Workforce Plan 2015/16

Workforce Plan 2015/16 NHS Highland Workforce Plan 2015/16 1

Table of Contents Page(s) Glossary of Key Terms 3 Introduction 5 Overview of the Current Workforce 11 Drivers for Workforce Change and Workforce Demand 16 Workforce Supply and Key Workforce Challenges 18 Workforce Projections 29 Workforce Plan Rolling Action Plan 2015/16 30 List of Figures and Tables Figure 1: The Golden Thread 6 Figure 2: Highland Quality Approach 8 Figure 3: NHS Highland Workforce Establishment Monitoring: Staff in Post WTE and Funded Establishment March 2014 to March 2015 12 Figure 4: NHS Highland Vacancy Trend March 2014 to March 2015 (WTE) 12 Figure 5: NHS Highland Staff Turnover and Stability Trend April 2014 to March 2015 13 Figure 6:NHS Highland Use of Flexible Workforce (Replacement) (WTE) 13 Table 1: NHS Highland Staff in Post as at 31 st March 2014 and 2015 by WTE 11 NHS Highland Workforce Plan 2015/16 2

Glossary of Key Terms AfC AHP BC BH BV CEL CHP DGH eess FY GP GPST HC HCS HCSW HEAT HPF HQA HR ISD IT KSF L&D LDP LUCAP MA / MA s MH&LD NRRP NES NHS NHSH N&M NMAHP NMWWPP NoSCAN NoSPG OOH OOPE PA / PAs PHN RGH RTC SAS SCAMPs Agenda for Change Allied Health Professional Better Care Better Health Better Value Chief Executive s Letter Community Health Partnership District General Hospital (electronic) Employee Support System Financial Year General Practitioner General Practitioner Specialty Training Headcount Healthcare Science Healthcare Support Worker Health Efficiency Access and Treatment Targets Highland Partnership Forum Highland Quality Approach Human Resources Information and Statistics Division (NHS Scotland) Information Technology Knowledge and Skills Framework Learning and Development Local Delivery Plan Local Unscheduled Care Plan Modern Apprentice(s) Mental Health and Learning Disability National Recruitment and Retention Premia NHS Education for Scotland National Health Service NHS Highland Nursing and Midwifery Nursing, Midwifery and Allied Health Professionals Nursing and Midwifery Workload and Workforce Planning Project North of Scotland Cancer Network North of Scotland Planning Group Out of Hours Out of Programme Experience (Medical Trainees) Physician Associate(s) Public Health Network Rural General Hospital Releasing Time to Care Scottish Ambulance Service Standardised Clinical Assessment and Management Plan(s) NHS Highland Workforce Plan 2015/16 3

SEHD SGC SGHD SOA SSSC SSTS Sq km SVQ SWISS UK VC WTE Scottish Executive Health Department (now known as SGHD) Staff Governance Committee Scottish Government Health Department Single Outcome Agreement Scottish Social Services Council Scottish Standard Time System Square kilometres Scottish Vocational Qualification Scottish Workforce Information Standard System United Kingdom Video Conference Whole Time Equivalent NHS Highland Workforce Plan 2015/16 4

Introduction The development and delivery of the workforce planning function for NHS Highland is facilitated by a partnership approach, engaged operationally with staff side representatives and Highland Partnership Forum (HPF). Specifically, workforce planning function is identified as part of the Staff Governance Standard and therefore accountable through the Staff Governance Committee to NHS Highland Board. Workforce planning is an important task for all NHS Boards. In order to deliver the requirements set out by government policy and respond to health and social care demand and demographic change, the Board must ensure it has a committed, well prepared, dedicated workforce that has the right knowledge, skills, values and behaviours - in the right place and at the right time - to respond to and deliver health and social care services now and in the future. The Board develops its Workforce Plan every year and it is appended with the Learning and Development Plan to deliver an integrated Workforce Development Plan, underpinned by the Local Delivery Plan and Financial Plan. This year, the Workforce Plan is updated to respond to a number of service developments within the Board, underpinned by national policies and Board plans and strategies that determine how health and social care services are to be developed and delivered in the short, medium and longer term. Rather than reproduce these well documented strategies here, the following links are provided that should be referred to in conjunction with the Workforce Development Plan 2015/16, in relation to: National Policy: The Healthcare Quality Strategy for NHS Scotland, 2010. Available from: http://www.scotland.gov.uk/resource/doc/311667/0098354.pdf Scottish Government 2020 Vision. Available from: http://www.gov.scot/topics/health/policy/2020-vision Everyone Matters: 2020 Workforce Vision, 2013. Available from: http://www.scotland.gov.uk/resource/0042/00424225.pdf NHS Highland Board Plans and Strategies: Highland Quality Approach. Available from: http://www.nhshighland.scot.nhs.uk/aboutus/hqa/pages/welcome.aspx NHS Highland Local Delivery Plan 2015/16. Available from: http://www.nhshighland.scot.nhs.uk/meetings/boardsmeetings/documents/bo ard%20meeting%2014%20april%202015/item%205.5%20local%20delivery%20pla n%20-%20appendix.pdf NHS Highland Workforce Plan 2015/16 5

NHS Highlands 10 Year Operational Implementation Plan. Available from: http://www.nhshighland.scot.nhs.uk/meetings/boardsmeetings/documents/bo ard%20meeting%203%20february%202015/item%205.3%20(2)%20nhs%20highla nd%2010%20year%20operational%20implementation%20plan%20revd.pdf The Highland Care Strategy: NHS Highland Improvement and Co-Production Plan. Available from: http://www.nhshighland.scot.nhs.uk/meetings/boardsmeetings/documents/boa rd%20meeting%2012%20august%202014/5.5%20highland%20care%20strategy.p df Adult Strategic Commissioning Intentions 2015/16. Available from: http://www.nhshighland.scot.nhs.uk/meetings/boardsmeetings/documents/boa rd%20meeting%202%20june%202015/item%205.3%20adult%20strategic%20com missioning%20intentions.pdf The Golden Thread model Figure 1 below illustrates the strategic and operational elements - national policies and Board plans and strategies, by which the NHS Board develops and delivers health and social care services. Figure 1: The Golden Thread National Programmes Local Delivery Plan The Golden Thread Improvement and Co production Plan Operational delivery Plans Team Plans Individual Objectives The elements of The Golden Thread are summarised below, for context: The National Person-Centred Health and Care Programme supports the delivery of the person centred aims and ambitions of the Quality Strategy, using a focused improvement approach to support the testing, reliable implementation and spread of interventions and changes that are known to support health and care services and organisations to be truly person-centred. NHS Highland Workforce Plan 2015/16 6

The high level aim of the Programme is that, by 2015, health and care services are more person-centred as demonstrated by improvements in care experience, staff experience and in co-production. The programme will be designed in four work streams. These are Leadership; Care Experience; Staff experience; and coproduction. The Scottish Government s 20:20 Vision is that by 2020 everyone is able to live longer healthier lives living at home, or in a homely setting and, that we will have a healthcare system where: We have integrated health and social care There is a focus on prevention, anticipation and supported selfmanagement Hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of readmission Everyone Matters 2020 Workforce Vision is that staff will be able to respond to the needs of the people we care for, adapt to new, improved ways of working and work seamlessly with colleagues in partner organisations. In addition we will continue to modernise the way we work and embrace technology. NHS Highland Board has agreed its Everyone Matters Implementation Plan covering the 5 priority areas of Healthy Organisational Culture, Sustainable Workforce, Capable Workforce, Integrated Workforce and Effective Leadership and Management. Workforce Planning is a key part of sustainable workforce and underpins delivery of the other priorities. NHS Highland s Local Delivery Plan (LDP) covers 6 key sections, these are: A Strategic Assessment of NHS Highland s Capability and Capacity to Deliver the 2020 Vision for Primary Care An outline of NHS Highland s future Improvement & Co-production Plan NHS Highland s contribution to Community Planning Partnerships HEAT Risk management plans and delivery trajectories NHS Highland s Financial Plans and Efficiency Savings Summary of the main workforce issues facing NHS Highland In order to deliver the actions outlined above the Board has developed the Highland Quality Approach (HQA) (Figure 2, below) NHS Highland Workforce Plan 2015/16 7

Figure 2: Highland Quality Approach Putting quality first to deliver better health, better care and better value - The Highland Quality Approach NHS Highland Board is committed to improve the health of the Highland population and develop high quality integrated health and adult social care services that deliver Better Health, Better Care, and Better Value to the people of Highland. Effective workforce planning is fundamental to sustainable service delivery and future workforce sustainability and is central to the success of the NHS Highland Board Vision: Quality Care to every person every day In order to ensure delivery, NHS Highland has established its overall strategy based on the Triple Aim of: 1. To deliver better health (BH) of our communities through population wide and individually focused initiatives to maximise health and well being and prevent illness. NHS Highland Workforce Plan 2015/16 8

2. To deliver better care (BC) of our patients through quick access to modern services, in the most appropriate settings and in clean and infection free facilities by well trained professional staff. 3. To deliver better value (BV) for the use of the public money we spend. This is by ensuring there is no waste and inefficiency, where money is spent only on what is needed and has evident therapeutic benefits. The Highland Quality Approach captures the spirit of how NHS Highland is working to improve care and outcomes for people in Highland. It describes our values, strategies (People, Quality and Care) and approaches that will support the delivery of high quality of care experience, right for individual people, every time. The Boards approach is to focusing on providing person-centred care while at the same time eliminating waste, reducing harm and managing variation. This approach places an explicit emphasis on how we will make best use all of our resources and deliver the Scottish Governments 2020 Vision. The Improvement and Co-Production Plan is the Highland Care Strategy, which outlines NHS Highland s vision for the future delivery of health and social care services for the people of Highland for the next 10 years. It sets out principles by which decisions on service development, redesign and delivery should be taken, the main drivers for change. NHS Highland is currently undertaking several major service redesign and strategic projects that will change the delivery of health and social care services for people in Highland. These are set out in Operational Unit Delivery Plans. Changing demography, increasing complexity of illness in an increasingly elderly population, increasing use of technology, developments in diagnosis and treatment and financial constraints are among the many substantial drivers for change in service provision. It is therefore of growing importance that the Board has a clear agreed workforce plan that will support and develop staff to be able to change and respond to the needs of the people in new care settings and under new models of care and work seamlessly with colleagues in partner organisations. In the delivery of HQA and the application of Lean methodology and Scottish Patient Safety Programmes, the Board has prioritised 4 areas on which to focus improvement and transformational change projects for 2015/16 in the following main work areas: Outpatient Services - Transforming Patient Flow and Experience in the Out Patient Setting Out of Hours Services - Transforming Patient Flow and Experience Out of Hours Adult Health and Social Care - Transforming Patient Flow and Experience in accessing Adult Health and Social Care Services in the Community Rural General Hospitals Transforming services for patients in our Rural General Hospitals Each Operational Unit also has Financial Plans in line with overall Board Financial Plan outlined each year in the Local Delivery Plan. In the annual planning cycle, workforce plans are integrated with service and financial plans through the NHS Highland Workforce Plan 2015/16 9

development of annual its Local Delivery Plan to deliver a three dimensional (integrated service, financial and workforce) approach, building on the iterative workforce plans developed in previous years. NHS Highland Workforce Plan 2015/16 10

Overview of the Current Workforce NHS Highland has systems that monitor workforce trends. Detailed staff in post workforce information is provided on a quarterly basis to the Board, its formal committees and operational units. At present, the workforce information systems reveal complex sets of data due to transition in workforce data systems, eess implementation, the integration of health and social care workforce, and ongoing staff re-categorisation in pay scale codes, types and number as a result of these processes. The following figures and graphs, illustrate NHS Highland workforce profile analysis in whole time equivalent (WTE) for 2014/15 (year to 31 st March 2015). Table 1: NHS Highland Staff in Post 31 st March 2014 and 2015 by WTE (Source NHS Highland extracted from SWISS and eess) * Medical data does not include doctors in training Mar 14 Mar 15 Change 7,977.9 7,995.8 17.9 Medical * 420.7 404.2-16.5 Dental * 68.7 65.1-3.6 Medical and Dental Support 214.2 211.0-3.2 Nursing and Midwifery 2,986.0 3,012.0 26.0 Allied Health Professional 594.8 590.7-4.2 Other Therapeutic Services 179.6 180.8 1.3 Healthcare Science 244.5 252.9 8.4 Personal and Social Care 943.3 942.3-1.0 Support Services 880.7 876.6-4.1 Administration Services 1,397.0 1,422.1 25.2 Senior Management (non AfC) 48.4 38.0-10.4 NHS Highland workforce has increased by 17.9 WTE between March 2014 and March 2015. NHS Highland Workforce Plan 2015/16 11

Figure 3: NHS Highland Workforce Establishment Monitoring: Staff in Post WTE and Funded Establishment March 2014 to March 2015 (Source NHS Highland extracted from SWISS) 10,000.00 9,500.00 9,000.00 8,500.00 8,000.00 7,500.00 7,000.00 6,500.00 6,000.00 5,500.00 5,000.00 4,500.00 4,000.00 3,500.00 3,000.00 2,500.00 2,000.00 1,500.00 1,000.00 500.00 0.00 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 WTE in Post Funded WTE Figure 4: NHS Highland Workforce Vacancy Trend March 2014 to March 2015 (WTE) (Source NHS Highland extracted from SWISS) 350.00 312.67 312.68 300.00 250.00 285.04 291.26 266.26 247.73 225.83 242.41 210.31 273.38 231.83 257.16 226.59 274.90 239.02 262.74 249.68 217.15 228.39 272.50 233.30 200.00 197.41 171.06 196.24 150.00 100.00 50.00 0.00 49.94 41.55 32.10 35.88 39.20 27.63 30.57 32.53 32.15 25.00 26.35 21.90 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Posts Waiting to be Advanced Posts being Processed Total NHS Highland Workforce Plan 2015/16 12

Figure 5: NHS Highland Staff Turnover and Stability* Trend April 2014 to March 2015 (Headcount) (Source NHS Highland extracted from SWISS) Staff Turnover Trends (Headcount) Stability Percentage 91.10 91.27 90.89 90.99 91.01 90.71 90.54 90.37 90.21 90.12 90.11 90.53 9.43 9.37 9.64 9.55 9.82 9.89 9.82 10.06 10.20 10.12 10.13 10.18 Turnover Percentage Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Monthly 13/14 0.71 0.60 0.78 0.67 1.30 0.97 0.62 0.66 0.82 0.70 0.67 0.94 Monthly 14/15 0.66 0.87 0.69 0.94 1.36 0.90 0.86 0.80 0.75 0.71 0.71 1.26 Annual 13/14 9.55 9.61 9.74 8.88 9.43 8.98 8.99 8.89 8.98 9.29 9.39 9.45 Annual 14/15 9.43 9.37 9.64 9.55 9.82 9.89 9.82 10.06 10.20 10.12 10.13 10.18 Stability 2013/14 77.19 77.22 77.29 77.30 77.27 79.82 88.43 88.61 91.04 91.04 91.03 91.26 Stability 2014/15 91.10 91.27 90.89 90.99 91.01 90.71 90.54 90.37 90.21 90.12 90.11 90.53 Stability* Factor is a measure of the percentage of staff in post 12 months ago, who are still in post Figure 6: NHS Highland Use of Flexible Workforce (Replacement) (WTE) as at 31 March 2014 (Source NHS Highland extracted from SWISS) 250.00 374.26 Bank figures scaled for clarity, value (WTE) shown next to line 364.61 200.00 268.57 303.37 314.00 315.39 313.69 319.42 281.03 293.55 301.83 322.11 150.00 WTE 100.00 50.00 0.00 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Excess Basic Hours Overtime Agency Consultant Locums Bank NHS Highland Workforce Plan 2015/16 13

Supplementary staffing costs (Bank, Agency, Overtime, Excess Part Time Hours) were 17,713m to month 12 in FY 2014/15, which is 6.58% of the total pay spend The Board improved its position by 596k from 2013/14. Medical Locum costs were 10.300m to month 12 in FY 2014/15, compared to 9.726m in 2013/14 so an increase in costs of 574k from 2013/14. The Board uses flexible workforce for a number of reasons: Using excess basic hours and bank staff to fill gaps arising from service demand or staff absence as a first response to maintain service quality and stability. Overtime is used in circumstances where excess basic hours and bank staff are not available; or where particular grades of staff are not available, for example Band 5 and above nurses or AHP or specialist staff in particular professions. This is also the case for agency staff use. Waiting time initiatives can require an increase in flexible workforce across all grades, particularly in the approach to the last quarter of the financial year (December onwards). Consultant Locums are in place particularly in the rural general hospitals and in some specialties, where there are recruitment challenges or long term absence, including maternity leave. Flexible workforce is also used to support quality improvement and service redesign programmes, as a short term measure to support change A key focus for the Board is to monitor flexible workforce use on a monthly basis in the form of regular reports for each operational unit that provide a breakdown of flexible workforce and cost trends. There is a need to reduce the workforce cost base arising from supplementary spend. The HPF is informed of such reports by regular financial and workforce reports, so that underpinning rationale can be discussed and understood. Flexible workforce trends are also monitored by the Staff Governance Committee on a quarterly basis, via the Workforce Plan Rolling Action Plan. Vacancy Management On occasion, the Board delays filling vacancies for both budget management and workforce flexibility purposes - when the service can adapt and it is safe to do so. In such cases the Board has in place mechanisms to ensure patient safety will not be compromised and any pressure on teams is closely monitored. Any such delays would only be for short periods, as is normal in many organisations. Quality improvement and service redesign often underpins reasons for holding vacancies and using supplementary staffing, within agreed parameters. All vacancies have to be approved by the Workforce Monitoring Groups in the Operational Units - Raigmore Hospital which meets on a weekly basis, and fortnightly or monthly, depending on demand, in the other operational units, These groups ensure posts are properly funded and that opportunities for service redesign or development have been considered. Vacancies approved through this route are NHS Highland Workforce Plan 2015/16 14

then forwarded to the recruitment staff to process. These groups have operational and clinical management, staff side, HR and finance representation. There are cases where despite best efforts we have been unable to recruit to particular clinical and non-clinical posts and where this has been the case we have had to look at both short-term and long-term solutions. Such cases are mainly down to shortages of particular specialties in the local and global labour markets. Workforce establishments are regularly reviewed and use validated workload and workforce planning tools, where available and other methods which allow the Board to understand acuity, variable demand, flow, such as Lean methodology, DCAQ and a range of tools that are used within the HQA. Figure 7: NHS Highland Age Profile as at 31 March 2015 (Headcount) (Source NHS Highland extracted from SWISS) 2000 1985 25.00 1800 1618 1600 HC Percentage 19.86 1491 20.00 1400 1200 Grand Total 1246 16.19 14.92 15.00 1000 800 600 400 200 0 920 12.47 803 739 638 9.20 8.03 7.39 6.38 313 214 3.13 28 2.14 0.28 <20 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+ 10.00 5.00 0.00 NHS Highland s workforce age profile reveals an ageing workforce with the majority of staff in the 50-54 age group, closely preceded by 45-49 age group and 55-59 age group (figure 7). This will have significant impact for NHS Highland in the coming years as the workforce ages and retires. The Board has in place a number of plans to address the age of the workforce profile including socially responsible recruitment plans and initiatives and focussed youth employment, to encourage those not traditionally destined for health and social care careers to be given opportunities through supported employment, work experience or apprenticeship roles. NHS Highland Workforce Plan 2015/16 15

Drivers for Workforce Change and Workforce Demand The health needs of our population are significant and changing, with increasing complexity and multi-morbidity in an increasingly elderly and frail population; the focus of health care therefore needs to move away from managing single conditions towards complexity, requiring staff to maintain specialist and develop generic skills People need to be supported to manage and maintain their own health and prevent crises. Staff need to be able to respond to unscheduled care needs and implement a range of reablement approaches to maintain and keep people in their own homes. Our services are not always organised in the best way for patients; we need to ensure it is as easy to access support to maintain people at home, when clinically appropriate. The development of integrated and co-located teams with single point of access will improve outcomes for patients The Board has challenges of providing high quality accessible health and social care in appropriate remote and rural settings. Recruiting and retaining staff in remote and rural areas is becoming more of a challenge - solutions need to be developed and implemented for longer term sustainability. There is growing pressure on primary care, community services and unscheduled out of hours care. Recruiting and retaining medical staff to work in out of hours periods is becoming more of a challenge and leading to costly (locum) workforce expenditure. There is a need to develop nurses and AHPs to take on generic skills and extended roles and integrate new staff (for example, physician associates), as well as improve recruitment for GPs and medical staff. People require high quality specialist care. This presents a workforce challenge in terms of small specialties, sub specialisation and succession planning these roles. There are specific recruitment challenges in cancer services at Raigmore plans are in place to address this. The Board continues to work with regional partners in the North and the West to address workforce challenges that are also becoming an issue in larger teaching hospitals in Scotland. Care pathways, regional and proleptic appointments are being progressed to maintain service delivery and succession plan challenges in consultant recruitment. A particular challenge for NHS Highland is maintaining service quality and sustainability with use of locum medical staff to cover hard to fill vacancies and when providing low volume services in rural general hospitals.. Increasing specialisation needs to be balanced with the need for coordinated care which takes an overview of the patient or client. A number of profession specific reviews have been undertaken at national level and the Board needs to develop plans to respond to and implement these, for example, Shape of (Medical) Training review, Revalidation for Nurses and Midwives. The Board is also engaged regionally with partner Boards to further develop clinical networks and access to specialist services. NHS Highland Workforce Plan 2015/16 16

Healthcare is changing and with it the need to keep pace with best practice, standards and clinical guidelines staff development is a key requirement and the Board has in place a Learning Plan appended to the Workforce Plan; that outlines and a number of learning and development approaches to ensure staff receive core training and a learning opportunities to enable them to change and adapt to future health and social care service demand. There have been many benefits of health and social care integration so far and the Board continues to work towards realising the full benefits of integration, recognising the preventive nature of providing excellent care support in the community and ensuring an appropriate balance of resources to meet these community-based needs. Horizontal integration of workforce skills and competences is required across health and social care settings. Staff rotation between hospitals, care homes, care at home and community care need to be implemented to develop a more generic workforce response. Working with the independent sector and progressing commissioning plans for care at home services requires joint application to workforce planning and development across sectors. There is a need to invest in IT development in view of rapidly changing communications technology. Staff access to IT and the development of IT skills is a key learning requirement. There is significant competition with the private sector for these skills and the Board must seek alternative ways of recruiting and retaining IT skills there are plans to develop apprentice roles specific to IT and grow our own specialist workforce to support IT development for health IT systems, telehealth and health IT applications. NHS Highland is the biggest employer in Highland. The labour market is tight with low unemployment in Highland 1.0% and Argyll and Bute 1.6% council areas compared to Scotland 2.2% 1. This presents a competative labour market with recruitment challenges for the Board in terms of competition for trades staff and other support staff, such as, domestic staff. There is also sector competition from the retail sector and tourism in the summer months. Staff in lower bands often leave for higher incomes in these sectors. The Board requires an ongoing, continual focus on recruitment strategies and close working with Job Centre Plus and a number of voluntary organisations to promote health and social care work and increase the labour marked through socially responsible recruitment practices. Workforce represents around 60% of Board expenditure. In Financial Year (FY) 2015/16, the Board is expected to find savings of 16.044m, of which workforce savings contribution is 5.444m. As in previous years there is an anticipation and expectation that there will be workforce contribution to financial savings arising from service redesign, quality improvement programmes, application of workforce and workload measurement tools and reduction in the reliance on locums and supplementary workforce. 1 Labour Market Information June 2015. Skills Development Scotland. Available from: http://www.skillsdevelopmentscotland.co.uk/media/1362103/monthly_unemployment_update_june_20 15.pdf NHS Highland Workforce Plan 2015/16 17

Workforce Supply and Key Workforce Challenges NHS Highland has recruitment challenges, which result in hard to fill posts for various reasons such as the ability of the Board to attract staff to fill specific posts particularly in remote and rural areas or national shortage of staff and / or skills for specific posts. To address recruitment challenges, the Board has to rely on locum staff to maintain service delivery, especially in remote and rural medical specialties in the Rural General Hospitals, Out of Hours services, especially in the North and West, Primary Care GP s and at Raigmore District General Hospital in Inverness for some medical specialities. Remote and Rural Workforce Challenges: The vulnerability and sustainability of Rural General Hospitals continues to be an ongoing challenge for the Board evidenced by significant recruitment and succession planning challenges in medical staffing, including high locum use. The Board is progressing Rural General Hospital medical workforce planning, working in partnership with Boards, NHS Education for Scotland (NES) and North of Scotland Planning Group, taking forward the residual work of the Remote and Rural Implementation Group. The Board has received funding from Scottish Government to take forward a programme of Testing new ways of delivering healthcare in remote areas: An Approach to Building Sustainability of Health and Care Services in Remote and Rural Areas called Being Here. The Board has hosted study tours from colleagues in New Zealand (West Coast) and Norway (Council leaders and chief executives from the 24 District Councils in the County of Troms). Common themes emerging from both visits were consistent with earlier feed-back received as part of an Alaskan visit in February: how best to meet the needs of rural communities medical workforce models rural recruitment and retention and how to maintain skills Integration Engagement with the public The Board is also engaged with the Recruit and Retain international project which aims to find solutions to the persistent problem of difficulties in recruiting and retaining high quality front line health care providers for the remote rural areas of Northern Europe. The problem of a lack of available qualified public service professionals working in remote rural areas is an ongoing concern in all seven countries included in the NPP (Scotland, Iceland, Norway, Sweden, Greenland, Canada and Ireland). The core project is addressing professional, educational and social issues and solutions with respect to health care workers. NPP includes within the core service package innovative approaches to: training NHS Highland Workforce Plan 2015/16 18

professional development and skills maintenance combating isolation securing social and family stability Primary Care: GPs: There are 100 GP Practices scattered across the NHS Highland area covering urban and rural communities. Of these 18 Practices are currently (as at July 2015) run by the Health Board. The other 82 are run by GPs under the General Medical Services (GMS) Contract. Recruitment of staff, particularly GPs, but not exclusively has been a longstanding challenge across the rural and remote parts of the Highlands. More recently it has become a problem affecting the more urban places as well. Practices in all settings are starting to find a whole range of innovative ways of replacing doctors who leave. Sometimes they do manage to source a replacement doctor but often they seeking other healthcare professionals to assist, and to take on some aspects of work previously undertaken by the doctor. For example, nurses of all grades and skills, prescribing pharmacists and pharmacy technicians, healthcare assistants, Allied Health Professionals (AHPs) and ambulance technicians and paramedics are all in the mix. Furthermore the new role of Physicians Associate (PA) is another idea gaining interest in primary care. There is no easy or exact answer to the "how many" GP vacancies there are in Highland, as each Practice is making its own decisions about how to replace doctor vacancies. It is also worth noting that very few GPs now work what would traditionally be thought of as "full-time". Increasing numbers have portfolio careers working a set number of sessions as front-line GPs. The precise level of doctor activity in a Practice, therefore cannot in any way be equated against the number of doctors who work in the Practice. A number of initiatives by NES are underway to make rural practice more attractive, such as the on-going development of a Scottish National rural-track Programme for GPST training to address supply issues A review of out-of-hours primary care services and a new approach to unscheduled care have been launched by the Scottish Health Secretary. The Board is already developing a new model for the delivery of primary care services, engaging and involving local communities in agreeing solutions to current workforce challenges. Small Specialties.: Some specialist areas have recruitment issues as the knowledge and skills for particular service delivery can only be gained within the NHS, for example, clinical scientists in specialist areas, radiotherapy physicists and radiologists, Sonographers, some pharmacy (see below), psychology and decontamination technician roles it is challenging to recruit staff in these areas as the specialist skills are not known to those out with the NHS. The Board is participating in a number of workstreams that are being nationally led to understand and address recruitment issues in small specialties for example in health care science, pharmacy and AHP professions. NHS Highland Workforce Plan 2015/16 19

Medical: Medical staffing continue to experience the following problems, that are not new, but are long standing as follows: Consultant Physicians (RGH) Consultant Surgeon (RGH) and Specialist Consultants at Raigmore (DGH) To support Rural General Hospital sustainability, there will be an expansion in the number of Emergency / Rural Practitioners. This is a role unique to NHS Highland which is currently in place in 2 units and is being trialled as part of a new model to support the front door in one of our RGH s. This role is open to doctors on the GP, EM or Acute Medicine register & additional training is provided in post. Other redesign projects will see a redistribution of the medical workforce resulting in greater joined up working across the Board with clinicians rotating between sites in a more formal & structured manner than previously. Further, within a small number of specialties there is a move toward Consultants providing first on call cover. This is being introduced in a phased approach within OBGYN & will see an increase in our Consultant establishment in the next 12 24 months. In addition to the continued frailty of the RGH s, there remain recruitment difficulties in a number of specialties within Highland at both Consultant & Specialty Doctor grade, including; Oncology Ophthalmology Psychiatry Radiology Rheumatology General Practice Medical Trainees: In 2015 NHS Highland introduced Clinical Development Fellows (CDF s) a new role that has been developed within NHS Lothian. CDF s are yearlong posts that whilst not attracting training status, offer other developmental opportunities for junior doctors at post FY2 level that have not chosen a final career path. In addition, CDF s are one measure being employed to address increasing levels of clinical activity & acuity in Raigmore Hospital & 2 of our RGH s. We are currently employing 6 CDF s and anticipate that this role will be continued for the foreseeable future. Trainee vacancies and gaps due to OOPE, mat leave etc remain challenging particularly in GPST and Anaesthetics Physician Associate (PA): NHS Highland continues to support Physician Associate training programmes by hosting clinical placements across a number of specialties and sites. These have been expanded to include General Practice (as outlined above) and Remote and Rural settings. A number of clinical areas are looking to the PA role as part of the future multidisciplinary team that will support workforce sustainability, resilience & capacity. NHS Highland Workforce Plan 2015/16 20

This year the Board is introducing a small number of PA Internships with a view to establishing a regular Internship Programme supported in the longer term by substantive PA s. However, there is currently a mismatch between supply and demand nationally and an urgent need to take a Scotland wide view of the future of the profession in terms of provision of training programmes, the development of a career framework and associated funding for both. The Board is actively recruiting to 2 WTE Physician Associate roles to support unscheduled care and 7 day working although the recent first round of adverts was unsuccessful in attracting applicants. The newly formed PA Faculty within the Royal College of Physicians, London, is very welcome recognition of the profession as a whole and we would further support an urgent move towards national regulation. Nursing: There are some challenges in the recruitment and sustainability of nursing posts and this is evident in our District General Hospital at Raigmore, in Inverness, as well as in remote and rural areas where sustainable recruitment is more challenging. In the Medical Division at Raigmore, fully qualified Clinical Nurse Specialist posts and Advanced Nurse Practitioner posts can be challenging to recruit and retain. In the Surgical Division at Raigmore the main recruitment issues is in theatres, where it is not challenging to attract nurses into post at Band 5 but retention of Band 5 staff in theatre is challenging as and is further impacted by a national shortage of Operating Department Practitioners. In Mental Health, there are some posts that are more difficult to recruit to, e.g. Learning Disability Nursing posts at Band 5 & 7. The age profile of experienced learning disability nurses is contributing to the recruitment challenges. Nurse practitioners in remote and rural areas Fort William, Caithness and Argyll and Bute The Board has a number of plans in place to mitigate against nursing recruitment challenges: There is a good supply of nurse graduates from Stirling University Campus in Inverness and the Board offers a nurse internship programme, consistent with the NHS Scotland approach. The Board has a healthy nurse bank to fill gaps and newly qualified nurses are on the bank in addition to internship posts so plenty coming in at Band 5 / newly registered levels. We are seeing a pattern that nurses wish to work flexibly and want to work on the bank to support work life balance. The Board invests in an extensive training period to support staff to take up advanced practice roles across the NMAHP professions. Raigmore Hospital is adopting a "growing our own" Nurse Practitioner scheme and have introduced training posts to promote future service sustainability and succession planning NHS Highland Workforce Plan 2015/16 21

Also at Raigmore, succession planning is an issue with some of the Clinical Nurse Specialist posts so there is a need to look at ways, at local level, to ensure this is being addressed. The Board is engaged with Glasgow University in support of the Learning Disability Nursing undergraduate programme and we have developed systems where local trainees can access the course and have placements locally, which will help to boost recruitment, sustainability and succession planning in this workforce in the future. However, there have been bed reductions in MH & LD in line with more investment and infrastructure and support for care in the community and there appears to be an increased acuity level that necessitates the same number of nurses - identified by using validated nursing and midwifery workload and workforce planning tools. More work from a triangulation and professional judgement perspective, and epidemiology trend analysis needs to be undertaken to understand why this is the case. Workforce is a key cross cutting theme in the Board s Unscheduled Care Action Plan. A review of out-of-hours primary care services and a new approach to unscheduled care have been launched by the Scottish Health Secretary and the Board has plans in place to develop workforce roles to sustain out of hours and unscheduled care services moving to 7 day working in the professions. Midwifery: The midwifery workforce remains stable. The midwifery national workforce tool is complete and a national run took place from July - September 2014. This offered an opportunity to look closely at the registered and unregistered workforce and midwifery activity. NHS Highland are well ahead with the planning for the tool run in 2015: the tool is uploaded onto the SSTS platform and leads are identified to co-ordinate the data inputs. There is a confidence in this new tool that we have not seen in the past: this is from the work that has gone into its development; the learning from previous tools; and testing and updating that has been done with this tool prior to sign-off. In conjunction with the professional judgement, we have an expectation that this will give us robust data and information about our midwifery workforce now and the changes we require to make for future sustainability. Nursing and Midwifery Workload and Workforce Planning Tools Work is ongoing to apply the mandatory application of the SSTS tools on an annual basis. These tools are an integral part of setting establishments, as part of the triangulated approach to workforce planning. A detailed report on the tools being used in practice has been drawn up and will be considered by HPF and SGC in their forthcoming meetings in August 2015. Examples of the tools being used in practice are: The Adult Inpatient tool has been widely used to inform establishment reviews and also used in areas where service redesign has occurred. NHS Highland Workforce Plan 2015/16 22

The Neonatal tool is used on a daily basis in the Special Care Baby Unit at Raigmore Hospital, Inverness The SCAMPS tool was used in the Paediatric Ward in Raigmore Hospital in November 2013 and repeated in 2014 A national run of the Mental Health tool has been undertaken in August 2014. There has previously been an exercise undertaken in New Craigs Hospital to ensure consistency of use. The Board plans to use the tool in 2015. A national run of the Midwifery tool is being undertaken in July 2014 for 3 months and the Board plans to use the tool in 2015. Allied Health Professions: AHP establishment review has been undertaken regularly since 2011 for AHP services across NHS Highland and Highland Council. This process was developed using tools developed for analysing nursing workforce establishment levels. As a part of implementing the requirement of the AHP delivery plan, a new approach to understanding workforce requirement to deliver high quality AHP services is emerging. Action 6.2 of the AHP Delivery Plan requires delivery of a 4 week Heat target for AHP MSK services by the 31 st of March 2016 and delivery of an 18 week RTT by December 2014. As a result of progressing on this action locally within NHS Highland it has emerged that a more accurate measure of AHP establishment requirements to support setting workforce establishment is applying Demand, Capacity, Activity and Queue (DCAQ) modelling. This approach has previously successfully been applied in Diagnostic Radiography which is an information rich environment due to the close alignment of activity and demand to the Radiology Information system. In the remainder of the AHP professions this is more difficult to robustly apply due to a lack of supporting e- infrastructure. To overcome the challenges posed as a result of lack of e-infrastructure, development is ongoing in partnership with service planning to facilitate appropriate mechanisms to capture demand and to draw information from existing systems in relation to activity levels to help understand the capacity required across all AHP services to deliver appropriate waiting times. This work will examine value added and value enabling activity and where waste can be removed from the system by introduction of new and more capacity efficient ways of working. The development programme aims to develop skills in the AHP workforce to apply DCAQ to support operational delivery of AHP services and is being run over a period of six months to support embedding the new approach. It is anticipated that following implementation of DCAQ within the AHP workforce the information available through this process will be used to inform the workforce NHS Highland Workforce Plan 2015/16 23

capacity and capability to deliver high quality and timely services. It will also inform the potential to reduce workforce capacity and where capacity may require to be increased to facilitate meeting increasing demands for AHP services. This year the application of this approach is in the development stages and as a result the anticipated projection for the AHP workforce remains unchanged year on year. When more detailed and transparent information is available following embedding of DCAQ revisions to these projections will be made. Integration and service redesign: AHP professional leadership and team structures have been reviewed across the Board to ensure they can provide sustainable service delivery and support delivering through the integrated team structures. Models for all AHP services are considering appropriate management, professional leadership and workforce establishment review to meet integrated service needs, aligning an integrated workforce with their medical, nursing and social work colleagues to meet service user and carer need. Examples of current initiatives are: MSK: Up-skill AHPs to undertake roles that will reduce pressure due to lack of capacity in DGH that impacts on treatment time guarantee particularly in OPD return / follow up and in response to DCAQ programme of work outlined above. 7 Day: plans to improve access to and assessment by AHPs by extending their availability to 7 days. The Board is scoping plans to put in place 7 day working in the OT and Physio workforce as a first phase and implement small tests of change and evaluation as the project is progressed. Unscheduled Care: plans to introduce 7 day access to dedicated AHP services at front door areas (Emergency Departments) and receiving units OT and Physiotherapy. These will be staff movements and role developments as a result of redesign to existing infrastructure and possible additional WTE, although not quantified at this stage. Out of Hospital Care: Develop specialist AHP roles / extend AHP skills to support generic staff in delivering care in the community, in care homes and in people s homes. Part of a wider approach to develop NMAHP workforce, particularly HCSW, Assistant Practitioner roles and Advance Practice Roles. Healthcare Science: Healthcare science workforce has undergone significant redesign in the past with the integration of blood (life) sciences (haematology, microbiology and bacteriology) which also gave the opportunity for workforce establishment review and redesign; also advantageous due to a number of retirements in 2013 and 2014. However there is still opportunity for skills development in terms of extended roles and consideration of 7 day working to improve waiting times and diagnostics turnaround. Healthcare scientists are actively involved in quality improvement programmes and there is already good progress in a number of Highland Quality Approach quality improvement programmes using lean methodology: NHS Highland Workforce Plan 2015/16 24

Good progress to reduce delays in processing laboratory samples Haematology was under the spotlight with a need to develop a new model to cope with increasing demands. The work so far has brought about a reduction in waiting times for patients The Board welcomes the consultation and publication on Healthcare Science National Delivery Plan for Healthcare Science Professionals in Scotland 2014-2017. The role of Healthcare Science Lead for NHS Highland is currently vacant and we are we planning to re-recruit to this post shortly. Performance against national cancer waiting times remains of concern both at Board level and at national level. These results are due in part due to increasing pressure in radiotherapy planning and supporting and increasing capacity in Radiotherapy Physics staffing. Further detailed work is also ongoing to review the processes in place to oversee the delivery of cancer waiting times in line with quality improvement and agreed milestones. The Board is also actively working with regional planning groups (NOSCAN) to secure workforce solutions for specialist cancer services, although national shortages in some specialties persist. Social Care: Social Work staff have an ageing profile and the Board has developed a Trainee Social Worker Scheme, as previously successfully delivered by Highland Council in the past, to succession plan social work staff. There are also recruitment challenges specific to Care@Home workforce across Highland but most notably in the inner Moray Firth area of Inverness and East Ross. There is ongoing work with the independent sector to look at joint recruitment initiatives and growing our own workforce by using Modern Apprentices and rotating posts across Care@Home, care homes, community care and day care in order to create a more sustainable workforce. The Board has outlined its Strategic Commissioning Intentions in partnership with the independent sector see Adult Strategic Commissioning Intentions 2015/16. Available from: http://www.nhshighland.scot.nhs.uk/meetings/boardsmeetings/documents/boar d%20meeting%202%20june%202015/item%205.3%20adult%20strategic%20commi ssioning%20intentions.pdf Pharmacy: Releasing capacity of pharmacists to deliver pharmaceutical care is an ongoing development at NHS Highland, facilitated by full utilisation of pharmacy technicians, support staff and considering new roles and the use of robotics in dispensing to improve safety and efficiency. Pharmacy services are delivering on Prescription for Excellence and contributing to Long Term Conditions. In acute settings pharmacy is moving to 7 day services, which will require additional capacity. At present it is not quantifiable how many posts will be required and some redesign and quality improvement outcomes may underpin 7 day developments, without the need for additional WTE. NHS Highland Workforce Plan 2015/16 25