. We need to be prepared to do something different if we are to escape the cycle of emergency measures to meet winter pressures (the effects of which now start to be felt in the autumn), lengthening waiting lists and ever more creative recruitment drives. No new structure is going to achieve resilience outcomes if the skills to deliver care in every setting are not planned for, or the demands on the system are not managed.
The question then is whether we are prepared to make the new model work. To do so demands that we do four things:
- Structure: pay proper attention to resourcing holistic community healthcare. This is the route to ‘right sizing’ the demand flowing through the NHS, with nurses and other primary care supporting good health at population level.
- Career progression: ensure that every new recruit is properly valued and supported to build and progress a rewarding career within the NHS; and encourage others to build and progress their career in the NHS, so that ‘boom and bust’ recruitment strategies are no longer needed. Programmes such as Getting to Equity are already starting to address this need for retaining and progressing skilled staff, but more can be done.
- Skills supply: work with universities to understand how capacity can be increased. This will ensure that the headroom created by increasing the numbers of international recruits is properly used.
- System demand: recognise that it will be impossible for the new model to work as designed unless the existing high level of failure demand is recognised and treated as such. Targets need to explicitly show how well the aims of the NHS Long Term Plan are succeeding in bringing about systemic change.