London Workforce Strategic Framework · Chapter 4: Local workforce agenda and priorities –...

London Workforce Strategic Framework

March 2016

This document was created in partnership with:

• Healthy London Partnership

• The 32 Clinical Commissioning Groups in London

• Health Education England

• NHS England (London Region)

• The Association of Directors of Adult Social Services

• NHS Improvement

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ForewordWe are pleased to present the LondonWorkforce Strategic Framework on behalf of the London Workforce Programme Board. This framework seeks to establish a coherentvoice around the most pressing workforcechallenges in London now, and to enable theworkforce to transform health and social careservices across the Capital.

The development of this London WorkforceStrategic Framework has been made possiblethrough the establishment of a collaborativeworkforce transformation programme on behalfof London’s clinical commissioning groups(CCGs), NHS England (London Region) andHealth Education England, through the HealthyLondon Partnership. This has been supported bypartners from across the system through theLondon Workforce Programme Board, DeliveryGroup and Senate.

We are also indebted to stakeholders across the system who have been involved in thedevelopment and review of this LondonWorkforce Strategic Framework. We thankclinical leadership groups and boards, workforce

steering groups, the London HR directors group, the London nurse directors group, theLondon social partnership forum, the Londonclinical senate and many others who have giventheir time to inform, challenge and clarify theworkforce challenges and potential solutionsrelating to their area of expertise. We want torecognise over 1000 stakeholders who havebeen involved to date.

We believe this framework outlines the strategicareas of focus for workforce action that will bestenable the transformation of health and socialcare services that are local to you. Thisdocument is the foundation for strategicworkforce planning in London going forward,and provides you with a guide to inform thedevelopment of your local multi-partnerworkforce transformation plans across London.We believe it also supports a continued dialogueacross the capital to promote the developmentof local solutions, enable common issues to beaddressed once, and to provide a coherent voiceto solve London’s workforce challenges.

Dr Angela Bhan

Chief Officer Bromley ClinicalCommissioning Group

Helen Bullers

Regional Director of HumanResources & OrganisationalDevelopment (London) NHS England

Julie Screaton

Director for London and South East for HealthEducation England

Foreword 3

ContentsExecutive summary 6

Background 8

Approach to determining London workforce priorities – workforce perspectives 9

Chapter 1: London’s workforce landscape 11

Chapter 2: The national workforce agenda and priorities 14

2.1 Five Year Forward View workforce agenda and new models of care 14

2.2 Five Year Forward View Mental Health Taskforce 16

2.3 Seven day working 17

2.4 Review of operational productivity in NHS providers (Lord Carter) 18

2.5 Better leadership for tomorrow: NHS leadership review (Lord Rose) 19

2.6 Distinctive, valued, personal. Why social care matters: The next five years 21

2.7 Summary 23

Chapter 3: London workforce agenda and priorities 24

– workforce implications of London transformation programmes

3.1 Cancer programme workforce implications 24

3.2 Mental health programme workforce implications 27

3.3 Children and young people programme workforce implications 29

3.4 Transforming primary care workforce implications 30

3.5 Urgent and emergency care programme workforce implications 32

3.6 CapitalNurse London programme 34

3.7 The Association of Directors of Adult Social Services workforce programme 36

3.8 London’s digital, personalisation and self-care programme 37

3.9 International healthcare models 39

3.10 Summary 40

4 Contents

Chapter 4: Local workforce agenda and priorities

– strategic planning group priorities 42

4.1 Barking and Dagenham, Havering and Redbridge (BHR) CCG partnership 43

4.2 Newham, Tower Hamlets and Waltham Forest CCG partnership 44

4.3 Barnet, Camden, Enfield, Haringey and Islington CCG partnership 45

4.4 Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCG partnership 46

4.5 Croydon, Kingston, Merton, Richmond, Sutton and Wandsworth CCG partnership 47

4.6 Harrow, Hillingdon, Brent, Ealing, Hounslow, West London, Central London, and Hammersmith and Fulham CCG partnership 48

4.7 Summary 50

Chapter 5: Key workforce findings 51

5.1 Retaining and recruiting the best staff 51

5.2 Supporting staff to collaborate across organisational and professional boundaries 53

5.3 Supporting workforce versatility to adapt to the multiple needs of patients 53

5.4 Developing leaders and managers at all levels 54

5.5 Supporting workforce agility to respond to change 55

5.6 Strengthening health systems: providers and commissioners 56

5.7 Ensuring the whole workforce has the right capability to deliver care in the right place, especially in primary health care and community services 57

5.8 Delivering improved value, quality and productivity through the workforce 58

5.9 Summary 58

Chapter 6: A framework for action 59

6.1 Supporting the delivery of tangible action to mitigate local workforce challenges 59

6.2 Longer term strategic projects 60

6.3 Conclusion 62

Appendix 1: Delivering the engagement and methodology 63

Acknowledgements 65

Glossary of terms and acronyms 66

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Contents

Contents

Executive summary

The health and social care system in Londonis highly complex due to the broad range ofservices it delivers to a diverse population. To achieve the Better Health for Londonaspiration of making London one of theworld’s healthiest global cities, and deliveringa quality service that meets the changingneeds of today’s population and thepopulation of the future, transformationalchange is required to existing services.

Delivering transformational change to services in this complex environment will require carefulthought on how to tackle the challenges this will have on the workforce. However, cuttingthrough this complexity is critical to thesuccessful delivery of better care across London.

Better Health for London (October 2014), andthe Five Year Forward View (October 2014),identified the need to focus on developing amodern health and social care workforce thatwill support the effective delivery of new modelsof care. In parallel, the Association of Directors ofAdult Social Services (ADASS) set out in Distinctive,Valued, Personal (March 2015) the distinctive roleand value of a 21st century social care workforcein the context of the Care Act 2014.

Across the health and social care system,workforce is consistently cited as the key areathat will make or break the transformation of services required in all parts of London. If immediate actions are not taken, that support the workforce to continue to deliverhigh-quality care to patients through this periodof transformation, there is a significant risk thatthe quality of services for patients now and inthe future could be affected.

The ambition in London is to support thedevelopment of a modern health and social care workforce that is trained, focused andsupported. The first step in achieving thisambition is to establish a coherent voice aroundthe most pressing workforce challenges inLondon now, and to mitigate challenges that will arise as a consequence of plannedtransformational change to services.

This London Workforce Strategic Frameworkseeks to achieve this ambition. It provides aqualitative evaluation of the workforceimplications of a number of key nationalreviews, London-wide and local transformationprogrammes and international models. Theseworkforce implications lead to eight workforcefindings, which provide the platform forimprovement.

These findings set a clear direction for where action is required. It is proposed thatcommissioners and providers across Londonembrace these findings, and use the insightsthey provide to support the development of local plans. Many solutions may be found locally,however during the development of thisframework, it has become clear that there maybe benefits in developing a number of solutionsonce for London.

This London Workforce Strategic Frameworkwill enable stakeholders across the system to develop coordinated action to workforcechallenges identified in the key findings. Inaddition, it will be important to continue to reflect on where solutions can be best solved once for London, as well as identifyinglocal solutions.

6 Executive summary

Executive summary

Executive summary 7

The eight workforce findings are:

Transforming London’s health and social care workforce

The ambition in London is to support the development of amodern health and social care workforce that is trained, focusedand supported to deliver transformed services in London.

1 Retaining and recruiting the best staff

2 Supporting staff tocollaborate acrossorganisational andprofessional boundaries

5 Supporting workforce agility torespond to change

6 Strengtheninghealth systems –providers andcommissioners

3 Supportingworkforce versatility to adapt to the multipleneeds of patients

7 Ensuring care isdelivered in the right place,with a particular focus onprimary health care andcommunity services

8 Delivering improvedvalue, quality andproductivity throughthe workforce

4 Developingleaders and managersat all levels

Background

The health and social care system is facingmany challenges. Greater demand on servicesis fuelled by an increasingly aged and frailpopulation, whilst patient expectation ofservices continues to grow. Growing demandcontinues to put pressure on current services,increasing costs and the demands on theexisting medical and non-medical health andsocial care workforce. It is widely recognisedthat serving this growth in demand is notsustainable, if we carry on the way we worknow. A change in approach is needed if weare to deliver the consistent high quality ofcare patients expect now and in the future.

Better Health for London (October 2014), and theFive Year Forward View (October 2014), identifiedthe need to focus on developing a modern NHSworkforce that will support the effective deliveryof new models of care. In parallel, the Associationof Directors of Adult Social Services (ADASS) setout in Distinctive, Valued, Personal (March 2015)the distinctive role and value of a 21st centurysocial care workforce in the context of the CareAct 2014. Across the health and social caresystem, workforce is consistently cited as the keyarea that will make or break the requiredtransformation of existing services.

The health and social care system is one thelargest employers of Londoners and is highlycomplex due to the varied range of services itdelivers to a diverse population. To deliverplanned transformational change in this complex environment will require significantconsideration of the workforce challenges.

However, cutting through this complexity iscritical to the successful delivery of better careacross London.

New models of care and initiatives to meetpatient and public needs have been developed.To deliver these new models, and mitigate theexisting challenges faced by health and caresystem, changes to workforce numbers, skillsand ways of working are essential.

To enable the delivery of this modern health andcare workforce in London for Londoners, acollaborative workforce transformationprogramme has been established on behalf ofLondon’s clinical commissioning groups (CCGs)and NHS England (London) (Healthy LondonPartnership) together with Health EducationEngland (HEE). Through working with partners,including ADASS and NHS Improvement, thisprogramme of work is recognised as an enablerto mitigate existing service workforce challenges,and ensure the successful delivery of newmodels of care across London.

This collaboration has developed this WorkforceStrategic Framework for London to establish acoherent voice around the most pressingworkforce challenges now, and as aconsequence of planned transformationalchange to existing services.

The objective of this document is to facilitate theco-ordinated delivery of those short-term (1-2years) and longer term (3-5+ years) actions,which deliver the most impact and value locallyfor Londoners.

8 Background

Everything comes down to the people, both right now and in thefuture: so we must pay attention now if we are to expect results in10, 15, 20 years. People are long term.

Source: Better leadership for tomorrow: NHS leadership review (Lord Rose) (2015)

Approach to determining Londonworkforce priorities – workforceperspectives

Better Health for London (BHfL) and the FiveYear Forward View (FYFV) both providedrecommendations to develop a modern NHSworkforce that will support the effective deliveryof new models of care, and mitigate existingworkforce challenges. In parallel, the Associationof Directors of Adult Social Services (ADASS) set out in Distinctive, Valued, Personal (March 2015)their vision of a 21st century social careworkforce in the context of the Care Act 2014.

However, since these were published there havebeen a number of developments with significantworkforce implications that need furtherconsideration. For example: the establishment of vanguard sites for new models of care;further progress of London-wide transformationprogrammes; and a greater understanding oflocal transformation programmes acrossproviders and commissioners.

Equally, additional stakeholder engagement hasdemonstrated that defining the workforceimplications of new models of care remainshugely challenging, due to their multi-facetednature and impact across local and London-widetransformation programmes.

Therefore, in ensuring this framework iscomprehensive, and accurately reflects a widerrange of views across London on the existingworkforce needs, the key findings in thisdocument were investigated through sevenworkforce perspectives:

1 Existing London - wide transformationprogrammes

A review has been conducted of majorLondon-wide transformation programmes.These are: urgent and emergency care;primary care; cancer; children and youngpeople; mental health; CapitalNurse; adultsocial care; and London’s digital,personalisation and self-care programmes.

2 A London local health economyperspective

A review of local CCG transformationprogramme priorities has been explored.

3 National workforce priorities and agenda

Recent national and London publicationshave been reviewed to assess the potentialworkforce implications.

4 Five Year Forward View new models of care

A review has taken place looking at theworkforce implications of vanguard newmodels of care.

Background

Background 9

Better Health for London (BHfL) and the Five Year Forward View(FYFV) both provided recommendations to develop a modern NHSworkforce that will support the effective delivery of new models ofcare, and mitigate existing workforce challenges.

5 International models

Three international models that are of interestto a number of commissioners and providersacross London have been reviewed with aparticular emphasis on the workforceconsiderations if they were applied in thehealth and social care system.

6 Current vs future modelling

A collation of available London workforcedatasets has been undertaken to support theestablishment of a workforce strategicbaseline for London.

7 Strategic drivers, barriers and enablers

Identification and analysis of thosefundamental strategic drivers, barriers andenablers from looking at all of the analyses.

Ensuring that London is able to educate,train, lead and support its workforceeffectively underpins the success of theambitious transformation planned acrossLondon. This framework provides insightsfrom a broad range of perspectives andderives a set of findings and recommendationswhich support both the development of theworkforce for the future, and enable theexisting workforce to work effectively in the transformed health and social care system in London.

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Background

Background

ReferencesDepartment of Health (2015) Better leadership for tomorrow: NHS leadership review, www.gov.uk/government/publications/better-leadership-for-tomorrow-nhs-leadership-review

London Health Commission (2014) Better Health for London, www.londonhealthcommission.org.uk/better-health-for-london/

NHS England. et al (2015) Better Health for London: Next Steps, www.london.gov.uk/priorities/health/publications/better-health-for-london-next-steps

NHS England et al (2014) The NHS Five Year Forward View, www.england.nhs.uk/ourwork/futurenhs/

Distinctive, Valued, Personal. Why social care matters: The next five years, www.adass.org.uk/uploadedFiles/adass_content/news/press_2015/Distinctive%20Valued%20Personal%20ADASS%20March%202015(1).pdf

Healthy London Partnership, www.myhealth.london.nhs.uk/healthy-london/about

For more information about themethodology used to develop thisframework please see Appendix 1 on page 63.

www.adass.org.uk/uploadedFiles/adass_content/news/press_2015/Distinctive%20Valued%20Personal%20ADASS%20March%202015(1).pdf


Chapter 1:

London’s workforce landscape

Through a review of available literature, and engagement with system-wide stakeholders,the following workforce trends are identified in London:

London is recognised as a centre ofexcellence for health training and education;locally, nationally and internationally. This ismade possible through:

n innovative local clinical and non-clinicaleducation and training workforce models,commissioned via LETBs working closely withlocal partners

n unique training opportunities. For example in specialist services using cutting edgetechnology and techniques

n links to high-quality, internationally-renownedresearch in health and healthcare subjectsproviding a centre of excellence for healthtraining

n the contribution of London medical andhigher education institutions in their deliveryof health training and education.

Chapter 1

London’s workforce landscape 11

To create a modern workforce in the capital, an appreciation of theunique workforce landscape that exists across London is required.

To create a modern workforce in the capital, an appreciation of the unique workforcelandscape that exists across London is required. This landscape is currently very challenging.Workforce gaps are often cited across many staffing groups, including urgent and emergencyconsultants, mental health nursing teams and GPs. There is a lack of sufficient workforcecapacity in certain care settings to meet patient demand for services (e.g. in the delivery ofcancer diagnostics in secondary care). It has been found that more than a third of the workforcewho train in London subsequently choose to move away. London’s health and social careworkforce is an ageing workforce, with 15% of London GPs aged 60 and over compared to 8% in the rest of England. Staff turnover is recognised as being higher in London than in other regions (e.g. for NHS111 attrition rates for health advisors are between six and 41%, and clinical advisors are between three and 36%).

London has a unique workforce profile, andcan be a challenging place to live and work.Particular trends in London are:

n turnover is high, and there are significantrecruitment challenges in some areas

n many newly qualified professionals leaveLondon shortly after completing their training.There are a number of reasons. However, themost cited is the high cost of living, inparticular the lack of affordable housing

n there is significant evidence to show a shiftfrom acute to community sector-basedworking in London.

Looking ahead, London’s health and socialcare workforce will need to adapt to deliverpersonalised care and enable whole systemtransformation. To do so:

n care will need to be delivered closer topatients’ homes, delivering the outcomes thatmatter most to them. The workforcecontinues to be a critical enabler to deliverthis personalised care based on localpopulations’ needs

n there is a need to promote a cultural andbehavioural shift in the way training isdelivered, the majority of which is in hospitals.This means that a hospital-focused mind-setpersists within the existing workforce

n there must be a significant increase in theoverall number of staff delivering primaryhealth care and community services

n a broader range of roles are required todeliver the specification set out in theStrategic Commissioning Framework forPrimary Care in London. Similarly, totransform the urgent and emergency caresystem, the varying workforce challengesfaced in different parts of London need to beaddressed with innovative solutions. Otherkey transformation programmes of work in,for example, mental health, children andyoung people’s services and cancer will alsosignificantly impact on the workforce

n the skills of the workforce need to evolve.There needs to be a greater emphasis onhaving a more flexible, generalist skillset; the ability to support people to care forthemselves; and skills which complementboth health and social care

n a change of mindsets and behaviours isrequired of the workforce to deliver greaterpersonalised care

n effective clinical leadership will beinstrumental in delivering new models of care, and must reflect the diverse nature of London’s workforce and Londoners themselves.

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Chapter 1

London’s workforce landscape

Looking ahead, London’s health and social care workforce willneed to adapt to deliver personalised care and enable wholesystem transformation.

London’s healthcare system is complex, with levers and barriers to change atmultiple levels:

n defining the workforce implications of new models of care remains hugelychallenging due to their multi-faceted nature,and impact across all local and London-widetransformation programmes

n addressing these issues will require a London-wide perspective and a collaborativeapproach to identifying core initiatives toaddress the issues at each level of the system.

London’s health and social care workforce needs to adapt to significantlyimprove productivity, whilst retainingquality and safety:

n there is a national focus on achievingsubstantial (2-3% per annum) efficiency gains

n Lord Carter’s review found that managingworkforce costs were a key part of improvingthe financial position of the NHS

n delivering the right care in the right setting,and finding new ways of delivering care, willbe critical to success and clearly has specificworkforce implications.

Chapter 1

London’s workforce landscape 13

ReferencesLondon Health Commission (2014) Making it happen workforce technical pack, www.londonhealthcommission.org.uk/supportingdocuments/

NHS England (London) (2015) Transforming Primary Care in London: A Strategic Commissioning Framework, www.myhealth.london.nhs.uk/healthy-london/primary-care/resources

Department of Health (June 2015) Review of Operational Productivity in NHS providers, Interim Report,www.gov.uk/government/publications/productivity-in-nhs-hospitals

Department of Health (2016) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, www.gov.uk/government/publications/productivity-in-nhs-hospitals

Healthy London Partnership transformation programmes call for evidence submissions

These trends in London demonstrate the complex environment in which a modern health andsocial care workforce needs to operate to deliver services that meet the needs of patients now,and in the future. Having an appreciation of each of these trends is important to ensure that thisframework is focused on addressing the workforce priorities which best support the existingworkforce to operate in this environment more effectively.

The following chapters reflect in more detail on the workforce implications of these trends, andthe workforce priorities that form the foundation of this London Workforce Strategic Framework.

Chapter 2:

The national workforceagenda and priorities

2.1 Five Year Forward Viewworkforce agenda and newmodels of care

The FYFV sets out a vision for the future of the health and social care system, recognises the challenges and outlines potential solutions to the big questions facing health and careservices in England.

As part of this framework, a clear workforceagenda for change is described focused on:

n Expanding new health and care roles

HEE will continue to work with its statutorypartners to commission and develop newhealth and care roles (e.g. with UniversitiesUK).

n Evolving working patterns, pay, andterms and conditions

NHS employers, staff and theirrepresentatives will need to consider howworking patterns, pay, and terms and

conditions can best evolve to fully rewardhigh performance, support job and serviceredesign, and encourage recruitment andretention in parts of the country and inoccupations where vacancies are high.

n New measures to support employers toretain and develop existing staff

New measures will be put in place to supportemployers to retain and develop their existingstaff, increase productivity and reduce thewaste of skills and money.

n Identifying the education and trainingneeds of the current and future workforce

HEE will work with employers, employees andcommissioners to identify the education andtraining needs of the current workforce,equipping them with the skills and flexibilitiesto deliver new models of care, including thedevelopment of transitional roles. HEIs andservice providers will play an important role indetermining the future workforce supply andquality requirements, especially in non-medical roles.

Since BHfL and the FYFV were published in October 2014, there have been a number of other significant national reviews citing their implications on the existing and future healthand social care workforce. A specific focus has been on developing a health and social careworkforce to provide ‘seven day services’ in both primary and secondary care; improvedleadership at all organisational levels; and increasing productivity across the system. It isimportant that this framework takes into consideration the workforce implications ofnational recommendations across the system, and reflects on the impact this could have in the context of service transformation in London.

This chapter provides an insight into the workforce implications of those significant nationalpublications which will shape the requirements of a modern workforce in a transformedhealth and social care system.

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Chapter 2

The national workforce agenda and priorities

Chapter 2

The national workforce agenda and priorities 15

A key focus of the FYFV vision is the implementation of new modelsof care to mitigate current challenges faced by the health and socialcare system.

The workforce focus of vanguard newmodels of care

A key focus of the FYFV vision is theimplementation of new models of care tomitigate current challenges faced by the healthand social care system. In January 2015, NHSorganisations and partnerships were invited toapply to become ‘vanguard’ sites. Each of thesesites is taking a lead on the development of newcare models, which will act as the blueprints forthe health and social care system moving forwardand be the inspiration to the rest of the system.

Workforce implications

1 Thematic reviews of each vanguard site,undertaken in collaboration with the NHSEngland national ‘new models of care team’,identified that a modern flexible workforce isintegral to the success of vanguards. Referencewas made to the fact that multi-disciplinaryteam working will be pivotal, with networks ofcare organised around patients and localpopulations – reflecting the diversity of thecommunities served.

2 In addition, further vanguard workforcepriorities were considered by HEE, whichidentified eight further key areas of focus tobest enable the successful delivery of newmodels of care:

n Workforce development

n New and extended roles, skills and training

n Pay and reward

n Grading and role design

n Organisational development and culture transformation

n System reform

n Alignment to local workforce strategy

n Leadership development.

3 As part of this initial assessment of vanguards,challenges associated with workforcedevelopment and cultural transformations wereraised as the top areas of focus to be addressedin order to achieve maximum impact.

4 As vanguards are testing and refining newmodels of care, identifying their workforcepriorities, it can safely be assumed that‘followers’ will be similarly challenged. As a consequence, consideration is neededon how support is extended to all serviceproviders in the longer term.

The FYFV sets a clear direction of travel, withfurther work still ongoing by the NHS Englandnational new models of care programme teamto conclude those national workforce supportpackages that will provide the greatest value tovanguard sites. However, these initial workforcepriorities provide an indication of the workforcepriorities London will need to focus on in future.

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Chapter 2


2.2 Five Year Forward View Mental Health Taskforce

In March 2015 NHS England launched aTaskforce to develop a five-year strategy toimprove mental health outcomes across theNHS, for people of all ages. This Five YearForward View for Mental Health clearly sets outhow national bodies will work together betweennow and 2021 to help people have good mentalhealth, and make sure they can access evidence-based treatment rapidly when they need it.


This five-year strategy outlines the multi-disciplinary workforce strategy for the futureshape and skill mix of the workforce required todeliver the Five Year Forward View for MentalHealth that will be developed by HEE, withstakeholders, in 2016.

Workforce recommendations from theFive Year Forward View for Mental Health include:

1 Recommendation 32: HEE should work with NHS England, PHE, the LocalGovernment Association and localauthorities, professional bodies, charities,experts-by-experience and others to developa costed, multi-disciplinary workforce strategyfor the future shape and skill mix of theworkforce required to deliver both thisstrategy and the workforce recommendationsset out in Future in Mind. This must report byno later than 2016.

2 Recommendation 33: NHS England shouldensure current health and wellbeing supportto NHS organisations extends to include goodpractice in the management of mental healthin the workplace, and provision of occupationalmental health expertise and effectiveworkplace interventions from 2016 onward.

3 Recommendation 34: NHS England shouldintroduce a CQUIN or alternative incentivepayment relating to NHS staff health andwellbeing under the NHS Standard Contractby 2017.

4 Recommendation 35: NHS England shoulddevelop and introduce measures of staffawareness and confidence in dealing withmental health into annual NHS staff surveysacross all settings.

5 Recommendation 36: The Department of Health and NHS England should work with the Royal College of GPs and HEE toensure that by 2020 all GPs, including the5,000 joining the workforce by 2020/21,receive core mental health training. Theyshould also develop a new role of GPs withan extended scope of practice (GPwER) inmental health, with at least 700 to be inpractice within five years.

6 Recommendation 37: The Department ofHealth should continue to support theexpansion of programmes that train people toqualify as social workers and contribute toensuring the workforce is ready to provide highquality social work services in mental health.This should include expanding Think Ahead toprovide at least an additional 300 places.

7 Recommendation 38: By April 2017, HEEshould work with the Academy of MedicalRoyal Colleges to develop standards for allprescribing health professionals that includediscussion of the risks and benefits ofmedication, and take into account people’spersonal preferences – including preventativephysical health support and the provision ofaccessible information to support informeddecision-making.

Chapter 2


2.3 Seven day working

Delivery of NHS services seven days a week isheadline news. The considerable drive to deliverthis agenda builds on a groundswell of reportsand initiatives since the turn of the decade,focusing on:

n Safety

The seven days a week forum developed tenclinical standards for access to urgent andemergency care services; their supportingdiagnostic services; and seven days a weekservices. This was to address the perceived gapin safety between mid-week and weekendservices. By 2020, 100% of the population willbe covered by these standards.

n Efficiency

Opening some services seven days a week hasbeen proposed as a way of maximising valuefrom expensive assets, such as imaging andradiotherapy equipment, as well as in dealingwith the increase in demand for diagnosticservices. In addition, it has been proposed thatimproving seven day access to services in theacute and community settings would reduce therisk of delayed discharge, leading to a reductionin length of stay.

n Access

Extending access to GP services across sevendays, and at times convenient to “hard workingpeople” has been a cornerstone of ConservativeNHS policy, and has been reiterated onnumerous occasions, despite scepticism from GPleaders over the cost and ability to implement.The initiative has been supported by PrimeMinister’s Challenge Fund investment in pilotareas, with seven pilot sites in London.


The key workforce challenges recognised whendelivering seven day working are:

1 The cultural and behavioural change required,especially for staff who have not traditionallyworked ‘out of hours’.

2 The need to increasingly work collaborativelywith staff to re-design working patterns,while ensuring flexibility and worklife balancefor staff.

3 The equality and diversity implications ofimplementing seven day working.

4 The availability of support services that enableservice delivery such as transport, child care,and the availability of core care services – forexample to support community discharge.

5 The cost and ability to recruit additional staffto move to shift systems, particularly with ageneral shortage of staff in primary care.

6 The reform needed of medical contracts andconsultation with 'agenda for change' staff.

7 The need to develop suitable rotas andassociated management skills and software.

8 The network working and joint rotas neededto enable implementation in areas with smallstaff numbers, or across primary care regionsor federations.

9 The adjustments required to clinical leadership.

10 The development of new and existing roles to support medical staff and to delivergeneralist skills in multiple settings, includingsome roles extension – for example forcommunity pharmacists.

11 Further development of the bridge betweenacute and primary care.

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Chapter 2


2.4 Review of operationalproductivity in NHS providers(Lord Carter)

The NHS in London faces a £4.76 billionaffordability gap between forecast funding levelsand the expected rise in demand for healthcareby 2020/21. Bridging this gap is partly dependenton improving quality and efficiency in NHShospitals, which will be challenging to deliver.

Lord Carter’s recent review of operationalproductivity in English non-specialist acutehospitals focuses on:

n optimising clinical resources (e.g. improvingpeople policies and practices)

n optimising non-clinical resources (e.g.procurement, corporate and administrativecosts)

n quality and efficiency across patient pathways(e.g. enabling digital technology andinformation systems)

n creating the model hospital and an integratedperformance framework

n engagement with trusts and implementationto deliver sustainable change.

Approach

The NHS is expected to deliver efficiencies of 2-3% per year, effectively setting a 10-15% realterms cost reduction target to be achieved byApril 2021. The review concluded that efficiencysavings could be realised through reducingunnecessary variation across key resource areas.These include clinical staff, pharmacy andmedicines, procurement, back-office functions,estates and facilities. This would be achievedthrough a combination of:

n a national people strategy andimplementation plan

n developing and implementing measures foranalysing staff deployment

n better collaboration and coordination ofclinical services across local health economiesto prevent avoidable admissions and supportearly discharge

n managing workforce costs by rationalisingcorporate and administration functions

n better procurement

n improving estates, diagnostics and imaging,pharmacy and medicines management

n leveraging further digital technology andinformation systems to improve quality andefficiency across patient pathways.


1 This report recommends that NHSImprovement should develop a nationalpeople strategy implementation plan, whichlooks to simplify system structures, raisepeople management capacity and build amore engaged and inclusive environment in which the workforce can operate.Development of effective leaders andmanagers will also be required to ensure thatbest practice approaches are adopted acrossthe areas described in this review, such asworkforce deployment, management offlexible working practices and ward roundeffectiveness.

2 The report focuses on improved governanceand reporting in order to measureperformance and efficiency improvements,citing the need for a clear set of metricssupported by one source of underlying data,benchmarks and appropriate managementcontrols. Alignment of incentives andmeasures at all levels to deliver high-valuehealthcare will be important.

3 Examples are given where effective use of key enablers could help to maximise theeffectiveness of clinicians and managers, forexample e-rostering, shared services andbetter procurement support.

Chapter 2


Key findings

The report highlighted key areas of concern, many of which it said were ‘chronic andunaddressed over an extended period’. These are:

• a lack of ‘one NHS vision’ and a commonethos

• insufficient management and leadershipcapability to deal effectively with the vastrange of changes to which the NHS iscommitted

• a need for overall direction of careers inmanagement across medical, administrativeand nursing cadres.

The recommendations of the review highlightedfive areas for focus:

Vision• Having a single communications strategy• Having a single NHS handbook.

Training • HEE to coordinate all NHS training • NHS Leadership Academy to transition to HEE• Accredit training establishments• Review and expand exemplar NHS management

development schemes• Remove barriers to progression to middle

management• Mandatory qualification for senior managers.

Performance management • Embed core management competencies and

behaviours • Ongoing career support for managers• Establish NHS appraisal system.

Management support • NHS-wide comments board • Minimum-term, centrally-held contracts for very

senior managers• Formally review non-executive directors and CCG

lay members.

Bureaucracy • Review data demands now and regularly • Merge Trust Development Authority (TDA) and

Monitor• Establish organisational balance scorecard• Burdensome impact assessment template.

4 Improved collaboration between staff across organisational boundaries will beneeded if coordination of clinical servicesacross local health economies is to beimproved, so that services can better meetthe needs of their local communities (e.g. by preventing avoidable admissions and supporting early discharges).

5 The desire to manage workforce costs byrationalising corporate and administrativefunctions will require, among other enablers,aligning ways of working across trusts todeliver the expected efficiencies.

2.5 Better leadership fortomorrow: NHS leadershipreview (Lord Rose)

In early 2014 Lord Rose was asked by theSecretary of State for Health, Jeremy Hunt, to review what more could be done to attracttop talent from inside and outside the healthsector into leading positions in NHS hospitaltrusts. In addition, this review was asked toinclude recommendations on how strongleadership in hospital trusts could be used as aforce for good to transform organisationalculture. In early 2015, the review was extendedto consider how best to equip CCGs to deliverthe FYFV. The ‘Rose Review’ was published inJune 2015.

Each of the 19 recommendations of the report were accepted ‘in principle' with a pledge that the Department of Health will work with the health and care system to develop plans “to implement eachrecommendation to the extent possible, subject to an assessment of proportionality, cost-effectiveness and affordability”.

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Social care is a vital connector of individuals to other services whichcan help prevent crisis and promote wellbeing. ADASS suggests thatsocial care is more than just an ‘add-on for the NHS’


The report draws attention to the significantmanagement and leadership challengespresented by recent NHS reforms, and thecontinuous pace of change. The implications for all NHS organisations from a workforceperspective, if accepted in full, could besignificant.

1 Local employers…

are likely to encounter greater coordinationand rigour in the availability of trainingprogrammes, but may face pressure to scaleback their own schemes. It will be a similarpicture for the appraisal infrastructure andexisting work on organisational values andculture. Employers will need to play a key rolein embedding managerial competencies andorganisational values, whilst identifying anddeveloping leaders. Employers may haveaccess to a wider pool of accredited leadersand managers both at the beginning of theircareers and in more senior roles, but will beexpected to take an active role in recruitmentfrom outside the sector.

2 Local CCGs…

are likely to have a core role in ensuringprovider organisations adhere to pan-NHSwork on shared values, as well as practicalapplications such as embedding newappraisal processes. At the same time localCCG leadership and management teamsshould benefit from greater access to pan-sector development opportunities andcareer pathways.

3 Regional bodies…

are given renewed focus by the Rose Review.Linking large-scale national initiatives, such as the NHS-wide staff handbook andcommunications strategy with employerorganisations is likely to require a regionalapproach. Similarly the roll out of significantchanges to performance management,training and ongoing support will probablyrequire regional support.

4 National bodies…

HEE will be challenged with new authority inthe direction of training, and will take on thehosting of NHS Leadership Academy.

2.6 Distinctive, valued, personal.Why social care matters: The next five years

The Care Act 2014 is an important step forward,replacing a myriad of historical legislation with asingle modern statute that reflects 21st centuryneeds and values of people in social care.However, legislation alone is not enough. Thereremain significant challenges with the adequacyof the current health and social care system tomeet the ever growing new and existing needsof those in social care. It is recognised thatexisting financial pressures are a significant causeof these challenges. However the quality of care,how the workforce delivers this care, and towhat extent services are integrated across healthand social care are all significant factors.

The Association of the Directors of Adult SocialServices (ADASS) published in 2015 ‘Why SocialCare Matters: The next five years’, whichoutlines the main challenges facing the adultsocial care system. This work, and its recognisedalignment with the recommendations of theFYFV, demonstrates the imperative of aligningaction in a coordinated way across the healthand social care workforce.

Approach

This report takes into consideration a number ofperspectives, and outlines why the current socialcare system needs to change. These include:

n Our needs are changing – The UK populationis growing and we are living longer. Thisincludes younger people with disabilities andhealth conditions. The number of people withlearning disabilities who will need social careservices is forecast to rise 25% by 2030. Thepattern of need is also changing dramatically(e.g. a greater number of citizens are livingwith co-morbidities). As a result, it isbecoming much harder for professionals todemarcate social care needs from those thatare the responsibility of the NHS.

n Building the right model of care andsupport – Social care is a vital connector of individuals to other health services, whichcan help prevent crisis and promotewellbeing. ADASS suggests that social care ismore than just an ‘add-on for the NHS’ andservices need to be aligned to removeorganisational barriers. The removal of thesebarriers, both within the NHS and betweenthe NHS and social care, would help tosimplify the health and social care system.ADASS suggests that the new delivery modelsoutlined in the ‘NHS Five Year Forward View’will not necessarily be any more effectivethan current organisational models, unlesssocial care services are integral to the design.Concern is also expressed about the mis-match in existing funding arrangement. Thedisparity is clear between a protected budgetfor the NHS, which is ‘a universal service freeat the point of use’, and an increasinglyrestricted social care sector, ‘rationed evermore tightly to those with the highest needsand lowest means’.

n Who pays for care – An ever increasingnumber of citizens are responsible for thecost of their own social care and support,whereas health care has largely remained freeat the point of use for all. This is even withthe support of local authorities who spend£14 billion a year on delivering social careservices, which is 35% of their total spendingand the biggest single budget that councilscontrol. This draws into question thedifference in approach to how health andsocial care services should be funded.

n Economic growth is also about a growingsocial care sector – most effective andsustainable providers are small businessesthat provide a sizable contribution to the local economy.

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n Funding needs to keep pace with populationneeds and expectations – It is recognised thatthe number of citizens needing social care andsupport has been increasing over time and willcontinue to do so. Equally, the UK populationwants more from available health and careservices. Our expectations about the quality ofcare we want for ourselves and our family, thedegree of choice and say in how our needsare met, and the kind of information onwhich to base these decisions, has changedbeyond recognition.

Vision and ambitions

This report set out a model for social care basedon a new relationship with citizens. At its core isthe continuity of a social care approach thatrecognises how our different individual needs sitwithin a wider network of personal and socialrelationships in the community. This model ofsocial care sees each citizen as an individual withrelationships, and a person living in a community.The model is based on four key elements:

n Good information and advice to enable eachcitizen to look after themselves and eachother, and receive the right help at the righttime as needs change.

n The recognition that we are allinterdependent, needing to build supportiverelationships and resilient communities.

n Services need to help citizens get back ontrack after illness, or support disabled peopleto be independent.

n When an individual is in need of care andsupport, there is a need for services that arepersonalised, of good quality, and effectivelyaddress that person's mental and physicalwellbeing. Integrated services built around anindividual’s needs, and those of our carers, isrecognised as the way forward. Personalbudgets are central to this approach.


To deliver this model of social care services, thereport makes reference to the workforcetransformation required to deliver this modeland overcome existing challenges. These include:

1 The ongoing sustainability of a workforcewhere levels of pay, training, skills and statusare not keeping pace with changing andmore complex levels of individual need. Thisdemands renewed attention to how servicesare led, commissioned, and funded. This is inconjunction with what kind of job roles andcareer pathways should be designed to meetchanging needs.

2 Many citizens with care and support needsare clear that they want to be treated asindividuals. They want equal attention paid totheir mental and physical wellbeing. Inpursuing closer integration of health andsocial care services, an avoidance of over-medicalised approaches to individuals’conditions needs to be considered. Furtherco-ordination with other services, such ashousing or the benefits system, are alsorecognised as important.

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ReferencesLondon Health Commission (2014) Better Health for London, www.londonhealthcommission.org.uk/better-health-for-london/

2.1 NHS England, et al. (2014), The NHS Five Year Forward View, www.england.nhs.uk/ourwork/futurenhs/

NHS England, et al. (2015), The NHS Five Year Forward View, Time to Deliver, www.england.nhs.uk/2015/06/04/time-to-deliver/

Health Education England call for evidence submission

2.2 The Five Year Forward View Mental Health Taskforce: public engagement findings,www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2015/09/fyfv-mental-hlth-taskforce.pdf

2.3 NHS Commissioning Board (2013) Everyone Counts: Planning for Patients 2013/14, www.england.nhs.uk/everyonecounts/

Report by the Future Hospital Commission to the Royal College of Physicians. Future hospital: Caring for medical patients (September 2013)www.rcplondon.ac.uk/projects/future-hospital-commission

Pym, H. (August 2015) “Seven-day NHS - claims and counter claims”, BBC News online, www.bbc.co.uk/news/health-33894506

NHS England (December 2013) NHS Services, Seven Days a Week Forum: Summary of Initial Findings, www.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/

National Audit Office (April 2011) Managing high value equipment in the NHS in England, https://www.nao.org.uk/wp-content/uploads/2011/03/1011822.pdf

NHS England (December 2013) NHS Services, Seven Days a Week Forum: Workforce and organisational developmentwww.england.nhs.uk/ourwork/qual-clin-lead/7-day-week/

Press release 4 October 2015, Prime Minister pledges to deliver 7-day GP services by 2020, www.gov.uk/government/news/prime-minister-pledges-to-deliver-7-day-gp-services-by-2020

NHS England (December 2013) Seven day a week clinical standards, www.nhsiq.nhs.uk/media/2498217/appendix_b_clinical_standards.pdf

NHS England (accessed 7 October 2015) Prime Minister’s Challenge Fund, www.england.nhs.uk/ourwork/qual-clin-lead/calltoaction/pm-ext-access/

2.4 Department of Health (2016) Operational productivity and performance in English NHS acute hospitals: Unwarranted variations, www.gov.uk/government/publications/productivity-in-nhs-hospitals

2.5 Better leadership for tomorrow: NHS leadership review (Lord Rose): Department of Health (2015) Better leadership for tomorrow: NHS leadershipreview, www.gov.uk/government/publications/better-leadership-for-tomorrow-nhs-leadership-review

2.6 Distinctive, Valued, Personal. Why social care matters: The next five years, www.adass.org.uk/uploadedFiles/adass_content/news/press_2015/Distinctive%20Valued%20Personal%20ADASS%20March%202015(1).pdf

Care Act 2014, www.legislation.gov.uk/ukpga/2014/23/contents/enacted

2.7 Summary

The combination of these national perspectives highlights the scale of planned transformation acrossa wide range of areas for an extended period of time. It is clear that implementing each of theserecommendations will have a significant impact on the workforce, and will need careful considerationas a consequence of their interdependencies. These insights reflect a clear ambition to establish amodern workforce that is increasingly productive, can deliver transformed services as part of newmodels of care, and increasingly work seven days a week in both primary and secondary care.

To deliver this modern workforce, national publications reflect on those key enablers to facilitatethis, which are:

1 Significant culture change to the way in which the current workforce operates is required tomove to a system that is able to deliver consistent services seven days a week, and produce thelevels of productivity anticipated to meet known funding gaps.

2 A focus on developing the existing workforce is needed to ensure staff have the skills,competencies and experience to deliver the new ways of working that will be expected as partof new models of care. This includes the support required to ensure the current workforceremains resilient to the continuous pace of change.

3 Adjustments to operational processes that hinder organisations from managing their workforceefficiently and inhibit the workforce from working in new ways across organisational boundaries.

4 Action to attract, develop and retain talent, particularly to improve the strength and depth ofleadership and management skills at all levels.



Chapter 3:

London workforce agenda and priorities

Workforce implications of London transformation programmes

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London workforce agenda and priorities – workforce implications of London transformation programmes

This chapter provides insights into the workforce implications of London-wide transformationprogrammes. Each programme summary reflects the analysis undertaken with a broad rangeof representatives from the major London-wide transformation programmes. The mostestablished Healthy London Partnership (HLP) programmes were chosen, in conjunction withthe London CapitalNurse programme and the Association of Directors of Adult Social Services(ADASS) London workforce programme.

The transformation programmes selected were:

n Transform cancer services

n Mental health

n Children and young people

n Transforming primary care

n Urgent and emergency care (including NHS 111)

n CapitalNurse programme

n The Association of Directors of Adult SocialServices London workforce programme

n London’s digital, personalisation and self-care programme.

Each programme summary provides a briefdescription of the programme context, theapproach being taken across London and the key workforce implications of the plannedtransformation.

By reflecting the workforce implications of these programmes, it has been possible toconsider the combined impact of their plannedtransformational change on the future andexisting workforce.

In addition, this chapter provides an insight intothree international models often cited asexemplars to be emulated across London. Theseare the Buurtzorg home care model, theChenMed primary care group practice and theNew Zealand primary care nursing developmentmodels. These have been selected as there issignificant interest in how aspects of thesemodels may be applied in London.

London’s population is unique and its composition changing –this will drive future need and demand for health and social careservices in London.

3.1 Cancer programme workforce implications

Achieving World Class Cancer Outcomes: A Strategy for England 2015-2020 waspublished in July 2015 and has been endorsedby all relevant arm’s length bodies. It has set new ambitions for cancer outcomes to ensureEngland can match those seen elsewhere in the world.

London has been successful in improvingpopulation awareness of the signs and symptomsof cancer, and promoting referrals from primarycare via the two-week wait pathway.

Approach

The Transforming Cancer Services Team forLondon (TCST) was set up in April 2014 toachieve world class cancer outcomes, andimprove patient experience across London. TheTCST delivers the national priorities set out inAchieving World Class Cancer Outcomes: AStrategy for England. This is in addition toregional priorities set out in A model of care for cancer services (2010) and more recently theFive Year Cancer Commissioning Strategy forLondon (2014).

The TCST continues to deliver against fivepriority areas set out in its plan for 2015/16.

These are:

Priority A: Earlier detection and awareness

Priority B: Reducing variation in outcomes, and service consolidation to deliver centres ofexcellence

Priority C: Living with and beyond cancer

Priority D: Supporting commissioning, including contract negotiation, management and monitoring

Priority E: Improving patient experience acrosshospitals, general practice and the community.

In addition, two new priority workstreamshave also been taken forward:

n Cancer waiting times

n Pan-London implementation of NICESuspected cancer: Recognition and Referralguidance.

These priorities are the focus for the TCST nextyear and are concurrent with the support requiredto deliver system changes through developmentof the cancer alliances and vanguards. Pan-London clinical engagement will need to bemaintained; this will need to be co-designed withthe vanguards and South East London.

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London workforce agenda and priorities – workforce implications of London transformation programmes 25

The Transforming CancerServices Team for London(TCST) was set up in April2014 to achieve world classcancer outcomes, andimprove patient experienceacross London.


From activities conducted, eight clear workforceinsights have emerged. The first relates to thechallenges largely in the acute and diagnosticsworkforce. Priorities two to eight relate to thelikely workforce implications of introducing newmodels of cancer care.

1 Growth in demand has led to a lack of capacityin key areas of the workforce includingradiology; endoscopy; medical oncology;clinical nurse specialists; and specialist alliedhealth professionals (AHPs), with variableaccess to end of life care and specialist palliativecare services. Current workforce planningmodels may not be fit for purpose to addressthese issues. Changes to ways of working, suchas networked models and the introduction ofnew roles, may increase capacity.

2 At present there is an insufficient secondarycare workforce to deliver the earlier cancerdiagnosis ambitions of the new NICE referralguidance (NG12); Achieving World-ClassCancer Outcomes; the 'straight-to-test'model; multi-disciplinary diagnosis centres(MDCs); and extension of current diagnosticcentre opening hours.

3 A significant culture shift is required in orderfor cancer to be recognised and managed as a long-term condition, with primary andsecondary care teams adopting similar ways of working to those used to support patientswith other long term conditions (e.g. diabetes)including behaviour-change support,empowerment to self-manage, and access to psychological support.

4 To support the prevention of unplannedcancer patient admissions to acute hospitals,and meet the anticipated rise in demand forcancer services in the community, a workforcewith a more generalist cancer skillset isrequired in the community. An enabler to thiswould be an adjustment in existing specialistand generalist training.

5 To raise the quality of service delivered tocancer patients across London, improvedcommunication is required between primarycare and acute hospital clinicians aroundpatients’ care plans (e.g. end-of-treatmentsummaries). This would support primary careclinicians to make more informed decisions,allowing personalisation of patients’continuing care.

6 Better communication and shared decision-making around patient care plans wouldsupport patients to have a greater awarenessof their condition and the confidence to self-manage, and make treatment choices thatreflect their own priorities.

7 To meet the anticipated increase in demandfor cancer services in the community,including end of life care, alternative ways ofworking will be needed using the existingnumber and capacity of clinical teams. Forexample there are known workforce shortagesin particular clinical roles. In secondary carethese include, cancer nurse specialists, AHPs,endoscopy, radiology, and pathology. Withinprimary care, GPs, healthcare assistants, AHPs,district and practice nurse numbers haveknown workforce issues. A multi-professionalapproach with greater flexibility in team rolesmay be required.

8 Specialist palliative care and end of life care have a major role to play in themanagement of cancer patients acrossLondon. There are significant inequities in thespecialist palliative care workforce in primaryand secondary care. The end of life careworkforce is facing a growing service demandand a reduction in workforce particularly GPs,district nurses, care and nursing home staff,therapists, and social workers.

26 London workforce agenda and priorities – workforce implications of London transformation programmes


3.2 Mental health programmeworkforce implications

Poor outcomes and care for people with mentalhealth issues produces significant financial andproductivity burdens on London and its services.According to the Mayor’s report London MentalHealth: the invisible costs of mental ill health(2014), the wider impact of mental illness coststhe city roughly £26 billion a year including £7.5billion in treatment costs, which are projected todouble by 2031.

Building clinical competence, confidence andcapacity along with awareness of mental healthin primary care will help ensure that more peopleare diagnosed and treated quicker and thatmental health services are equipped to respondto increasing demand.

There is evidence of the need to increase the skillsof the workforce to diagnose and treat mentalhealth illness. A better trained primary careworkforce could support the delivery of better,more integrated services leading to improvedoutcomes and experience for service users.

Approach

The London Health Commission supported arange of recommendations that aim to improvethe mental health of Londoners. These includeambitions to reduce the gap in life expectancybetween adults with serious mental illness andothers, and recommendations that cover mentalhealth in primary care, access to digital mentalhealth and developing a pan-London responseto people in crisis.

To respond to these challenges and support thesystem, the following priorities and workprojects have been agreed by the Mental HealthTransformation Board.

The HLP mental health programme, working inconjunction with the mental health strategicclinical network, has identified the following aspriority areas of work:

n Addressing the mortality gap for people withsevere and enduring mental illness byaddressing physical risk factors and improvingaccess to support with a focus on pan-Londonopportunities and inter-agency working.

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n 75% of mental illnesses present by theage of 18.

n More than 15% of London’s adults arelikely to have a common mental illnesssuch as depression or anxiety, however,of these only 24% are likely to bereceiving clinical help.

n Even though there is unmet need,between a quarter and a third of all GPconsultations are related to mentalhealth concerns.

n People in London with a serious mental illness (such as psychosis,schizophrenia or bipolar disorder)experience a life expectancy 15-20 yearsshorter than the rest of the population.

n Londoners with a serious mental illnesshave a 74% higher risk of death after adiagnosis of cancer compared to others.

n 40% of all cigarettes in England aresmoked by someone with a mentalhealth problem.

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n Strengthening the response for people inmental health crisis by focusing on theinterface between crisis care and emergencydepartments, and by supporting theimplementation of crisis care commissioningstandards and crisis care concordat plans.

n Building the confidence, capacity andcapability of those working in primary care tosupport patients with mental health issues.

n Improving access to perinatal mental healthcare by influencing and improving thecommissioning across London.

n Improving access to psychosis care by helpingprepare London for a new national accessand waiting time standard for earlyintervention in psychosis.

n Improving access to early intervention bydeveloping an online mental wellbeingservice to support self-management of issues.

n Further improving the strategiccommissioning of mental health.

These priorities reflect and will respond furtherto those outlined in the Five Year Forward Viewfor Mental Health, published in February 2016.


Through engagement with the mental healthstrategic clinical leadership group and otherclinical leaders, the following workforce prioritieswere identified as priority areas of focus:

1 The high vacancy rate (up to 20%) in mentalhealth nursing teams and difficulty recruitinginto other key staffing groups. How to makecareers in this area more attractive; improveretention by addressing existing culture andbehaviour; and make London more ‘liveable’for lower paid staff must be addressed.

2 The lack of ‘tier one’ mental health skills in thegeneral health workforce, with a particularneed to address the “lack of compassion” inA&E (as identified by the CQC in their report,Right here, right now (2015)) and across allstaffing group and areas. This includesrecognising the need to raise awareness ofmental health issues across other sectors suchas social care and the voluntary sector.

3 The need to build capacity, capability andconfidence to address mental health issues inprimary care through improvements in trainingand through building sector leadership.

4 The need to improve the ‘physical’ healthskills of mental health staff to address thephysical risk factors associated with severemental illness. Allied to this is the need toimprove collaboration between organisationsand individuals to address these issues.

5 The need to review and improve ways ofworking in teams dealing with people incrisis, including access to liaison psychiatry,allied mental health professionals andensuring coverage across London for crisiscare home resolution teams.

6 The need to strengthen commissioning andcommissioning skills in an increasinglycomplex environment.

The need to address the specific workforceissues and shortages associated with meetingthe new early intervention in psychosis (EIP)access standards, as demonstrated by the NHSbenchmarking report. There will also need to bea response to required improvements in perinatalmental health care across a multidisciplinaryworkforce, ensuring adequate supervision froma perinatal lead or specialist in mental health inmaternity services, supportive supervision forstaff and how to use the skills of health visitors.

The programme will also respond to the multi-disciplinary workforce strategy for the futureshape and skill mix of the workforce required todeliver the FYFV for Mental Health that will bedeveloped by HEE, with stakeholders, in 2016.

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3.3 Children and young people programme workforce implications

Transformation of health services for children andyoung people in London is urgently required.Children and young people suffer from poorhealth outcomes in a number of areas and thereis marked variability in key outcomes across thecapital. These outcomes are delivered across ahealth system which has fragmented servicedelivery across different areas and providers.

The London Health Commission highlightedpoor outcomes for children and young peopleranging from mortality and serious illness tomental ill health, common diseases such asasthma, and public health issues such as obesityand poor school-readiness.

Approach

A transformation programme was established torebuild healthcare around London’s children andyoung people. Working with a wide range ofstakeholders, the NHS in London came togetherto agree the following five joint priorities for2015/16 and beyond:

n Develop an approach to delivering care forchildren and young people across definedgeographies by developing population-basednetworks to join up public health,commissioners and providers.

n Reduce variation in quality of services forchildren and young people by developingstandards of care for commissioners includingacute care, community care and Children andAdolescent Mental Health Services (CAMHS).

n Develop new models to integrate care across primary and secondary healthcareservices, acute systems and multispecialtycommunity providers.

n Improve commissioning by developingchildren and young people commissionersand support new commissioning models todeliver effective pathways of care acrosshealthcare settings.

n Develop innovative access models of careusing 21st century technology.

Transformation efforts need to be targeted todevise and implement an integrated system ofcare that can be easily navigated by children andyoung people, their families and the healthprofessionals delivering their care. Achieving thisaim will mean that London has a 21st centuryhealth system able to deliver the best outcomesfor children and young people.


The programme and its clinical partners have identified the following core workforcechallenges:

1 There is a lack of skills and structures tosupport children in primary, intermediate andintegrated care, including for those acutelyunwell children living at home or in thecommunity. This includes variable skills ofGPs, practice nurses and the wider practiceand community teams in supporting childrenand young people and the under-provision ofschool nurses and paediatric specialist nursesworking in the community. This is reflected inthe potential challenge of implementing theasthma standards.

2 Staff find it difficult to train and work acrossorganisational and professional boundaries.This entrenches divisions between ‘generalist’and ‘specialist’ skill sets.

3 There are staff shortages across the childrenand young people’s workforce, with aparticular issue for GPs, practice nurses,paediatricians, children’s nurses, allied healthprofessionals and other key staff groups. Theaffordability of living and working in London,and the 'leaky bucket' as staff move to othergeographical and professional areascontributes to these issues. There is a need to look at new ways of working, new roles,training, and removing barriers of entry to the workforce as well as developing attractivecareers for all staff.

4 Acute workforce models are unsustainable,with a high likelihood that the new acutecare standards will not be met in areas suchas anaesthetics, radiology and surgery, and ade-skilling outside of the specialist centres.Change is made difficult by the reliance onmedical trainees to deliver core services andthe interlinkages between paediatric andneonatal medical rotas. It is also recognisedthat this is compounded by the lack of skilledneonatal nurses.

5 There is a skills deficit in the general andchildren and young people workforce interms of supporting children and youngpeople with mental health issues both withinCAMHS and the wider workforce.

6 Skills and quality of commissioning services isinconsistent, with a need to developcommissioners and commissioning skills in acomplex environment. This is reflected in alack of visibility of children and young peoplein strategic and local service planning.

3.4 Transforming primary care workforce implications

Patients tell us they want better continuity ofcare (‘my doctor’, ‘my nurse’). They also wantbetter access to services when they need them;to contact a health professional when they needto; to have care closer to home; to stay healthierand more independent for longer; and moresupport to enable them to manage their ownhealth more effectively.

Our patients’ needs are different now and keepchanging. The systems that are in place to carefor them have to evolve to keep pace with thischange. As demand for health services grow,patients will need a good understanding of theservices and resources available to them to staywell and look after themselves through minorillnesses. General practices will be recognised ascentres in each neighbourhood that aresupporting Londoners to stay healthy and as well as they can.

If London is going to meet the challenges we allface there will need to be additional resource,but we will also need to achieve significanteconomies of scale and be more innovative inthe way we deliver primary care.

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If London is going to meet the challenges we all face there will needto be additional resource, but we will also need to achieve significanteconomies of scale and be more innovative in the way we deliverprimary care.

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Approach

At the heart of Transforming Primary Care inLondon: A Strategic Commissioning Frameworkis a new service specification for generalpractice. This supports the need to define andcommission a more constant service for allLondoners. Three characteristics are needed forgeneral practice to thrive and deliver the carethat patients need and value:

n Proactive care

n Accessible health

n Coordinated care.

The Strategic Commissioning Framework focuseson 'function' not 'form' and sets out a newpatient offer for all Londoners that can only bedelivered by primary care teams working in newways and by practices forming larger primarycare organisations. Further to this, the quality ofgeneral practice estate is highly variable andthere is a real challenge to improve it. A poorestate means a poorer patient experience, poorworking conditions for London GPs and lostopportunities to improve health and healthcare.It is expected that modern, state-of-the-artfacilities will be required. It is likely that generalpractice will need to transition out of theexisting estate gradually as investment is madein more modern buildings.

For primary care to lead and sustain change, it isimportant that systems and processes are inplace to enable this to happen. For examplecontracts, incentives and technology. However,there is widespread recognition that there mustbe provider-driven change as well, and that thiswill not come from a top-down managedprocess or through a hierarchical leadershipmodel. It is essential to ensure that there is focuson the development of transformationalleadership capacity and capability-building.


Re-designing the workforce is pivotal to achieving the scale, pace and sustainability of the transformation outlined in the StrategicCommissioning Framework. Through engagementwith primary care commissioners and HEE, andbuilding on existing workforce implications raisedin the Strategic Commissioning Framework, thefollowing workforce priorities have been raised as areas to be addressed to enable primary care transformation:

1 Strengthen the alignment between servicecommissioning and health educationcommissioning to improve local workforcedelivery plans.

2 Re-establish and promote local networks witha focus on primary care (e.g. CommunityEducation Provider Networks).

3 Identify the skills required and the resourcesneeded to deliver and manage GPfederations, in alignment with the existingprovider development support programme.

4 Improve career pathways and ensure greaterclarity on individual roles and responsibilities.

5 Strengthen the mechanisms by which localworkforce planning informs nationalworkforce planning, with a particularemphasis on primary care.

6 Develop solutions to identified barriers (e.g. employee contract, pension andindemnity, and terms and conditions toenable desired change).

7 Strategic Planning Group baselining of theexisting primary care workforce, anddeveloping the description of the futureworkforce as a result of new models of care.

8 Understanding the workforce implications on primary care of findings to date, to define the impact on the primary caretransformation programme.

3.5 Urgent and emergency care programme workforce implications

Better Health for London calls for better urgentand emergency care to provide Londoners withthe consistent high-quality care that they expectand rightly deserve, seven days a week, in orderto improve patient experience and outcomes. Thisis reinforced by the Five Year Forward View, whichoutlines that urgent and emergency care serviceswill be redesigned to integrate emergencydepartments, GP out-of-hours services, urgentcare centres, NHS 111, community services andambulance services. This is in line with the visionof Professor Sir Bruce Keogh’s Urgent andEmergency Care Review, of enabling patients toreceive the right care first time, as well as thevision of the Seven Days a Week Forum toaddress variation in services and close the gap incare between weekdays and weekends.

The urgent and emergency care system inLondon is facing many challenges. An ageingpopulation with increasingly complex needs isleading to ever rising numbers of peopleneeding urgent or emergency care. There arealso many people who are struggling to navigateand access a confusing and inconsistent array ofurgent care services provided outside hospital,which can result in them defaulting toemergency departments. There are issues withrecruitment and retention of the workforce.Every winter the ongoing challenges facingLondon’s urgent and emergency care services arehighlighted further. The signs of this are mostvisibly seen in efforts to deliver the urgent andemergency care four hour waiting timestandard. However, the challenges for London’surgent and emergency care services are notsimply issues within emergency departments or aresult of seasonal variation. Issues are present allyear round and across the entire urgent andemergency care system.

Approach

To address these challenges, and establish amore integrated approach to the provision ofurgent and emergency care services to patients,a fundamental shift towards a more closelyintegrated urgent care service is underwayacross London, and nationally. Building on thesuccess of NHS 111 in simplifying access forpatients, the intent is to deliver a functionallyintegrated 24/7 urgent care service that is the‘front door’ of the NHS, and which provides thepublic with access to both treatment and clinicaladvice. This will include NHS 111 providers andGP out-of-hours services, community services,ambulance services, emergency departmentsand social care. The offer for the public will be asingle entry point – NHS 111 – giving themaccess to fully integrated urgent care services inwhich organisations collaborate to deliver highquality clinical assessment, advice and treatment.Achieving this ambition will address existingvariation in service delivery and quality acrossdifferent settings.

The development and commissioning of theLondon Quality Standards for Acute Emergencyand Maternity Services has led to someimprovements in these services across London.The development of the national clinicalstandards (with which the London qualitystandards are congruent) of Professor Sir BruceKeogh’s Seven Days a Week Forum (December2013), has reinforced their importance. Sanctionsfor non-compliance with the standards will be in place by 2016/17, however to implementthem properly will require wider systemtransformational change. There are serviceredesign programmes in train in some areas ofLondon to move toward a clinically andfinancially sustainable provider landscape,supported by out-of-hospital providerdevelopments including the integration of health and care services through Better Care Fund plans.

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A central part of this proposed transformation to 24/7 integrated urgent care access, treatment and clinical advice service will be the development of a ‘clinical hub’ offeringpatients access to a wide range of clinicianswhere required – both experienced generalistsand specialists. However, these and otherproposals rely on existing issues in the urgentand emergency care system inside and outsideof hospital being addressed.

There have also been calls for change to thecommissioning of urgent and emergency careservices, with the implementation of incentivesto drive the right behaviours coupled withMonitor’s recent recommendation for reform ofthe activity-based payment system that isineffective and unsustainable for some elementsof urgent and emergency care.

To address these demands and issues the NHS inLondon has come together to agree the followingthree priorities for urgent and emergency care,supported by underlying activities:

n Achieving integrated urgent care acrossLondon’s urgent and emergency carenetworks and supporting personalised accessto the most appropriate setting to receive theright care, first time.

n Embedding and developing urgent andemergency care networks to oversee theplanning and delivery of the urgent andemergency care system.

n Implementing the specification for London’surgent and emergency care system innetworks including designating facilities toensure London quality standards are met,seven days a week.


In London, national representatives, urgent and emergency care (U&EC) clinical and networkleads have come together in collaboration toshare evidence of existing workforce challenges,and reflect on the workforce implications offuture delivery plans and specifications. Thisengagement with the London U&EC ProgrammeBoard, Strategic U&EC Clinical Leadership Group and over 200 delegates at a U&EC‘Implementing the Urgent and Emergency CareVision in London’ event concluded with a list ofworkforce priorities to take forward. These are:

1 Having sufficient numbers of U&EC staff,with the right competencies to meet existingpatient demand for services, and maintainexpected service quality standards should beensured. A priority focus should be to addressfactors that hinder the retention of the U&ECworkforce, and impact significantly on theirhealth and wellbeing. This is anticipated tolead to a reduction in agency usage.

2 A significant cultural shift is required for allmembers of U&EC networks, including theclinical workforce, to participate and deliverchange collaboratively rather than asindividual organisations. A potential enablercould be the alignment of staff within eachU&EC network to collectively definednetwork objectives. This alignment could alsobe applied within individual organisations.

3 To achieve the desired quality of service ofnew urgent and emergency care models, it isimportant to make sufficient investment inthe frontline workforce. Low pay, anti-socialworking hours and limited personaldevelopment are identified as reasons for ahigh attrition rate of this workforce. Possiblemitigations include the provision of personaldevelopment rotations across the service toraise individuals’ awareness of referralpathways, and more clearly defined andcommunicated career pathways.

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The CapitalNurseprogramme is focused ondeveloping solutions to solvenursing workforcechallenges in London.

4 New urgent and emergency care models ofcare will require greater multi-disciplinary andcross-organisational boundary working acrosshealth and social care settings (e.g. thedelivery of a proposed multi-disciplinaryintegrated urgent care clinical hubs).

5 It will also be necessary to find ways to makethe new urgent and emergency care modelsin out-of-hospital and in-hospital settingsmore attractive to the clinical workforce: forexample, by encouraging further clinicaltraining placements in NHS 111 and in thecommunity, or overcoming the challenge ofnot being able to provide training placementsin private providers.

6 In parallel with building an effective andefficient urgent and emergency care system,there will be a need for the workforce tofocus on promoting appropriate self-care for patients. This will ensure that strains on capacity do not impact the quality ofservice delivery.

7 Furthermore, urgent and emergency caremust also ensure parity of esteem betweenmental and physical health. U&EC staff willneed to have the skills to recognise a patientthat presents in mental health crisis, andensure that a patient’s physical health andmental health are both given the same levelof focus and priority.

3.6 CapitalNurse Londonprogramme

The CapitalNurse programme is focused ondeveloping solutions to solve nursing workforcechallenges in London. This concentrated workaims to develop and sustain a healthcareworkforce in the capital that is affordable, andto ensure the delivery of consistent high-qualitycare for all users of healthcare within andbetween organisations. This will be achieved byhaving employers, health education institutions(HEIs) and commissioners working together tobuild a compelling vision of the CapitalNurse.The three overriding objectives of this work are:

n to ensure the partners work collectively inplanning the transition to new methods offunding for pre-registration nursing educationin London

n to ensure the ongoing supply of anappropriately skilled nursing workforce tomeet the changing requirements ofhealthcare within London

n to ensure ways of working and organisationalgovernance are in place to deliver high-quality person-centred care across London.

This work is shaped around four nursingworkforce priorities:

1 Employability of student nurses

It is recognised that employability is importantand always an issue. The purpose of thisscheme of work is to move towardguaranteed employment for all London-LETBsponsored graduates successfully exiting fromnursing programmes. This is in addition todeveloping a framework for improvedstudent mentorship.

This work will look to:

– achieve a partnership agreement that all eligible students will be offered employment on completion of their programme in their host organisation

– gain London-wide commitment that a successful nursing qualification provides sufficient assurance for employment, and automatic recognition of key skills

– achieve London-wide agreement and development of consistent tests, where trusts require them, to be used across all HEI programmes before students qualify

– build on existing work to ensure that mentorship is fit for purpose and supports staff and students development at all stages of their career. This includes piloting and reporting on a range of new models that are currently being explored in London.

2 Developing career pathways

Having visible career pathways is seen asessential in managing staff movement inLondon, and can be seen as a cornerstone inincreasing staff retention. The purpose of thiswork is to develop a robust nursing careerframework that encompasses current andfuture workforce delivery models and anagreed set of standards for all providers andcommissioners to achieve in recruitment andretention of the local workforce.

This work will look to:

– collaborate with newly-qualified nurses to develop a clearer ‘story’ of the benefits of working in London as a nurse

– signpost and share best practice in approaches to preceptorship in the capital

– promote a number of career pathways, suchas in older person, neonatal, mental health, primary and community care that harness thewealth of unique opportunities in London.

3 Use of agency staff

There is a need to gain commitment acrossLondon to reduce reliance on agency staff.This work will look to achieve further sharingof data on pay rates for bank and agency staffin London, exploring options to align andpotentially integrate bank supply provisionand develop recommendations around the useof agency and bank staff.

4 Reform of support for nurse, midwiferyor allied health professional students inEngland

At present, new full-time students accepted onan NHS-funded course in England, starting onor before 2015/16, which leads to professionalregistration as a nurse, midwife or allied healthprofessional, may be eligible for an NHSbursary to help with the cost of study.

In June 2015, Universities UK (UUK) and theCouncil of Deans of Health issued a jointstatement around reforming initial educationfunding for nursing, midwifery and allied healthprofessional students in England. It stated thatstudent number controls were creatingdifficulties with workforce planning, andfunding through grants was causing difficultieswith under-funding for courses and students. Inthis statement a case for change was set out forreform of the current funding system.

This case for change asked the government tochange student funding from grants to loans. Inresponse, the government’s 2015 autumnstatement announced the intention to replaceNHS bursaries with student loans for studentsstarting courses in nursing, midwifery and alliedhealth subjects. This announcement alsoincluded the removal of the cap on the numberof student places for these courses. Under theproposals, from September 2017 new studentsin nursing, midwifery and allied healthprofessions on pre-registered courses inEngland, will take out maintenance and studentloans, rather than getting an NHS bursary.

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The government has stated that it expects thereform to provide up to 10,000 additionalnursing and health professional training placesover the course of the 2015 parliament.Critics of the policy point out that reducingNHS bursaries will deter potential candidatesfrom applying, and therefore lead to areduction in the numbers of nurses, midwivesand allied health professionals in the longterm. Under this proposal, HEE will retainresponsibility for the management of theclinical placement element of programmesand the mechanics of how this would work isbeing debated. The implementation of thisnew policy (not the policy itself) is subject toconsultation, which launched in the finalquarter of 2015/16.

3.7 The Association of Directors of Adult Social Servicesworkforce programme

Social care (‘formal care’) comprises personalcare and practical support for adults withphysical disabilities, learning disabilities orphysical or mental illnesses, as well as supportfor their carers. Services aim to enhance adults’quality of life, delay and reduce the need forcare, ensure positive care experiences, andsafeguard adults from harm.

Publicly funded care makes up only a minority ofthe total value of care, and this proportion isdecreasing. Most care and support is providedunpaid by family, friends and neighbours(‘informal care’), while many adults pay for someor all of their formal care services. Localauthorities (LAs) provide a range of universal andpreventative services, many of which areavailable without assessment of need. Localauthorities commission most care from theprivate and voluntary sectors, with home careand care homes the most common services.

Legislative and other changes are increasing therole of adults in shaping their own care andsupport, diversifying the types of care availableand changing how they access it. The Care Act(2014) aims to rationalise local authorities’obligations, to introduce new duties based onindividual wellbeing, and to mitigate pressureson self-funders and carers.

The Future Care Workforce noted that the adultsocial care sector in England will need to addapproximately one million workers by 2025 inresponse to an ageing population and the impliedincrease in the number of people with disabilities.The workforce will also have to be increasinglydiverse in order to deliver a more personalisedservice to those in need of care and support.

Approach

The Association of Directors of Adult Social Services (ADASS) London Branch has establisheda workforce transformation programme tosupport the delivery of identified workforcepriorities. The programme is governed by aSocial Care Workforce Steering Group (SCWSG)and supported by the ADASS Learning andDevelopment Group.

The current focus for the programme is to:

n lead and support the registered managersnetwork (building on local good practice)recognising managers as crucial to success

n focus on how to commission good nursinghomes in collaboration with partners

n jointly work with the United KingdomHomecare Association (UKHCA) and Skills forCare (S4C) to bring together and promotethe business case for better employmentpractice as a way to improve recruitment andincrease retention of the workforce

n develop a London-wide learning anddevelopment response to the London-widesafeguarding adults procedures.

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3.8 London’s digital,personalisation and self-care programme

‘The NHS belongs to the people’, is enshrined inthe NHS Constitution. The NHS is thereforeobliged to become more orientated towards thepeople it serves, keeping pace with patientdemands for more personalised healthcare and fora modern customer service that enables greatercontrol, convenience and ability to self-serve.

This is the ambition set out in the Five YearForward View and the National InformationBoard’s publication Personalised Health and Care2020, which aim to put technology to work forpeople, whilst also tapping into the renewablesource of energy that can be unlocked bygenuinely enabling people to be activeparticipants and not simply passive recipients ofhealth and care.

The good news is that people are willing andready to engage in this way (evidenced by thefindings of research commissioned by NHSEngland in 2015 using a representative sampleof England’s population). People want toexperience the same levels of convenience,control and personalisation in their interactionwith the NHS that are afforded to them in theirinteractions with other service industries.

The single biggest challenge for the NHS is to re-imagine itself whilst staying true to itsfounding principles. That requires a significantre-modelling of the workforce articulated withinthe new models of care that emerge from thesustainability and transformation plansunderpinned by local digital roadmaps.

Particular areas of focus include:

n Enabling people to be more activeparticipants in managing their own healthand care enabled through digital technology.

n Implementing citizen-centric informationexchange that is capable of scaling andembedding into workflows in order to delivervalue in local health economies and acrossthe region for services that transcendorganisational boundaries, such as urgentand emergency care.

n Driving increased utilisation of existingtechnical capabilities.

In the context of a forecast reduction in overallworkforce and estate and a drive towards sevenday services it is a necessity, and an opportunity,to maximise the capabilities that both peopleand technology bring.

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In the context of a forecast reduction in overall workforce andestate and a drive towards seven day services it is a necessity, andan opportunity, to maximise the capabilities that both people andtechnology bring.

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In order to make best use of the capabilities that will be delivered through the work of theLondon digital, personalisation and the self-careprogramme in supporting new models of care,there are significant workforce implications whichare encapsulated in the seven groupings below:

1 Activate people as assets: Requires afundamental shift away from the‘paternalistic’ to ‘personalised’ models of careand a workforce equipped with the rightskills, behaviours, knowledge and attitudes toenthuse people to be more active inmanaging their health, in decision-making,administering and even commissioning theirown solutions.

2 Activate community assets: Requires theNHS and social care to partner with industryand the voluntary sector to find ways to makeself-help assets, peer-to-peer support andvolunteering in local communities morewidely accessible. This requires a workforcethat steps back from ‘medicalising life’ and isprepared to support people in takingresponsibility and managing risk differently,especially as more of the population haveaccess to health and care budgets with whichthey will want to commission more flexibleservices (especially personal assistants).

3 Embed technology in workflows:Technology needs to be fully embedded andmainstreamed into the workflows in order tobe adopted by the workforce and make theirday-to-day jobs more effective and efficient.This means understanding new models ofcare and the aspects of care pathways thatneed to be standardised or personalised inorder to drive value.

4 Mobile working: Investing in Wide AreaNetworks (WAN) technical infrastructure and access to records and data sharing isessential in enabling flexible and mobileworking (especially in the context of ashrinking workforce and estate, andcustomers of health and care that want to beable to interact with health and care serviceson the fly).

5 Train people to deliver care differently:The existing and future workforce will needtraining in how to use technology such aswebchat, webcam and email in theassessment and treatment of patients. Theyalso need training in how to approach thenature of their work differently in the movetowards more collaborative approaches thatinvolve shared decision-making, peer-to-peersupport and a reduction in the reliance onprescriptions with a shift towards supportingpeople to define their goals and makeinformed choices about courses of action.

6 New roles and skill mix: Lower skilledworkforce may be enabled with decisionsupport systems. There may also be a greater need for telephone operators for triage especially in primary care andurgent care. New roles are required that can support people to access greater levels of self-help enabled throughtechnology, and help in better managingchoices, risk and responsibility.

7 Automation and customisation: There willbe a need for the workforce to be trained inhow to customise services and how to utilisegreater levels of automation (for exampletechnology-driven early warning systems,remote monitoring, alerting, and virtualconsultations). The workforce will also need totake on the role of supporting people in theuse of technology and automated systems inthe same way that other businesses likebanks, airlines and retail have done.

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There is a need to develop strategies to ensure that professionalscan be attracted into areas which may historically have been lessattractive. For example, primary care and community services,urgent and emergency services, and mental health services.

3.9 International healthcaremodels

The three international models reviewed as partof this analysis all provided insights into hownew ways of working may be required inLondon, should aspects of the transformationproposals be applied. The models can besummarised as follows:

n New Zealand primary healthcare nursing development model

This model focused on implementing newprimary healthcare nursing leadershippositions to assist with reducing inequalitiesand developing the capacity of the primaryhealthcare nursing workforce. This is inresponse to the New Zealand primaryhealthcare strategy and the development ofmore integrated services.

n Netherlands Buurtzorg home carenursing model

This is a unique district nursing system whichis nurse-led and delivers both nursing andsocial care services in the Netherlands. Careand treatment is outcomes focused, aimed atpromoting independence and mobilising‘social capital’ around the individual tosupport care. The Buurtzorg nurses areembedded in the community setting.

n US ChenMed primary care group practice model

ChenMed is a primary care-led group practice model which serves low to moderateincome elderly patients with multiple chronicconditions. With 350 – 450 patients per doctor,it allows for more intensive health coachingand preventative care and aims to achieve low levels of unnecessary hospital admissions.It is a one-stop shop approach and is a multi-speciality model, based on the individual.


1 All three models require significant changes in culture for the healthcareprofessions, which need to work effectivelytogether in teams in non-traditional ways.Often this also involves working acrossorganisational boundaries.

2 Although all of the models are different, acommon characteristic is the clear alignmentof incentives and working practices to thechosen model of care.

3 The models target different groups ofpatients, but in all of them there is a sense of a ‘whole person’ approach working withdifferent health (and social care) professionalsas required. There is a great clarity on who isresponsible for an individual.

4 There has been a clear investment in ensuringthat the right number and type of roles arepresent to deliver the model – this issupported by clarity on the model of care.

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3.10 Summary

Working with the eight very diverse transformation programmes to understand workforceimplications of proposed transformation, and reviewing three international models, hasrevealed a number of key insights:

1 The need to ensure that there are strong linkages between service transformation planning,workforce planning and education commissioning is critical. This has been specifically cited inthe findings from the primary care programme but is indicated in all of the programmes as thereare references to the need for increases in specific roles, developing new roles, or utilisingexisting roles in a different way.

2 Consideration needs to be given to the combined impact of these programmes on the existingworkforce. This is especially true for the primary care and community services workforces.Implementation of elements described in Transforming Primary Care in London will in itselfrequire significant changes in roles and the way that roles work together. However this becomeseven more critical when it is overlaid by the anticipated requirements of the other programmeson primary care and community services.

3 A number of programmes describe either the development of networks (e.g. in urgent andemergency care; and children and young people's services) or teams working together indifferent ways, often across traditional boundaries. In addition, as care becomes more complex,professionals will need to work together differently in multi-disciplinary teams to meet thechanging needs and expectations of the population. This may require new skills, but alsocultural changes to the way that individuals work with each other.

4 There will be a need to ensure that commissioning develops with a greater focus in some areas(e.g. mental health) but also becomes increasingly strategic in its approach (e.g. in thedevelopment and implementation of ambitious transformation plans).

5 It will be important to ensure that there is a clear alignment of incentives, contractual forms,and performance to enable the workforce to be effective in these transformed environments.

6 A number of gaps are identified in key roles needed to deliver the transformed services e.g.nursing and emergency consultants. This is a potential issue which, if not solved, may preventthe realisation of the transformed services. But new roles and the right number of existing roleswill be required to deliver the new transformed services.

7 There is a need to develop strategies to ensure that professionals can be attracted into areaswhich may historically have been less attractive e.g. primary care and community services,urgent and emergency services, and mental health services. In some areas there are particularissues in retaining staff (e.g. high turnover has been cited in NHS 111 frontline staff). There areprogrammes of work underway in different areas of London which are trying to address theseissues (e.g. the nursing workforce programme), and it has been suggested that the learningcould be adapted for different professions.

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References3.1 NHS England (London) (2014) Five year Cancer Commissioning Strategy for London, www.england.nhs.uk/london/wp-content/uploads/sites/8/2014/01/lon-canc-comm-strat.pdfIndependent cancer taskforce (2015) Achieving world-class cancer outcomes: a strategy for England 2015 - 2020, www.cancerresearchuk.org/about-us/cancer-taskforceLondon Cancer Alliance (October 2014) Allied Health Professionals: mapping and requirements, www.londoncanceralliance.nhs.uk/media/88180/ahp-mapping-and-workforce-requirement-report-2014.pdfHealthy London Partnership transforming cancer services programme call for evidence submission3.2 Mayor of London (2014) London Mental Health: the invisible cost of mental illness, http://dera.ioe.ac.uk/19257/Right here, right now: Mental health crisis care review (2015), www.cqc.org.uk/content/right-here-right-now-mental-health-crisis-care-reviewDepartment of Health and Concordat signatories (February 2014) Improving outcomes for people experiencing mental health crisis,www.gov.uk/government/publications/mental-health-crisis-care-agreementNHS England (March 2015) Mental Health Taskforce: A Five Year Strategy for Mental Health Terms of Reference, www.england.nhs.uk/wp-content/uploads/2015/03/mh-tor-fin.pdfLondon Strategic Clinical Networks (July 2014) A commissioner’s guide to primary care mental health, www.londonscn.nhs.uk/publications/London Strategic Clinical Networks (September 2014) Commissioning recommendations for psychological support, www.londonscn.nhs.uk/publications/Healthy London Partnership Mental Health programme call for evidence submission3.3 London Strategic Clinical Networks (December 2014) Children and young people’s health services in London: A case for change,www.londonhp.nhs.uk/services/children-and-young-people/case-for-change/Royal College of Paediatrics and Child Health (2015) Facing the Future: Standards for Acute General Paediatric Services Workforce Implications – adiscussion document, www.rcpch.ac.uk/sites/default/files/page/Workforce%20Implication%20of%20FtF%202015%20FINAL.pdfHealthcare for London (Nov 2009) Meeting the health needs of children and young people: Guide for commissioners, www.londonhp.nhs.uk/new-nhs-guidance-on-healthcare-for-children-and-young-people-in-london/London Strategic Clinical Networks (June 2015) London asthma standards for children and young people, www.londonscn.nhs.uk/wp-content/uploads/2015/07/cyp-asthma-stds-062015.pdfLondon Strategic Clinical Networks. (April 2015) London acute care standards for children and young people, www.londonscn.nhs.uk/wp-content/uploads/2015/06/cyp-acute-care-stds-042015.pdfLondon Health Programmes (February 2013) Quality and Safety Programme Acute Emergencies and Maternity Services London Quality Standards,www.londonhp.nhs.uk/wp-content/uploads/2013/06/London-Quality-Standards-Acute-Emergency-and-Maternity-Services-February-2013-FINALv2.pdfHealthy London Partnership children and young people programme call for evidence submission3.4 NHS England (London) (2015) Transforming Primary Care in London: A Strategic Commissioning Framework, www.myhealth.london.nhs.uk/healthy-london/primary-care/resourcesHealthy London Partnership transforming primary care programme call for evidence submission3.5 NHS England, Urgent and Emergency Care Review End of Phase 1 Report (November 2013) High quality care for all, now and for future generations: Transforming urgent and emergency care services in England NHS England, NHS 111 with CCGs (September 2015) Integrated Urgent Care Commissioning Standards National Clinical Standards,www.england.nhs.uk/wp-content/uploads/2015/10/integrtd-urgnt-care-comms-standrds-oct15.pdfDepartment of Health, Department of Communities and Local Government. (December 2014) Better Care Fund Policy Framework,www.gov.uk/government/publications/better-care-fund-how-it-will-work-in-2015-to-2016London Quality Standards for acute emergency and maternity services, www.england.nhs.uk/london/our-work/quality-standards/NHS Services, Seven Days a Week Forum, www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdfHealthy London Partnership urgent and emergency care programme call for evidence submission3.6 CapitalNurse programme call for evidence submission3.7 ADASS call for evidence submission 3.8 Personalised Health and Care 2020. Using Data and Technology to Transform Outcomes for Patients and Citizens. A Framework for Action,www.gov.uk/government/uploads/system/uploads/attachment_data/file/384650/NIB_Report.pdf3.9 Ministry of Health (2007) The Evaluation of the Eleven Primary Health Care Nursing Innovation Projects. A Report by the Ministry of Health by the PrimaryHealth Care Nurse Innovation Evaluation Team Wellington, www.health.govt.nz/publication/evaluation-eleven-primary-health-care-nursing-innovation-projectsRoyal College of Nursing. RCN Policy and International Department (2015) The Buurtzorg Nederland (home care provider) model. Observations for theUnited Kingdom(UK) Updated edition, www2.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdfde Blok,J. (2013) Buurtzorg: better care for a lower cost, www.kingsfund.org.uk/sites/files/kf/media/jos-de-blok-buurtzorg-home-healthcare-nov13.pdfde Blok, J.; Kimball, M. (2013) Buurtzorg Nederland: Nurses Leading the Way! journal.aarpinternational.org/a/b/2013/06/Buurtzorg-Nederland-Nurses-Leading-the-WayTanio, C.; Chen, C. (2013) Innovations at Miami practice show promise for treating high-risk Medicare patients doi: 10.1377/hlthaff.2012.0201 HealthAff June 2013 vol. 32 no. 6 1078-1082, content.healthaffairs.org/content/32/6/1078.full?ijkey=cgHaArAQbEBss&keytype=ref&siteid=healthaff> Wherry, K. (2015) ChenMed Care Model: Creating change and transformation in general practice Nuffield Trust event presentation by ChenMed,www.nuffieldtrust.org.uk/talks/slideshows/chenmed-care-model-creating-change-and-transformation-general-practice Agency for Healthcare Research and Quality (US Department of Health and Human Services). (2015) Physician-Led Clinics Offer Integrated, CoordinatedCare to High-Risk Seniors Under Capitated Contracts, Leading to Strong Performance on Quality Metrics, Low Inpatient Use, and High Patient Satisfaction,innovations.ahrq.gov/profiles/physician-led-clinics-offer-integrated-coordinated-care-high-risk-seniors-under-capitated

https://www2.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdf

journal.aarpinternational.org/a/b/2013/06/Buurtzorg-Nederland-Nurses-Leading-the-Way

journal.aarpinternational.org/a/b/2013/06/Buurtzorg-Nederland-Nurses-Leading-the-Way

content.healthaffairs.org/content/32/6/1078.full?ijkey=cgHaArAQbEBss&keytype=ref&siteid=healthaff>

innovations.ahrq.gov/profiles/physician-led-clinics-offer-integrated-coordinated-care-high-risk-seniors-under-capitated

https://www2.rcn.org.uk/__data/assets/pdf_file/0003/618231/02.15-The-Buurtzorg-Nederland-home-care-provider-model.-Observations-for-the-UK.pdf

Chapter 4:

Local workforce agenda and priorities

Strategic planning group priorities

Over a number of years, CCG Strategic Planning Groups (SPGs) have been developing ambitioustransformation plans to meet the needs of the local population in their geographical area. Eachof these transformation programmes is very distinct to its local area, but all share a common needto support the development of their local health and social care workforce in order to deliver amodern workforce for the future.

This chapter provides a brief overview of each SPG transformation programme, and summarisesthose local workforce priorities on which they are currently focused.

Through sharing local workforce priorities, it is possible to establish common areas of focusacross London where the most value can be delivered locally.

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Local workforce agenda and priorities – strategic planning group priorities

4.1 Barking and Dagenham, Havering and Redbridge (BHR) CCG partnership

The vision for the BHR health economy is toimprove health outcomes for local peoplethrough best value care in partnership with thecommunity. This local strategy aims to ensurethat everyone will have a greater chance ofliving independently for longer and spend lesstime in hospital, but when they do go tohospital, patients will have a better experiencethan now. Services will be better integratedboth within and across organisationalboundaries, with more streamlined access andmore services being offered 24/7, deliveringhigh-quality health and social care to patientscloser to home. BHR workforce priorities include:

Recruitment and retention

Improve the ability of the system to attract,recruit and retain a workforce to meet safestaffing levels, improve consistency and qualityof care, and reduce bank and agency spend.Specifically this will include the delivery of:

− a workforce development group (subgroup ofthe SRG), which has been established locallywith a short-term aim focused on how topromote opportunities and make the areamore appealing to potential staff.

− overseas recruitment drives.

− Care City, which is a test-bed bid to develop anew health and social care research,education and innovation hub in East Londonwith a remit to support healthy ageing andsocial regeneration.

− the Health for North East London acutereconfiguration programme to help addressgaps in emergency care workforce,particularly at senior levels.

Supporting new models of care

Redesign the urgent and emergency carepathway to create a simplified, streamlinedurgent care system, delivering excellent urgentcare and patient experience with financialstability. This is being lead through the localUrgent and Emergency Care Vanguard. This willbe facilitated by empowering the workforce toidentify opportunities, co-design the new model,and deliver stepped change, including:

− contractual solutions to enable the workforce to rotate across organisational and pathway boundaries.

− clinical champions and other leadership opportunities to deliver change and staff engagement.

− work in partnership with CEPN to identify and commission training and development opportunities.

− workforce strategies alignment across organisations across BHR

− consider how the development of an Accountable Care Organisations (ACOs) might accelerate and enhance performance and outcomes

Primary care workforce sustainability

Address challenges in primary care workforcesustainability including recruitment and retentionof GPs and practice nurses. A key priority willalso be to consider the use of other primary careprofessionals and different skill mixes that can beutilised to support general practice including:

− undertaking workforce modelling and review outcomes; including using all the information currently held.

− working in partnership with CEPN and other borough organisations like colleges to identify any opportunities that can be used to promote and retain staff.

− developing new roles to support delivery of new models of care and an accountable care partnership (ACP).

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4.2 Newham, Tower Hamlets and Waltham Forest CCG partnership

The Transforming Services Together (TST)programme is a partnership between three eastLondon CCGs, NHS England, Barts Health NHSTrust and other hospitals, community and mentalhealth providers, primary care and localauthorities, including public health and socialcare. The aim of the programme is to deliversafe, sustainable and high-quality services for theresidents of east London. It focuses on improvingphysical and mental healthcare in Newham,Tower Hamlets and Waltham Forest, while alsothinking about how changes in these areas couldimpact on neighbouring boroughs. TST’s changeprogramme aims to address the system-widechallenges anticipated as a result of a forecastpopulation rise of 270,000 patients in the areaover the next 10 years, including addressingalready challenging workforce supply shortages.Some of the key workforce priorities to meet theneeds of a growing population include:

n ensuring recruitment to new and establishedprimary care staffing levels is as efficient andeffective as possible

n addressing retention difficulties experiencedin primary care and especially with healthcareassistants (HCAs), GPs and practice nurses

n introducing new models of integratedmultidisciplinary care and new cross-boundary roles to support them (e.g.pharmacists, physician associates andadvanced practitioners)

n developing and upskilling existing roles (e.g.HCAs, care navigators, health coaches andother clinical and non-clinical staff).

More specifically, operational task and finishgroups have been set up for 2016, focusing on:

Physician associates: implementing fundingand sponsorship across the TST partnership,developing a curriculum from St George’sHospital to run education programmes forphysician associate students at Queen MaryUniversity of London.

Promoting and marketing new and existing roles: with a particular focus on HCAs, physician associates and pharmacists.

Education programmes, rotations and cross-sector pathway working: determining what is commissioned for the future and what sponsorship will be made available for new trainees.

This is the start of the TST mobilisation aroundworkforce. As the programme progresses, moreand more projects will evolve to support deliveryof the TST strategy (for example, physicianassociates are just the first of a number of newroles under consideration; other roles includeHCAs, primary care pharmacists and ANP).

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TST’s change programme aims to address the system-widechallenges anticipated as a result of a forecast population rise of270,000 patients in the area over the next 10 years.

4.3 Barnet, Camden, Enfield, Haringey and Islington CCG partnership

The five CCGs of north central London (NCL)have (with their partners, local authorities andNHS England) identified a long-term plan totransform health and social care to be focusedon delivering personalised care for all those whoneed it. This includes a multiple set of responsesand adjustments to the changing needs,expectations and size of local communities.

These models include:

n strengthening and developing comprehensiveprimary care services

n building of integrated teams from acrosssectors and organisations wrapped round thepatient or service user

n greater emphasis on prevention and earlyintervention that in turn leads to a greateremphasis on out-of-hospital care

n building on the specialist hospital care whenit is needed ensuring NCL is at the forefrontof innovation in healthcare

n supporting the development of FYFV new models of care (e.g. accountable care organisations) where they benefit thelocal population

n developing a workforce to deliver seven day working.

The workforce vision for north central London isto ensure that all health and social care servicesare able to deliver integrated, high-quality, cost-effective care through a workforce (clinical andnon-clinical) of the right number, in the rightplaces, and with the right knowledge and skills.

The workforce strategy for NCL is:

In the short term:

n Develop existing workforce plans based onqualitative and quantitative data through thefive CEPNs of NCL.

n Model future workforce needs alongsidecolleagues at Health Education North Centraland East London (HENCEL) and Health andSocial Care Information Centre (HSCIC).

n Develop locality plans for direct and indirectfunding.

n Identify the core workforce skills required todeliver integrated care, and developintegrated training frameworks (includingidentification of quick wins for joint training).

In the medium term:

n Agree borough-based workforce plans withall stakeholders.

n Establish NCL programmes based on themodels outlined above, including:− entry level (widening participation and apprenticeships)

− core training (care certificate, undergraduate placements)

− postgraduate training (blended roles, practice nurse training)

− understanding the needs of new organisational models(cross sector leadership training, review of specialist skills training, whole system approach across health and social care, voluntary and third sectors)

− retention of staff (career diversity, cost of living, career pathways)

− developing capacity locally (mentorship, clinical supervision – including new integrated models and preceptorship).

In the long term:

n An agreed NCL-wide workforce developmentplan that is supportive of the SPG vision.

n Greater control on workforce spending, inpartnership with HEE.

n Establish education and training faculties thatare co-developed and organised by providers,HEIs and commissioners.

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4.4 Bexley, Bromley, Greenwich, Lambeth, Lewisham and Southwark CCG partnership

Current NHS spending in south east London is £2.3 billion. Through the Our Healthier South East London (OHSEL) workforcesupporting strategy and overarchingprogramme, there is an aspiration to develop a workforce with the right people, who havethe right skills and values, in the right place and at the right time, to deliver high quality,personalised and integrated care across southeast London.

This vision will be achieved by supporting local care providers to find ways to addresscurrent demand and short term pressures.At the same time consideration will be given to whether the current workforcecomposition can achieve the ambitions of future models of care.

The OHSEL workforce strategic framework has been developed in alignment with theLondon workforce key findings. By taking intoconsideration local, regional and nationalpriorities and initiatives, OHSEL will maximiseand leverage resources and expertise available in the wider NHS at local, regional and national levels.

The main south east London workforceobjectives are:

n to support the review and redesign of theworkforce to address short term challenges,and deliver the ambitions of the new models of care

n to support the development of skills andcapabilities to ensure effective delivery of new models of care

n to facilitate system-wide capacity andcapability to support culture change.

Key OHSEL objectives for 2016/17 andbeyond include:

n continuing to examine local requirements to develop and support the development ofnew roles within the community (e.g. ‘carenavigator/coordinator’ roles)

n supporting service transformation bypromoting culture and behavioural changeinterventions (e.g. by utilising the ‘makingevery contact count’ framework)

n supporting commissioning workforcedevelopment to deliver the OHSELoverarching transformation programme (e.g. through development of ‘communitiesof practice’)

n supporting existing workforce developmentand engagement (e.g. through training inskills and tools of improvement science tomake positive changes in health, healthcare,and the daily life of staff)

n supporting the development of leadership andmanagement at all levels (e.g. by supporting asystematic approach to leadership and talentdevelopment across OHSEL).

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Current NHS spendingin south east London is £2.3 billion.

4.5 Croydon, Kingston, Merton,Richmond, Sutton and Wandsworth CCG partnership

In February 2014 the six south west London NHS Clinical Commissioning Groups(CCGs) – Croydon, Kingston, Merton,Richmond, Sutton and Wandsworth – and the health commissioners from NHS England(London) agreed to work together withhospitals, mental health, primary andcommunity care service, local councils, localpeople and patients on a five year plan toimprove health services for everyone in southwest London. This partnership, which nowincludes SWL providers and neighbouringSurrey Downs commissioners, is called theSouth West London CommissioningCollaborative (SWLCC).

In June 2014 a case for change and outlinestrategy was published to respond to NHSEngland’s Call to Action.

This strategy aims to ensure that:

n people in south west London can access theright health services when and where theyneed them

n care is delivered by a suitably trained and experienced workforce, in the mostappropriate setting with a positiveexperience for patients

n services are patient-centred and integratedwith social care, focus on health promotionand encourage people to take ownership oftheir health

n services are high quality but also affordable.

In delivering this vision, SWLCC will aim to:

n improve the quality of care across southwest London

n address the workforce gap

n ensure local NHS services are financiallysustainable

n confront the rising demand for healthcare.

There has been a strong history of engagement around workforce in south westLondon, which can be seen in the strongworking relationships with Health EducationSouth London and the development of theCEPNs in each borough.

Workforce priorities for SWLCC as set out in the five year strategy include:

n expansion of the community workforce and adaptation to seven day working in the community

n training to upskill the incoming communityworkforce

n identification of opportunities to work across organisational boundaries

n recruitment, education and support of carers

n reduction of the gap in the workforceneeded to deliver London quality standards

n ensuring the workforce is trained to delivernew models of care

n engagement with stakeholders such asHealth Education England and SWLcommunity provider networks to developnew training models to address longer termshortages in certain specialities.

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The four acute providers in south west London(Croydon Health Services NHS Trust; Epsom andSt Helier University Hospitals NHS Trust; StGeorge’s University Hospitals NHS FoundationTrust; and Kingston Hospital NHS FoundationTrust) formed an acute provider collaborative(APC) to collectively address the challenge ofimplementation. This collaborative is currentlyworking towards the flexible use of workforceby sharing workforce between south westLondon sites, and a shared staff bank across thefour acute providers and South West Londonand St George’s Mental Health NHS Trust.

The local commissioners and providers are planning to work together to address their collective challenges in delivering systemsustainability and transformation. They arereviewing the current programmes to strengthen and build on the work done so far. This will involve a review and refresh of workforce priorities and implementationplans, and a re-launch of the workforceworkstream in early 2016.

4.6 Harrow, Hillingdon, Brent, Ealing, Hounslow, West London, Central London, and Hammersmith and Fulham CCG partnership

North West London (NWL) was awardednational pioneer status to develop integratedcare. As a result, a large-scale and innovativeprogramme of activities is in progress to improvehealth and social care in the sector.

These include:

n Whole systems integrated care

Focusing on older adults with one or morelong-term conditions and developing a modelof care that focuses on patient needs anddelivering care in the community. To supportthis, integrated teams working acrossorganisational boundaries are beingdeveloped to ensure care is joined up andpeople receive the care they need when theyneed it. Further tools and resources need tobe developed to enable this to happen.

n Primary care

Improving health and wellbeing outcomesand access, reducing inequalities andimproving the patient experience as well asproviding more joined-up services closer topeople’s homes. This relies on improvementsin workforce, buildings, extended openinghours and co-commissioning.

n Like-minded

Enabling North West London to work inpartnership to deliver excellent, joined-upservices that improve the quality of life forindividuals, families and communities thatexperience mental health issues.

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North West London(NWL) was awardednational pioneer status todevelop integrated care

n Acute reconfiguration

Concentrating some services into specialistunits to improve the care patients get whenthey need it most. This will allow patients tobe seen by more specialist staff and allowmany more senior staff to be present 24/7.

The workforce priorities in North West Londonare focused to support the overall strategic aimsof the sector and transformation programmesoutlined above.

The workforce priorities for NWL are:

Workforce planning

n This is a key priority to inform otherworkforce priorities. The strategy is toimprove workforce planning in NWL toensure the emerging care models from theprogrammes will have sufficient well-trainedstaff to deliver care, and to highlight areaswhere there are staff shortages or wherecurrent staff need training and education toenable them to work in new ways. This willbe achieved through modelling, starting with a baseline view of the existing NWLworkforce (numbers in roles and theirrespective skillsets), to understand any gap inworkforce requirements, that must be met toachieve the aspiration for new models of care

n Developing new roles and new ways ofworking to address the gaps that theworkforce planning is identifying.

Recruitment, training and education

n Opportunities to support development of theprimary care workforce are being exploredthrough a series of workshops with frontlinestaff and employers (including GPs, nursesand community pharmacists). An outcome of the workshops will be for staff to buildnetworks and relationships across theperceived boundaries in NWL (betweenboroughs and professions) and to empowerstaff to work toward implementing ideas and action plans that can be supported andfacilitated by the work of NWL’s strategy and transformation team.

n Developing the community nursing workforceas a key to delivering integrated care. There isan opportunity to achieve this by embeddingHealth Education England’s (HEE) educationand career framework for district and generalpractice nursing.

n There is potential to introduce new roles intogeneral practice, such as physician associates,and to develop a career pathway to upskillreceptionists, healthcare assistants and nursesto support GPs’ workloads and attract morepeople into the professions.

n There is an opportunity to work withboroughs and federations to strengthen the‘NWL brand’ to attract and retain permanentstaff to fill vacancies. This may includedeveloping a consistent set of terms andconditions, aligned to Agenda for Change, to promote equity across NWL, and to createdevelopment opportunities and clear careerpathways to help attract and retain staff.

n Ensuring staff are developed to work to the‘top of their licence’ across the system, toensure professionals are focused on the workthey have been trained to do and explorehow they can work in more efficient andeffective ways.

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Change Academy

n Building a sustainable workforce that canadapt to future changes and priorities. TheChange Academy programme will includedevelopment of skills and approachesincluding leading change across boundariesand delivering transformation projects.

n Developing integrated multi-disciplinaryteams. The Change Academy programme willtake a team-based approach and focus onworking across different organisations todeliver transformational change. A team could be comprised of system leaders,commissioners, providers in primary,secondary and community and social care(including GPs, nurses and mental healthpractitioners), and the voluntary sector.

n Behaviour change from both staff andpatients/service users to ensure person-centred care and better management ofhealth and wellbeing through the healthcoaching programme, which will train morehealth professionals to use coaching skills tohave more meaningful conversations withpatients. The programme will use asustainable ‘train the trainer’ model toharness existing capability and ensurewidespread reach.

4.7 Summary

Each SPG transformation programme summary reflects the distinct focus of each localarea. However, there are common themes across a number of those SPG workforcepriorities. These include the need to:

1 implement coordinated recruitment and retention strategies to fill existing vacancies across local professions, and remove the existing reliance on bank and agency staff – in particularacross primary care

2 develop workforce models that align to planned new models of care upon which localworkforce development plans can be built

3 establish a local workforce baseline across those professions that support the delivery of existing services

4 define the skills, competencies and responsibilities of new and existing staff who will deliverintegrated, multi-disciplinary care across organisational boundaries.

It is important to note these insights in order to ensure that any focus of this framework aligns to the needs of local transformational services.

ReferencesCCG Strategic Planning Groups call for evidence submissions

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Key workforce findings

5.1 Retaining and recruitingthe best staff

Ensuring that there are sufficient high-quality staff to deliver health and social care services isparticularly challenging, given London’sprofessionally and personally demandingenvironment. This affects all professions, butparticularly lower paid staff.

Common insights include:

n Low pay, anti-social working hours, limitedpersonal development and work-life balanceare all factors contributing to significantworkforce attrition, and existing high vacancyrates across a number of professions.

− Even though, from a public sector perspective,a number of health professions are consideredto be well paid, there are professions whereexisting low pay is a cause for individuals to seek alternative employment away from thehealth and social care system, or to work within it but for agencies.

− Where there is limited flexibility available to members of staff in determining their working hours, for example as a result of strict rostering timetables, this may cause a migration of the workforce to bank and agency providers that offer a greater degree of flexible working.

− Where organisations do not provide their workforce with sufficient personal and professional development opportunities and support within their existing roles, it leads to high turnover.

The health and social care system in London is undergoing substantial transformation, withambitious goals over the next five years. This chapter brings together the key findings fromanalysis of all of the reviews described in previous chapters.

More than 70% of the current workforce will be the workforce in ten years. Therefore, it isclear that if substantial transformation is to happen over the next five years, there will need to be a clear focus (and a balance of investment) on supporting the existing workforce, todeliver this planned transformation. This is in addition to ensuring that the right numbers ofprofessionals are being educated for the future. A balance in the investment available for bothbuilding the future workforce and developing the existing workforce is needed. This will needto be considered across service and education commissioning systems, and employers in theirrespective care settings. In collaboration and through extensive engagement with over athousand clinical and non-clinical stakeholders from across the capital (including strategicplanning group workforce leads, CCG chief officers and providers, HR directors, and tradeunions) eight key areas of focus have been identified.

These eight key workforce findings provide a guide to those areas of focus where action isrequired to ensure the health and social care system develops and delivers the workforce tomeet the needs of patients now, and in the future. They are:

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n A cause of high vacancy rates acrosscertain professions, care settings andgeographical locations in London is as aconsequence of the lack of perceivedattractiveness of these careers.

− There are specific challenges recruiting in certain parts of London. Reasons vary but include affordability, publicised challenges with local providers, and financial incentives. Specific challenges exist (e.g. in east London due to large scale developments leading to forecast large increases in population).

− Some professions (e.g. those delivering care in the community and across primary care environments) are seen as less desirable by prospective staff. This may be due to poor publicity or perceived underinvestment. A lack of exposure to training and working in these areas meansthat many staff are not aware of the benefits of working in this sector in comparison to other sectors (e.g. acute hospital settings).

− A number of specific staffing gaps have been identified across the different transformation programmes in London. Although the reasons vary, there is a general concern that unless specific short-term gaps are addressed, then the ambitions of the transformation activities described may be difficult to achieve.

− A number of organisations are looking at improving vacancy rates by ensuring that the composition of the workforce reflects the community it serves and is indeed drawn from the local population.

n A lack of a clear workforce baseline acrossexisting professions, care settings and Londongeographies may lead to inaccurate futureworkforce forecasts to inform effectiverecruitment and retention strategies.

− The existing maturity of understanding around the impact on the workforce of new models of care and interventions; and the implications of proposals for community, mental health, primary care and acute care, means there are limited clear assumptions on which to base future forecasts for workforce demand.

− Where there are no established mechanismsto consistently capture, interrogate and challenge workforce data from varying sources, the ability to maintain an actual workforce baseline is challenging.

n The high cost of living in London means that recruiting and retaining staff remains asignificant challenge.

− At the inner and outer London weighting boundaries, and particularly where there islimited geographical difference between organisations/sites, staff tend to migrate toinner London (and the greater pay). This happens within and across organisations.

− Where there is a lack of affordable housing, this impacts on a region's ability to attract new members of staff for existing vacancies. There is a trend for staffto travel further to get to work in inner London organisations.

− The rising cost of transport in London influences where people choose to work, impacting employers' ability to recruit and retain staff. Transport links, and the accessibility of where employers are geographically located, are also an important factor.

n Known factors that improve the retention ofthe existing primary and community careworkforce are where staff have a clear careerpath with roles and responsibilities defined ateach stage of their career; opportunities toexpand their knowledge and expertisethroughout; and ways of working thatsupport them to be released to receivedevelopment training.

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5.2 Supporting staff to collaborate acrossorganisational andprofessional boundaries

The increasingly complex needs of the populationmean that staff must be supported to workacross organisational and professional boundariesto develop and deliver integrate services basedaround the patient. From the ability to put asideorganisational loyalties to collaborate innetworks, to increasingly developingcollaborative working arrangements acrossdifferent organisational structures, this needexists across the health and social care economy.


n Many of the transformation programmesdescribed above outline a need to work in apatient-centred way and often acrosstraditional organisational and professionalboundaries.

n Where roles and responsibilities are unclearacross the workforce, this can impact on thedelivery of coordinated patient care by multi-disciplinary teams.

n Where shared objectives have not beensufficiently defined and agreed between careproviders, this can inhibit staff fromcollaborating effectively and potentiallyundermine trust between organisations.

n Where maturing network ways of workingexist between professionals in different caresettings, sharing knowledge and resourcesbetween staff across organisationalboundaries can be limited. This is a commonsymptom of silo working arrangements andthe culture of some individual departmentsand organisations. Particular examples ofnewly established networks that will need toensure they agree clear shared objectivesinclude urgent and emergency care networksand GP federations.

n Some organisational governance barriers exist which prevent the movement of staffacross organisational boundaries to work indifferent care providers. Examples includeemployment contract terms and conditions;indemnity insurance; and the ability of staff in sub-contracting organisations toaccess NHS pensions.

n The lack of visibility and inconsistentcommunication of a patient’s care planbetween professionals in a multi-disciplinaryteam. This acts as a barrier to moreintegrated patient-centred services.

n Where an autonomous organisation’s cultureis at odds with the collective needs of thewider local health economy in which itresides, a culture shift within the workforce isrequired in order for staff to participate incollaborative working arrangements inpartnership with other local care providers.

5.3 Supporting workforceversatility to adapt to the multiple needs of patients

There is a need to meet the increasingly complex care needs of patients throughencouraging a much greater versatility in theworkforce. The ability of individuals and multi-disciplinary teams to adapt to provide care indifferent settings, at different times and indifferent organisational and team structures isbecoming even more essential. To achieve thisthere will need to be an improved balance ofgeneralist and specialist skills across the currenthealth and social care workforce.

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n There is an increasing tendency towardsgreater workforce specialisation. Whilstexperts in their field are an essential part ofthe future workforce, there is a need to buildadditional generalist expertise in the existingworkforce. For example, there could be agreater role of clinical pharmacists in theoptimisation of medicines for patients withlong-term conditions and pharmacy roles inmanaging minor illness and medicines advice.

n To meet the increased demand for careservices across the NHS, there is a need forhealth professionals to deliver services closerto the patient. In many areas where there areshortages in professions, use of other suitablehealth professionals should be considered.For example, it has been stated thatpharmacists and HCAs are examples ofunderutilised health professionals in theexisting workforce.

n Where further multi-disciplinary team-working can be improved to enhanceworkforce versatility to meet patients'complex needs, a greater focus should bemade on agreeing clear roles andresponsibilities between team members. Inaddition, emphasis should be on staffcompetencies to ‘do the job’, rather than justqualifications held (i.e. determine who is bestplaced to meet the needs of the patient, notwhat qualification they have).

n There is a need to encourage new ways of working that ensure rapid access isprovided to a broad range of expertise in theright settings.

n Through adapting practices to address thedesire to provide seven day services there maybe an opportunity to provide a morecomplete service to individuals with multipleco-morbidities.

5.4 Developing leaders andmanagers at all levels

To manage the increased scale and pace ofchange in such a complex and interdependentoperational environment, there is a need tofurther identify, encourage and develop clinicaland non-clinical leaders and managers. This willensure the scale of transformation is achievedand delivered efficiently and effectively.


n To drive forward the health and social caretransformational agenda, further capabilityand capacity amongst leaders and managersis needed at all levels.

n Inconsistent health and social care appraisalapproaches do not provide managers andleaders with sufficient mentoring andprofessional development opportunities. As a consequence, a lack of overall directionand support for careers into management will develop. This could act as a barrier todeveloping emerging leaders and managersacross the frontline workforce.

n Given the degree of change at all levelsacross the health and social care system,leadership competencies in moderntransformed services will differ to previouslyunderstood requirements. Existing leadershipdevelopment programmes and methods mayneed to adjust to reflect this shift.

n In cases where the scale, pace and complexityof change is high, leaders and managers willhave significantly reduced capacity to focuson their professional development whilst alsodelivering the required change.

n The development of leaders and managers at all levels is hindered by the shortage ofsufficient leadership programmes to deliverthe scale of professional development neededacross the existing workforce.

n Where there is a gap between the diversity ofthe local population and that of the workforce,including trust leadership and seniormanagement, studies have highlighted thatthis under-representation adversely impacts onthe provision of services across London.

n Joint accountability for financial managementand clinical delivery between managers andclinicians delivers improved value.

n To ensure that best practice approaches areadopted in workforce deployment,management of flexible working practices,including ward round effectiveness, it isrecognised the development of effectiveleaders and managers will be required

5.5 Supporting workforce agility to respond to change

A constant feature of the health and social care system is that it is always undergoingsignificant change. There is no reason why this will not continue into the future. There willbe a need for greater agility in the current andfuture workforce to respond to, and manage,repeated change. Creating a workforce whichcan adapt to change quickly will be crucial, but this must be underpinned by anorganisational culture in which staff are suitably supported and empowered to workwithin this changing environment.


n The success of new models of care forpatients, which will require the workforce to undertake greater multi-disciplinary andcross-organisational boundary working, isdependent on staff being more proactive,resilient and adaptable to change.

n Change often adds additional pressure,uncertainty and burden onto the existingworkforce. Without sufficient health andwellbeing support for staff, to enable them to be more resilient to change, there is anincreased risk of a higher rate of attritionacross the current workforce.

n Given that much of the change anticipatedthrough new models of care is unprecedented,limited best-in-class examples exist to guidethe workforce through the delivery ofplanned changes to services.

n In many cases the characteristics andbehaviours expected of the workforce todeliver transformational change remainunclear or undefined. This can lead to a lack of direction in the ways in which theworkforce should look to focus theirdevelopment to better respond to change.

n Developing agility and resilience is not always prominent in workforce education and training. There is a need to support newand existing staff to learn these skills in theever-changing NHS environment.

n A robust level of health and wellbeing for the workforce positively affects patient careand patient experience.

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A constant feature of the health and social care system is that it isalways undergoing significant change.

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5.6 Strengthening health systems: providers and commissioners

Service commissioners and providers areincreasingly urged to work together to delivermore integrated care for their local populations,for example through accountable careorganisations). To balance national and localpriorities, alongside the transformational journeybeing undertaken to deliver new models of care, there is a need to build and strengthen the capability and capacity of providers andcommissioners to lead transformational changein a complex and changing environment.


n To establish and deliver a shared healthsystem vision that meets the needs of a local community, alongside regional andnational priorities, requires providers andcommissioners to work together throughshared governance to shape, own and deliverthe strategic priorities of this shared vision.

n To enable the delivery of those agreed sharepriorities between providers andcommissioners, performance and financialmeasures within each partner organisationmust align and promote the behaviours thatdeliver these shared goals.

n Where local patient and clinical involvementis not sufficiently sought to shape local health economy sustainability andtransformation plan priorities, theachievability of delivering the plannedtransformation at pace can be limited.

n To facilitate commissioning services that aremore closely aligned to the needs of localhealth economies, commissioners andproviders should be encouraged to ensurethey have strong links into CommunityEducation Provider Networks (CEPNs).

n To ensure that commissioners and providershave the information they need to makeinformed commissioning decisions, there is aneed to improve the consistency and accuracyof workforce data available within the system.

n To best enable the effective delivery ofservices, commissioners and providers need to take into consideration workforcecapacity and capability when making servicecommissioning decisions. Having clear rolesand responsibilities is essential.

n Where high vacancy and attrition rates existamongst commissioning and providerorganisations, improved clarity and definitionis required around the career paths andprogression opportunities in existingcommissioner roles.

n There is a need for greater alignment betweenservice commissioning and health educationcommissioning to ensure that appropriatenumbers of professionals are educated andtrained to meet future needs. This includesgreater links between provider workforceplanning submissions (to LETBs) andcommissioners’ strategic transformation plans

n To best ensure commissioned services meet the needs of local health-economypopulations, and deliver the desiredoutcomes in the future, there needs to be a suitable balance of commissioner andprovider time focused on transactionalcommissioning activity versus longer-termstrategic commissioning and planning.

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5.7 Ensuring care is delivered in the right place, with a particular focus on primary health careand community services

Transformed health and social care services of thefuture will deliver the right care for patients, inthe right place and at the right time. To achievethis transformation across all care settings, theworkforce in each will require the necessary skillsand capabilities to deliver appropriate care thatmeets patients' needs. The combined impactupon primary health care and communityservices, of existing local, regional and nationaltransformation programmes is significant. Manyof the proposed changes across London requireprimary health care and community services tooperate in a different way, to ensure patients areat the centre of care. Without fundamentalchanges to primary health care, or appropriatedevelopment and support of the workforce, thebenefits of moving care away from hospitals andinto the community will not be realised.Therefore, a particular focus on the primaryhealth care services’ workforce is needed.


n Where the existing medical workforce doesnot have capacity to meet the growingdemand for primary and community careservices, this burden could be reduced bysharing clinical responsibilities with otherhealth professions, for example byempowering practice, district and communitynurses to manage a greater proportion ofgeneral practice workload.

n As a consequence of existing vacancies and anageing workforce, there is an increasing needto make careers in primary and communitycare more attractive, to encourage moremedical and health professionals to want towork in these settings.

n New ways of working in networks betweenprimary and community providers should beencouraged, to enable professionals to shareknowledge, expertise and resources acrossorganisational boundaries, and improve theirgeneral skills base.

n A planned shift in patient care away fromhospital settings will require a shift in theprovision of staff training into the community.

n Given that shifting patient care into thecommunity is a key part of the plannedservices transformation in London, it is vital tounderstand the combined impact of alltransformation programmes on the primaryand community care infrastructure andworkforce, in order to enable the successfultransition of care services.

n More training placements should be offeredin primary and community care, so moretrainee health and care professionals canexperience the benefits of working in thesesettings and see their attraction.

n Given the important role of the workforce insystem transformation, funding for trainingneeds to be more closely aligned to primaryhealth care and community services.

n Building greater capacity and expertise in theworkforce is necessary to achieve the healthand social care transformation ambitions forchildren and young people, mental health,cancer, and urgent and emergency care.

n In delivering greater patient interventions inprimary health care and community services,it will be equally important to consider theimpact on secondary care service providers.

n It is recognised that a fundamental shift away from ‘paternalistic’ to ‘personalised’models of care is needed, and this requires a workforce equipped with the right skills,behaviours, knowledge and attitudes toengage patients in managing their ownhealth, in decision-making, administering andeven commissioning their own solutions.

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5.8 Delivering improved value, quality and productivity through the workforce

The NHS in London is facing a £4.76 billionaffordability gap by 2020/21. Delivering the right care in the right setting, improvedproductivity in existing services, and establishingnew ways of delivering care are all recognised as areas of opportunity for the workforce todeliver improvement value for patients.


n The combined regulatory requirements on themedical workforce above and beyond theircore duties as clinicians can create additionalbureaucracy and increase the non-productivetime of the workforce.

n Inconsistent ways of working in undertakingworkforce planning and rostering can be a cause of reduced productivity in thefrontline workforce.

n Where organisations' finance and governancemodels are at odds with new ways ofworking, this can limit change and innovationacross the existing workforce.

n Where procurement of clinical supplies andnon-clinical services are not tracked ormanaged consistently in an organisation, this can limit the workforce from deliveringoptimum care to patients that reflects value for money.

n Where there is a lack of bank and agencystaff pay-rate harmonisation, there is a riskthat organisations will incur unnecessarilyhigh agency costs to meet the shortfalls inpermanent workforce rosters.

n Where different local employers in a similargeographical area, or departments within the same organisation, undertake similarorganisational processes (e.g. recruitment)independently of each other, streamliningthese processes can deliver efficiencies.

n By implementing the Right Care approachthrough Public Health and commissioneragendas maximises the value the patientderives from their own care and treatment,and the value the whole population derivesfrom the investment in their healthcare.

n Increased input from hospital pharmacistsworking in multi-disciplinary teams will improve outcomes, reduce waste,improve prescribing decisions and reduceavoidable harm.

5.9 Summary

The key findings described here offer a focus on where action is needed to best enable theworkforce to meet the demands of patients now, and as part of a transformed NHS in future.Addressing each key finding in turn will require varying degrees of action and coordination acrossall parts of health and social care in London, as well as nationally. To best support commissioners,providers and the current health and social care workforce to deliver sustainable action aroundeach of these findings, the next chapter describes the London-wide support available in the shortand long-term as part of the London Workforce Programme.

6.1 Supporting the delivery oftangible action to mitigatelocal workforce challenges

To best support commissioners and providerslocally across London, feedback has indicatedthat the following broad types of support wouldadd value locally across each of the LondonWorkforce Strategic Framework’s eight keyfindings. These include:

n Gaining an understanding of the currentworkforce baseline and the impact ofproposed transformation activities.

n Where there are solutions that mitigateexisting workforce challenges, there is a need to more effectively disseminateexamples of these solutions.

n Where solutions are not yet identified there is a need to bring together the appropriateresources to identify potential solutions andto disseminate them.

n Establish a London Workforce web presenceto facilitate the sharing of successful solutions to existing workforce challenges,lessons learnt and promoting a workforcedevelopment community.

It is proposed that this short-term support wouldbe made available to the system through thefollowing five core packages of work.

Across the health and social care economy in London, workforce is consistently cited as the keyarea that will make or break the transformation of services required. If immediate actions arenot taken that best support the workforce through this period of transformation, there is asignificant risk that the quality of services for patients now and in the future could be affected.

Development of this London Workforce Strategic Framework mitigates this risk and provides theplatform to support the development of a modern health and social care workforce in London.

The eight key findings (see chapter five) set a clear direction for where action is required inLondon. It is proposed that commissioners and providers across London embrace thesefindings, and that they inform the focus of local plans. Many solutions to existing workforcechallenges may be found locally. However, it has become clear that there may be benefits todeveloping a number of solutions once for London.

This chapter recommends the support that would be needed in the short term, and thosestrategic London-wide actions around which a single voice for change is needed to enable thelong-term delivery of new models of care as part of a transformed health and social care system.

A framework for action 59

Chapter 6:

A framework for action

Workforce modelling for futurerequirements

The proposal is to develop mechanisms forsharing workforce modelling techniques,approaches and skills to support others to buildsustainable and cost effective workforce models.Over the longer term, the ambition is tomaintain a single source of data on existingworkforce numbers in London, which is updatedregularly and available to all. It is anticipated thiswork will include modelling of future workforceworkloads, capacity and demands to optimisestaffing at every level. In addition, furtherdatasets around workforce migration patterns,future workforce needs, funding andeducational implications of new models of care will also be made available. This work aims to facilitate an understanding of the impactof proposed transformation activities in Londonon the workforce.

Through our existing engagement withCCG/SPG workforce leads, the initial areas of focus recommended are to support:

n system dynamic modelling to baseline current workforce and create adaptablefuture models (e.g. modelling new models of primary health care)

n improved use of existing NHS workforcedatabases to enable benchmarking acrossorganisations

n development of a simple online resource and directory from healthcare professionalsseeking information.

Enabling workforce development,innovation and adoption

The proposal is to establish and maintainmechanisms that facilitate the sharing of bestpractice examples across London where localworkforce challenges have been resolved. It is suggested a workforce development andinnovation portal is established and stakeholderevents are organised around agreed priorityareas for commissioners and providers.

Where existing solutions do not exist, but there is a desire to find solutions once forLondon, it is proposed that project support bemade available to facilitate and co-developsolutions to known workforce challenges.Through our existing engagement withCCG/SPG workforce leads, the initial areas offocus recommended are to support:

n the delivery of employment governancewhich enables cross-boundary working, witha specific focus on key operational areas (e.g.clinical indemnities or employment contracts)

n the development of consistent approaches inLondon for specific workforce roles (e.g. forclinical pharmacists and physician associates).

Continue London-wide partnershipworking

Through the work to date, the focus has beenon understanding the workforce implications ofLondon-wide transformation programmes forprimary care, cancer, mental health, urgent andemergency care, and children and young people.It is proposed that continued project support bemade available to these HLP programmes tofacilitate the embedding of identified workforcepriorities into local delivery plans. In addition, Itis proposed that this supports enables thedelivery of specific actions aligning to theiragreed workforce priorities.

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Chapter 6


6.2 Longer term strategic projects

During the development of this LondonWorkforce Strategic Framework, it has becomeclear that to develop a modern health and socialcare workforce in London that is ready to deliver

new models of care, a number of strategicsystem-wide areas of focus need to be addressed(see below). This will require input and challengefrom a wide range of system stakeholders. It isproposed that a range of London-wide strategicprojects need to be mobilised to coordinate,engage and collectively deliver action.

Affordable housing was raised as a potential barrier to recruiting and retainingworkforce in the BHfL recommendations. Since then, other significant barriers havebeen raised (e.g. inner and outer London weighting and the cost of transport). It isproposed that reviews of the key barriers to recruitment and retention are undertakenand clear recommendations are made.

A recurring theme throughout the review has been the fact that 70% of the currentworkforce will be the workforce in ten years. The question that has therefore beenraised is whether the degree of investment in supporting the existing workforce isappropriate. It is proposed that a review of investment in the current workforce tofurther develop their skills, roles and training to better enable them to deliver newmodels of care is required.

Whilst experts in their field are integral to the future workforce, there is a need todevelop greater generalist expertise within the existing workforce. Especially given the current direction of travel of an environment of ever increasing workforcespecialisation. It is recommended that HEIs propose recommendations to how thiscould be delivered.

There is a need to review specific leadership capacity and capability issues associatedwith the combination of transformational activities across London. It is proposed thatHLP, the NHS Leadership Academy, HR directors, HEE and commissioners developleadership support programmes to address the capacity and capability requirementsidentified in the review.

To best identify and effectively address the needs of the workforce to deliver transformedservices in London, greater alignment is needed between provider workforce planning,education and service commissioning. Building on work done to date, it is proposed thatactions should be identified to improve this alignment.

Commissioning of services is becoming increasingly complex, with commissioners having to balance national and local priorities alongside new models of care thatchallenge traditional boundaries between themselves and providers (e.g. accountablecare systems and integrated care models). There is a need to review the implications forcommissioners as the NHS transforms.

There is a need to significantly shift the balance of training provision into thecommunity to support the service transformation described in CCGs’ strategic plans.However there are two related issues that need to be particularly investigated.1 The degree of dependency of the acute sector on trainees delivering acute services.2 The capacity of the primary and community services to provide training places.

The strategic system-wide areas of focus:

Strategicbarriers toworkforcerecruitmentand retention

Investigate thebalance ofinvestment inthe currentworkforce

Shift balancefrom specialistto generalisttraining

Expandingleadershipcapacity andcapability

Continuedalignment ofeducation and servicecommissioning

Shift fromtransactional to strategiccommissioning

Shiftingtrainingprovision into the community

Chapter 6

A framework for action 61

6

Keyfinding

7

Keyfinding

3

Keyfinding

6

Keyfinding

45

Keyfinding

Keyfinding

432

1

Keyfinding

62

Chapter 6

6.3 Conclusion

This London Workforce Strategic Framework provides a qualitative evaluation of the workforceimplications raised by a number of key national reviews, and London-wide and local transformationprogrammes. These workforce implications led to eight key findings.

These findings set a clear direction for where action is required to best support the workforce todeliver the best quality care for patients now and in the future. Many solutions may be found locally,however there may be benefits to developing a number of solutions for London as a whole. Acrossthe system, workforce is consistently cited as the key area that will make or break the transformationof services required in all parts of London. If immediate action is not therefore taken to properlysupport the workforce through this period of transformation, there is a significant risk that the quality of services for patients could be affected.

This London Workforce Strategic Framework will enable stakeholders across the system to developcoordinated action to address the workforce challenges identified in the key findings. In addition,it will be important to continue to reflect on where solutions would be best developed once forLondon, as well as identifying local solutions.

If you have any feedback on this framework, please email the London workforce [email protected]


ReferencesLondon Health Commission (2014) Better Health for London, www.londonhealthcommission.org.uk/better-health-for-london/NHS England et al (2014) The NHS Five Year Forward View, www.england.nhs.uk/ourwork/futurenhs/

Appendix 1

Appendix 1 63

Appendix 1:

The methodology used to develop this LondonWorkforce Strategic Framework

Delivering a workforce strategicframework for LondonTo gain consensus on those workforce prioritieswhich will deliver the most value to local healthand care economies, CCG Strategic PlanningGroups (SPGs) and London’s wider systemstakeholders, a broad stakeholder engagementapproach has been undertaken. In delivering thisframework for London, we have spoken withclinicians, CCGs, providers, HR director groups,local authorities, directors of nursing, tradeunion partners and many others to identify thoseworkforce priorities which will deliver the mostvalue to them.

In developing this framework, there has been aconcerted effort to support those responsiblelocally for transformation activities to developtheir understanding of associated workforceimplications and actions to address them.

A shared language across London –workforce methodologyTo facilitate a shared dialogue across London todescribe workforce challenges now, and as aconsequence of planned transformationalchange, a workforce methodology was developedand adopted to establish shared actions.

The sphere of influence model provides a guideto determine the workforce implications offuture models of care, and identify whereactions to support implementation can be mosteffectively taken.

This section describes this methodology and thereplicable approach that has been used to identifyand prioritise groups of workforce activities toinform this framework’s key workforce findings.

It is important to recognise that just increasingthe number of staff is only part of the solution;there are a further five workforce segments forparticipants to consider when identifying andgrouping workforce implications of plannedtransformational change to services.

National

Regional

Local

Employees

Governance

Workforce numbers

New

way

s of w

ork

ing

Developing skills and roles Education and training

En

able

rs

The sphere of influence model

These six segments are defined as:

1 New ways of working Some of theworkforce implications to consider are relatedto cultural and behavioural change, ways tofacilitate leadership at all levels and how multi-disciplinary and cross-sector relationshipsacross health and social care can be developed further.

2 Developing skills and roles The adjustmentrequired to the skills and roles of the existingworkforce to mitigate current workforcechallenges, or to deliver new models of care.It is important to consider what new roles arerequired, the skills and competencies neededand what career path will be available as partof each role. The maturity of career pathwaysis also an element that will need to beconsidered as well as how roles will workacross organisational boundaries.

3 Workforce numbers The long-term forecastfor workforce supply and demand, includingrecruitment and retention implications. Aconsideration has to be made regarding whatnumbers will be required, with a need toidentify the existing baseline.

4 Governance The organisational and legalgovernance elements that may impact theability of the workforce to operate in thetransformed environment. For example,adjustments to contracts and impact onprofessional legislation. A number of topicsshould be taken into consideration includingemployment arrangements; governance andmanagement roles; organisational design andteam structures; performance managementand incentives; alongside accountability andprofessional regulation.

5 Education and training The education andtraining required to deliver the requiredchanges to skills and roles to build capacityand expertise in the existing workforce. Theapproach to the provision of education andtraining is considered as well as curriculadevelopment, logistics and supervision.

6 Enablers Those support elements that wouldaccelerate delivery of new models of care bythe workforce, or improve the ways ofworking of the existing workforce. Forexample, data availability, improved estatesand IT systems.

Each of these workforce priorities is thenassessed across four spheres of influence to support the identification of suitable system owners to lead on their resolutionand mitigation.

The national sphereOrganisations and bodies that influence andmake workforce decisions at a national level[e.g. Professional bodies, Trust DevelopmentAgency, Monitor, NHS England, HigherEducation Funding Council for England,Universities UK, Health Education England (HEE),Association of Directors of Adult Social Services,amongst others]

The regional sphereThose organisations and bodies that influenceand make workforce decisions at a regional level[e.g. Strategic Planning Groups (SPGs), HealthyLondon Partnership (HLP), HEE Local Educationand Training Boards (LETBs), NHS England(London Region), Social Care Workforce SteeringGroup, amongst others]

The local sphereThose organisations that influence and makeworkforce decisions on a local level [e.g. CCGs,service providers, community education providernetworks (CEPNs), Higher Education Institutions(HEIs) and local authorities]

The employers sphereEmployers of the local health and social care workforce who influence local workforcedecisions.

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Appendix 1

Appendix 1

Acknowledgements 65

AcknowledgementsWe would like to acknowledge the significantcontributions made by all the programme teams,boards and reference group members to thedevelopment of this London Workforce StrategicFramework. These include the members of the:

• London HR Directors Forum • London CapitalNurse Programme Steering Group• London Nursing Leadership Forum• London Nursing Workforce Reference Group• London Clinical Commissioning Group

Workforce Leads• NWL Critical Care Network • London Community and Education Provider

Networks (CEPNs)• Health Education England London Education &

Training Board (LETBs)• Health Education England NCEL Allied Health

Professional Network• London Social Partnership Forum• London Scientific and Diagnostics Network• London Allied Health Professionals Network • ADASS Developing London Workforce Plan

Conference• London Diabetes Strategic Clinical Leadership

Group • London Cancer Clinical Leadership Advisory Group• London Cancer Executive Team • London Mental Health Transformation Programme

Board • London Mental Health Clinical Leadership Group• London Mental Health Nurse Directors Group• London Mental Health Chief Officer • London Children and Young People Clinical

Leadership Group• London Primary Care Transformation Board • London Primary Care Strategic Oversight Group• London Urgent and Emergency Care Clinical

Expert Group• London Urgent and Emergency Care Clinical

Advisory Group• London Urgent and Emergency Care Programme

Board• Urgent and Emergency Care ‘Implementing the

Urgent and Emergency Care Vision in London’Conference

• Our Healthier South East London WorkforceSteering Group

• North West London ‘Shaping a Healthier Future’Joint Workforce Steering Group

• North West London Collaborative• North East London Advisory Group• Transforming Services Together Workforce

Steering Group• London Clinical Senate Forum • London Clinical Senate Council • London Workforce Senate• London Workforce Programme Board • London Workforce Delivery Group• London Commissioning System Design Group• HEE London Medical Workforce Steering Group• London Health Chief Officers Group• End of Life Care Network: Education, Training &

Workforce Group• HENWEL Joint PEC and Patient Forum

Special thanks go to those members of theLondon Workforce Programme team for theirsignificant contribution to the development ofthe London Workforce Strategic Framework:

• Kay Sigsworth, London Workforce ProgrammeTeam, Healthy London Partnership

• Kathryn Alley, London Workforce ProgrammeTeam, Healthy London Partnership

• Jasvinder Kaur Perihar, London WorkforceProgramme Team, Healthy London Partnership

• James Crisp, London Workforce ProgrammeDelivery Lead, Healthy London Partnership

• Emily Kessler, London Workforce ProgrammeDelivery Lead, Healthy London Partnership

• Paul Roche, London Workforce ProgrammeDirector, Healthy London Partnership.

Further thanks go to those members of the teamwho are turning this framework into action byfinding solutions to workforce challenges thatare best solved once for London:

• Sarah Ferguson, London Workforce ProgrammeDelivery Lead, Healthy London Partnership

• David Lane, London Workforce Programme Team,Healthy London Partnership

• Tom Houston, London Workforce ProgrammeDelivery Lead, Health Education England

• Alex Goodman, London Workforce ProgrammeModelling Analyst, Healthy London Partnership

• Claire Ripley, London Workforce ProgrammeTeam, Healthy London Partnership

Glossary of terms and acronyms

A&E Accident and Emergency

ACO Accountable Care Organisation

AHP Allied Health Professionals

BHR Barking and Dagenham, Havering and Redbridge

CAMHS Child and Adolescent Mental Health Services

CCG Clinical Commissioning Group

CEPN Community Education Provider Network

CYP Children and young people

FYFV Five Year Forward View

GP General Practitioner

HCA Health Care Assistant

HEE Health Education England

HEI Higher Education Institution

HLP Healthy London Partnership

LETBs Local Education and Training Boards

MDCs Multi-disciplinary Diagnosis Centres

Monitor NHS regulator

NCL North Central London

NHSE NHS England

NWL North West London

OD Organisational Development

SCN Strategic Clinical Network

SPG Strategic Planning Group

TDA Trust Development Authority

TCS Transforming Cancer Services

TST Transforming Services Together

U&EC Urgent and Emergency Care

Vanguards Sites which will lead on the development of new models of care and will act as a blueprint for the NHS moving forward.

66 Glossary of terms and acronyms

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