London’s strategic health authority last week announced its workforce plan to deliver a polyclinic-led NHS for the city.
Workforce for London – A Strategic Framework puts flesh on the bones of proposals set out by Lord Ara Darzi in July 2007.
The strategy has been drawn up with input from London’s directors of nursing, chief nurses and nursing academics.
NHS London’s chief executive Ruth Carnall introduced the plan with a cautious reminder.
‘There is a whole series of failed strategies for London. This was caused, not because they did not have good ideas but because people did not think through seriously how to implement them,’ she said.
However, she added: ‘[Past strategies] were written by eminent outsiders, whereas this was written by a practising consultant.
We are determined to think through the important initiatives to make sure this gets implemented this time round.’
NHS London will have to totally reshape its workforce if it is to deliver on its promise to move care closer to home and create a network of 150 polyclinics across the capital – the first five of which were announced this month (NT News, 16 September, p2).
The SHA’s aims are ambitious. Over the next 10 years, it wants to see a 50% shift of A&E activity into community care settings, up to a 41% shift in outpatient activity to polyclinics and a 10% reduction in hospital inpatient admissions through better management of long-term conditions in the community.
The strategy envisages the ‘whole workforce being able to work dynamically and flexibly along care pathways in a variety of settings’.
To achieve its goals, the SHA states it will need to train or retrain 15,000 healthcare workers to work in the community – which will include the creation of an extra 4,000 posts. This figure breaks down to include around 1,500 more nurses, 200 more midwives and 8,000 healthcare support workers.
The intention is that over the next decade there will be an 18% increase in the percentage of London’s nurses currently based in community settings – from 22% to 40%. Additionally, the SHA plans for the number of doctors based in the community to rise from 25% to 47%.
Overseeing care at the polyclinics and other community settings will be a new generation of clinical leaders, which the health authority hopes will come from the ranks of the existing healthcare workforce.
In particular, the SHA plans for a ‘significant increase’ in the number of advanced practitioners – specially trained nurses, midwives and other non-medical staff – with a particular focus on out-of-hospital settings.
It is envisaged that this group will be responsible for managing caseloads and interpreting results and information
supplied by more junior staff.
The role of HCAs and assistant practitioners will also be expanded in both numbers and remit – with the rehabilitation assistant practitioner being cited as one such new role.
The SHA acknowledges a need for investment in training. ‘This will require new training programmes both for existing and future staff,’ the strategy states.
Bernell Bussue, director of RCN London, said this was an area he had significant concerns about. He said he would be seeking assurances that the shift to the community was fully planned ‘with a robust training and support programme to ensure the right skills and the right staff in the right place delivering good quality care’.
The training budget earmarked for the strategy comes to £132m, which the SHA says
will be found by closing failing training courses, redirecting money used to train hospital staff and ‘growth money’ from the continued increase in central investment in the health service.
However, there must be question marks over the authority’s record on training. The SHA failed to spend £39m of its staff training budget in 2007–2008 (NT News, 26 August, p2). Additionally, the authority currently receives around £1bn annually for training, making the planned £132m over 10 years seem far from excessive.
Another key strand of the strategy deals with the overall way in which workforce planning is to be handled in London.
Responsibility for most of this planning function will be decentralised to clusters of service providers that will plan local staffing needs based on information from local commissioners – most likely PCTs. Overseeing this will be a central workforce planning unit that will supervise the overall bigger picture and make adjustments where necessary.
It is hoped this approach will cover the needs of specific areas, with the central body ensuring workforce planning is joined up across the capital.
‘Employers would come together in clusters to plan their workforces in response to PCT commissioning intention. We
will also create a London-wide workforce intelligence unit,’ said Anne Rainsbury, NHS London’s director of people and organisational development.
RCN policy adviser Jane Naish backed the plans to decentralise workforce planning. ‘You can’t do workforce planning for the whole of London – it makes sense to do it at a local level and use the local community to recruit from,’ she said.
However, the document states that the current workforce provided by educational institutions does not meet the needs of NHS London’s strategy. The system is not fit for purpose, the document says, and must be changed if the plan is to be effective.
‘There is no point continuing to train people to work in hospitals,’ warned Ms Carnall.
As a result, clinical education in the capital will be overhauled, with poorly performing nurse training courses being shut down.
Some courses have already run into trouble. Chelsea and Westminster Foundation NHS Trust said earlier this year that it would cease to take placements from students at Thames Valley University, citing concerns about quality (NT News, 5 February, p2).
Such moves, the SHA hopes, will allow more money to be spent on new courses, which will offer training to nurses and other healthcare staff to equip them with the necessary skills to work in the community.
Also included in the plan are proposals that will make it easier for clinicians to take a step up the management ladder. Until now staff could only be considered for board membership if they were nominated by the trust’s chief executive. But in future they will be able to receive training for top board-level posts if they have received a nomination from an existing board member.
For example, this could mean a ward sister being fast-tracked if they have been nominated by their director of nursing, if they are on the board.
‘You don’t need to go down the traditional route where the chief executive has to nominate you. You just need the support of one board member,’ said Ms Rainsbury.
‘If a nursing director wanted to nominate a ward sister, they would not need to go through the traditional hierarchy.’
Nurses will also have the opportunity to take part in ‘Darzi Fellowships’, through which they will be able to undertake international placements to develop management skills. There will also be an emphasis on ensuring more staff from ethnic minorities are promoted through the ranks.
Overall, Mr Bussue described the strategy as a ‘positive move in the right direction’.
Unison also welcomes the plans overall. Michael Walker, Unison’s London regional officer, said: ‘We accept that there need to be changes to healthcare in London and accept that there will be closures of some hospitals.’
But these sentiments are not universal among all clinicians.
In particular polyclinics and the move way from hospitals is unpopular with doctors’ leaders. The British Medical Association
is concerned that the proposals will limit career opportunities.
But a bigger barrier to the plan could be political change itself – with a general election due to be held by June 2010. It remains to be seen whether a potential Conservative government would continue with the strategy, or replace it with plans of its own.
‘A majority of healthcare professionals in London know where we need to go – but the NHS is under huge political pressure at regional and local levels,’ said Mr Walker.
‘Decisions are often made on political grounds rather than healthcare needs.’
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