Mental Health Workforce Strategy

Transcription

1 Mental Health Workforce Strategy

2 Contents Contents... 2 Foreword... 4 Executive Summary... 5 Introduction... 6 Mental Health Taskforce Public Consultation Feedback... 6 Five Year Forward View Workforce Strategy Objectives... 8 Current and Future Mental Health Workforce The current workforce picture The future workforce The workforce gap Cross-system strategic solutions- Five Pillars Pillar One- Increasing Productivity Pillar Two- Increasing Attractiveness and Reducing Attrition Pillar Three - New Staff Pillar Four- New Roles Pillar Five- New Skills Measurement and evaluation and data strategy HEE Support Offer HEE organisational structure Patient and Public Engagement Leadership Academy Technology Enhanced Learning Sustainability and Transformation Plans Workforce and Career Planning Career and Education Framework New Staff New Roles New Skills Transformation across key pathways Children and young people s mental health Perinatal mental health Adult mental health: common mental health problems Adult mental health: community, acute and crisis care Adult mental health: secure care pathway and health and justice New pathway transformation Beyond the Recommendations from the Five Year Forward View for Mental Health

3 3 Mental Health Workforce Strategy

4 Foreword To be written by DEQ team Prompts include : Rising rates of poor mental health and suicide; Widening inequalities in mental wellbeing and mental illness; Unsustainable health service provision - new models and prevention focus; Reduced public resources impacting on core resilience; 4

5 Executive Summary Mental Health Workforce Strategy Health Education England exists to support the delivery of excellent healthcare and health improvement to the patients and public of England by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviors, at the right time and in the right place as set out in The Health and Social Care Act The Five Year Forward View for Mental Health 2 has made an unarguable case for transforming mental health care in England. The costs of mental ill health whether to the individual, their family or carer, the NHS or wider society are stark. The opportunity of action cannot be ignored, and this document describes how we will enable change. Over the past thirty years, mental health services have undergone a radical transformation, and in many areas have gone further in developing multi-disciplinary, community-based alternatives to hospital than any other part of the health system. This should provide the platform needed to build the fuller vision of the Five Year Forward View for Mental Health and embed lasting change. People can, and do, recover from mental ill health. The evidence is clear that improving outcomes for people with mental health problems supports them to achieve greater wellbeing, build resilience and independence and optimise life chances, as well as reducing premature mortality. But moreover, the evidence is equally clear on the potential gain for the NHS and wider public sector from intervening earlier, investing in effective, evidence-based care, and integrating the care for people s mental and physical health. The case in the Five Year Forward View for Mental Health, therefore, is about moving beyond the moral imperative and the clear clinical and individual benefits, and recognising this as a financial necessity to manage the challenges of the years ahead. Implementing this plan will benefit people of all ages, reflecting the specific needs of all groups, from children and young people through to older people. As such, our aim to improve mental health and wellbeing cannot solely be achieved by the NHS, but must be delivered in partnership with other local organisations including local government, housing, education, employment and the private, independent and voluntary sectors. HEE is responsible for developing and delivering 8 specific Taskforce recommendations in addition to working in partnership with other NHS Arm s Lengths Bodies (ALB s) to deliver the full suite of NHS recommendations; HEE has a central role to play in ensuring that the vision set out is achieved

6 Introduction Mental Health Workforce Strategy The Five Year Forward View for Mental Health sets out ambitious plans to extend and improve the provision of mental health services across England. It sets out a programme of improvement and associated investment which will lead to an increase in CCG baselines to deliver expanded services across a number of treatment pathways: psychiatric liaison; community crisis care; early intervention in psychosis; specialist perinatal mental health; Improving Access to Psychological Therapies; liaison and diversion; community eating disorder services and Child and Adolescent Mental Health Services. This mental health workforce strategy describes the actions that need to be taken to address the capability and capacity needs of the workforce to deliver this expansion as well as the needs of the wider mental health workforce, including in primary care and the private, independent and voluntary sector. This workforce strategy is designed to be a living document. The landscape is changing rapidly and workforce interventions must be receptive to this fact, adapting as needed to deliver the best possible care for those suffering mental ill health and their friends and families. Delivering the recommendations in the Five Year Forward for Mental Health means an increase in demand for all core professional groups: psychiatry, mental health nurses, allied health professionals, clinical psychologist and therapists, or those with therapy skills. This workforce strategy looks sets out the workforce gap that exists across the system and in the pathways receiving investment to drive transformation. It lays out a five themes or pillars pertaining to a range of interventions and actions that will need to be made by system partners to ensure a sufficient workforce is in place for 2020 and beyond and that this workforce has the right skills, in the right place, at the right time. The strategy also describes in more detail the actions that Health Education England will take and recommends the actions that other system partners will need to take. The FYFV MH describes a flexible and sustainable workforce of the future caring for more people, in the right settings at the right time. HEE s workforce strategy lays out the enabling actions, process and infrastructure that can make it a reality. It operates on multiple levels; a national strategy provides clarity and consistency but local areas and health economies are encouraged to innovate and adapt. Mental Health Taskforce Public Consultation Feedback The project team will launch the workforce strategy consultation from 25 October 30 November The feedback will be reviewed and included into the strategy as applicable. As patient and public consultation was undertaken only a year ago as part of the consultation for the Five Year Forward View for Mental Health Taskforce, we have successfully sought approval to re-use this recent and extensive feedback to represent the views of patients and the public. 6

7 Three clear themes emerged from the patient and public engagement; prevention, access and quality. The importance of integrating care and support was also identified as a critical factor to the successful delivery of equitable access and improved outcomes. The need to prioritise equality, particularly for BAME groups, older and younger people also came out strongly across each of these themes. The full report can be found on the NHS England website

8 Five Year Forward View Workforce Strategy Objectives Mental Health Workforce Strategy HEE should work with NHS England, PHE, professional bodies, charities, expertsby-experience and others to develop a costed, multi-disciplinary workforce strategy for the future shape and skill mix of the workforce required to deliver both this strategy and the workforce recommendations set out in Future in Mind. This review should address training needs for both new and existing NHS-funded staff and should report by no later than the end of This workforce strategy should include: Clear projections for required staff numbers to 2020/21 and what action will be taken to plug any gaps Core training in basic mental health awareness and knowledge, understanding of mental health law, public mental health, compassion and communication skills For professions involved in the care and support of people with mental health problems, tailored curricula with competencies in dealing with the common physical health problems people may present with, shared decision-making, mental health prevention (including suicide), empowering people to understand their own strengths and self-manage, carer involvement and information sharing. Drawing on the best available evidence, this should also ensure that professionals are equipped to provide age-appropriate care and reduce inequalities. HEE and PHE should develop an action plan so that by 2020/21 validated courses are available in mental health promotion and prevention for the public health workforce (including primary care). Implement local plans to transform children and young people s mental health, ensuring that 70,000 more receive high quality evidence based care each year by 2020/21. Ensure full roll out of the CYP IAPT development programme across England by 2018/19 Provide for a further expansion of access to integrated psychological therapies for adults with anxiety and depression to reach 25% of need, with a focus on those with long term physical health conditions and people who are out of work Ensure Crisis Resolution and Home Treatment Teams (CRHTTs) are providing a 24/7 community based mental health crisis response as an alternative to acute inpatient admission for adults in all areas across England, with equivalent provision for children and young people Ensuring acute hospitals have mental health liaison services available in emergency departments and inpatient wards, with at least 50 per cent meeting the core 24 service standard as a minimum Expand the Early Intervention in Psychosis (EIP) standard so that 60% of those who are referred for treatment receive NICE concordant care within two weeks of referral 8

9 Put in place evidence based screening and interventions to meet the physical health needs of at least 60% of adults with severe mental illness, in accordance with NICE guidelines Ensure that up to 29,000 more people per year living with mental health problems should be supported to find or stay in work through increasing access to psychological therapies for common mental health problems and doubling the reach of Individual Placement and Support (IPS). These recommendations are being developed and delivered according to their broad treatment pathway. The table below shows the proposed mental health pathway and infrastructure development programme: Figure xx: Proposed treatment pathways (Five Year Forward View for Mental Health, p.36) 9

10 Current and Future Mental Health Workforce Delivering the Mental Health Workforce Plan in response to the Five Year Forward View for Mental Health (NHS England 2016) and Future in Mind (NHS England 2015) relies heavily on good quality workforce data as its starting point. Identifying suitable baselines for both current supply and anticipated/projected demand must be the first step towards developing this workforce strategy to bridge any gaps (either in terms of workforce numbers or skills) or develop the workforce into one fit to fulfil the ambitions of those documents and fulfil the recommendations of the Five Year Forward View for Mental Health. The current workforce picture Creating a true picture of how many staff are required to deliver the recommendation s enhanced and expanded services is complex. There are a large number of data sources, reports, collections, censuses and audits about mental health workforce numbers and skills, capacity and capability. A large number of both quantitative and qualitative sources have been gathered together to inform this workforce strategy. Figure xx: Current staff (FTE) employed in Mental Health Trusts 10

11 Supply data in mental health is complex, due to the amount of service provision that takes place outside the NHS (very little is known about the non-nhs employed workforce). Even for staff employed by NHS providers (and therefore recorded on the NHS Electronic Staff Record), the data shows how many psychiatrists, mental health nurses and clinical psychologists are employed but it is not possible to determine where these staff work (i.e. in which service or team). While one can assume that the majority of psychiatrists or mental health nurses recorded on ESR are working in mental health, it is not apparent from the data whether they are working for CAMHS, services, Early Intervention in Psychosis teams or in a Perinatal MH Mother and Baby Unit. This difficulty in accurately mapping the current workforce is exacerbated when looking at Allied Health Professionals, support to clinical staff or administrative and infrastructure staff. It may seem obvious that Clinical Psychologists are mainly employed in mental health areas, but for staff such as Occupational Therapists, Speech and Language Therapists and Social Workers, and Healthcare Assistants, Medical Summarisers and Receptionists, it is not clear whether they spend some or all of their time working in/with a mental health team. For this reason, the accurate identification of current workforce normally takes place through individual, subject area audits or censuses. These are normally undertaken by professional or academic groups with an interest in a particular area (for example the Royal College of Psychiatrists Faculty of Liaison Psychiatry commissioned the 1 st and 2 nd annual census of liaison psychiatry teams, which were carried out by the University of Plymouth (2014, 2015)). However, in some cases audits may be commissioned by one of the ALBs for historical or budgetary reasons (for example, NHS England has traditionally carried out the adult IAPT census (NHS England, HEE 2016). A full list of data sources is available in Appendix xx. Figure xx: Total adopted current workforce (FTE) by expansion area 11

12 The chart above shows that CAMHS and Adult IAPT are the largest areas (by staff FTE) in the expansion areas. Some areas only show minimal current staffing, for example perinatal or Children and Young People s crisis teams (the latter has never had a specific workforce collection, however it is likely that there are dedicated CYP teams working within CHRTTs or Liaison MH services). However, it is important to recognise the contribution of core mental health services, which provide the majority of patient care and employ the majority of staff, when compared with the areas that are specifically recommended as expansion areas in the Five Year Forward View for Mental Health. The relative size of the expansion areas in comparison to all staff employed in Mental Health and Community Trusts can be seen below. Mental Health Trusts themselves account for 14% of the NHS-employed workforce and employ approximately 150,00 FTE staff. Figure xx: Relative size of core and expansion workforces Skills for Care estimate that there are 47,000 nurses working in the adult social care sector in 2015, a 4% decrease from Of these, they estimate that 8% were registered with the Nursing and Midwifery Council as a mental health nurse. In addition, there are approximately 1300FTE qualified social workers employed by Mental Health Trusts (just over half of all social workers employed by the NHS). 4 Skills for Care The state of the adult social care sector and workforce in England ( 12

13 The future workforce There are a number of sources of evidence and data sources (see Figure xx below). Populations sources include official forecasts on how the population is expected to change; for example, the number of people over the age of 65 is anticipate to rise significantly in the next few years and also include information on the prevalence or incidence rates of a particular type of mental health diagnosis; for example how many women have required treatment for perinatal mental health issues, including post-partum psychosis? The population quadrant (see Figure xx below) tells us how many people are likely to require care and the next two quadrants tell us how many health care professionals may be required to deliver that care. These guidelines may come from professional bodies such as NICE or the Medical Royal Colleges or be rooted in a politically-set target such as the Access and Waiting Time/Evidence-based Treatment Pathways. Finally, HEE asks services themselves to articulate how many staff they both (currently) have and need (now and in the future) to deliver care. ONS population forecasts Activity (MHDS and POPPI/HES) Prevalence (PHE fingertips tool) RCPCH RCPsych NICE Best practice Population Clinical Provider demand Policy targets HEE annual collection NHS Benchmarking audit Productivity assumptions 5YFV MH Future in Mind Commissioning guidelines Figure xx: Four quadrant model of demand articulation For the purpose of the mental health strategy, an internal model (Figure xx above) was developed to bring together the need and demand aspects of each expansion area to enable them to be mapped against each other, compared and one aspect to be agreed as the true (although not necessarily right ) measure of demand for that area. This approach was necessary as HEE cannot, itself, determine appropriate demand lines for any individual service or for the sector as a whole, as the organisation does not provide clinical interpretation of epidemiology or clinical treatment guidelines published by other bodies, the political levers to create policy targets different from those already published by government or the technical or moral authority to contradict the annual collection of provider-expressed demand. Therefore, the reliance on other primary sources must be acknowledged and assessed. Each expansion area had charts populated with all of the possible demand lines that had been harvested from external sources. Then, a series of confirm and challenge meetings were held with internal and external stakeholder to adopt a single definition/source of demand, i.e. to declare one true. In nearly every case, the political target was adopted as the primary target. HEE acknowledges the increasing bias towards alignment with political objectives, however 13

14 through this open process, hopes to mitigate against unconscious bias by making the adoptive process and co-produced outcomes explicit. Workforce supply Due to the strategic nature of the project, a three dimensional model was chosen to display the current supply of the workforce. The segmentation by staff group, clinical care/expansion area and estimated skill/seniority level as a proxy for competency are all required to view the workforce holistically. A key issue facing mental health is that each of the expansion areas in the Five Years Forward View for Mental Health was developed by NHS England and the NCCMH and proposed expansions and team models are based on available best practice. This strategy begins the process of mapping these expansion goals to available workforce supply, however further work will need to be undertaken in some professions where (due to length of training) the forecast future supply is largely fixed for the next five years (for example psychiatry). Figure xx: Model of current workforce (FTE), by staff group, expansional area and levels 14

15 Figure xx: Model of current workforce (FTE), by staff group, expansional area and levels While the future workforce forms a key part of the strategy, it is vital to note that the bulk of patient care up to 2020 to be delivered by the already existing services and workforce HEE anticipates that more than 80% of staff currently providing mental health services will still be providing those services in Psychiatry Psychiatrists (medically qualified doctors) look after patients with mental health problems such as depression, bipolar affective disorder, anxiety disorders, learning disabilities, eating disorders, schizophrenia, dementia, and drug and alcohol abuse. After completing foundation, doctors will study core psychiatry for three years (CT1 - CT3), before choosing one of the following six specialties within psychiatry: general psychiatry - this is the largest group of psychiatrists and they look after psychiatric patients aged in inpatient and outpatient settings child and adolescent psychiatry - these doctors specialise in managing psychiatric patients under the age of 18 old age psychiatry - these are psychiatrists who deal with adults over the age of 65. Psychiatric problems are more common in this age group, especially depression and dementia psychiatry of intellectual disability - psychiatric illness is common in people that have a learning disability 15

16 forensic psychiatry - these doctors provide psychiatric care to prison inmates and those in secure hospitals. They often act as expert witnesses in trials medical psychotherapy - this group of psychiatrists specialise in the diagnosis and treatment of psychiatric disorders through psychotherapy Psychiatry has historically suffered from poor fill rates at core level, which has subsequently led to a lack of available applicants to attract into higher specialty training. However, significant programmes of work by HEE and the Royal College of Psychiatrists has led to steady increases in the numbers of doctors choosing psychiatry training schemes. Figure xx: Forecast Psychiatry (all branches) CCT outturn from education The chart shows forecast growth for the aggregate of all psychiatry specialties based on: - numbers in training currently (April 2016 Stocktake) - estimated attrition from training and transition to employment (both based on observed data over three years) - and observed age-gender related retirement rates. The forecasts indicates output from training will barely sustain very modest workforce growth. In fact if past patterns of net outflow under 55 pertain, the workforce is likely to decline marginally. The current shortfall is unlikely to be is highly addressed over the next five years and even with the modest decline in provider expressed demand from the 2015 data collection. HEE is forecasting under supply through and beyond the period. This will be felt in most areas and will be most acute in the north of England. One of the distinguishing features of the psychiatry workforce is the reliance on EU and wider overseas staff. The proportion of Consultants aged under 55 with non-uk Primary Medical Qualifications grew from 42% to 45% in the period This dependency is reducing 16

17 slowly- trainees with non-uk PMQs represent 34% in 2015 compared with 47% in Amongst non-training, non-consultant grades two thirds have non-uk PMQs, and this has not changed over the last four years. Overseas doctors from outside the EU/EEA outnumber those from European countries significantly. Mental health nursing HEE has sustained its investment and increased the number of mental health nursing commissions each year since 2013/14. However, despite this consistent investment, the numbers of mental health nurses employed in the NHS has reduced in recent years. Some of this reduction is likely to be a reflection of the increasing variety of settings in which mental health care is delivered, and HEE is working with NHS Digital to develop ways to identify the valuable service that non-nhs staff provide to patients across England. Figure xx: Forecast MH nursing (FTE) outturn from education The available supply of mental health nursing is expected to grow significantly over the next five years. However, outturn from education has not historically translated into rising employment rates; the chart above shows a decline in mental health nurses in the NHS over the last several years, despite the availability of qualified mental health nurses. This may indicate that further work needs to be done to support staff, especially early in their careers to encourage NHS employment and prevent burnout. HEE is currently working with the Nursing and Midwifery Council to encourage nurses to return to practice. So far, this scheme has produced 111 registrants who have returned to full registration with the NMC. 17

18 Clinical Psychology Figure xx: Forecast Clinical Psychologists (FTE) outturn from education Clinical psychology is expected to see modest growth in available workforce supply, however this is unlikely to meet current demand from services before 2020 (and may not factor in the expansion areas of the Five Year Forward View for Mental Health). HEE continues to support the psychological workforce through the training of CBT and In addition to the three professional groups above, HEE has previously commissioned (and in some cases, continues to commission) training programmes for Child Psychotherapists, Hit Intensity Therapists and Psychological Wellbeing Practitioners in IAPT services, as well as other modality IAPT therapists for children and adults. Mental health teams also include a range of other professionals such as learning disability nurses, occupational therapists and other allied health professionals who are supported through HEE training programmes. HEE have developed training programmes that will enable health and care employers to ensure that all staff have an awareness of mental health problems and how they may affect their patients. These programmes include an awareness of the links between patients mental and physical health and the impact of co-morbidity and the importance of work to health and health outcomes as well as the actions they can take to ensure that patients receive appropriate support. The workforce gap The difference between the identified supply and the adopted demand varies significantly between areas facing extremely significant shortfall (perinatal and liaison services in particular) 18

19 and those with only minimal, or no, gaps (such as CHRTTs). In the charts below, the expansion areas are shown separately from the total provider-expressed demand in eworkforce. The charts below show the extent of the recommended expansion in specific staff groups, especially psychiatry and mental health nursing (see Figure xx below). The proposed expansions are also disproportionately spread across areas, with CAMHS, EIP and Adult IAPT facing particularly rapid expansion (see Figure xx overleaf). Figure xx: Current workforce (FTE) and workforce required by 2020 (FTE) These areas of expansion are particularly challenging as the strategy s timeframe is only five years; this means that there is limited opportunity to expand these professional groups through training new staff. The supply forecasts previously described show that psychiatry and clinical psychology are unlikely to meet existing service gaps by 2020, and will certainly not be able to meet agreed expansion targets. MH nursing supply may meet nursing demand; however historic trend data shows that nurses are leaving the system at an accelerated rate (not through retirement), leading to a downward trend in staff in post. Based on the current and future staff projected in the graph above, HEE estimates that the total staff spend in MH services will rise from 8.3bn to 9.8bn by Staff Group Change Medical 1,000,000,000 1,200,000,000 20% Nursing and Midwifery 2,400,000,000 2,900,000,000 21% AHP/ST&T 2,500,000,000 2,900,000,000 16% Support to clinical staff 1,400,000,000 1,600,000,000 14% Infrastructure support 1,000,000,000 1,100,000,000 10% Total 8,400,000,000 9,800,000,000 17% Table xx: Estimated total paybill cost 2016 to

20 However, all of these gaps assume that the NHS continues to provide mental health care in the same way, by the same professional as now. While there have been some attempts to shift from planning for professional roles to planning for skills hours or similar metrics (CfWI 2015), many of the targets are still expressed in traditional professions-based roles. HEE is working with system partners to develop core competency frameworks across mental health. It should be noted that the future supply of the regulated workforce roles above, will turn out from education as newly qualified staff and will require significant support initially. Any additional new supply will be an unregulated workforce, which will support the existing workforce. The professional development of both qualified and unqualified staff remains an employer responsibility. More granular data is required to fully the understand all the flows within the mental health workforce, for example from junior to senior roles, between clinical areas or teams, or from acute to community roles. There is anecdotal evidence to suggest that some of these flows are viewed as inevitable (for example the high proportion of band 5 nurses in acute settings and higher banded nurses in community settings), however this may give teams space to explore new ways of working to recruit, train and retain staff. The NHS England new models of care programme 5 will lead to the development of new ways of working which best enable service providers to deliver care or to make improvements in prevention of illness. These vanguards, as well as the countless examples of local innovation across the NHS, may well have a profound impact on the type of workforce required to deliver high quality care to patients; this may result in a different skill mix or structure needed for service delivery

21 Cross-system strategic solutions- Five Pillars This strategy will describe five overarching pillars that when implemented together can provide a blueprint towards meeting the workforce gap. The five pillars are themselves rested on the need to evolve a different approach to workforce planning, moving from planning to traditional roles towards planning against competences needed to deliver care. This does not preclude the need to ensure certain roles are filled but will enable the available workforce to be utilised more effectively. A key component for success will be the ability for stakeholders to know when to align with a common approach to enable transformation to occur at scale and when possible at pace; and when to develop workforce solutions to solve idiosyncratic problems. Sustainability and Transformation Planning Competency based workforce planning These five pillars describe the means as to which the workforce gap can be closed and the 5YFV-MH ambitions can be realised. Each pillar represents a range of interventions that will need to be led by different agencies but with shared responsibility or the need for high levels of collaboration. These interventions will not be alone sufficient to address the workforce capacity gap. Commissioners and employers will be advised to take a flexible approach to workforce planning and service development. This will require balancing the need for specific roles to be filled by relevant professional groups as well as recruiting to the competences required to deliver care. We need to change the shape of the workforce to become more flexible, more affordable and also to be better equipped with skills and competencies to deliver NICE concordant care. In addition, the development s in place based planning through the Sustainability and Transformation Planning process will help realise positive implication for the workforce. A focus on for instance, prevention and early intervention, on the use of third sector, education and primary care may lead to a distribution of demand around the system. This approach to planning will also enable a way of utilising the workforce in smarter working, such as through co-located services. 21

22 Figure xx: Current and future supply with changes (FTE) Importance of managing workforce stability A significant level of expansion can be achieved through the investment being made available to mental health for the pathways yet these pathways are but a portion of all mental health services. The creation of new jobs will lead to an increased mobility of the workforce as existing staff move to new opportunities. This may entail staff moving horizontally at their existing band or grade, or moving vertically as new, more senior opportunities arise. This will to a degree be offset by utilising new roles, yet the impact these can make by 2020 will be limited. Therefore, there will be the need to minimise unintended negative consequences. These may include depleting community mental health services and inpatient services of experienced staff without a plan to ensure that quality is not reduced as they leave. A new approach to workforce planning The workforce of the future requires flexibility and a competency based approach. This may mean a different skill mix for teams or the freedom to allow local innovation to develop new services for patients. This strategy addresses workforce issues from support worker to director level. 22

23 Specialist Advanced Practitioner Practitioner Associate Practitioner Pillar One- Increasing Productivity The drive towards gaining efficiencies through increasing productivity in the delivery of care can provide direct impact on the level of workforce required. Productivity targets have not yet been set for Mental Health and Community Trusts, however it is expected that similar targets as the acute sector will be set after Lord Carter finishes his review in In the meantime, it is expected that Mental Health and Community Trusts, as part of their STPs may be subject to whole health economy productivity increases and efficiency gains. This may lead to a reduction in the workforce required to deliver care at the same level of quality. Increasing productivity is high priority for service providers and this strategy will not set out further guidance on this. Services providers will need to engage in ambitious productivity programmes in order to meet this and will need to be supported by commissioners and regulators. Key outcomes of productivity improvements need to lead to support the effective utilisation of staff, including enabling staff to operate at the top of their competences and utilisation of support/ assistant workforce; greater clinical capacity and better utilisation of community resources. This may be addressed through investment in technology such as early awareness and sign-posting, as well as self-care and digitally delivered therapies, as well as through systems of management and supervision and relationships with third sector organisations. Productivity and efficiency gains may not be possible in all pathways of care yet gains made elsewhere can enable staff to be freed up to be available where services are expanding. In addition, place based planning may lead to further rationalisation of care between organisations, opening up opportunities for staff to move to areas of expansion between organisations. It will be important to enable efficient use of professional groups which will experience a sustained shortage in the short to medium term. This includes the effective utilisation of psychiatry, both at junior or non-training grade and at consultant level. HEE, through this strategy will seek commitment from system partners to engage in a range of activities to improve productivity and to establish its effect of workforce needs. Cross- system solutions 23

24 Health Education England Placement/training quality Supporting wider system to access education and training including through: competence frameworks and e-learning NHS England Commissioning- moving away from block contracts Specialised commissioning New models of care, Vanguards, PMCF, BCF Outcomes based commissioning NHS Improvement Financial/workforce monitoring Implementing Carter Intensive Support teams Regional support structures NHS Employers 2% Implement outcome of Carter review Productivity and efficiency Embracing new care models Innovative ways of working Utilisation of digital technologies, eg comms, e-rostering and digitally delivered therapies/interaction Management and clinical supervision, adequate support services (top and tail quals) Supporting individuals to work at the top of their competence Private, voluntary and independent sector employers Royal Colleges and professional bodies Regulators GMC and NMC Other government agencies As above New care models support, innovation, etc Supporting new models and new roles Supporting staff to develop relevant competence in mental health, including in education, criminal justice, employment services Pillar Two- Increasing Attractiveness and Reducing Attrition In addition to increasing productivity, there will need to be a concerted effort to increase attractiveness to careers in mental health and to reduce attrition from training as well as from the existing workforce. Any actions taken to address the workforce gap by 2020 will need to occur in parallel with actions to support the longer term workforce supply. Increasing 24

25 attractiveness to careers needs to include attracting potential staff at all levels, however in particular at the entry level. As the bulk of care in the next five years will provided by the existing workforce or those currently in training there is a fundamental need to ensure these staff are retained and find employment. Increasing Attractiveness This includes growing new entrants to the workforce as well as supporting the existing workforce in their career aspirations. A central tenant of attractiveness is to ensure that there is a coherent and well-articulated vision as to the careers available in mental health. This vision needs to include the roles available across metal health services, whether in NHS settings or as mental health workers in the third sector, in education or in other settings. The vision needs to articulate opportunities for advancing in careers if so desired as well as the qualification required for such roles. This would enable individuals to plan their careers as well as employers to support professional development. HEE, through this strategy, will seek commitment from system partners to engage in a coordinated range of activities to improve attractiveness to mental health careers. Cross- system solutions Health Education England Articulating a coherent unified narrative around careers in mental health including in third sector and social care Career campaigns (Health Careers) Support with addressing regional recruitment to training issues Supporting professional groups to attract future workforce Talent for Care programme to develop support workforce RePaIR- programme to reduce attrition from training Local Workforce Action Board interventions Engagement with providers outside of NHS Trusts NHS England NHS Improvement Communication of mental health systemwide transformation and its impact on improving outcomes for patients Working with/supporting employers to - Reduce agency use - Reduce turnover - Develop of clinical leadership CCGs Investment, job creation Adequate funding for teams Flexible approach to commissioning, workforce planning, team 25

26 delivery NHS Employers Good HR policy Bullying/harassment statistics Staff retention programmes Training/development opportunities supported Backfill and release of staff to training First year attrition addressed- mentorship, preceptorship, buddying schemes etc Skill mix MDTs, working across organisation boundaries, settings Engage in widening participation programmes Private, voluntary and independent sector employers Royal Colleges and professional bodies Support for staff development Attractiveness of professions CPD opportunities Networking and knowledge share/transfer Regulators GMC and NMC Recognition of skills, credentialling Public perception Higher Education Institutions Ensure effective communications potential students Ensure support for widening participation Schools, colleges and further education institutions Support campaigns to increase interest in mental health careers Develop courses to support mental health workforce Reducing Attrition Attrition of staff can occur at a number of points in an individual s career. This may be during training, between qualification from training and gaining employment and out of employment. Interventions need to be put in place to address attrition at each of these points. Many reasons for attrition are unavoidable, such as leaving due to ill health and retirement; however some of them can be avoided. Avoidable reason from training include poor experiences during clinical placements or poor learning experiences in college. Reasons for failure to transition from training to employment may be due to employer recruitment practices or due to newly qualified staff being unprepared for employment. Reasons for attrition from service are many but they may be due to everything from stressful work practices leading to burnout, to lack of flexible work practices. Actions need to be taken to minimise attrition from these three sources. This will be of even greater importance due to the effect that rapid expansion may have on the workforce. The increased movement of staff may lead to increased pressure at both senior and junior levels, due to both meeting higher 26

27 demand or having to learn to operate in a new environment or new model of service delivery and work at the top of their level of competence. The need to address attrition can include ensuring that training is fit for purpose and delivering the quality required, ensuring that employment practices and workforce planning supports service delivery and ensuring that there are good staff welfare and HR policies in place. All of this will require system leaders in education and in service provision and service managers ensure a continued focus on looking after their staff or the training of such individuals. HEE, through this strategy will seek commitment from system partners to engage in a coordinated range of activities to reduce attrition. Cross- system solutions Health Education England Quality Framework for training placements Competence Frameworks Workforce planning tools: Generic role templates, team templates Leadership Academy RePAIR Programme Local initiatives e.g. Capital Nursing Programme in London NHS England CQUIN for staff welfare Implementation of Occupational health standards NHS Improvement Employers Organisational Development and leadership development. Reduction in use of locum staff and short term contracts Value of Portfolio: Working in inpatient and community and exchange programmes [cross-skilling] Propose to employers to develop a project to pilot a flexible workforce between acute and community settings to potentially address retention? Research feasibility of newly qualified nurses [AfC Bands 5+6] practicing straight into the community to as there will be less acute beds as healthcare becomes based on prevention. Develop a placement infrastructure to provide early experience in community care settings for AHP s and Nurses [preregistration] Develop mentorship training into community care. Higher Education Institutions Ensure highest standards of training to ensure transition to employment 27

28 Ensure effective mechanisms to manage student welfare Pillar Three - New Staff New staff expected to complete training over the course of the next five years will make an extremely important contribution to developing the workforce needed. These need most importantly to be available to take up employment in addition to new starters into support and assistant practitioner roles. Due to the length of time it takes to train newly qualified staff, there is a fixed supply of newly qualified regulated workforce that will be available to employers in the next few years. The existing HEE training pipeline will continue to produce new staff who will be available to the system, however actions need to continue be taken to ensure that jobs are available and people are attracted to roles. HEE, through this strategy will seek commitment from system partners to engage in a range of activities to ensure that newly qualified practitioners find employment and that the support and assistant workforce is grown accordingly to meet expanded demand. Cross- system solutions Health Education England Quality framework to ensure quality of training and training environment Continue to output professionally qualified staff as detailed in chart below Working with HEIs Good supervision Reducing avoidable attrition Coordination to ensure effective use of apprenticeships Talent for Care to grow un regulated workforce and widening participation Engaging with Private, voluntary and independent sector employers NHS England NHS Improvement HEFCE HEIs NHS Employers Private, voluntary and independent sector employers Monitor increased investment by CCGs Conversion of bank/agency into substantive Teaching Experience Framework Ensure continued inflow of new trainees- esp nurses, AHPs Values based recruitment Creating posts and making them attractive Developing own workforce through new roles Good HR policy Supporting junior staff- refer to above Attracting qualified regulated professionals Utilising apprenticeship route Supporting training through clinical placements CCGs Invest to create posts Ensuring funds are available for new roles, inc utilising 28

29 apprenticeship route Prof. Regulators Prompt entry to registers Light touch regulation Figure xx: New staff (FTE) Pillar Four- New Roles Despite the potential impact of increasing productivity, reducing attrition and employing new staff, it is unlikely that this will enable service providers to close the sizable workforce gap. New roles will be required which will support an expansion of the available workforce in real terms. The new roles proposed here include ones that have been developed recently as well as roles that have been available for some time but have been historically underutilised in mental health, namely nursing associates and physicians associates respectively. Supply for these two roles is expected to increase over the next five years with regulation and funding for training expected to be agreed in the near future. In addition to these, there is also a need to develop new support roles. HEE recommends that a coordinated national approach is taken to this to support sustainability, transferability and career progression. This should include the employment of users by experience and peer support workers. An example of this will be in the use of support time workers in liaison and diversion services. HEE, through this strategy, will seek commitment from system partners to identify how to integrate new roles into care and ensure consistent approaches to this drive training demand to support sustainability. Cross- system solutions 29

30 Health Education England Career pathways Widening access Workforce planning tools Core skills framework Cross system coordination NHS England CCGs NHS Employers Commissioning guidance Flexible funding to allow for skill mix innovation Widening access Ensuring funds are available for new roles, including utilising apprenticeship route Accommodate new roles, appropriate supervision and support Invest in CPD to create new opportunities Developing the Assistant practitioner and support roles in line with coordinated approach Widening participation Collaborate with other providers to ensure sufficient demand in place for sustainable training pipeline and training fit for purpose Innovation in roles and service delivery Encourage use of competence frameworks to map against CPD and team development Private, voluntary and independent sector employers Developing new roles in line with coordinated approach and collaborating with training institutions Encourage use of competence frameworks to map against CPD and team development Royal Colleges and professional bodies Support introduction of new roles and socialise with existing members Accreditation of new role training Regulators Higher Education Institutions Schools, colleges and further education institutions Providing regulation/course accreditation Deliver the training for new roles and collaborate with service providers Support the development of support worker and assistant practitioner roles through delivery of training and education Collaborating with service providers to ensure workforce fit for purpose 30

31 Figure xx: New roles (FTE) Pillar Five- New Skills The final theme of this strategy is the development of new skills into the workforce that will support individuals moving into new roles or the accommodation of existing roles such as qualified social workers or psychological therapists within multidisciplinary teams. New skills may include the upskilling of staff to deliver psychological therapies, leading to extending capacity to deliver NICE concordant care. It may also include the development of staff with other clinical skills such as non-medical prescribing and in leadership that will expand capacity for clinical leadership and management. New skills also include supporting team development or individual professional development that does not necessarily require post-graduate qualifications. This will entail utilising existing training resources, such as e-learning, and where available, innovations such as simulation training. In order to support the development of new skills, training will need to be available and funding identified, employees will need to be available to training and then use the skills on qualification. HEE, through this strategy will seek commitment from system partners to engage in a coordinated range of activities increase relevant skills into the workforce. Cross- system solutions HEE elearning developed for specialist ahnd universal skills and made widely available Supporting providers to discharge their own responsibility to staff Workforce planning tools e-learning Support access to education and training, including simulation training and short courses (not necessarily HEE funded) NHS Leadership Academy programme to support leadership 31

32 development across health system Support the development of the clinical academic workforce NHS England Support the development of clinical leadership Commissioning for outcomes across pathways and supporting new models of care NHS Improvement Ensuring quality of care Development of effective clinical leadership NHS Employers Providers to support staff to develop their career. Utilise career framework, competence frameworks and workforce development tools to guide staff development Ensuring that Trusts demonstrate clinical leadership and encourage Continuing Professional Development [CPD] of post registration staff during their preceptorship year to provide a better working environment. In addition to signposting various specialties and offering peer support and networking opportunities. Private, voluntary and independent sector employers Making space in teams CPD/training Recruit for skills rather than professions Making roles attractive Utilise career framework, competence frameworks and workforce development tools to guide staff development as well as the commissioning of education and training Higher Education Institutions Utilise competence frameworks to map against course curricula Deliver the training for new skills in collaboration with service providers Work with service providers to develop clinical academic skills Schools, colleges and further education institutions Utilise competence frameworks to map against course curricula Deliver the training for new skills in collaboration with service providers Other government agencies Utilise competence frameworks to guide staff development 32

33 and commissioning of education and training Prof. Regulators Accreditation/ credentialing of new skills Figure xx: New skills (FTE) Measurement and evaluation and data strategy Metrics will be established between Health Education England, NHS England and NHS Improvement to enable the progress and milestones within the five pillars to be measured to develop capacity in the workforce. Measurement will support future decision making and allocations of resource. In order to support this HEE will work with NHS Digital on a strategy to improve the data held on the workforce through the existing mechanism of the Minimum Workforce Data Set and the electronic staff record. This will include working with providers in the NHS, third sector and independent sector to enhance the level of information held on the work force and to preclude the need for additional workforce collections. HEE Support Offer HEE recognises that it has a central role to play in the delivery of this strategy. In addition to working with system partners to ensure a coordinated delivery of the strategy, HEE will be delivering its responsibilities as detailed within. There are within this a range of responsibilities that address the while workforce or are pertinent across all pathways. The support offered by HEE will both enable NHS providers to develop the capacity and capability required as well as 33

34 to support in collaboration the private, voluntary and independent sector and sectors managed by other government agencies. HEE organisational structure In order to hardwire the workforce in mental health as described in the FYFV-MH at the pace and scale required to meet ambitions, HEE is developing its governance and organisational infrastructure across the local, regional and nation levels HEE will work with, NHSE, NHSI, NHS and LA providers, NHSE clinical networks, commissioners, AHSNs and training providers collaborate to address the needs of the mental health workforce at a local and regional level. This will include support for workforce planning, workforce data collection, workforce upskilling and reskilling, as well as managing local supply issues. It will facilitate a forum for addressing local challenges to recruitment and retention. Regional forums will be created to support investment decisions for HEE transformation monies or other national level funding in to training; new role development or routes into clinical practice, such as physicians associates and apprenticeships. Local, regional and national leadership on mental health workforce will support the Local Action Workforce Boards to deliver the workforce needed with the sustainability and transformation planning footprints. Patient and Public Engagement HEE will work with patient and public advisors in the development of resources, including any frameworks and learning materials to ensure that their views and needs are appropriately and adequately represented in the materials produced. This does not however preclude the need for patient and public involvement at the local level of implementation. The participation of patients and public in the development of the workforce needs to include the views or young people and their families as well as views of the older person as well as, representatives of groups in a minority such as with regards to ethnicity, religion, disability and sexuality. Leadership Academy The work of NHS Leadership Academy as a whole system resource will support the transformation in leadership capacity and capability required to meet the objectives of the NHS. The Academy will work with national and local stakeholders and partners to provide support through a wide range of applied offers, programmes, development and leadership thinking and advice. The Academy s key role is to provide development that liberates leadership talent across the NHS, develops highly innovative and effective leaders and increases the capacity and capability of leaders to create high quality, continuously improving, compassionate care. Technology Enhanced Learning HEE has a very active programme developing the use of technology enhanced learning. Technology such e-learning will be used to support the dissemination of knowledge and skills across universal and specialist competences. Technology will also be developed through the course of this strategy and beyond to further support the learner. It will also be utilised to support career development and workforce planning. E-learning when developed should also include educational needs of patients, families and carers. It should also be supported with guidance on how to use the resource within blended learning. These resources will be free at the point of access to support both health and care sectors. The use of technology and digital care innovations will also require a focus on the digital educational needs of the workforce. The use of technology and also the development of 34

35 technology to solve workforce issues will be a focus within this programme. This will include the implication of human factors in the design and use of this technology. This will also include online tools to support other workforce issues such as recruitment, an example is the skills passport. This is an online tool which can be used to assist in the process of recruiting new staff. Individuals create a Skills Passport profile which houses CVs, qualifications and references all in one place which prospective employers can then review. In order to verify and track employee skills, competencies and training compliance, the passports need to be linked to an online Skills Register tool. Sustainability and Transformation Plans Sustainability and Transformation Plans [STPs] provide the local vehicle for strategic planning, implementation at scale and collaboration between partners. Implementing the commitments of this plan will improve access and outcomes, deliver seven-day services, reduce inequality and realise efficiencies across the local health and care economy and wider society. Mental health should be an intrinsic element of every STP threaded throughout and not an afterthought. Joint working with Local Government, housing, employment and voluntary sector will be a particular focus of the STP s Local Workforce Action Boards (LWABs) As of August 2016 Health Education England established across the country Local Workforce Action Boards in order to develop and implement workforce plans as part of the Sustainable Transformation Planning. The entities are co-chaired by a senior HEE staff member and a chief executive within the STP footprint. The LWABs will have a line of accountability to the national Workforce Advisory Board (WAB) which is the cross-nhs board accountable for workforce aspects in view of the Five Year Forward View. Membership will be drawn from health and social care organisations within the STP and the LWABs will act as delivery groups alongside other relevant enabling functions within the STP governance arrangements. They are tasked with produce a Five-Year Workforce Strategy for the local health and social care workforce delivering care to the population of the STP. This national mental health strategy will support the development of these LWAB workforce strategies. Through this process the LWABs will create a workforce development plan based on robust commissioner intentions and provider plans. Use the workforce strategy and development plans as the basis for decisions about investment in education and training locally and to advise the investment decisions of the transformation funds, vanguard funds and HEE funds. They will at the local level, ensure appropriate governance and infrastructure arrangements are in place to hold the system to account for workforce development. Work in partnership with universities, other education providers and research and innovation organisations to develop responsive provision & disseminate best practice. Work with local authorities and health and well-being boards in taking a joined-up approach across the local health, public health and care workforce, considering the wider non-traditional workforce of volunteers, carers and self-care. Workforce transformation through the LWABs will be deliver in line with the components of the following model. This model aligns with the objectives of this strategy. 35

36 Workforce and Career Planning In order to support the improving the attractiveness of careers in mental health, to facilitate career development and a competence based approach to workforce planning and recruitment, a number of tools and resources will be created. These tools will support individuals looking to work or progress in mental health careers as well as employers and commissioners when planning their workforce. Career and Education Framework Central to attractiveness and also supporting future workforce supply, including new roles is the well-articulated vision. HEE will commission the development, collaboration with system partners, career frameworks which will describe career pathways across professional groups and speciality areas. A well-articulated career needs to be well communicated through a number of channels. HEE will achieve this by working with Health Careers, running focussed campaigns and through the use of the internet, including social media. HEE will also work with system partners with this such as the royal colleges and professional bodies and third sector organisation, as well to communicate the vision across all professional groups. Competency frameworks for specialist pathways and universal skills In addition to the development of a career and education framework, HEE will work with experts and system partners to either collate or develop when needed competence frameworks that encompass the skills needed to deliver care in mental health, in line with NICE concordant levels of care and commissioning guidance. These frameworks will link to the career and education framework. HEE will seek to host these or provide access to them from a central location on the internet. 36

37 These frameworks will enable individuals to establish their own continuing professional development needs, as well as employer to do the same at a team level. They can enable decisions to be made with regards to team planning and recruitment to posts, including on decision about upskilling and reskilling. Frameworks will cover the full range of care pathways where possible, an example of this the perinatal mental health competence framework. They will also cover a range of generic competences that are relevant across pathways. The frameworks developed will extend beyond the Mental Health Core Skills and Knowledge Competence Framework (HEE, Skills for Health and Skills for Care). This framework sets out the core skills required from people who come in contact with individuals with mental health problems and their families across all ages. A timetable of the development of proposed frameworks is described below. The frameworks included in this strategy does not preclude the construction of additional frameworks or curricula if so required to support further skills being developed into the system. Where possible key learning resources will be identified that can be mapped to the competences described in the framework (not necessarily endorsed by HEE). All frameworks where possible will be hosted on the internet at the HEE website and a timetable of review will be published. There will be additional frameworks that will be developed that comprise skills and knowledge needed across all of health care. An example of the is the developments in Human Factors and team work and decision making in clinical setting as driven by the Human Factors Concordat and HEE s role in this. Another example will be in the development of competences in person centred care, end of life care and dementia care. Role and Team Templates In order to support the planning of a workforce both based on the competences required as well as with the compliment of staff from the right professional groups, HEE will develop a suite of tools and guidance to support this. Tools will enable providers and commissioners to workforce plan to meet the outcomes and performance targets expected within a pathway. The tools will support the development of an affordable workforce. They will also support the process of moving staff between areas of working and when used with the competence and career framework, identify any need to upskill or reskill. HEE will work with service providers and system stakeholders in their production. Role Template - Advanced Clinical Practitioner - Service Manager - Practitioner - Associate Practitioner - Assistant Practitioner Team Template - Based on competence by population need - Recommended Team - Develop Workforce Planning Guidance 37

38 2016/ / /19 Career and Education Frameworks Regulated NHS Support/ Assistant roles in NHS and third sector roles Role and Team Templates Pathway Specific Role and Team Templates Universal Frameworks Core Skills and Knowledge Psychological Skills and Knowledge for SMI Care Coordination Suicide and selfharm prevention Core physical health management in MH Equality and Diversity: cultural sensitivity in practice Mental Health Law/ Mental Capacity Act Medication Management and prescribing in MH Pathway Specific Frameworks IAPT (UCL) Child and Adolescent Mental Health: inc. CYP IAPT & eating disorder (UCL) Perinatal Mental Health Early Intervention in Psychosis Liaison Mental Health (City) Community Crisis Care (City) Liaison & Diversion (OHC) 38

39 New Staff Over the course of the next five years in the region of 24,000 FTE professionally qualified workers will be available to work in mental health; including from psychiatrists to psychological therapist, mental health nurses and allied health professionals. In addition, individuals will be starting new training courses, training to be the future workforce. HEE will ensure that there is a system of support in place to support the development of this workforce whilst in training and the recruitment of the workforce into training, as well as encouraging new entrants to the workforce. Equally importantly, unregistered new staff will also be joining mental health teams, including support staff in clinical roles and administrative and infrastructure staff. Health Careers Health Careers is part of HEE and its role is to provide support for individuals looking to find a career in healthcare, as well as to commission campaigns to encourage recruitment and to provide guidance and advice to schools and colleges to support career planning. Health Careers will continue to develop the resources available for careers in mental health, as well as manage campaigns to support recruitment into expanding roles. Health Careers will support work that HEE is developing with schools and further education colleges, as well as with higher education institutions to encourage interest and enthusiasm to take up roles in mental health. Quality Assurance of Training HEE has an evolving role in how it delivers its responsibilities for the supply of the healthcare workforce. Following the governments reforms to education funding announced in 2016, HEE will no longer directly commission the training for nursing and allied health professionals, with these course being funded through the student loan system. HEE retains its role in medical training and a role in commissioning a range of other courses. It also retains a role in managing clinical placements within the nursing and allied health professional training courses, as well as those it retains commissioning responsibility for. In terms of the prior courses, HEE will have at its disposal the placement tariff funding that will be used to support providers in deliver high quality clinical placements within the courses now supported through student loans. This will in part help ensure that students are learning across the range of clinical settings to deliver a workforce with the required experience. Across all training where HEE manages clinical placements, it is evolving its approach to quality assurance. As of 2017 HEE will be implementing its Quality Framework. This will set expectations for service providers and training bodies in the delivery of the highest quality training experience. Developing the future workforce at support and assistant levels The Talent for Care programme partnership and the national Talent for Care strategic framework is published by Health Education England (HEE) on behalf of the Talent for Care programme partnership, which includes: Health Education England, National Skills Academy for Health, NHS Employers, Skills for Health, Social Partnership Forums and/ Trade unions. The programme aims to broaden the ways into training and employment in the NHS, especially to attract more young people and improve diversity within the workforce Challenge and support every NHS employer and contractor to implement a development programme for all support staff that is over and above annual appraisals and mandatory training. All new Healthcare Support Workers and Adult Social Care Workers to achieve the new Care Certificate. The Care Certificate is a set of standards that non-regulated health and social care workers stick to in their daily working life. It is the minimum standards that should be covered as part of induction 39

40 training of new care workers and also offers opportunities for existing staff to refresh or improve their knowledge. It includes mental health awareness Widening Participation HEE engages in a range of activities that seek to widen participation into roles in healthcare, seeking to ensure a workforce that is representative of the populations it serves. This is as important for mental health as it is for other areas of healthcare and HEE will focus activities into widening participation into a range of roles. This will involve developing a plan with relevant service providers and training providers where greater diversity in the workforce is required. HEE will also promote the Health Ambassadors scheme. This where a service provider agrees to pledge the time of five staff members from a variety of roles to attend careers events and to engage in other activities seeking to promote careers in health to schools, colleges and local communities. Reducing Pre-registration Attrition and Improving Retention (RePAIR) In March, 2015 HEE was mandated by the Department of Health to develop a programme of work to address attrition from pre-registration training and the RePAIR programme was developed. This aims to understand the factors that lead to attrition from training and to identify best practice and to promote this across England, leading to a nationally agreed approach. Training to develop mental health professionals are included within this programme. Working with Royal Colleges and Professional Bodies HEE will work with, workforce regulators the professional groups whose members comprise the range of regulated or accredited mental health professionals that make up the largest proportion of the workforce. That includes bodies representing: doctors, nurses, allied health professional, therapists and pharmacists. HEE will work with the National Midwifery Council, General Medical Council and the Health and Care Professions Council to ensure that education standards and re-validation are supporting the needs of service users of the future. Return to Practice HEE has an active return to practice programme for nursing in collaboration with Nursing Midwifery Council, providers and higher education institutions. This has facilitated 111 mental health nurses back into practice since This will continue to be active in bring nurses back into practice and facilitate movement (and learning) across sectors. New Roles As previously described the mental health workforce will need to expand to ensure that sufficient capacity is available to deliver the ambitions of the 5YFV-MH. New roles that can be trained to deliver high quality levels of care and to be available to employers within short periods of time will enable such expansion. HEE have invested in three such roles which would provide significant benefits if integrated into mental health provision. These roles are not as an alternative to other regulated or accredited staff but would enable that fixed commodity to be better utilised as well as provide new routes into potential careers. Nursing Associates The nursing associate is a new role that fits in between a health assistant with a care certificate and a registered nurse. They will support registered workforce in the delivery of care and at the same time complete a foundation degree. This role can be a step towards pre-registration training and will support widening participation within the nursing profession. 40

41 Physicians Associates The physicians associate is trained to be a generalist who can operate across a range of settings. This role has been in existence for over a decade but has not yet had much presence in mental health settings. Training can be modulated to include significant levels of mental health and people with these skills can assess, diagnose, analyse results and develop management plans. They operate under the supervision of a qualified doctor Psychological Wellbeing Practitioners in Children s Mental Health In order to support the expansion of the therapy workforce delivering care for children in child and adolescent mental health services HEE, in collaboration with other system partners has developed a low intensity therapist role. Individuals will be trained to deliver a range of low intensity interventions expanding the capacity of teams to offer NICE supported interventions. These individuals will also be available in the longer term to grow the high intensity level therapist workforce. New Skills HEE will support the acquisition of new skills which will enable the upskilling and reskilling of staff. This will support the capability to deliver care and also enable vertical and horizontal movement of staff. This will be achieved through a number of sources, and will supplement how individuals and service providers conduct continued professional development. HEE will support this through providing free to use e-learning resources, guidance for blended learning, access to funded short courses and access to funded/ self-funded long courses. Training and education will be pathway specific or may be universally applicable. Pathway specific roles such as in the psychological therapies will be described within the pathway specific sections below. It will be important to support access to education and training both within the health workforce as well as in other settings such as social care and education. Competence frameworks provide guidance for employers and commissioners in any setting to develop training or commission training that will be in line with expert guidance. Technology Enhanced Learning E-learning offers the ability to disseminate knowledge and skills to large populations. However, it is important that the learning is accurate, trust worthy and up to date. Health Education England has invested in developing e-learning for health learning hub as a central source for such materials. HEE will review its existing portfolio and will develop new material for each expansion pathway; to be hosted either on the elfh or MindEd learning hubs. HEE will support the development of (learning modules for carers and families for supporting the wider workforce. Along with the e-learning modules, HEE will commission the development of blended learning or simulation guidance. This guidance can be utilised by providers to support team development. Credentialing Pilots HEE is working with the Department of Health, NHSE and the Royal College of Psychiatrists on two pilots to credential psychiatrists into liaison psychiatry and perinatal mental health. It is hoped that these pilots support the attainment of specialist skills within these areas, growing capacity in specialised consultants and where possible for other doctors, in training or not. Sources of Funding for Training and Education Sources of funding for the pre-registration training in the regulated professions into mental health have been allocated to HEE, however many of these routes are now being liberalised to provide greater access to students. Sources of funding for the reskilling and continued development of the workforce will depend upon the education and training to be completed. The following sources of funding will need to be utilised to ensure sufficient skills are established in 41

42 the workforce. Funding will be available at the national level from HEE and NHSE for defined period of time to support the development of the workforce in a number of pathways; including, IAPT and CYP IAPT therapists. Funding for training will also be available from local transformation funding at HEE and NHSE and other locally held funding, however some of these will need to cover the whole health system and thus not limited to mental health. Commissioners will need to ensure that sufficient funding is available to service providers where needed to increase capability to deliver care, such as when building new services or transformation at pace and scale to accommodate new models of care. Providers retain the responsibility for the professional development of their staff and will need utilise funding available for this to ensure that training required achieved and are encourage to discuss this with their commissioners to manage funding flows. Regulated and accredited individuals are also responsible for their own continued professional development. Many sources of education are free to access, including high quality e-learning, articles and books and the use of these should be encouraged by employers and linked to from learning and development resources. Colleges and professional bodies develop learning resources for their members and these should also be utilised to ensure skills are updated. Some short courses such as those to develop support and assistant practitioner roles as well as, long courses such as degrees, diplomas, masters degrees will be funded through additional relevant sources. Self- funded courses allow access for some to acquire new skills as well as will accessing student loans where possible. Apprenticeships will be an important source of funding for short and long courses and the apprenticeship levy (from April 2017) will enable service providers build the skills needed in their workforce and to encourage recruitment into roles. In addition to funded or free to access materials, education and training is also achieved through mentoring, placement opportunities and clinical supervision. Learning and development departments or relevant managers in organisations should develop learning plans for teams working within clinical pathways around the competence frameworks and the resources and training opportunities available. National Mental Health Training Contract HEE have a contract with the Tavistock and Portman Foundation Trust to deliver the Mental Health National Training Contract for England. Through this contract HEE provides subsides courses across a range of topics in health and social care and enables these to be delivered across the country. The contract also brings additional resources which will support activity in transforming the workforce and to deliver education and training. Other Activities HEE are currently reviewing the possibility to include mental health into the NHS mandatory training to enable the whole workforce to obtain, at the very least, a basic introduction to mental health. HEE also supports the development of clinical academic careers working with the National Institute for Health Research. 42

43 HEE will establish a project of work with stakeholders that addresses the prescribing standards for mental health in line with the recommendation made in the 5YFV-MH. This will build upon framework produced by the Royal Pharmaceutical Society (published July 2016), to be completed by April In line with the recommendation made in the 5YFV-MH, HEE is working with Public Health England and to establish access to an accredited mental health awareness training programme. Within scope of this work is a review of the Public Mental Health core curricula framework, identification of mental health public health training programmes, the development of the accredited programme, and evaluation of cascading this training and its impact. In addition to this, the development of relevant e-learning materials, including in mental health promotion and prevention, Making Every Contact Count (MECC) 6 best practice materials and the creation of a network of public health nurse suicide prevention champions. In line with the recommendation made in the 5YFV-MH, HEE is working with system partners to support the primary care workforce. It is working with system partners implementing the Primary Care 2020 strategy. It is also working the Royal College of General Practice in terms of training GP receive both during training and after qualification; including the development of GP with extended roles. In addition, it is ensuring that mental health is a component of its practice nurse development strategy. Social care and the education workforce are also considered within this strategy. It is envisaged that their knowledge and skills will be supported by the competence frameworks published as well as through access to e-learning and blended learning guidance on learning hubs such as MindEd. Staff will have access to gain qualifications in the psychological therapies across adult and child pathways dependent on meeting entry criteria and funding availability. 6 MECC encourages conversations based on behaviour change methodologies (ranging from brief advice, to more advanced behaviour change techniques), empowering healthier lifestyle choices and exploring the wider social determinants that influence all of our health. 43

44 Transformation across key pathways Mental Health Workforce Strategy Children and young people s mental health Implement local plans to transform children and young people s mental health, ensuring that 70,000 more children to receive high-quality evidence-based care each year by 2020/21. Ensure full roll out of the CYP IAPT development programme across England by 2018/19. In order to develop the work force for this pathway all of the five pillars will need to be implemented. This work will also need to be completed in collaboration between partners at a local level, implementing revised Local Transformation Plans. HEE in 2016 commissioned the most comprehensive census of the CAMHS workforce to date, which identified 9000FTE staff in NHS-provided CAMHS services and an additional 2100FTE staff (including 1000FTE in Youth Offending Teams who may not be CAMHS specialists). Further details on this workforce can be found in appendix xx. Figure xx: NHS-employed CAMHS workforce summary The Five Year Forward View for Mental Health Implementation Plan recommends that at least 3,400 existing CAMHS staff be upskilled in CYP IAPT therapies. HEE is delivering this with central funding until 2018/19 and will work with the system to ensure the sustainability of psychological therapies workforce beyond this point. 44

45 Figure xx: Forecast trajectory of available CAMHS staff HEE has identified resources to develop a new role into the delivery of therapies in children and young people s mental health. Training for this new role - Children and Young People s Psychological Wellbeing Practitioner (PWP) will commence in January 2017 via a 1 year fully salary supported training position. From 2018 (when the current central funding terminates), HEE are looking at ongoing funding arrangements. To address the current vacancies and proposed expansion of the pathway, HEE will develop and implement a range of new routes into the CYP Therapist workforce roles. HEE is continuing to support the roll-out of the CYP IAPT programme through the training of existing CAMHS workforce through the CYP IAPT curricula. In addition, HEE is expected to receive 115 million; this is expected to pay for the following training: 2016/ / / / /21 Supervisors Recruit to Train CYP PWPs Upskilling of existing staff In addition to the education commissions above, this funding will also be used for investing in the following areas: HEE have commissioned training for Community Eating Disorders Teams to support the introduction of access and waiting time standards in April HEE is working with RCPsych to encourage more applicants into child and adolescent psychiatry training. 45

46 Developing the MindEd learning hub HEE estimates that the total paybill in CAMHS services will rise by 22% ( 111m), with the largest area of growth being psychological therapy staff to deliver the Taskforce recommendation of treating 70,000 more children annually. CAMHS Staff Group Difference Medical 81,000,000 99,000,000 18,000,000 Nursing and Midwifery 114,000, ,000,000 24,000,000 AHP/ST&T 222,000, ,000,000 57,000,000 Support to clinical staff 37,000,000 44,000,000 7,000,000 Infrastructure support 48,000,000 54,000,000 5,000,000 Total 502,000, ,000, ,000,000 Table xx: Estimated paybill costs in CAMHS services 2016 and 2020 Perinatal mental health Provide timely, evidence-based specialist perinatal care for all women who need it, to support an additional 30,000 women per year to access care. Perinatal mental health services are highly specialist services covering significant geographical areas. There are fifteen specialist inpatient units across England, which are supported by community teams. To date, the workforce has been very small, drawing predominantly on psychiatrists, mental health nurses and midwives, and support staff including health care assistants and nursery nurses. In order to develop the work force for this pathway all of the five pillars will need to be implemented. Figure xx: Expansion trajectory in perinatal services 46

47 The proposed expansion of perinatal services will require a significant increase in the employed workforce that cannot be met from new staff alone. This must therefore include attracting existing professionals from other areas of mental health (e.g. psychiatrists, mental health nurses, psychologists and support staff) or new staff groups such as nurse associates. There may be other qualified professionals who would be suited to working in this care pathway, such as health visitors, specialist midwives and social workers. In addition, the proposed significant demand for psychiatrists cannot be met from existing training pipelines and commissioners and service providers will need to develop alternative options for senior clinical leadership, for example advanced clinical practitioners. To deliver the recommendation HEE are currently undertaking the following: Working in partnership with NHS England and the Royal College of Psychiatrists on a project that will train 10 specialist perinatal mental health Psychiatrists in 2016 and upskill general psychiatrists, Obstetricians and General Practitioners in PMH. The plans are in place for the training to begin for 10 x psychiatrists. Working in partnership with the Tavistock and Portman NHS trust, Royal Colleges and other key stakeholders to develop an online Tiered Competency and skills Framework for the multi professions across care pathway. An Expert Reference Group (ERG) has been established to lead on the development of the competency framework and a workshop took place in May 2016 to agree scope and draft skeleton of competencies. A writing group has begun to develop the first draft of the competency framework which will then be sent out to multi professionals as part of a consultation exercise due to complete by March This will inform local training organisations as well as training opportunities, which can be accessed through existing training relationships or develop these where they do not already exist. Working with HEE local teams to link in with NHSE clinical networks and service providers to determine training requirements locally across care pathway for PMH and agree what training should be available for local teams to access. HEE estimates that the total paybill in perinatal services will rise by 710% ( 115m), with the largest area of growth being nursing staff to deliver the Taskforce recommendation of treating 30,000 more women annually. Perinatal Mental Health Staff Group Difference Medical 5,000,000 18,000,000 13,000,000 Nursing and Midwifery 5,000,000 49,000,000 44,000,000 AHP/ST&T 3,000,000 25,000,000 22,000,000 Support to clinical staff 300,000 19,000,000 18,700,000 Infrastructure support 3,000,000 21,000,000 18,000,000 Total 16,300, ,000, ,700,000 Table xx: Estimated paybill costs in perinatal mental health services 2016 and 2020 Adult mental health: common mental health problems Provide for a further expansion of access to integrated psychological therapies for adults with anxiety and depression to reach 25% of need, with a focus on those with long-term physical health conditions and people who are out of work. 47

48 Trial new models for delivering psychological therapies and building a robust invest-to-save case for integrating psychological therapies into primary care and secondary acute specialist teams to support the wider expansion programme and to increase access for adults with psychosis, bipolar disorder and personality disorder. The IAPT workforce accounts for one of the larger expansion pathways in the Five Year Forward View for Mental Health. The most recent IAPT census 7 identified Nearly 7000 FTE staff in post providing psychological therapies. This workforce consists predominantly of high intensity CBT therapists, therapists qualified in other modalities and Psychological Wellbeing Practitioners. There are also a small number of employment advisers in IAPT teams, although many services refer their clients out to Job Centres or other external organisations. This census identified high levels of movement of staff between services. The 2016 census (due to report in early 2017) will provide more detail about the reasons for this movement and the destinations of staff. HEE has made a strong commitment to IAPT since the beginning of the programme and has now commissioned more than 7700 training opportunities. Figure xx: Expansion trajectory in Adult IAPT services HEE is working with NHSE to support the delivery of the Five Year Forward View Independent Taskforce Report objectives of providing for a further expansion of access to integrated psychological therapies for adults with anxiety and depression to reach 25% of need, with a focus on those with long-term physical health conditions and people who are out of work. There is an emphasis on developing the expanded workforce to work in new integrated long term conditions (LTCs) and medically unexplained symptoms (MUS) IAPT pathways

49 This involves collaboration on detailed workforce planning and education commissioning to support NHSE to utilise ring-fenced funding that has been made available through the CSR to expand and upskill the existing IAPT workforce to increase access, develop robust integrated models for delivering psychological therapies and develop a sustainable plan for growth and further development of the IAPT workforce over the next five years. During 2016/17 it is anticipated new therapists will be trained to develop co-located IAPT services for people living with long term physical health conditions and medically unexplained symptoms. The IAPT expansion programme will accelerate with additional investment in 2017/18 in order for NHSE to build the case further investment through CCGs up to Replacement (based on 15%) High Intensity Therapists Replacement Psychological Wellbeing Practitioners Expansion Expansion LTC LTC High Intensity Therapists Psychological Wellbeing Practitioners High Intensity Therapists Psychological Wellbeing Practitioners 2016/ / / / / In addition to the above HEE are: Support recruitment into training Improving Recruitment Access to IAPT training Support NHS England in ensuring a choice of therapies in IAPT HEE estimates that the total paybill in IAPT services will rise by 710% ( 115m), with the largest area of growth being High Intensity Therapists and other modality therapist staff to deliver the Taskforce recommendation of increasing the access rate for services to 25% annually. Adult IAPT Staff Group Difference Medical Nursing and Midwifery AHP/ST&T 344,000, ,000, ,000,000 Support to clinical staff 62,000,000 99,000,000 37,000,000 Infrastructure support 71,000,000 71,000,000 0 Total 477,000, ,000, ,000,000 Table xx: Estimated paybill costs in adult IAPT services 2016 and

50 Adult mental health: community, acute and crisis care Mental Health Workforce Strategy Expand the Early Intervention in Psychosis (EIP) standard so that 60% of those who are referred for treatment receive NICE-concordant care within two weeks of referral In order to develop the work force for this pathway all of the five pillars will need to be implemented. Work is ongoing to identify existing competencies and any resulting skills gap analysis. HEE continue to offer elearning opportunities to all staff including EIP teams. HEE will work with system partners to identify unmet training needs in order to commission courses for advance practitioners and work with regulators/professional bodies to recognise the new courses. Figure xx: Expansion trajectory in Early Intervention in Psychosis services In 2017/18 there will be an aim to begin a programme of expanding CORE 24 crisis care and improved psychiatric liaison in acute hospitals. (50% by 2021). There will be a plan in place to address the education and training needs to achieve this including commissioning products such as competence framework to enable this. A liaison psychiatry workforce (all ages) survey was conducted in autumn 2016, with the final report due in November Up-skilling/re-skilling existing workforce plan will follow March These pieces of work will inform the further development of this expansion pathway. 50

51 Figure xx: Expansion trajectory in liaison mental health services There is an aim to begin a programme of expanding provision of crisis resolution home treatment teams. A survey of all age Crisis Resolution and Home Treatment Team (CRHTT) is being conducted, with the final report due in December This work will inform the further development of this treatment pathway. Adult mental health: secure care pathway and health and justice To support the objective to transform pathways in and out of secure care, a workforce strategy setting out multi-disciplinary skills and capacity requirements will be produced based on development of community service models, and demand modelling. A Skills and Competency Survey is ongoing and is expected to be completed by October. This will be presented to the NHS England Steering Group by December, which will inform the further development of this area. New pathway transformation The Five Year Forward View for Mental Health sets out a timetable of additional clinical pathways over and above those mentioned so far in this strategy. Please see the full pathway chart in the introduction above on page xx. 51