NoSPHN Horizon Scanning Project: Workforce Evidence

NORTH OF SCOTLAND PLANNING GROUP NoSPHN Horizon Scanning Project: Workforce Evidence This paper has been written in response to the call for evidence by the North of Scotland Public Health Network (NoSPHN) to inform the horizon scanning work in advance of the NoSPG event on 21 st September 2011. This paper is provided in response to a request to provide a workforce specific contribution to the overall literature review, providing evidence and insights into the key factors which have the biggest impacts on the provision of health services in the future, over a three to five year horizon. In addition, NoSPHN provided a number of workforce specific references identified in the horizon scanning work undertaken to date by NoSPHN, summarised using RefWorks, a knowledge management system available through the NES Knowledge Management System, for analysis. NoSPHN provided a proforma for review of the evidence, which asked for information submissions to be structured to provide information on trends, key factors/drivers, likely impact, other issues and the unknowns. The paper will address each of these issues but has been structured to provide a context in which the NHS workforce will be working, how this will impact on the future workforce strategically before considering some of the professional groups within health in more detail. In doing so, however, the paper consciously concentrates on the strategic workforce issues facing health in Scotland, having assumed that colleagues submitting the clinical evidence will make reference to any specific workforce concerns relevant to their area. References Some of the evidence provided through RefWorks are relevant and will be referred to the in the course of this paper. Some of the documents refer to UK or International evidence and the Scottish health position may be different. It is also noted that much of the evidence is quite dated, with three of the thirteen reference documents older that the suggested 2006 timeframe. Other documents may no longer be relevant, due to policy changes and these have been disregarded. We have conducted a slightly separate literature search of both the SHOW website and the Scottish Government website, using workforce as the key word. The SHOW website identified 52 documents, of which 24 were of relevance. The Scottish Government website provided 16 relevant documents, all of which appear on the SHOW list. In addition to the documents identified above, this response has also pulled on more recently published documents including the recently published report of the Christie Commission 1, the McClelland Report 2, a discussion paper from the Institute of Healthcare Management in Scotland 3, the 1 (2011) Commission on the Future of Public Services June 2011. www.publicservicescommission.org APS Group Scotland DPPAS 11647 (06/11) 2 McClelland JF (2011) Review of ICT Infrastructure in the Public Sector in Scotland June 2011, Scottish Government, Edinburgh. www.scotland.gov.uk ISBN 978-1-78045-229-6 (web only) 3 (2011) Getting into Shape: A discussion paper to inform the debate about how the NHS in Scotland should respond to the challenges presented by the UK Comprehensive Spending Review Feb 2011, IHM Scotland, www.ihmscotland.co.uk 1

NHS Scotland Quality Strategy 4, Delivering for Remote and Rural Healthcare 5, the follow-up Final Report of the Remote and Rural Implementation Group 6 and the recent speech of the Cabinet Secretary for Health and Wellbeing in the Taking Scotland Forward debate 7. Context for the NHS Scotland Workforce Demography The population projections available from GROS, as summarised by NoSPHN 8, identifies that the population in the North of Scotland is projected to increase, but these increasing populations will consist of older people, with a 72% increase in the number of people aged 65 or over by 2033. In an earlier population projection, prepared by the NoSPG team, in advance of an event to consider the sustainability of the Rural General Hospitals (RGH) in July 2010, those in the over 65 9 age group were projected to account for 25.4% of the total population by 2033 and those aged 15 and under would account for 16.2% which was higher than previously thought. This latter projection was linked to a growth in the birth rate. 10 75 & over 75 & over 65-74 65-74 50-64 50-64 30-49 30-49 16-29 16-29 - 2 - Male Female 0-15 Male Female 0-15 Chart 6: Age distribution - Scotland 2008 Chart 7: Age distribution - Scotland 2033 Both reports also make reference to the reducing numbers within the working age population across the North of Scotland, as the population ages. In the 2010 population projection, the percentage reduction in the working age population across the NoS Boards was projected to be -4.5% by 2033, with a projected decrease in most areas except Aberdeenshire, Highland and Perth & Kinross. Table 1 below summarises the projected percentage change in the different age bands for the council areas within the North. 4 (2010) The Healthcare Quality Strategy for NHSScotland may 2010, Scottish Government, Edinburgh. ISBN 978-0-7559-9323-9 (web only) 5 (2008) Delivering for Remote and Rural Healthcare May 2008, Scottish Government. Edinburgh. RR Donnelley B 56045 05/08 6 (2010) Final Report of the Remote and Rural Implementation Group Oct 2010, www.nospg.nhsscotland.com/remoteandreural 7 (2011) Taking Scotland Forward Achieving Sustainable Healthcare in Scotland s Healthcare/Cities Strategy 8 th June 2011 www.scottish.parliament.uk/officialreport/8june2011 8 (2011) GROS Population Projections NoSPHN, June 2011. 9 The age bands used in GRO 2002 based projections were 0-4; 5-14; 15-29; 30-44; 45-59; 60-74; and 75+ 10 (2010) Population Profile www.nospg.nhsscotland.com/?page_id=844/populationprofile 2

Board Council Area All ages 0-15 Working age * Pensionable Grampian Aberdeen City 4.39-4.88-5.1 56.7 Aberdeenshire 22.32 10.58 4.7 108.9 Moray 2.91-6.34-13.4 69.4 Highland Highland 17.58 7.57 0.3 88.2 Argyll & Bute -5.65-13.65-21.8 49.5 Orkney 12.12-1.21-7.1 88.5 Shetland -7.47-32.53-24.5 88.5 Tayside Dundee City -5.08-7.85-14.2 30.6 Angus 7.67 0.39-8.9 67.5 Perth & Kinross 26.86 24.4 13.3 73.1 W. Isles -4.06-17.44-19.3 51.3 North 10.56 2.31-4.5 72.0 Scotland 7.27-1.51-4.02 64.5 * note the change in women s state pension age between 2010 and 2020 Table 1: Population projections 2008-2033 percentage change by NHS Board and Age Band The consequence of this demographic change is a reduction in the available potential workforce resource from which health might pull from, a reduction in the tax paying population and those in the wealth creating sectors, together with an ageing and reducing workforce within the wider health and social care sector. It would also suggest that those who provide care for others will also be ageing. Despite projecting an ageing population, it is quite difficult to predict what impact this will have on the requirements of a health and social care workforce. It is known, however, that as the population increases, the demand for care and the number of repeat admissions increase. NHS Scotland has done much to improve this but as the number of older people increase, even if these people are enabled to live in the community, many will still require support to do so and this has an implication for the roles that staff will undertake. The total workforce for the NHS Scotland as at 31 st March 2011 is reported as 135,459 (wte) and 156,754 (headcount), excluding General Medical Practitioners and General Dental practitioners 11. Of these, the North Boards employ 31,920 (wte) and 38,338 (headcount), which equates to 23% of the total whole time equivalent staff and 24% of the total headcount of the NHS workforce. The current population of the North 12 is reported as 1,314,542, which means that 2.9% of the total population and 4.5% of the working age population work for the NHS in the North of Scotland Boards. This excludes GPs and GDPs, as noted above, therefore the proportion of the total population employed in healthcare will be slightly higher than reported. It is not easy to predict the number of staff who will work for the NHS in Scotland or indeed the North in the future, however, NHS Boards are asked to make projections on an annual basis. In 2010, the NoS Boards projected 13 a reduction of 1194 in the total whole time equivalent number of staff, within 11 (2011) NHS Workforce (comprising: Agency and bank nurse usage; Equality and diversity summary; Sickness absence; Staff in post; Staff turnover; Vacancies) 28 th June 2011 ISD Scotland. www.isdscotland.org 12 GROS, 2008 13 (2010) NHS Board Projected Staff in post WTE Changes in 2010/11 June 2010, Scottish Government Health Directorate. www.show.scot.nhs.uk 3

one year, which equates to a one year reduction of 3.7% in the total workforce, across all Boards, excluding NHS Western Isles, which projected no reduction. Given the economic climate, the reductions in all public sector budgets announced in the Comprehensive Spending Review and the significant proportion of public sector budgets accounted for by workforce, this trend in reducing staff numbers is likely to continue as NHS Boards and the wider public sector seek to achieve more with less. The challenge, however, is to project the extent and nature of these reductions. Evidence from all of the North Boards suggest that attracting suitably qualified staff to remote areas can be extremely challenging and this challenge is likely to continue. Different approaches, including significant service redesign will be needed but will not completely remove the requirement to employ staff in these locations. The age profile of the NHS workforce may also gradually become older, changes in the tax rules might mean that some of the higher earners in the public sector retire earlier and in significant numbers over the next two to three years, leaving a skills gap, particularly amongst the consultant staff workforce but changes to the public sector pension arrangements and the increasing retirement age, will also mean that other staff work with the NHS until they are older. These staff may be less able or decide to work more flexibly. It may also mean that there are not the opportunities for younger people coming through training to take up posts for which they are trained because they blocked by older workers. Policy Changes The rising demand for public services will take place in an environment of constrained public spending public services will have to achieve more with less labour accounts for a large percentage of public sector costs. Given the rising demand and falling budgets, it is clearly important to minimise the direct costs associated with meeting demand, especially when external costs pressures will be ever more evident. 14 The future public sector, including the NHS will be characterised by an outcome focussed service, which is more integrated across the different sectors, delivering improved performance and cost reduction. The focus in the future will be aimed at a preventative approach, addressing inequalities within communities rather than the institutional focus which the NHS in particular tends to prioritise. The current system creates a bias towards institutional spend in hospitals rather than health improvement, in care homes rather than home care, result[ing] in top-down, producer and institution focussed approaches where the interests of organisations and professional groups come before those of the public. In summary, we believe that substantial reform of how we deliver our public services is required. 15 Christie acknowledges the challenge that the radical reform they recommend will be for public sector staff but argues that if there is to be a secure and sustainable future for public service delivery in Scotland then the staff providing these services must be outcome focussed, integrated and collaborating, across a common set of competencies. Whilst it has not yet been confirmed that Scottish Government will accept all of Christie, the multidisciplinary, integrated approach to the healthcare workforce, with an emphasis on prevention and tackling the causes of ill health has been signalled in a number of policy documents 16 17, and has recently been reiterated in a speech made by the Cabinet Secretary in the Taking Scotland Forward 14 (2011) Christie, Ibid, p vi and p17 15 (2011) Christie, Ibid, p20-22 16 (2009) A Force for Improvement: The workforce Response to Better Health, Better Care January 2009, Scottish Government. Edinburgh. ISBN 978-0-7559-5896-2. RR Donnelley Bs57904 01/09 17 (2010) The Healthcare Quality Strategy for NHS Scotland may 2010, Scottish Government, Edinburgh. ISBN 978-0-7559-9323-9 (web only) 4

debate in the Scottish Parliament, where she stressed the changing demography and the need to tackle the big public health challenges facing the population: this 20/20 vision is of a system where we have integrated primary and social care, a focus on prevention, anticipation and supported self management, in order that everyone can live longer, healthier lives at home, or in the community for as long as possible..make sure that people are admitted to hospital only when it is not possible or appropriate to treat them in the community recognis[ing that this] will result in changes in the pattern of acute care. 18 A different pattern of care and a different emphasis in priorities for healthcare will mean that the type and range of skills required for the workforce of the future will be different. This has implications for the way in which we train our public sector workers and the numbers and skills of those to be employed in the future. The economic climate and indeed the emerging reports and guidance would suggest that the number of staff employed will be less than at the current time, that technology will have a part to play in delivering care to patients and there will be a significant culture change required to remove the silo mentalities and break down the culture of professional dominance in public bodies that have made them unresponsive to changing needs and risk averse about innovation. 19 The policy priorities identified by the Minister in her recent speech will also have implications for the way and priorities of individual services, with an emphasis in supporting self-care or care in the local area, enabling older people to remain healthy and active for longer. The emphasis on obesity, discouraging physical inactivity, the effects of smoking and alcohol and the need to manage long term conditions better would suggest that some skills, including health improvement, supporting self-care and fostering independence, will require different approaches from both healthcare professionals and for communities. Increasing integration will also require changes to the structures within which public service workers work, supported by changes to the terms and conditions under which staff are employed. The Government remain committed to a no compulsory redundancy commitment to NHS staff. Closer integration with other public sector workers might suggest that this is no longer either sustainable or desirable. Impact on staff roles It is likely that the tight economic and financial climate, the changing policy context and the demography of Scotland and of the NHS workforce will have implications for the number and roles of staff employed in the future. The emphasis on integration will mean that the skills set of staff will be need to be augmented to undertake those roles currently undertaken by someone else. The proposals from Christie for a common set of core competencies for all public sector workers will mean changes to the way all professional disciplines are trained and work in the future. The emphasis on addressing inequalities would imply that the public health role, inherent within the role of all health workers, will need to be more prominent in their practice and it would also suggest that the role and number of public health professionals will need to change, if more mainstreaming is to be realised. The move from institutional based care to more services being provided in or close to the patient s home or in community settings will not only change the way that people work but also the proportional split between those working in institutions and those in community. Community based 18 (2011) Taking Scotland Forward Achieving Sustainable Healthcare in Scotland s Healthcare/Cities Strategy 8 th June 2011 www.scottish.parliament.uk/officialreport/8june2011 19 (2011) Christie, ibid, p 21 5

care is more labour intensive and, if to be sustainable, will require more self-care, community resilience and for those employed, flexible teams of non-registered staff, led by healthcare professionals, working at the higher end of their skills level, where they will add most value. Outcome focussed approaches are identified as the future but this might require staff to demonstrate a different set of skills. Services should be evidence based and this may result in some services being changed in focus or stopped. This will have an impact of the number of staff and the flexibility and adaptability required of the staff employed. Delivering for Remote and Rural Healthcare and the Final Report of RRIG make a number of specific workforce and education recommendations, including the development of new roles for rural practitioners, necessary to deliver safe care in the RGH and a framework of care for the remote community hospitals. Many of these new roles will require new education programmes, continuing professional development and ongoing educational support to be available locally to ensure sustainability of the role and service improvement. Increased demand for high quality education and training at reduced cost will require significant change in the way education is designed and delivered. Changes in education A different pattern of care and a different emphasis in priorities for healthcare will mean that the type and range of skills required for the workforce of the future will be different. This has implications for the way in which we train our public sector workers and the numbers and skills of those to be employed in the future. NHS Education for Scotland (NES) has a key role to play in assisting Boards to deliver improved care by providing the education solutions that are required to support change in the NHS workforce within an increasingly challenging financial environment. Many of the changes required relate to ways of working and delivering care.these will increasingly require a focus on adaptive education solutions in addition to technical solutions or resource provision. That is in providing education that helps change the way in which the workforce delivers care to effect the required quality improvements for patients.for some of the healthcare workforce this may require a significant shift in approach and change to the way they were originally trained to practice. Education providers will need to ensure education and training programmes have sufficient focus on these adaptive and behavioural aspects of care and practice. There is a significant need to address the educational and training needs of the workforce in use of technology in practice to help achieve the required improvements to patient services 20. This will require a collaborative approach from education providers in order to ensure that the workforce can achieve increased competence and confidence in adapting their existing practice and using new and existing technology appropriately to deliver quality care. Although the focus of the education programmes, tools and resources produced by the Remote and Rural Healthcare Educational alliance (RRHEAL) is on remote and rural workforce solutions, the way in which these resources are being made available means they are and will also be of increasing value to the workforce outwith remote and rural areas 21. Economics, increased integration of services and a geographically dispersed workforce highlight the need to focus on developing inclusive education programmes across Scotland 22, that is programmes, learning opportunities and resources that are as accessible and relevant to as much of the workforce as possible. There is a need to increase the range and quantity of education, training and learning opportunities that can be delivered for the workforce in a high quality flexible learning format. That is a blend of at distance education with minimal face to face or travel requirement. There is substantial evidence to 20 (2009) Review of the Scottish Centre for Telehealth (SCT): November 2008 to January 2009. Scottish Government. Edinburgh. October 2009. www.scotland.gov.uk/publications/2009/08/31160526/0 21 (2011) Collaborate to compete Report to HEFCE by the Online Learning Task Force. January 2011. www.hefce.ac.uk/pubs/hefce/2011/11_01/11_01.pdf 22 (2011) Inclusive Education and Learning Policy. NHS Education for Scotland. June 2011. www.nes.scot.nhs.uk/media/1178254/inclusive%20education%20policy%20v9%20final%20w%20remote%20rural%20appe ndix.pdf 6

support the need to ensure that the remote and rural workforce can access appropriate education on an ongoing basis from their own local area and that this also has a positive impact on recruitment in those areas 23. RRHEAL are working with education providers across Scotland to ensure more courses, programmes and resources are developed that are remote and rural inclusive. RRHEAL are leading the development of a Distributed Education System for the remote and rural healthcare workforce across Scotland. Profession Specific Changes Medical and Dental staff Hospital Services The number of HCHS medical and dental staff in post across NHS Scotland, as at 31st March 2011, was 12,786 (headcount), compared to 12,757 (headcount) as at 30th September 2010, an increase of 0.2% (29 headcount) 24. Within the North, across all specialities there are 3469 doctors (3007.7 wte), which equates to 27.12% of the total NHS Scotland medical workforce by headcount and 26.33% of the whole time equivalent workforce. The number of consultants in post as at 31st March 2011 is 4,714 (headcount), compared to 4,670 (headcount) as at 30th September 2010, an increase of 0.9% (44 headcount). Within the North, the number of consultants in post at 31 st March was 1209 (headcount), which was 0.98% higher than in September 2010. Across all grades of hospital medical and dental staff, the increase between 30 th September 2010 and March 2011 was 0.6%, which suggests that there were reductions in grades other than consultant staff. It is Scottish Government policy to move towards a service delivered by trained doctors and to reduce the reliance on doctors-in-training for front line service delivery 25. In 2010, Scottish Government consulted on the projected intake numbers for specialist medical training 26, which projected a surplus across all specialities of 1500 hospital and community doctors and 900 GPs by 2014. In September 2010, the National Reshaping the Medical Workforce Programme Board approved proposals 27 for submission to the Cabinet Secretary for a reduction in the numbers of doctors in specialist training. The proposal was to reduce the number of doctors in specialist training by 674 posts to 2774 across Scotland from a reported establishment of 3448 as at 30 th September 2010. This was broadly accepted and in January 2011 28, the Cabinet Secretary agreed a reduction of 49 posts for 2011. The reductions for 2012 are not yet available but early projections suggest that the reduction across Scotland will be in the region of 150 to 180 posts. The proposed reductions, where the hospital specialties have a target annual intake of more than 10, are to be distributed across the country by an agreed deanery distribution of 50% in the west, 25% in the south east; 15% in the north and 10% in the east. The North and East Deaneries are in the NoSPG area. There are also a number of smaller specialities and these are to be dealt with nationally on a programme by programme basis. In 2011, the North deanery lost 9 posts and the east deanery lost 7 posts. If the reductions for Scotland in 2012 are at the predicted level, in the larger specialities, the share for NoSPG will be 23 23 (2010) Increasing access to health workers in remote and rural areas through improved retention - Global policy recommendations. World Health Organisation. http://whqlibdoc.who.int/publications/2010/9789241564014_eng.pdf 24 (2011) NHS Workforce (comprising: Agency and bank nurse usage; Equality and diversity summary; Sickness absence; Staff in post; Staff turnover; Vacancies) 28 th June 2011 ISD Scotland. www.isdscotland.org 25 CEL 28 (2009) Reshaping the Medical Workforce 30 June 2009. Scottish Government Health Directorate. www.sehd.scot.nhs.uk 26 (2010) First Draft of Medical Speciality Training Intake Numbers for 2011-2015 13 July 2010. Scottish Government 27 Cook A (2010) Draft Medical Training Numbers 2011-2015 Paper RMW 2010(15), National Reshaping Medical Workforce Programme Board 7 th October 2010 28 Nicholls J (2011) Medical Speciality Intake Numbers for 2011 14 January 2011, Scottish Government, health Workforce Directorate, Edinburgh 7

27 posts for the North deanery and 15 18 posts for the east deanery. This is of course also dependent on there being vacancies available to reduce. Nationally, NES are working with the Regions, through a working group, to develop glide paths for all of the non-national programmes and early indications suggest that the North share of the reductions will be 93 posts in the North deanery and 62 posts in the east deanery. Across the NoS, the major specialities where significant changes are projected from the current numbers 29 include anaesthesia, general surgery, histopathology, O&G, paediatrics, Trauma and orthopaedics, General adult psychiatry (north only), emergency medicine (east) and gastroenterology (east). These changes will have a significant impact on the design of services for the future. One example is the projected numbers for obstetrics and gynaecology. In 2012, it is projected that across Scotland 55 doctors will complete training. In 2012, it is projected, however, that only 16 posts be recruited to and 39 posts will be lost. That equates to a loss of 4.6 posts in the North and 4.4 posts in the east deaneries. Both deaneries provide doctors in training across a number of rotas and sites. The minimum number of doctors for a rota is 8. These proposed changes will equate to loss of at least half a rota, and in effect one rota, for both deaneries, affecting the medical cover provided at specific locations. In addition, the experienced trainees tend to run labour wards on a daily basis, the loss of significant numbers of experienced trainees will mean that the roles they covered will have to be provided by someone else. Where medical skills are required, the alternative to a doctor in training will be a speciality doctor or a CCT holder, currently consultant grade staff. Obstetrics and gynaecology for medical training purposes is a run through speciality, in that there is no break point in the middle of training, as in some other specialities, which have decoupled (i.e. introduced a break) between core and higher training. Without a break, it is almost impossible to develop speciality doctors in any significant numbers. Introduction of a rota for CCT holders will have implications for the design of services, as consultants providing 24/7 cover, in the hospital, will mean a loss to services elsewhere, unless there is a significant increase in consultant numbers. Boards are unlikely to be able to afford significant increase in the number of CCT holders, and in 60% of roles 30, a CCT holder would be over-qualified for the role required. This is likely to mean that for some specialist services, the location of care will be limited to a few specialist centres that will support care in other locations by use of technology. For some services, this may limit the provision of some specialities to one or two centres for Scotland, for others, even some quite mainstream services, e.g. stroke services or paediatrics, these may be supported out of hours by one on-call service for Scotland. Some local provision for emergency care will still be required. This is likely to be provided through networks of care, linked by means of technology and will make staffing small hospitals even more of a challenge. In addition to the proposed reductions, the NoS would appear to be a less favoured option for training for some programmes and following Scottish annual recruitment the number of vacancies within programmes each year can be challenging. For example, in 2011, 23% of the places (14 posts) within the GP programmes in the North deanery were vacant at the end of June 2011. Trainee doctors, new to programmes, take up post at the beginning of August each year. 10 of these vacancies were in Rural General Hospitals (RGHs), reflecting the relative lack of popularity of the programmes which include RGH placements. 29 (2011) Glidepaths for major specialities produced by Medical Directorate, NES, 23 June 2011 30 NHS Boards responses to the CEL 28 (2009) consultation across all specialities. A Speciality doctor was identified as appropriate in 60% of situations and a CCT holder in 40% of situations, where the response required medical skills. In some situations, another healthcare professional might be appropriate. 8

The North deanery are working to make programmes more attractive, including developing and implementing Rural-track specialty training as designed by the 4 Rural-track Specialty Groups (General Surgery; Physicianly Medicine; GP and Anaesthesia) and increasingly popular Rural-track Foundation options. In a linked initiative, the University of Aberdeen Medical School has established a successful Rural-cohort of students, based as senior students in Inverness, and through selected placements offered a unique Remote and Rural experience as an integral part of their education. The expectation is that this student cohort will be more likely to continue with their R&R interest and pursue careers in R&R places, including the North. In 2010, the Remote and Rural Implementation Group (RRIG), hosted a summit to develop a framework for sustainability of the RGHs, recognising that reliance on doctors in training needed to change and that new roles of rural practitioners were required for the future. The model for the RGH was recommended to be revised and the Final Report of RRIG recommended that: RGH Boards should design a safe system of emergency care within the RGH that is consistent across all RGHs, underpinned by a robust system of governance. The system of care will be supported by an Emergency Care Obligate Network, with identified larger centre(s) that adopts an anticipatory approach to risk management and emergency care and is supported by a clear governance structure, agreed pathways of care and clinical decision support requirements. RGH Boards should establish a team based approach to care within the RGH that includes Core Medical Responsibility role, Rural Practitioners, generic and general staff and a matrix of support. RRHEAL should develop an education and training pathway for Rural Practitioner and commission educational programme, with educational objectives appropriate to need. NoS Workforce Planning & Development Group, working with RRHEAL, should establish a Career Framework, to support implementation of new roles. RGH Boards should review the role of the Consultant to establish clear leadership and governance role. RGH Boards should review the roles that general and generic staff could provide if roles were extended, as recommended in Delivering for Remote and Rural Healthcare and implement these across remote and rural Scotland. RGH Boards, working in collaboration with SAS and EMRS should define the additional transport requirements to support Emergency System of Care and ensure that transfer rates are routinely monitored. Remote and Rural Boards should develop a peer review system between RGHs and Acute Care Remote Community Hospitals. 31 These recommendations will have implications for the design of services, for a network approach to working, joint responsibility and responsibility of services in remote areas for some doctors. It suggests changes to the role of doctors within remote hospitals and the development of a new rural practitioner role, which might not be a medic, to support out of hours emergency care. It also suggests changes to the roles that other staff in these locations and in larger centres may have to adopt. In the North, early work to establish a cross Board Emergency Care Network 32 that will provide decision support to the first responder within the community or remote hospital, is to be piloted, aimed at ensuring responders have the right information, can obtain specialist advice and make the correct decision about whether to transfer or whether the patients can be managed in their own environment. The use of technology, including telehealth, remote decision support and more radical 31 (2010) Final Report of the Remote and Rural Implementation Group p15-6, Oct 2010, www.nospg.nhsscotland.com/remoteandreural 32 (2011) Proposal for an Emergency Care Network Paper 43/11, NoSPG meeting 29 th June 2011 9

solutions like robotics will drive changes in the roles that doctors and all other healthcare professionals will undertake. General Practice The General Medical Practitioner Workforce is reported by ISD 33, by headcount only, as 1515 for the North Boards, the majority of whom are independent practitioners, who contract with the local NHS Board to provide service. At September 2010, only 17.3% of GPs were employed by Boards, excluding those who work in GP out of hours arrangements. The number of salaried doctors varies between NHS Boards, with island Boards reporting much higher percentages of salaried staff. In NHS Shetland, for example, 58.8% of GPs are reported as salaried. The gender balance within the GPs workforce has changed over time. In 2004, the percentage of women doctors working as a GP in the NoS Boards was 45.37%, with the higher percentages in mainland Boards. By 2010, there were 50.5% female GPs, with a much more even balance between the Boards. The highest percentage of female GPs in the region is in Shetland (61.29%). There is emerging evidence that women doctors are more likely to work as salaried doctors than independent practitioners, at least in early years of practice and this might suggest that the number of general practitioners, employed by Boards will increase, particularly in island Boards, over time. There is no reported data specifically relating to the doctors working in NHS Board out of hours arrangements, but the NoS has 47 of the 51 practices in Scotland who continued to provide out of hours services and have not contracted out. These however, reflect only 13.9% of practices within the region and are more likely to be in the very remote areas. Again, Islands have a much higher incidence of practices providing out of hours. Orkney has the highest percentage, with 8 of the 14 practices (57.1%) providing out of hours care. This has implications for the working patterns of doctors and the costs of services. There is no corresponding data for General Dental Practitioners and a significant proportion of dental care in Scotland continues to be provided by the private sector, which would make any NHS estimation wholly inaccurate. Nursing and Midwifery Nursing is by far the single biggest group of staff employed within the NHS in Scotland. The number of nursing and midwifery staff in post across NHS Scotland, as at 31st March 2011, is 57,166.9 (WTE), compared to 57,878.3 (WTE) as at 30th September 2010, a decrease of 1.2% (225.5 WTE). The corresponding headcount also showed a decrease of 1.2% (834 headcount) from 67,259 as at 30th September 2010 to 66,425 as at 31st March 2011 34. For the North, there are 13,044.6 wte nurses and 761.8 wte midwives employed across the NHS Boards. This equates to a total of 16,537 nurses and midwives. There are 10.4 Nurses and midwives per 1000 of the population employed by the North Boards, with 24.4% of those banded at Agenda for Change bands 1 to 4 and 75.5% banded at band 5 and above. Band 5 is the minimum band for a registered nurse or midwife, although once a midwife has demonstrated a level of competence he/she automatically progresses to band 6. The majority of registered nurses are employed as band 5. In the North, nurses and midwives represent 43% of both the total whole time equivalent workforce and the headcount. It is anticipated that as the support worker role Band 4 is developed and embedded in organisations, concentration will be on development of the capacity and capability of the registered nurse workforce into more highly skilled and focused roles, for example, the specialist and /or the advanced practitioner and nurse consultant. 33 (2010) Number of GPs in post by NHS Board and Gender: 2004-2010 30 th Sept 2010, ISD Scotland. www.isdscotland.org 34 (2011) NHS Workforce (comprising: Agency and bank nurse usage; Equality and diversity summary; Sickness absence; Staff in post; Staff turnover; Vacancies) 28 th June 2011 ISD Scotland. www.isdscotland.org 10

The Nursing and Midwifery Workforce and Workload Planning Project 35, started in 2004, introduced a systematic approach to the planning of the nursing and midwifery workforce across Scotland, linked directly to the workload. The project has developed a number of sector specific tools for workload measurement and is now embedded across the country. The suite of evidence based tools give confidence to the planning and modelling of current and future nursing and midwifery workforce needs aligned to service and financial planning. Any change to the model of service delivery will impact on the nursing and midwifery workforce, with the most likely impacts on the nursing workforce. Many NHS Boards intimated their intention to review the nursing skill mix, in the workforce plans submitted in 2010 36. The 31 st March 2011 wte and headcount would suggest that Boards have both reduced their nursing workforce, although this is not as significant as had been predicted, and reviewed the grade mix within the nursing workforce. The 75.5% registered and 24.4% non-registered skill mix reported within the nursing and midwifery workforce within the NoS could be considered to be quite rich, especially when one compares this to the reported skill mix for the west of 28.1% non-registered and 71.8% registered. Care must be taken with this simple comparison, however, as there are a number of variables that need to be taken into account in considering the impact of a changing skill mix, most importantly the impact on quality of care. Table 2 summarises the skill mix ratios by NHS Board. Table 2: % of Nursing & Midwifery Workforce by AfC bandings NoS Board Bands 1-4 Band 5+ Grampian 23.7 76.3 Highland 24.6 75.4 Orkney 19.7 80.3 Shetland 25 75 Tayside 25.3 74.5 W. Isles 22.2 77.8 NHS Greater Glasgow and Clyde report a percentage split of 27.9% non-registered and 69.8% registered. It is suggested that there will be pressure for Boards to review skill mix, in way that does not affect quality but reduces costs. Changes to medical staffing almost always affect nurses and the roles which services expect nurses to undertake. The significant reduction in the number of junior doctors will mean that Boards will review their requirements and consider whether nurses with additional training could undertake these roles. Given the proposed changes to the numbers and roles in the registered nurse workforce, this workforce may no longer be the panacea for resolving these key issues. There are already a small number of nurses who undertake roles, previously undertaken by junior doctors, particularly in the more junior rotas and there is scope for further development of roles within the multi-professional team. The reduction in more experienced doctors, known as middle grade doctors, will be more challenging but there is some evidence that in some Boards and services this is being considered. One example is the development of Advanced Neonatal Nurse Practitioners in neonatal units and for transport. Any such changes will take time, require to be supported by appropriate education programmes and will probably require more nurses than the corresponding medical headcount. It should also be noted that these roles may be unattractive to nurses. Anecdotally, nurses have mixed views on these developments, some very positive but others less so. Nurses want clarity and recognition on their role 35 (2004) Nursing and Midwifery Workforce and Workload Planning Project April 2004, Scottish Executive, Edinburgh. ISBN 0 7559 0984 4 Astron B324556 4-04 36 (2010) NHS Board Projected Staff in post WTE Changes in 2010/11 June 2010, Scottish Government Health Directorate. www.show.scot.nhs.uk 11

and contribution 37,38,39 to patient outcomes and do not want to be seen as only undertaking roles that doctors can no longer fulfil. Nurses are competent practitioners in the delivery of care, to follow protocols and direction. Doctors are competent practitioners in making decisions and taking risks. Any plan to transfer responsibility from one to the other must be supported by a clear governance framework to protect workers and the public alike. The changes identified by Delivering for Remote and Rural Healthcare identified changes to the roles nurses undertake, whether through extended roles as part of an Extended Community Care Team, or within hospital environments, where Boards were encouraged to develop special interests for their nurses and consider where services might be nurse led, particularly in acute care and in enabling care. These roles need not be confined to remote and rural practice. The changing priorities within NHS Scotland, the need for integration between health and social care, the emphasis on community resilience, maintaining people in the community, and prioritising day case approach to hospital care will have an impact on the roles and numbers of nurses for the future. It is likely that the development of support workers, working in support of registered nurses will continue to grow, with non-registered staff trained to support anticipatory care plans and provide support within community environments in support of nurses and social care staff. Allied Health Professionals The Allied Health Professions include some 11 different professional groups, including Art therapy, Dietetics, occupational therapy (OT), orthoptics, orthotists, physiotherapy, podiatry, prosthetics, radiography diagnostics and therapeutic, speech and language therapy and multi-skilled AHPs who work across disciplines. There is quite a significant variation in the size of each profession. Prosthetics is the smallest with only 20.5 wte across Scotland and 21 people, compared to 2609.2 wte Physiotherapists (3231 headcount), which is the largest profession within the grouping. In Scotland, there are 9510.6 wte AHPS and 11479 headcount, with 2369.7 wte (24.9%) and 2914 headcount (25.4%) in the North region. The majority (81.2%) of AHPs in the NoS are banded at AfC band 5 and above, with only 18.7% banded at bands 2 to 4. In the north in the last year, the overall number of AHPs fell by 0.9% across all professions except dietetics (0.5%), therapeutic radiographers, where there was a 4.2% increase and Speech and Language Therapy (1.6%). The most significant reductions were in Prosthetics (-9.1%), Art therapy (-7.1%) and in multi-skilled AHPs where a -10.1 % reduction is reported. Like other groups, the changes in the design of services will change the roles and numbers of AHPs. The move to independent living and enablement will require increases in the proportion of time that AHPs spend working within the community, particularly for the bigger groups including OT, physiotherapy, SALT and dietetics. As with nurses, a tighter financial climate may see pressure to develop further the assistant practitioner roles. The continuing increase in cancer in Scotland, earlier diagnosis and improving outcomes will mean that the demand for therapeutic radiographers is unlikely to diminish and the growth of radiology towards intervention will put demand on the number and skills for diagnostic radiographers. As with nursing, Delivering for Remote and Rural Healthcare identified the requirement for multiskilled generalist AHPs, some developing specialist interests in specific fields of practice. Administrative and Support Staff 37 Tillett, J., (2011), Practicing to the Full Extent of Our Ability: The Role of Nurses in Healthcare Reform, Journal of Perinatal & Neonatal Nursing, 25 (2), 94-98 April/June 2011 38 Harder, R., (2011), Forging forward: Future of Nursing special, Nursing Management, 42,(3), 34-38, March 2011 39 Aiken, L., (2011), Nurses for the Future, New England Journal of Medicine, 364 (3), 196-198, January 2011 12

The drive to reduce staff numbers in the NHS in Scotland are likely to be felt most acutely within the administrative and support staff across Boards. The drive to reduce costs is already driving Boards to consider shared services and despite staff opposition to a wholesale approach to shared services, it is likely that this will be revisited, particularly as Boards are currently required to reduce the number of senior managers and the need to introduce leaner management structures can be addressed through sharing of services. The skills required in the NHS in future are also likely to change, with an emphasis on remote working utilising new technology. One are of growth will be the use of telehealth and the need to support this 24/7, 365 is an area which urgently needs to be addressed. Whilst the drive is to reduce staff, this does not mean that there will not be increases within specific staff groups. If administrative and lower value tasks are removed from doctors and nurses, there may need to be a corresponding increase in administrative, clerical or housekeeper-type staff time. Improving technology and IT based systems, together with smart scheduling is likely to significantly reduce the back room services such as medical records staff, but create a higher need for high tariff IT jobs to support systems. This may be through direct employment or, more likely through partnerships with business. Fewer acute beds and an overall reduction in the size of the NHS estate will mean that the requirement for facilities staff including domestics, porters and catering staff will reduce, although this will need to be carefully managed if the gains in cleanliness and reducing infection rates are to be maintained. Conversely, the need to support self care may introduce more support worker roles in the community e.g. home helps. Summary This paper does not consider all staff groups, nor does it consider all of the strategic challenges that will face the healthcare workforce going forward. It does signal a policy context and public sector climate that will see an emphasis on an anticipatory approach to services, encouraging and fostering personal and community responsibility for wellbeing. It suggests a bigger role for health professionals, working with social care providers, supporting people in their home environments. It also suggests a smaller, more efficient acute sector, networked to ensure continuity of care and specialist opinion. All of these potential futures will have an impact on all of the staff employed and the skills they will require in the future of the NHS in the North of Scotland. Attractiveness, improved and continued fill of some of our posts in the future will be in part dependent on the success of a grow your own philosophy that has been tried and tested as sound in other global settings. Dr Annie Ingram Director of Regional Planning and Workforce Development North of Scotland Planning Group 14 July 2011 13

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