What's gone wrong with NHS workforce planning?

NHS workforce planning is not rocket science, workforce capacity and capability is fairly predictable. Staff don’t suddenly retire, care pathways don’t suddenly change, the NHS enables change at a planned pace. An accurate skill and capacity profile matched to predicted epidemiology, and the anticipated treatment pathway is the core of NHS workforce planning. The environment and location where care is delivered is affected by the available labour market in that geographic location. It’s not difficult to assess workforce capacity against anticipated supply and demand, and it needs to include all skill levels and all professions, and crucially afford opportunity across the labour market.

So, what stops this? I would argue four things: professional protectionism, traditionalism, resistance to change, and the financial resources to bridge the change between where we are and where we need to be.

Elitism, exclusion, and inequity clearly exist in our NHS Scotland (NHSS) workforce. I remember having to fight to develop a healthcare academy which offered those furthest removed from the labour market sustainable training and work opportunities in NHSS. It is safe to say there were more obstacles than enablers. Everyone needs to remember no matter the level you work at career opportunities are in the control of others, for every job interview you attend your success depends on someone saying “yes”. Academic attainment is not the only indicator of academic ability, it simply means you had the right opportunities, some people are late developers, or lack chances because of life circumstances.

Planning for the future means not replicating a 1970s workforce design and asking it to deliver current and future care. NHSS workforce planning largely focuses on the university-educated workforce, but this excludes huge swathes of the labour market, there is no valued career pathway below degree level. Our college sector is willing and able to develop the care sector SHNC and SHND workforce and ensure education standards at all levels of healthcare, but the numbers speak for themselves. NHS England have, in truth, been much better at having an inclusive workforce strategy.

The reality is you don’t need a degree to do every job in the NHS. Valuing all skill levels would go a long way to relieving the workforce crisis moving forward. For example, around 26 per cent of the nursing and midwifery workforce are below degree level. In the last Census (2011) 27.1% of the population had a university degree or professional qualification, this percentage varies vastly across location. The reality is for most NHS jobs this 27% represents the available labour market, but it is also the labour market all other degree-based professions are competing for. The labour market arithmetic speaks for itself.

Nursing in the UK became an all-degree profession in 2009. There was nurse training and a nursing workforce before degrees; many such staff remain practising registered nurses.

I am not arguing that there shouldn’t be degree courses, I am arguing that a degree shouldn’t be the only route, finishing point, or valued qualification. The NHS workforce should be inclusive, all types of skill are needed in a modern healthcare workforce, and all grades and sectors should have the opportunity of structured education and career progression.

What skills are needed within health and social care? More of the same is not the future, the workforce needs to match the future design of healthcare. We access more healthcare as we age and future generations who have grown up with digital are likely to want to access healthcare differently; the experience of those currently designing healthcare services is different, more traditional and bed based. The focus of healthcare workforce planning remains largely on the protected groups of doctors and nurses, and whilst these staff groups are the core of the service, the future requires multi-faceted expertise.

Artificial intelligence and digital are the future, yet we plan for traditional skills. The pace of change in medical science, pharmacology and IT is accelerating, yet I remember many conversations with clinical colleagues, particularly in primary care, about implementing necessary change to meet predicted demand. Privately they would tell me the plans made sense, but then vote against them at health board meetings because the status quo suited them and their cohort well.

AI and digital will have a significant impact on our healthcare future. It is already shaping diagnostics. Any workforce plan that does not include the impact of technology is severely limited. Digital skills, data analysis, and data science are an in-demand skill in healthcare. Healthcare workforce planning should be undertaken on the principle of co-production with future users, especially young people.

The associated risk in failing to train staff for new roles in a more digital and technology-driven environment is a real one. There is significant scope for retraining and redeployment in healthcare which will require sophisticated understanding and planning. However, this is only possible if the impact of digital advances is fully understood. Tech experts must be a core part of future healthcare planning.

Digital services are already changing how long-term conditions are managed. There are NEAR ME virtual appointments. My own village hall in Argyll became the first mainland Scotland Non-NHS NEAR ME hub. Remote technology already gives users more control, promotes self-care and wellness, gives international access to expertise, provides consistency, and takes healthcare into people’s homes and communities reducing the need to travel.

Increasing workforce capability in relation to technology will be vital, planning healthcare with only traditional skills is a recipe for failure. Technology cannot replace human care, compassion, and empathy. However there are functions where digital technology can provide transformation such as HR, finance, system administration, management, and other backroom functions. Look around at other services and industries we use every day and learn. Without doubt technology can provide opportunities for streamlining and reducing duplication and cost across health boards.

The pandemic offered extreme circumstances and pressures, but from this there will undoubtedly be key lessons for workforce planning and these must not be lost. Patients are becoming accepting of wearable tech, using virtual consultation, using self-testing and online information - will this impact on the role of general practice as they offer less face-to-face interaction? Perhaps the future primary care model is a hybrid model with heath boards?

In recent years workforce planning has become an HR tick box exercise. Workforce planning is a unique skill which requires experience and a breadth of knowledge across the care spectrum, but tech has a big part to play too. Healthcare workforce planners are generally independent and will give a professional view rather one which is politically motivated. We need to value this.

Finally, perhaps the biggest barrier is finance. Healthcare is an expensive business. Future demand will grow as people live longer, clearly this is a good thing. However, this brings with it the need for increasing demand both elective and emergency, routine and complex, and spread across geographically diverse locations.

We have never properly resourced preventative healthcare and public health. Meeting the challenges of the future on the current model will require substantial additional investment. Will future generations use healthcare differently? The skill profile of the required social care has also never been analysed in detail and always feels like an add-on rather than a focus, the Cinderella service so many depend on.

Change costs money. NHS Scotland will need bridging finance to allow the service to continue to meet the needs of people today whilst modernising for the future. Failure to find this money will see the NHS disintegrate over time and constant pressure will be the norm. People who can afford to will go private or take out medical insurance. People who cannot afford this will receive a different level of basic service. However, a note of caution: private sector healthcare fishes in the same finite labour market pool as the NHS.

Ultimately, the decisions that are required are political. What type of society do we want to live in? A society that believes private healthcare is an acceptable option, or one which has a vision of universal healthcare provided free at the point of contact based on clinical need, where public health is a priority, and the employment practice produces a workforce truly representative of the people it serves, not just the elite. Critically this needs to be recognised not just in warm words and acronyms in meaningless, endless more of the same NHS Scotland workforce plans, but with real investment.

I hope it’s the latter. An NHS free at the point of need is one of the two essential components of a civilised society (the other is education); it can be achieved. The resource required does exist. It will come down to the choices we make and political courage to lead. On this we need our leaders to be solid as a rock not blowing in the wind.

Now is the time for a full and frank debate on the NHS a bedrock of society.

Professor Alan Boyter is a former CIPD HR Director of the Year and former NHS HR Director in NHS Lanarkshire, Glasgow, Tayside and Lothian. He is now MD of Dignity HR Solutions Ltd.