14. STAFFING MATTERS
In any ambitious plan to change the shape of services people want to know what it means for staff. The first questions that usually get asked are often:
These are important questions but they are only the tip of the iceberg of a much more complicated set of issues that will affect staffing during the next ten to twelve years.
In this leaflet we look at some of the wider trends in health care staffing and then try to make connections between them and our local plans for improving acute hospital services.
In other leaflets we have described the importance of increased specialisation in many aspects of health care. Many staff (medical, nursing, physiotherapists, physicists and so on) are working in services where the demands of specialist expertise and the ability to use advanced technologies are a major part of their working lives. They may find themselves spending more of their time in their specialist service and less time on other things. They need to keep their skills and knowledge up-to-date in a world where technology and evidence of best practice keep developing. This is not just an issue for individuals, specialisation is usually about specialist teams (doctors, nurses, physiotherapists and so on). They are likely to become even more important in coming years as evidence starts to grow that specialist teams achieve better results for many hospital patients.
A related trend involves developing what are called "enhanced roles" for nurses. This involves nurses exercising their own discretion in quite different relationship with patients and doctors.
Nurse practitioners are specifically trained to carry out certain tasks which means that doctors can concentrate on the tasks that only doctors can do. Both types of patient gain – those seen by the nurse do not need to wait for the doctor and those who need the doctor are seen more quickly. For example, nurse practitioners in minor injuries units make their own assessment of patients and provide treatments unless a patient needs the skills and knowledge of a doctor. This role is carried out within guidelines agreed between nurses and doctors. We expect the scope for enhanced nursing roles to increase over the next decade.
So specialisation and enhanced roles are about the leading edge in using knowledge, new technologies and skills. But there are some other trends pointing in different directions. In some places in the USA, Australasia and the UK there is a growing experience of training some staff to have a wider range of skills than just those of their own profession. Nurses trained to do simple x-rays or some physiotherapy. Radiographers or physiotherapists who provide a wider support to patients – the sort of support nurses provide. Sometimes it is a case of nursing assistants who also provide social care support in the home or home helps who expand their skills into providing basic nursing care. The jargon terms for these initiatives are "multi-skilling" or staff becoming "generic workers". These initiatives are often controversial because they cut across the traditional boundaries of different staff groups. It is not yet clear whether they will become more common or whether some of them will fizzle out as interesting experiments that led nowhere.
As happens in many workplaces and industries the traditional image of different professions and jobs in the NHS is likely to change. New technologies will change the skill requirements for staff – sometimes making work even more complex, sometimes making it simpler. The revolution in information – the Web, helplines such as NHS Direct in England, digital TV – will inevitably result in patients having more information about their illness (some of it right, some misleading or wrong!). Better informed patients will increasingly expect more from the NHS and rightly so.
All of this will increase the demand for services to be designed around the patient’s own experience and needs, weakening the old tribalism of different professions.
The legal requirement that people should not work more than an average of 48 hours a week will also have an impact – mainly on doctors. Our leaflet on doctors’ hours explains this in more detail. But in a nutshell our plan to re-shape hospital services will play an important part in ensuring that doctors do not get impossibly stretched in providing cover for 24 hours a day, 356 days a year. The need to plan the use of doctors’ time better will also lead to further encouragement of nurses to extend their role.
There is another ticking time-bomb facing the NHS and its ability to staff its services properly. The age profile typical of the NHS nursing workforce in Glasgow is shown in the box below. It shows that over the next ten to twelve years a large proportion of our present nurses will reach retirement. Our ability to recruit new young nurses to replace them is going to be a tough challenge.
Age profile for registered nurses at Victoria Infirmary,
Southern General, GRI and Stobhill (1998\99)
|Less than 25||25-29||30-39||40-49||50-59||over 60|
|Number of nurses||321||700||1735||921||226||115|
The local education and training for nurses is provided mainly by Glasgow Caledonian University. Each year they take on approximately 400 young people for nurse training. The drop-out rate during the course is, typically, around 20% or more. There are many other careers competing for the very same people the NHS wants to recruit. The NHS has many attractions – better employment security than most other industries; interesting work; face to face with a great variety of people; the satisfaction of helping patients; new technologies and approaches that will improve what we can do in partnership with patients. But the flip side is less helpful – a perception of tightness over pay and a lack of family friendly flexibility. These things are being tackled but even so replacing the staff who retire is not going to be easy.
Against this background what do our plans for acute hospitals add up to for staff?
Will we need more staff or fewer? The answer is that overall in the Glasgow NHS we will probably need more but many of the jobs may be different from the present ones. Different places of work. Different skills. Fewer staff working on wards (because there will be fewer surgical beds) but more staff working in ambulatory care (see our separate leaflet which tells you what ambulatory care is), and in primary care (with GPs). We also propose to use the opportunity of there being fewer beds to strengthen the staffing on the remaining wards – more nurses per ward and a better balance of skills.
We think that a principle of no compulsory redundancies can be our watchword. But some staff will need to adapt their skills and, in some cases, to work in different places. NHS conditions of employment have protection arrangements to cover these situations. The Health Board and Trusts will need to work out the cost of providing excellent programmes for training and re-training staff to help them make the best of future career opportunities. It is possible that a very small number of staff will not be adaptable in these ways and in those circumstances they may be adversely affected by change. We would work hard with staff to keep this and the ultimate spectre of redundancy to an absolute minimum, especially since we expect there to be a difficult workforce supply position during the next ten to twelve years. The tone of the decade will be about attracting and retaining staff, not losing them.
Another factor affecting staff arises from the likelihood that some parts of the plan for new hospital building may be pursued through Public Private Partnership (PPP). This involves the private sector putting up the capital, proposing detailed design and, running some of the non-clinical support services. In the past the predecessor of PPP, the Private Finance Initiative (PFI) provoked a lot of controversy because non-clinical staff feared the threat to their security of employment, their pay and their pension rights. These issues were tackled by the new incoming government following the 1997 general election. If PPP is pursued for parts of our hospital building plan, NHS Trusts in Greater Glasgow are committed to working in partnership with staff and their trade unions to ensure the best possible transition to any new working or employment arrangements under PPP.
There is a Greater Glasgow Partnership Forum of the Health Board, Glasgow NHS Trusts and trade unions. It is already overseeing an exercise to work out what the future workforce numbers will be and how we can plan to recruit, train, re-train and retain the right mix of staff.
In the meantime we believe our plans for hospital services offer many opportunities for NHS staff. And very few threats, although we recognise we need to help NHS staff to sustain their self-confidence as they look ahead to the prospect of change.
The shape of the NHS Workforce in Scotland
Chapter P of the "Scottish Health Statistics 1999" (published by the Information and Statistics Division of the NHS in Scotland) gives Scotland-wide information about staffing. Greater Glasgow’s staff profiles will be broadly similar in their proportions.
• 72% of staff are involved in direct patient care (doctors, nurses, midwives, professions allied to medicine, scientific staff).
• Nurses and Midwives alone add up to 46% of all NHS staff.
• 28% are support staff (cleaning, catering, laundry, maintenance, clinical, management).
• 51% of female staff work part-time compared to 13% of male staff.
• There are around 8000 hospital doctors in Scotland compared with 4000 GPs.
• The annual intake of new students into general nurse education in Scotland was 1679 in 1997\98.
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