building the right workforce

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© Nuffield Trust Building the workforce as we transform the delivery system Candace Imison The Commonwealth Fund and the Nuffield Trust 15 th International Meeting on Improving the Quality and Efficiency of Health Care Pennyhill Park 17 July 2015

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© Nuffield Trust

Building the workforce as we

transform the delivery system

Candace Imison

The Commonwealth Fund and the Nuffield Trust

15th International Meeting on Improving the Quality and Efficiency of Health Care

Pennyhill Park

17 July 2015

© Nuffield Trust

Overview

• The challenges we face

• Workforce – the English context

• The opportunities offered by changes in skill mix

• The challenges of skill mix change

• Lessons for the future

© Nuffield Trust

The challenges we face – the need for

transformation

• Ageing population + rising burden of chronic disease and

co-morbidity

• Changing expectations of, and relationships with patients

• 24/7 working

• Impact of new medical and information technologies

• Financial context – unprecedented productivity challenge

– £22bn by 2020

© Nuffield Trust

NHS Workforce profile in England

0% 5% 10% 15% 20% 25% 30% 35%

NHS Infrastructure support

Support to clinical staff

Additional professional, scientific andtechnical (including healthcare scientists)

Allied Health Professionals (includingqualified ambulance staff)

Nursing and Midwifery Registered

Medical and dental

% Total earnings % FTE

FTE data: NHS Hospital & Community Health Service (HCHS) and General Practice workforce as at 30 September 2014. Total earnings

calculated through using estimated average earnings per staff group (taken from 12 month period ending February 2015) and FTE data.

Data sources: NHS Workforce Statistics in England, 2011-2014, HSCIC; NHS staff earnings estimates to February 2015 - provisional

statistics, HSCIC.

Staff employed by NHS organisations – hospitals, mental health and

community providers General Practice staff contracted to the NHS

0 25000 50000 75000

GPs

Practice Nurses

Advanced & SpecialistNurses

Direct Patient Care(HCAs)

Other

Admin & Clerical

General Practice Staff FTE

FTE

© Nuffield Trust

UK has seen significant expansion of medical

workforce (but not evenly distributed)

-15%

-10%

-5%

0%

5%

10%

2009 2010 2011 2012 2013 2014

Axis

Tit

le

Medical and dental

Nursing and Midwifery Registered

Allied Health Professionals (includingqualified ambulance staff)

Additional professional, scientific andtechnical (including healthcarescientists)

Support to clinical staff

NHS Infrastructure support - includinghotel, estates and managers

Data source: NHS Workforce Statistics – February 2015, provisional statistics, HSCIC. Data taken from December of

each year shown.

© Nuffield Trust

England – workforce supply issues

Recruitment difficulties & forecast shortages

Nursing – hospital, primary care and community

Doctors – A&E, acute medicine, psychiatry, general practice

Social and informal care

Changing workforce expectations

More flexibility

Less organisational allegiance

How sustainable is continued restraint on pay?

Geographical variation – recruitment black spots

© Nuffield Trust

Royal College Physicians survey highlights some of issues

© Nuffield Trust

Skill mix change could offer some solutions

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Deliversmore patientfocused care

Addressesgaps inmedical

workforce

Addressesgaps inskillednursing

workforce

Deliverssavings in

service costs

Improveshealth

outcomes

Improvesoverall

recruitmentand retention

Addressesgaps in allied

healthprofessionals

workforce

Other Deliverssavings in

training costs

What would be the benefits of skill mix change for the area with the greatest potential to benefit? (n=17)

© Nuffield Trust

All service areas have potential to benefit from skill mix

change – but particularly primary and community care

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Communityservices

Hospitalinpatientservices

(secondary)

Hospitalinpatientservices(tertiary)

Hospitaloutpatientservices

(secondary)

Hospitaloutpatientservices(tertiary)

Mentalhealth

services

Pharmacyservices

Primarycare

Social care Support forself-care

How much potential do the following health and social care service areas have for skill mix change (recognising the opportunities offered by new technologies)? (n=18)

Great potential

Moderate potential

Little potential

No potential

© Nuffield Trust

New (alternative) worker

New work

Old worker

Old work

increasing the numbers of

nurses, doctors, and other

health professionals

expanding the job

descriptions of existing

workers, such as

community matrons, to

include work previously

not done by anyone

handing off existing tasks

to other workers, such as

nurse practitioners and

general practitioners with

specialist interests

creating new jobs for work

previously not done by

anyone, such as genetic

counselors, and lay

providers to support self-

care

Redistribution Creation

Capacity expansion Retraining

Source: Bohmer, Imison. Health Affairs 2013, 32(11), 2025-2031

Framing the options for skill mix change

© Nuffield Trust

Summary: considerations in workforce redesign

1. Complements vs. substitutes; previously new roles have been

added w/out decommissioning old roles with a net increase in costs

2. Importance of role definition; new classes of worker often have

poorly defined roles, especially in relation to the roles of others

3. Benefits of seniority; senior clinicians, although more expensive by

the hour tend to order fewer tests and utilize fewer bed days,

admissions and procedures

4. Risks of fragmentation; dividing the work among more (cheaper)

workers increases team coordination costs

5. Importance of a career; new roles benefit from a formal career

structure, national recognition and portability

© Nuffield Trust

Messages from Time to Think Differently

• The staff we will have are the staff we already have

– don’t rely on the pipeline

• Align the workforce to the work – not the other way

round

• Develop teams not just individual professional

groups

• Support and “activate” patients

• Support the informal workforce

• Reverse the inverse training and investment law

• National facilitation but local action

© Nuffield Trust

Conclusion

“New technologies will force changes in delivery models that we have not yet thought of. Without building capacities and capabilities in our workforce for a world of continuous change and emergence of new roles and possibilities, we risk being perpetually out of step and continually rebuilding our workforce to do yesterday’s not tomorrows health work” Professor Richard Bohmer

© Nuffield Trust 17 July 2015

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