The Ward Round: New roles, same problems

It’s been widely reported that there are record numbers of staff working in the NHS, but it appears to being doing less hospital activity than before covid — hence allegations the service overall has become “less productive”.

The reasons for this are complex and last week the Nuffield Trust brought together a group of workforce experts to delve into one of the possible causes: the “rush” for new types of staff roles in the NHS.

Professor Alison Leary, chair of healthcare and workforce modelling at London South Bank University, described the “explosion” in different roles across a wide range of functions. There are now as many as 77,000 different job titles in the English NHS, Professor Leary revealed, based on her routine scraping of NHS job adverts.

She acknowledged roles change as industries evolve, but argued NHS workforce modelling — which brings in the new jobs — was often driven by a “lack of understanding” of what work is actually done. “New roles don’t solve old problems,” she argued. 

This was echoed by Candice Imison, associate director of evidence and dissemination at the National Institute for Health and Care Research and former Nuffield Trust policy director. She lamented the over reliance on “quick fixes” for NHS workforce modernisation and a failure of policymakers to understand that NHS work is changing, rather than just a numbers game.

Professor Leary also criticised a “Taylorism” approach to workforce planning, which sees an employee as “a vessel of skills”, and the rise of “taskification” in healthcare – resulting in adding more and more support workers compared to registered clinicians. Professor Leary has previously higlighted a proliferation of titles involving the word “nurse”, some of which are not for registered nurses.

“There is a fairly substantial body of evidence that shows adding more support workers doesn’t actually improve patient outcomes, but more clinical decision makers does,” she said.

Of course, many new roles are created because of demand or a specific need in a local system. In some cases this involves a “fancier title” but not a higher pay banding, however, Professor Leary said.

So, what can be done about this? There is a strong argument for rationalising roles and taking a more “humanistic” approach to workforce, rather than pushing staff to work “at the top of their licence” which may increase risk of burnout.

Skill mix is expected to feature heavily in the NHS long-term workforce plan, which is still elusive but now promised for spring. But there are clearly fears among workforce experts it will not provide this clarity, and might instead focus on the numbers, rather than the work. 

Spiral of doom

There have been hints this week on Twitter that the national “Getting it Right the First Time” programme is considering taking certain specialties off the general medicine rota.

When approached by HSJ, a GIRFT spokeswoman said she was not aware of new guidance suggesting a reduction in medical commitment, but the suggestion has understandably prompted hot debate.

The obvious fear is who on earth will staff the rota, particularly in a smaller hospital with fewer consultants? And, as highlighted by acute consultant and Nuffield Trust senior clinical fellow Louella Vaughan, removing a specialist from the gen-med rota increases the burden on those who are left, who are then more likely to leave, creating a “spiral of doom”.

“We would recommend that staffing at smaller organisations needs to be taken at whole service level and not departmental level. It should take into account the service need across the whole of the acute medical pathway – general, elective and specialty work,” Dr Vaughan added.

GIRFT is increasingly focused on getting the elective waiting list down and the enormous 7.2 million waiting list of incomplete patient pathways looks looks like a compelling reason to pull gastroenterologists, for example, off the general rota, the trade-offs could be too risky. As well as compounding dangerous workforce shortages, it undermines the wider NHS ambition — highlighted in the NHS long-term plan and elsewhere — to work towards a more “generalist” medical workforce. 

Midwifery leaders reliant on goodwill

A Royal College of Midwives survey of directors and heads of midwifery paints a very worrying picture of workforce shortages, recruitment struggles and burnout.

The fragile state of the midwifery workforce is well known but this new survey of senior midwives also gives insight into the high level of goodwill the service runs on; almost all respondents said they rely on “moderate” to “significant” levels of goodwill from midwives to deliver safe care.

The increasing reliance on bank and agency staff was also reiterated, with three quarters of respondents reporting calling in temporary staff every day.

Although the latest NHS workforce data has revealed a slight uptick in the number of midwives working in England between September 2022 and October 2022 (a 3 per cent increase) this is nowhere near enough to have any real impact on pressures and years of supply failing to keep pace with demand.