The risk when trying to deal with complex and hard challenges is to aim for the easy targets. From a distance, workforce planning in the NHS looks like a sitting duck in the UK’s biggest blame game. Get closer though, and the picture shifts.
Even putting seven day working aside, we know that the NHS struggles at times. Mid-Staffs was a wake up call for everybody and, at a conference I attended a couple of years ago, senior NHS leaders from across the UK were taking the view of “there but for the grace of God, go I…” Under staffing the NHS had proven to be deeply damaging. The spin then was that the NHS had managed to recruit monstrous nurses. Somewhere, somehow, the NHS had managed to find people who were uncaring, heartless, and cruel yet had been drawn to become nurses. This applied to managers just as much, if not more, so political parties began to talk about throwing the evil ones in prison as a warning to others. Somebody, somewhere, actually thought that what the NHS needed was an injection of more fear and stress.
The truth is that if you put people under stress they behave differently. Put them under extreme stress and they behave extremely differently. When I worked in the NHS I was able to meet and speak honestly with others from NHS trusts all across the UK. I heard stories of ward managers displaying all the signs of nervous breakdown, of nurses stopping their cars on the way to work to vomit as a result of the nerves they felt at the prospect of going back on shift, and of relationships failing outside of work because of the impacts on the person in work.
Professor Chris Ham from the King’s Fund (an NHS think thank) was interviewed on the Radio 4 Today programme this morning and was asked about the challenges the NHS faces in achieving a seven day working model. With this being the NHS, there was of course also the question of whose fault the current problems were. The conclusion was that we are dealing today with the failure of workforce planning in the past. How could it be otherwise? We haven’t got the workforce we need to deliver the services we want today and it was the job of somebody 5 years ago to ensure that we did.
Like all the best scapegoats, workforce planners in the NHS don’t make a lot of noise, move fairly slowly and deliberately, and tend to see themselves as enablers rather than challengers. Nevertheless, it was not difficult to imagine even this mild mannered group bristling as they listened to the radio this morning.
Workforce planning in the NHS is fundamentally about crystal ball gazing. All of the normal disciplines of planning in organisations with any degree of autonomy go out of the window. The theory of workforce planning – which can be applied effectively in most organisations – is to understand the business plan for, say, the next five years. Having done that, you then look at the workforce required to optimally deliver that plan and compare it to the workforce you have today. The workforce plan should then detail in a very clear way how you are going to close the gap between the workforce you have today and the one you will need to deliver the future plan. It’s not rocket science.
The only thing we knew for sure 5 or 10 years ago about the NHS was that our prediction of the future would be wrong. This wasn’t because we didn’t have confidence in ourselves or have a coherent plan, it was because the NHS Trust exists in bondage. The illusion of provider independence and autonomy only applies a long as it is useful when the Department of Health or one of its many agents needs to point the finger. When it comes to autonomy of direction, the NHS Trust has next to none. As a provider of commissioned services the Trust is required to deliver whatever it is that the commissioner has decided it will pay for. As a regulated body, it has to prioritise delivery against key targets determined (variously) by Government. Financially, the Trust must operate closely in accordance with the view of a group of super accountants collectively known as MONITOR. When it comes to actual care, it is the priorities of the health service’s version of OFSTED, the Care Quality Commission, that need to be reflected. All of this happens within a national framework that is prone to political reorganisation and change at any point.
The main example used on the Radio this morning to demonstrate workforce planning failures was that of hiring consultants in Acute and Emergency Medicine. I know from experience that this is incredibly difficult. A couple of years ago, while working in an NHS Hospital, I put the spreadsheets and NHS Employers best practice guides away and went to speak to the consultants doing those jobs now. I asked them why we couldn’t hire enough consultants, and they told me.
These consultants told me about how different acute and emergency medicine are to other specialisms. As well as being subject to huge variations of demand and capacity, emergency and acute medicine offers no obvious route to private practice – which our health service incentivises by the way it is set up. Unlike surgery, the load can’t be managed. Although I believe most clinicians try and avoid it, cancelling or postponing operations is an effective way of managing elective surgical capacity. That’s not so easy when somebody is acutely unwell or has just been knocked off their motorbike by a lorry. They also told me about the obsession with the target of 95% of attendances at Emergency Departments being dealt with within four hours. The magic of real time reporting and iPads had resulted in consultants working with patients whilst non-clinical managers literally looked over their shoulders asking how long that patient had been in the Department because their name was flashing red on a screen in somebody’s office. All of this is happening in the midst of life and death situations.
The conversations were long and detailed – the issues I’ve mentioned here are just examples. The conclusion from the clinicians, in those jobs that are apparently now unfilled as a result of failed workforce planning, was the same in every case. It’s a miracle that anybody chooses to become an acute or emergency consultant. Why would they?
Until we accept the hard truth that medics are choosing not to go into emergency and acute medicine because they are fundamentally less attractive than other specialisms we won’t make progress. If large numbers are choosing to go elsewhere – and they obviously are – we need to speak to them and ask why they aren’t choosing to go into the shortage areas. I think that, given a safe place, they will be very clear on the reasons and none of them will mention the phrase “workforce planning”. Instead, they will talk about a system under enormous strain, with insufficient budgets, and caring people pushed to breaking point.