2 Demand and Supply Factors
This chapter addresses the factors that drive demand for the healthcare workforce. NHS Scotland needs to anticipate these factors by assessing their future impact and taking the necessary action, whether through adjusting the size and shape of the workforce or by redesigning services and addressing education and regulatory implications.
2.1.1 Policy priorities, standards and targets
The Scottish Executive's priorities for Health are expressed in the 2003 Partnership Agreement11 commitments. They are further supported by the 12 National Priorities set for the NHS in the HDL (2003)56. These commitments set clear objectives for the improvement of healthcare provision and the promotion of safer and healthier lifestyles. They include a number of specific workforce commitments, including commitments on workforce growth.
An overarching policy priority is to improve access targets and, as mentioned in Chapter 1, the Scottish Executive has set improved standards on Waiting Times. Fair to All, Personal to Each - The Next Steps for NHS Scotland12 outlines the following targets for tackling waiting times:
no patient will wait more than 18 weeks from GP referral to an outpatient appointment
no patient will wait more than 18 weeks from a decision to undertake treatment to the start of that treatment - down from the current 9 month maximum wait guarantee
patients will be able to rely on shorter maximum waits for specific conditions:
- 18 weeks from referral to completion of treatment for cataract surgery
- 4 hours from arrival to discharge or transfer for accident and emergency treatment
- 24 hours from admission to a specialist unit for hip surgery following fracture; and
- 16 weeks from GP referral through a rapid access chest pain clinic or equivalent, to cardiac intervention.
An additional target for diagnostic tests has since been announced:
Meeting these targets will require a mix of service redesign, improved efficiency and effectiveness, and workforce growth, both on a short term non-recurring basis (to reach the targets) and on a long term recurring basis (to maintain the targets).
2.1.2 Legislative and regulatory drivers
There are a number of statutory and regulatory requirements which impact on the capacity of the workforce and drive the demand for workforce:
The Working Time Regulations set minimum requirements for employed staff in relation to working hours, rest periods, annual leave and working arrangements for night workers. In particular they will reduce the working hours of junior doctors to 48 hours per week by 2009.
Many of the professions working in the healthcare sector are governed by regulations to safeguard patients and set appropriate standards. New regulations or standards, driven for example by the development of clinical governance, may impact on the workforce both as staff get to grips with changes and in the longer term if there are increased monitoring requirements. Furthermore, new roles or evolving professions may require the development and introduction of new regulatory frameworks. Protecting patient and public safety and securing future services will be both the catalyst for change and the underpinning principle of any new developments.
New legislation will also drive changes to the workforce. For example the Mental Health (Care and Treatment) (Scotland) Act 2003 introduces new arrangements for the detention, care and treatment of those with a mental disorder. The Education (Additional Support for Learning) (Scotland) Act 2004 brings in a new system for identifying and addressing the additional support needs of children and young people who face a barrier to learning.
2.2 Demographic changes
Changes in the size of the population and age structure affect the demand for healthcare and, in turn, the healthcare workforce. In Scotland the total population is expected to fall slightly while the proportion of older people will continue to rise. This is well illustrated in the graphics in Building a Health Service Fit for the Future, reproduced here (Figure 6). The combination of a declining and ageing population sets Scotland particular challenges.
Figure 6: Demographic Changes in Scotland 1911-2031
These demographic changes will reduce the pool of potential employees for NHS Scotland. As the numbers in the lower age brackets fall the number of young people from which to source new trainees for the workforce will reduce. This dynamic will also affect other employers in Scotland and elsewhere in the UK and further afield, so competition for potential employees will sharpen. The change in population will also mean that the workforce itself will be older.
2.3 Patterns of ill health
The overall health of the nation will of course have a profound impact on future workforce needs. Scotland's health is improving - there are fewer premature deaths from heart disease and cancer and overall life expectancy has risen. The promotion and adoption of healthier lifestyles based on better diets, less alcohol consumption, reduced numbers of smokers, and more exercise should continue to increase life expectancy and lengthen healthy life expectancy. However Scotland's health in general compares poorly to other countries in the UK and beyond. Higher levels of deprivation present particular challenges and there is evidence that prevalence of certain conditions and diseases is increasing. For example it is expected that there will be a 28% increase in the number of people diagnosed with cancer over the next 20 years; 13 and by 2010 it is estimated that almost 30% of Scottish adults will be obese. 14
Perhaps the most striking development which we can expect in years to come is a further extension of the already widespread prevalence of long-term chronic conditions in Scotland. As Building a Health Service Fit for the Future points out, in the Scottish Health Survey 62% of those aged 65-74 (and 45% of those aged 45-54) reported at least one long-standing illness. In the UK patients with a chronic condition account for 80% of all GP consultations and are twice as likely to be admitted to hospital and experience longer stays when admitted. 15
This development is taking place against a pattern of NHS provision currently geared largely to acute episodic care rather than long-term management of chronic care in the community. The changes in healthcare provision required to respond to this shift clearly have fundamental implications for the healthcare workforce of the future.
2.4 Medical and technological advances
Advances in medical technology clearly have an impact on the workforce. It is widely accepted that new medical technologies can increase the demand for healthcare, principally by increasing the number of treatable patients. But it also has the potential to make interventions more efficient and to increase productivity in the workforce, either through swifter and more cost effective treatment or by opening up the provision of care to a wider pool of healthcare staff.
Likewise advances in non-medical technology and its increased use in the NHS may also impact on the efficiency and effectiveness of the workforce. For example the use of advanced Information Management & Technology can help to transform processes and increase the throughput being handled by a given number of staff.
2.5 Rising expectations about access to care and treatment
People are becoming more aware of their health status, their potential health problems and the range of treatments available. This increased awareness of individual health is naturally resulting in increased support for and development of self-care. It is estimated that 70-80% of people with long-term conditions will treat themselves primarily through self-care 16, and the role of carers and volunteers is pivotal to the overall fabric of care that supports chronic long-term illness. This will have implications for the future NHS workforce, particularly in equipping staff with the skills to encourage and promote self-care, to tutor patients in self-management and to train carers in the deployment of specific skills.
Increasing individual awareness of health and knowledge of the healthcare responses to ill health also lead to increased expectations of the NHS. The long-term vision for the shape of the NHS established in Building a Health Service Fit for the Future will in itself raise expectations for short and medium-term improvements in health services.
2.6 Pay modernisation
Pay modernisation is a major programme of reform now being delivered across most of NHS Scotland's 150,000-strong staff. It impacts on every individual member of staff's contribution to service delivery. It encompasses the New Deal contract for doctors-in-training, the new General Medical Services ( GMS) Contract for general medical practitioners ( GPs), the new consultant contract and Agenda for Change (affecting NHS Scotland's 130,000 non-medical staff). New terms and conditions are also being developed for staff and associate specialist doctors, community pharmacists, dentists and optometrists.
Pay modernisation is a service reform package that will improve recruitment and retention of staff, but is also a powerful lever to help drive the service change and new ways of working required to deliver benefits in improved services to patients. Pay modernisation therefore influences the demands on the workforce and the process of workforce planning through a number of complex and interlocking factors:
there are straightforward impacts on workforce capacity such as the increase in annual leave/public holidays, harmonisation of weekly hours and new overtime arrangements provided for under Agenda for Change.
there are a number of levers for improving the effectiveness and efficiency of the workforce and supporting redesign, through greater flexibility, team-working, development of skills and knowledge, clinical workforce redesign through the creation of new roles, and more efficient scheduling and organisation of clinical activity. It is not possible to accurately predict the precise impact of these factors at this time, but NHS Boards will be able to take them into account in their workforce planning as they begin to use pay modernisation to secure these benefits.
the new GMS and consultant contracts include provisions to better manage workload and fairly recognise on-call and out-of-hours commitments, ensuring that terms and conditions for employed staff are aligned with the statutory requirements of the working time regulations. This may mean that some doctors do not work the extra 'unrecognised' hours which they may have worked previously, thus ensuring that the NHS is providing the safe working conditions and work/life balance required of an exemplar employer in the 21st century. These contracts will in this way provide a sustainable platform of working patterns for our medical workforce and comprehensive management information on the amount and type of clinical activity being undertaken. This will allow NHS Boards to systematically and transparently assess, plan and organise the amount of clinical activity they require to deliver their objectives, delivering efficiencies which maximise the contribution of the human resource at their disposal and providing a sounder basis for medical workforce planning.
2.7 Modernising Medical Careers
Modernising Medical Careers ( MMC) will deliver modernised and focused career structures for doctors through a major reform of postgraduate medical education and training across the UK. MMC will result in shorter lead times to produce new consultants, thus producing a quicker supply of trained specialists and shifting much provision of care from doctors-in-training to trained doctors. This is a positive development which will drive up standards of care. However these new approaches to training will reduce the availability of clinical time at junior doctor level. In partnership with NHS Education for Scotland NHS Boards are currently designing solutions to this workforce pressure.
Further information on MMC in Scotland can be obtained from the MMC Scotland website at www.mmc.scot.nhs.uk
As the population of Scotland ages (it is estimated that 8.8% of the population will be over 75 by 2021) proposals have been developed for changes to NHS employees' pension rights. Possible legislative changes could have an effect on the age of retirement and staff in future could work longer than the current retiral age.
If such changes were to go ahead the effect on the workforce would be twofold:
Proposals are currently undergoing consultation and the effect of any changes will need to be factored into workforce planning when the outcome becomes clear.
Delivering improved workforce performance and effectiveness in NHS Scotland is seen as increasingly important, particularly following the significant investment in pay reform.
High level workforce productivity indicators will be published by the Scottish Executive this year. Each NHS Board will be expected to review the factors that affect workforce productivity to ensure that they are benchmarking appropriately against their colleagues in Scotland. Particular emphasis will be placed on reducing staff absence across Scotland and increasing consultant productivity. It is expected that time released by these two initiatives will be reinvested back into the workforce, thereby increasing output for the same level of input. NHS Boards will need to account for this when developing their workforce plans.
2.10 Service redesign and new roles
Service redesign is closely tied to improvements to quality and standards, better access for patients and productivity growth. Examples of service change include shifting activity from acute to primary care sectors, treating a far higher proportion of chronic disease cases in the community and avoiding emergency hospital admissions through expanded roles for primary care teams (operating via GP practices but also taking in broader joint provision with community health services, local authority social services and community pharmacies), led and driven by the newly-established Community Health Partnerships. In acute services, diagnostic centres provide an opportunity to free up a serious bottleneck in the patient route through the NHS, while the continued shift to day surgery procedures and the streaming of planned and emergency care offer opportunities to make a significant impact on productivity rates.
Maintaining and improving access to services for patients is a concern particularly for Scotland's remote and rural areas. Working in a sparsely populated area is a challenge to the maintenance of clinical skills because of low throughput, and it is difficult to justify the existence of large teams to meet working time regulations when the workload is so small. There can also be challenges for recruitment and retention. These pressures drive a search for more innovative solutions around service redesign and new roles.
Service redesign is already a feature across NHS Scotland. Building a Health Service Fit for the Future now suggests an era of considerable and accelerated service change that will of course affect the workforce. The workforce will need to take on new roles, new ways of working and new technologies to deliver the vision for the NHS which it outlines. The focus on management of chronic disease in community settings, anticipatory care in deprived communities, new approaches to planned elective care in hospitals, diagnostic services, and care in remote and rural settings - these all have major implications for workforce planning.
In redesigning services new roles and new ways of working are being developed to make the best use of the human resources at the NHS's disposal. This is about shifting the focus from particular staff groups and their historical functions to a more team-based approach where emphasis is on what can be done to provide a quality patient-centred service, not who should be doing it. Examples that are being developed or considered for development include non-medical endoscopists, anaesthetic and critical care practitioners, and musculo-skeletal physiotherapy practitioners, working for example in the area of low back pain.
2.11 Demand for staff from the independent, voluntary and other sectors
Healthcare is not the exclusive domain of the NHS and there are a number of other providers of healthcare in the same labour market. The Scottish Independent Hospitals' Association provides data on seven independent acute hospitals and three mental health/substance misuse hospitals. Workforce numbers are small in relation to NHS Scotland, involving around 360 whole time equivalent registered nurses and 110 registered AHPs. Other groups of staff permanently employed by the independent sector include paramedical, technical staff and pharmacists. Although numbers are not great the independent sector provides competition for recruitment and retention of staff. The sector also takes on a number of staff employed in the NHS on a sessional basis, such as consultants, a factor which requires to be accounted for by NHS Boards and regions when assessing the potential capacity they can secure from their available workforce.
The social services workforce is comparable in size to NHS Scotland, comprising approximately 118,000 people and growing. It covers social work and social care staff and others working in community care - spanning services for older people and for those with physical disabilities, learning disabilities and mental health problems, as well as child and family services and services to reduce re-offending and improve public protection. It also covers those working in early education and childcare services.
The Regulation of Care (Scotland) Act 2001 and the establishment of the Scottish Social Services Council ( SSSC) and the Scottish Commission for the Regulation of Care (The Care Commission) signalled a new era for social work, social care, early education and childcare services and for the workforce in these sectors. Developments in the regulation of the workforce offer better safeguards for service users and strengthen professional standards. There are over 1700 care homes in Scotland, 900 of which are for the elderly with over 34,000 residents, and 158 for children, with over 1000 places. 17 It is estimated that over 6,500 registered nurses work in care homes in Scotland.
Skilled staff, such as occupational therapists, may choose to work within social services rather than in the health service. Information available on occupational therapists working in social services as at October 2004 shows 396 whole time equivalent occupational therapists and 207 occupational therapy assistants in post which, although fewer in total than those employed by NHS Scotland (1,364.5 WTE and 175.4 WTE respectively at September 2004), is still considerable.
Connections are being made at national level between workforce planning for social work and health workforce planning. A Draft National Strategy for the Development of the Social Service Workforce 2005-2010: A Plan for Action18 was issued for consultation on 17 December 2004. The outcome from the consultation will be published by the end of this year.
Other employers of staff skilled in healthcare are the prison service and the armed services: additionally a proportion of staff working in NHS Scotland are members of the reserve forces. There are currently around 300-350 doctors, nurses, AHPs, paramedics and administrative and clerical staff in the Army Medical Services in Scotland. In recent years, mobilisation of these staff to areas of conflict around the world for specified periods of time has occurred. Such service brings benefits in the personal and professional development of individuals helping to meet the UK Government's and the wider international priorities, but absence from NHS Scotland also has an impact on workforce capacity. Legislation allows for reservists to be called up once every 3 years, but there is a possibility in the future of operating a policy of a definite call up once in every 5 years. Once the policy position has been confirmed, this will be a factor which NHS Boards will wish to incorporate into their workforce planning.
The voluntary sector also attracts staff skilled in healthcare. For example charitable organisations may employ nurses, doctors and Allied Health Professionals to advise and provide particular services. Generally their numbers are small but these organisations provide a choice of employment and, as with the independent sector, recruit from the same pool of staff.