Confederations - its influence in England

In March 1999, the House of Commons Health Select Committee recommended that their should be a major review of Workforce planning in the National Health Service.

The Government accepted this view and set out a number of key principles which should govern the review.

1. The NHS and the NHS Executive must be clear about service needs and the skills and staff required to deliver those services efficiently and effectively.
2. Thinking about services, workforce and resources should be done together to ensure plans and developments are consistent and co-ordinated.
3. There should be an appropriate mix between central (top down) and local (bottom-up) planning.
4. Planning should cover the whole health care workforce looking across sectors: primary, secondary and tertiary, employers: public, private and voluntary and staff groups: nurses, doctors and dentists and other professionals and other staff, and should take account of revolving roles.
5. Workforce planning arrangements should reflect clear and agreed responsibilities and accountabilities with effective performance management systems.

The outcome resulted in the establishment of 27 (now 24) Workforce Development Confederations in England.

The relationships of Workforce Development Confederations (WDCs) to existing and emerging bodies e.g. primary care trusts (PCTs) and Strategic Health Authorities (StHAs) is complex and a report can be reviewed at www.wdc.nhs.uk

The Executive of the British Geriatrics Society has received a paper on the 21st March 2002 from the BGS Workforce Committee analysing the current workforce issue for geriatrics in the UK in the light of previous publications and with added commentary.

However, the essence of this article is to point out to working geriatricians, members of the BGS, how best to benchmark current workforce issues in the specialty and influence the decision making process which plans for future upward pressures in health and social care in relation to older people.

Targets
With this in mind national targets for older people have been set which are informed by the National Service Framework document (NSF) for older people.

Examples of such targets are as follows:

1. Improve the quality of life and independence of older people so that they can live at home wherever possible, by increasing by March 2006 the number of those supported intensively to live at home to 30% of the total being supported by social services at home or in residential care.
2. By December 2004, all assessments of older people will be given within 48 hours of first contact with social services and all assessments will be completed within 4 weeks, and 70% within 2 weeks.
3. By December 2004, following an assessment, all social services for older people should be
   provided within 4 weeks, and 70% of services within 2 weeks.
4. By December 2004, all community equipment for older people (aids and minor adaptations)
   provided by Social Services will be delivered within 7 working days.
5. Each year there will be less than 1% growth in emergency hospital admissions and no growth in re-admissions.
6. 80% of people with diabetes will be offered screening for early detection of diabetic retinopathy in a systematic programme which meets national quality standards by 2006.
7. Intermediate care capacity expanded to meet the NHS Plan targets of an increase in the number of intermediate care beds by 5000 and the number of people benefiting from intermediate care by 220,000, in 2004 compared to 2000.
8. Service capacity increased in other key serviceswhich support people at home so that in 2006:
   30,000 more people a year receive care packages involving 5 hours or more a week of home care; 500,000 more pieces of community equipment are provided; there are 6,900 more extra care housing places - to contribute to an increase of 6,000 and the number of people in care homes supported by councils over the 3 years to 2006. By 2006 councils increase their intermediate care places to benefit an extra 70,000 people a year.
9. An additional 130,000 carers a year receive services in 2006, using the increased investment in the existing carers special grant.
10. As a result of investment in extra capacity in the introduction of reimbursement of the NHS by councils, delayed transfers of care reduce to a minimal level by 2006 and by April 2004 all general hospitals caring for people with stroke to have a specialised stroke service. By April 2005, an integrated fall service should be established across all local health and social care systems.

Current mathematical modelling of trends is arrived at centrally and can be based on historical trends which may be imperfectly understood.

However, once arrived at they are handled on a sectoral basis now that Strategic Health Authorities (StHAs) are almost completely coterminous with WDCs nationally.

Local Development Plan
Each “player” be it Trust, secondary or primary, is obliged to detail their workforce projections into a Local Development Plan (“LDP”) which outlines the workforce, doctors, nurses and professionals allied to medicine etc. which will be required to deliver on national targets as set. These plans include the pressures placed by current and future demography.

The new system has been designed by a project board involving representations from PCTs, Trusts, Workforce Development Confederations and Strategic Health Authorities with input from local Government. It is intended to be a radical departure from an established practice, which was widely believed to be unsatisfactory.

For the new system to work better, however, it will need more than careful design - they will also need practice and behaviour to change. The period in which plans are developed is a critical test of the new system. A fundamental change in relationship between PCTs and trusts, strategic health authorities and Department of Health is needed.

The new planning system is based on a single 3-year “local delivery plan” (LDP) which covers NHS and joint NHS/social care priorities. This change reinforces previous guidance simplifying the planning system for social care.

Local delivery plans will need to be developed by primary care trusts (PCTs), and strategic health authorities (StHAs), and for trusts in critical areas such as “access”. Work on “access” is almost complete.

Roles and responsibilities
The following sections sets out the high level roles and responsibilities for organisations under the new planning framework.

Department of Health

• Set priorities, targets and planning framework
• Allocate capital and revenue funding
• Provide developmental support to StHAs
• Sign-off StHA local delivery plans

Strategic Health Authorities

• Establish and oversee an effective planning process, involving all key stakeholders, local government and other agencies
• Ensure that overall plans will meet nationally set targets, including overall financial balance within the StHA
• Ensure coherence between and adding value to local plans
• Manage StHA-wide and supra-StHA issues
• Ensure SLAs/contracts are consistent with local delivery plans, and are signed-off by March 31st
• Ensure that planning takes account of anticipated change such as the new financial flows system or new NSFs
• Sign-off PCT local delivery plans, and trust plans for critical access targets

PCTs

• Lead production of integrated whole systems local delivery plans
• Represent the NHS in broader local planning arrangements and partnerships with key local stakeholders
• Ensure effective stakeholder involvement in planning processes – as a minimum PCTs’ local delivery plans should:
  • be signed-off by the PEC and Lay Board
  • demonstrate that clinicians and front line staff have been engaged in the development of plans and support proposals
  • demonstrate that provider organisations have been engaged in the development process and are supportive of planning proposals
  • demonstrate the contribution of local government and other key non-NHS partners
  • involve local communities and the voluntary sector in the development of plans
• Develop credible profile trajectories for delivery of targets
• Ensure flexible arrangements to handle anticipated changes such as the new financial flows system or new NSFs
• Provide NHS Trusts and social service partners with open book access to information
• Negotiate provider SLAs/contracts, ensuring that agreements are in place to underpin plans by March 31st (PCTs and Trusts will be held jointly accountable by StHAs for the delivery of robust plans)
• Resolve commissioner/provider disputes at a local level, and jointly with trusts alert StHAs at the earliest time where dispute cannot be resolved.

NHS trusts

• Provide PCTs with open book access to information as part of the planning process
• Actively support PCTs in developing plans, so that they represent provider as well as commissioner intentions and actions
• Produce trust plans for relevant targets (access, workforce)
• Ensure that provider SLAs/contracts are agreed and in place to underpin local delivery plans by March 31st.
• Resolve commissioner/provider disputes at a local level, and with the PCT(s) alert StHAs at the earliest time where disputes cannot be resolved.

Social Care

• Lead production of local delivery plan sectionfor relevant priority area(s)
• Provide PCTs with open book access to information for relevant priorities
• Actively support PCTs in developing plans for the delivery of robust local delivery plans
• Ensure appropriate social care input to allow provider SLAs/contracts to be agreed
• Resolve disputes at a local level, and with the PCT(s), alert StHAs at the earliest time where dispute cannot be resolved.

Councils with social services responsibilities and PCTs will need to jointly agree their contributions to achieving targets. Local delivery plans must record the contributions of both the PCT and council. Local agreements will need to be consistent with Best Value requirements for councils.

To date the emphasis has been on capacity around “access” issues i.e. waiting times, transit times and A&E. But local delivery plans will need to be done for older people, amongst others, by the end of March 2003.

Local delivery plans will need a standard format to facilitate aggregation at StHA and national level. A standard national template has been designed, consisting of two main sections. The first section is a strategic executive summary. A national format for this section of LDPs will not be prescribed, however, as a minimum the management summary must:

• Summarise short, medium and long term service development plans and priorities,
• Summarise capital and revenue implications for those plans
• Demonstrate affordability of proposals
• Summarise how key partner organisations, front line staff and stakeholders have been engaged in the process and how supportive they are of service proposals
• Consider the strategic context both nationally and locally, lining to the NHS Plan, NSFs and partnership arrangements.
• Summarise the level and cost of service provided currently and how this will change as a result of the plans
• Provide evidence to support the use of local capacity assumptions, where these differ to national assumptions
• Describe local arrangements for monitoring against trajectories, setting out thresholds for management action
• Indicate major risks to delivery and risk management arrangements
• Set out the plans for implementing the new system of financial flows.

Once numbers required in various professional groupings have been decided upon, the Workforce Development Confederations are obliged to commission the relevant education and training with whichever body is relevant, for example, higher education institutions, deaneries, etc.

An example, pertinent here, would be organising increased amounts of national training numbers (NTNs) with deaneries to provide for increased consultant numbers.

However, it must be remembered here that there is latitude within the process to consider that much of increased geriatric workload may be dealt with (for example) by increased numbers of nurse practitioners or nurse consultants rather than medical staff.

Such considerations will almost certainly occur to some primary care trusts. The nature of new geriatric consultants and their location and focus is also available for discussion and decision i.e. whether or not they work within the intermediate care field or the notion of the community based geriatrican.

This makes it imperative that geriatricians keep apace with education and training issues for professionals, other than doctors, who are interested in the care of the older patient.

Therefore geriatricians must learn their communication lines in their institutions to the person(s) involved in capacity planning, for example, operations manager in a trust and the commissioning managers at PCT level. Engaging at this level will ensure input into the form and function of geriatric services locally not only from a medical aspect but also involving allied professionals.

Kevin Kelleher

References
1. A Health Service for all the talents. Developing the NHS workforce
2. Shifting the Balance of Power
3. Improvement, Expansion and Reform
4. Working Together – Learning Together
5. Improving Working Lives
6. Information for Health
7. Funding Learning & Development for the Heathcare Workforce

1-7 Available at http://www/doh.gov.uk/index.htm

8. Delivering the NHS Plan sets out the full package of system reform – it is available from the DoH website at http://www.doh.gov.uk/deliveringthenhsplan/index.htm
9. Improvement, Expansion & Reform: The Next Three Years is at http://www.doh.gov.uk/planning2003-2006/index.htm
10. Guidance on the financial flows systemis available at http://www.doh.gov.uk/nhsfinancialreforms/financialflowsoct02.htm
11. A support pack will be available (including links to sources of expert advice about programme management and a new toolkit on service configuration to support hospital managers), at www.doh.gov.uk/hospitalconfiguration
12. The Modernisation Agency has a range of support resources at its website, www.modernnhs.nhs.uk. In particular, it has developed a series of concise practical guides to modernising services, available at ttp://www.modern.hmg.com/improvementguides/