The Ward Round: It’s the workforce, stupid

The NHS’ 70th birthday has come and gone, an entire long-term plan for the health service has been published, and yet there is still no sign of the workforce strategy NHS staff were promised by Jeremy Hunt last summer.

The reason given for the delay was so it could be aligned with the long-term plan, and, in the meantime, an additional offer for staff would be published. But NHS staff are not only still waiting for this extra offer, but the main workforce strategy too.

It has not been forgotten, the long-term plan reassures its readers. It’s on its way and will be packaged as a new ‘workforce implementation plan’. But with workforce placed above finance as many NHS leaders’ top concern, it should surely be embedded within any serious long-term plan – not as an afterthought, or as a separate document altogether, but at the very heart of it.

The challenge presented by workforce shortages has been hit home again by health minister Stephen Hammond. Mr Hammond answered a Parliamentary written question earlier this week, which confirmed NHS vacancies are now almost at 103,000 and it is expected they will be filled by agency and bank staff. This is something NHS Improvement is trying to discourage, but desperate times call for desperate measures – NHS trusts literally have no option if they are to maintain safety.

Almost every chief executive cites workforce as the issue keeping them up at night, so it’s difficult to understand why this workforce implementation plan is still under development, given the scale of the challenge presented by workforce shortages.

The success of numerous aspects of the long-term plan hinge on a robust workforce strategy. In particular, the plan said by 2028 it aims for the proportion of cancers diagnosed at stages one and two to rise from around half to three-quarters of cancer patients. It also wants to radically overhaul how diagnostic services are delivered for patients. But it has failed to set out who will carry out this ambitious work. Cancer Research modelling has predicted the cancer workforce will need to double to cope with the demand, but the plan talks about what it wants to achieve and brushes over the cohort of new staff needed to make this happen.

Another area is overseas recruitment. The recently published immigration white paper was a cause of concern for many and, although the long-term plan promises “new national arrangements to support NHS organisations in recruiting overseas”, trusts are struggling to recruit now.

The long-term plan also acknowledged a significant reason for staff leaving is not receiving personal career development and said it expects CPD investment to increase over the next five years. It added “support from employers” is key to ensure staff can take time out to learn new skills. But it stopped short of setting out how much it would like the CPD investment to increase by, whether it will be anywhere near 2012 levels and how exactly employers will be supported to free-up staff to complete training.

And finally, the mental health access targets. The plan described how it wants to introduce specific waiting time targets for emergency mental health services and ambitiously said there will be 4,000 more mental health and learning disability nursing trainees by 2023-24. But it fails to mention how they will be recruited or indeed what part psychiatrists would play here. The Royal College of Psychiatrists has previously called for them to be placed on the shortage occupation list, but there has been no acknowledgement of this.

When the notion of a long-term plan was first launched back in the summer, it was presented as a birthday present to the NHS from the government. Perhaps it’s cynical to suggest leaving out the true scale of the workforce challenge was intentional. But it would certainly have made the plan a less optimistic read.

The workforce strategy is overdue. The deadline has passed. NHS trusts, staff and patients need a robust plan that isn’t an appendix and they need it now.

Exception reporting is being undermined

It’s been two years since the controversial 2016 junior doctors’ contract was implemented. This week, HSJ published its analysis of the use of exception reporting – a key element of the contract – which, for the first time, gives a picture of how much junior doctors are overworking.

The analysis revealed there have been more than 60,000 instances of overwork reported since the new contract was implemented and a quarter of a million in fines paid by trusts. But this story is about much more than the figures alone.

After speaking to junior doctors and guardians of safe working, it is clear there is some way to go in changing the culture of exception reporting. Doctors are being told not to report, or to put it through as a locum shift. This not only skews the data but undermines the entire process.

Not only can trusts learn from exception reporting but it is crucial in putting forward new business cases. I was given the example of a guardian of safe working using the data to successfully recruit a phlebotomist. Also, crucially, they are an important indicator of safe staffing.

This culture can only be changed from the top – it’s up to senior leaders to make sure intimidation and bullying are not preventing the junior doctors’ contract from being properly implemented.