Primary Care Workforce

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Page | 1 Quality education for quality patient care, transforming our workforce

Primary Care Workforce

Introduction

HENW’s macro analysis of the 2014 secondary care provider workforce plans and locally collected workforce data for general practice from across the North West highlighted five key themed areas of priority for workforce planning: nursing, medical, urgent and emergency care, primary care and radiology.

The purpose of this paper is to explore the issues around the primary care workforce in more depth. It identifies in detail the key issues and areas of work that emerge from a more detailed region-specific analysis, and sets out ways forward and the implications for HENW’s work.

Key Story Messages

The Primary Care Workforce Transformation Programme focuses on four areas: general practice, and out of hospital pharmacy, optometry and dentistry. This chapter will highlight key successes in the 2014/15 work programme and identify next steps for taking the programme forward.

 Significant progress has been made in establishing connections and networks with new stakeholders and organisations, creating intelligence, and developing HENW’s primary care offer.

 The General Practice Workforce data collection was implemented with a 28% uptake to date across the North West and is already highlighting significant issues concerning the general practice workforce that need to be addressed.

 Based on the data received so far, additional investment has been identified and allocated in 2014/15 to kick start the need to up-skill and develop the workforce in general practice:

o

Increasing the cash allocation for CPD as well as responding to bespoke

CPD requirements, i.e. the Core Foundation Programme

o Ring-fencing of 30 Assistant and Advanced Practitioner commissions for primary care in 2015/16 across the North West, with an additional 30 ring-fenced for community care and 30 for urgent and emergency care

o Additional commissions of 30 Community Specialist Practitioner programmes for 2015/16 across the North West

o Commissioning 40 places for new roles in the North West, such as Physician Associates

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 A GP returner scheme is being funded with 13 GPs having returned to practice by January 2015.

 Connections with Local Professional Networks, particularly for optometry and

pharmacy, have been established and are being built on, with a view to defining

their contribution, establishing training gaps and meeting provision

demands/requirements.

 Optometry workforce data collection pilot across Greater Manchester, led by optometry on behalf of NHS England Greater Manchester, yielded 65% return and indicated no immediate need for concern around supply for this workforce.

Strategic Context

Over 90% of all patient contact occurs within primary care (Deloitte 2012, p.4) with national policy directing an emphasis on moving care closer to home to improve patient experiences and to reduce cost to the overall system. The NHS Five Year Forward View (2014) indicates that the foundation of the NHS should remain list-based primary care, via a range of service models, with a stronger role in prevention and condition management. This is demonstrated by Transforming Primary Care which introduced a named accountable GP for every patient aged 75 or over and initiated the Proactive Care Programme for the most vulnerable patients (Department of Health, 2014).

As care shifts to the community and the demands on the workforce across all sectors of health and social care changes, the development of the primary care workforce is fundamental to support and enable new models of care. The HEE Strategic Framework’s vision of the future workforce suggests that new ways of working and new roles are required to create a workforce which is responsive to evolving change, fit to act flexibly across health economies and not bound by traditional sector lines.

The HEE Mandate 2014-15 (DH, 2014) reflected the strong focus required on the development of the primary care workforce to support a whole system approach to complex condition management and prevention. To support this, HEE is mandated to:

 ensure the workforce will be trained and developed to enable them to work across different care settings and in multi-disciplinary teams

 ensure that 50% of medical trainees completing foundation level training enter GP training programmes by 2016

 develop tariffs for primary care medical education and training with stakeholders including the Department of Health

 develop the Care Certificate for Health Care Assistants and Social Care Support Workers.

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The development of a workforce planning framework for primary care continues to be a key national priority led through the Workforce Information Architecture programme1, with a local programme being driven and aligned by HENW.

Units of Analysis

Intelligence has been gathered from local workforce data collections, national publications and research, and engagement with commissioners, providers (including local councils) and education, as a system partner.

Findings

Analysis of the General Practice Workforce data collection in 2014 confirmed anecdotal workforce issues, such as an ageing workforce and recruitment difficulties, and also indicated new intelligence, for example the general practice workforce profile and clinical areas of risk.

The national profile of the general practice workforce indicates that just over 50% of the workforce is admin and clerical staff (Figure 1), compared to 58% in the North West. The percentage of the general practice workforce that is defined as admin and clerical differs across the CCGs2 , however in all instances it was greater than the national proportion. Anecdotally we know that the admin and clerical workforce, such as receptionists, provide a supply into the clinical workforce in general practice through Phlebotomist and Healthcare Assistant roles. The greater proportion of admin and clerical staff in the North West provides the potential for practices to “grow your own” clinical workforce into these Direct Patient Care3 roles through Apprenticeship programmes, providing a formalised route of development.

The mix of clinical staff within general practices also varies considerably across the North West. While the national data indicates a 2:1 ratio of GPs to Practice Nurses, the North West data is closer to 1.6 GPs for every 1 Practice Nurse. Across the CCGs, this ratio varied between 0.7:1 and 2.7:1. Similarly, when comparing the ratio of GPs to Direct Patient

Carers, while the national ratio (3.5:1) is close to the North West ratio (3.9:1), the variance at CCG level was large with the minimum ratio 2:1 and the maximum ratio 7:1.

Figure 1

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http://www.hscic.gov.uk/wMDS

2_{Reports were produced for CCGs with a set percentage return across the sub-regions. The following CCGs}

received reports: Knowsley, Liverpool, St Helens, Trafford, Salford, South Manchester, Bury, Bolton, Heywood Middleton and Rochdale, Wigan, Eastern Cheshire, Blackpool, Fylde and Wyre, Lancashire North, East Lancashire, West Lancashire, Greater Preston and Chorley South Ribble.

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Page | 4 Quality education for quality patient care, transforming our workforce Figure 2

General Practice Team England: % FTE, 2013

* Does not include retainers and registrars

Data source: Centre for Workforce Intelligence (2014) In-depth review of the general practitioner workforce . P.29, Figure 7.

26.9 12.5 7.5 51.4 1.5 GP* Practice Nurses Direct patient carers Admin and clerical Other

General Practice Team North West: % FTE

Data source: HENW General Practice Data Collection Data Extraction Date: 01/12/14

22% 14% 6% 58% 1% GP Nurse

Direct Patient Care Admin & Clerical Other

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Page | 5 Quality education for quality patient care, transforming our workforce The Health and Social Care Information Centre (HSCIC) publish the GPs per 100,000 population in their annual General Practice Census data. This data was triangulated with Office for National Statistics (ONS) data and HENW local workforce data collection. In the main the data correlated, though there were some differences caused by discrepancies between ONS population estimates and HSCIC population size. The HSCIC published data demonstrated that the North West has a slightly higher proportion of GPs per 100,000 population4 than the national average (66.9 in the North West compared to 66.5 across England), with the national outliers being the East Midlands with 62.5 GPs per 100,000 population and the South West with 76.1 GPs per 100,000 population. ONS data indicates a projected 3.7% increase in population over the next ten years in the North West; however, there is a discrepancy between the ONS estimates and the HSCIC patient population data which indicates a larger population.

The age and gender profile of the general practice workforce, as indicated by the HENW workforce data collection, confirmed the national view that the workforce is increasingly female and working part-time5. Working patterns for GPs across the CCGs differed: in some areas the proportion of GPs working part-time increased after the age of 50, whereas with others it was under the age of 50. However, the overall picture indicated a GP workforce where female GPs tend to work part-time, with 56% of female GPs across the North West working less than 0.8 fte, and male workforce tend to work full-time, with 32% of male GPs across the North West working less than 0.8 fte. With pending retirements and increased part-time working likely, with 21% of GPs in the North West aged 55 or over (HSCIC, 2013), this indicates a growing pressure on the supply of GPs.

For other parts of the general practice workforce (nursing, direct patient care and admin and clerical staff) the majority of the workforce were female (95%) and also a high proportion of the workforce were aged 50 or over: 44% of nurses, 39% of Direct Patient Carers and 42% of admin and clerical staff were aged over 50. There is no national data with which to triangulate this data, and with an average of 14% of null records for year of birth for these staff groups this data provides an indication of potential workforce risks but does have some caveats.

Another area that provided valuable data that is not currently collected nationally was the collection of “area of work” for non-medical staff. Again, this was an area with data

completion issues, with only 43.8% of secondary areas of work and 49% of tertiary areas of work completed across the North West. However, it does provide some initial indications of potential areas of clinical risk related to the nursing workforce, particularly concerning long-term condition management where 37% of the nursing workforce was recorded as having skills within this area, of which nearly 50% were aged 50 or over. In addition, key areas that would indicate the involvement of nurses working in expanded and leadership roles, such as management, minor illness and telephone triage, showed lower reported involvement (3.5%, 7.6% and 6.7% respectively).

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Based on HSCIC data of GP headcount (excluding registrars and retainers) and patient population of 7,460,272 as at 30 September 2013.

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Page | 6 Quality education for quality patient care, transforming our workforce Data was collected on leavers from general practice across the 6 month period prior to collection to provide an indication of reasons for leaving (Figure 3) and level of turnover in general practice. Over the period 312 staff left their existing employment in general practice, with 17% of those retiring. Figure 3 shows a significant number of staff leaving their

employment for better reward packages, promotion, relocation and work-life balance, indicating flux within the general practice workforce. As data is collected over time, trend data will allow for more informative analysis.

Similarly, the vacancy data will improve over time. 126 vacancies were recorded in the data collection during this period of which 47% were for admin and clerical staff. 46% of all vacancies did not have an end date at time of reporting, indicating recruitment difficulties as vacancies remain open.

In Greater Manchester, the Optometry Workforce data collection key findings6 demonstrated a workforce with a broadly 50:50 gender split with 20% of the workforce aged in the 50-59 age group. The balance between part-time and full-time working is evenly split, with 47% working full-time (0.8 fte or greater).

In 2015, HENW are upgrading the general practice data collection to align with national requirements and investing in additional functionality in WRaPT to develop workforce collections for Community Pharmacy and Optometry.

Figure 3

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Workforce Development & Future Workforce Solutions

HENW are investing in the primary care workforce to:

 ensure sufficient supply

 develop the existing workforce

 support education in practice

Sufficient Supply – Health Education England

 HEE Workforce Plan 2014-15 proposes an increase of 222 GP training places nationally, taking the total to 3,099. This is in addition to a range of initiatives progressing the target of ensuring 50% of trainees completing Foundation level training choose to enter GP training programmes by 2016.

 Similarly for nursing, HEE is commissioning an additional 500 pre-registration places in 2014/15, taking the total nationally to 13,228 – this being factored alongside the need to manage down attrition rates and deliver anticipated service transformation plans.

General Practice Leavers North West Whole Workforce: 6 month period, Headcount

Data source: HENW General Practice Data Collection Data Extraction Date: 01/12/14

* Redundancy: includes voluntary and compulsory

* Voluntary early retirement: includes with and without actuarial reduction

0 10 20 30 40 50 60 65+ 60-64 55-59 50-54 45-49 40-44 35-39 30-34 Under 30 Null

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 In addition, a national £1m campaign to support Return to Nursing was launched in October 2014, providing resource to both Returners as well as practices committed to employment on completion.

Sufficient Supply – Health Education North West

 The Investment Plan identifies the supply figures being commissioned each year and alongside an anticipated growth of GP trainees by 28 in 2015/16, taking the total target recruitment figure to 478 across the North West. There are currently c.1,200 GP trainees on programme across the North West.

 From 2015/16, HENW will operate a single GP School and manage the allocation of trainees across the North West based on GP workforce data in primary care, bringing increasing emphasis and importance to the accuracy and validity of data for both existing as well as leaving staff.

 Unlike GP posts, there is limited evidence of primary care recruiting nurses from the newly qualified pool, but rather from existing experienced staff in secondary care. The undergraduate programme is the same for acute and primary care nurses, with the majority of Practice Nurses registered on the Adult Nursing branch of the

professional register, but without a specific Practice Nursing qualification. HENW intends to commission 2,218 Adult Nursing places in 2015/16 and it is believed that initiatives to increase primary care exposure during training may prove helpful in increasing supply.

 The Community Specialist Practitioner programme for practice nursing provides further specialist training to develop field experts and leaders and despite the very low uptake in recent years, HENW will be commissioning (and marketing) an additional 30 places for the North West in 2015/16.

 There is also local investment being made in return to practice for both GPs and nurses. The success of this year’s locally tailored GP Returner project will result in 12 additional GPs, facilitated by funding support to both the returner and the training practice and this is likely to be repeated should demand be identified. Similarly for nursing, funding to resource c.160 returners has been included within the Investment Plan for 2015/16, an increase of 25 on 2014/15 with scope to increase should there be demand. This is in addition to those subject to the national campaign.

Workforce Development

 Alongside additional supply, there is a clear need from the quantitative and qualitative analysis of the workforce returns to recognise the scope to improve the multidisciplinary function of primary care through a range of workforce development and education support initiatives. These include:

o upskilling the existing workforce o improving the skill mix

o reducing unnecessary administrative duties of clinical staff

o addressing the well-recognised obstacles to recruitment and retention of the primary care workforce

In view of this, and running concurrently to the data capture exercise, the Workforce

Transformation Team have been developing a range of immediate investment areas across the North West, given the strength of anecdotal evidence. This includes:

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o

The commissioning of a Core Foundation Programme for practice nursing,

commencing September 2014. Across Lancashire, the programme is available locally through Cumbria and Central Lancashire Universities – as well as there being other HE providers across the region. The programme is accessible through a variety of routes e.g. afternoon and evening tutorials, e-learning etc. to maximise flexibility of access and is available in both

accredited and non-accredited forms. This new programme is aimed at reducing the variation in skill set across the practice nursing workforce and can also facilitate eligibility to enter the Community Specialist Practitioner for practice nursing.

o The additional cash allocation of £800,000 across the North West for the continuing professional development (CPD) of non-medical clinical staff in 2014/15. CCGs have been encouraged to identify an accountable lead officer to ensure the appropriate governance of funds, without which the allocation cannot be made. It can be used to resource additional existing CPD provision from HE e.g. non-medical prescribing, support access to new programmes such as the Core Foundation Programme for Practice Nursing, or may be used to fund bespoke education and training identified across the practice team e.g. behaviour change training, managing conflict and supporting patients with special needs, etc.

o The commissioning of Physician Associate education provision in the North West. Physician Associates are relatively new roles nationally (although well developed in the US) and provide an additional solution to boosting capacity and capability in primary care. Drawn from existing science graduates (rather than health professionals), Physician Associates are equipped to work alongside the GP, increasing patient access and throughput of non-complex complaints. The funding model supporting this new programme is yet to be determined and needs to be informed by primary care, in preparation for delivery in 2015/16.

o The commissioning of 202 Assistant Practitioners and 136 Advanced

Practitioners across the North West, facilitating both career development and improved skill mix. Both roles are well developed in acute care and are increasingly evidencing a central contribution to service transformation. Commissions for 2015/16 are based on acute demand, but there are plans to facilitate a health economy model should demand from primary care and wider community based services be there.

o The development of a ‘conversion’ programme to equip those currently working in acute services to work in primary and community based care. It is anticipated this will be available from March 2015 through a portfolio route and will be a key enabler to enhancing the recruitment of experienced non-medical clinical staff to primary care.

o The appointment of a dedicated post to scope the level of demand for Apprenticeships in general practice and the model by which these would be supported and delivered. HENW has achieved considerable acclaim

nationally for its apprenticeship strategy, which has resulted in more than 10,000 new apprentices across the North West NHS in recent years.

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Page | 10 Quality education for quality patient care, transforming our workforce Apprenticeships are available to both new and existing staff across both clinical and non-clinical roles. The scoping exercise is scheduled to report in March 2015, with an expectation that primary care will be included in the delivery target of 3,400 in 2015/16.

o Opportunities for upskilling existing optometry and pharmacy workforce to support the reduction of referrals into hospital and the shift of services into the community exist, partially due to the stability of the workforce.

Education Support

 Further investment is anticipated in a range of initiatives centred on supporting education in practice, informed by both national and local developments.

 Nationally, the pilot of the Care Certificate targeted at developing Healthcare Assistants is anticipated to produce a toolkit for system wide implementation, the expectation being that completion of the standards will be a pre-requisite during an identified induction period in the future.

 Locally, it is proposed to spread the Core Skills Framework7 across primary care to help standardise and quality assure statutory and mandatory training – both reducing

unnecessary duplication whilst also providing assurance to practices in readiness for CQC inspection. A project plan is in development for implementation across 2014/15 – 2015/16.

 The North West’s unique Clinical Placement Development Network is a

multi-professional function, tasked with ensuring sufficient, high quality clinical placements for learners in clinical settings. Given both the short and longer term incentives to increase capacity in primary care, the Network will be looking to work with practices on initiatives to enhance both the number of students/trainees as well as the length of exposure to primary care in 2015/16. The qualitative narrative in some returns suggests

consideration of collaborative ventures with other practices to enhance capacity and this may make an ideal model for training the future workforce.

 Projects to develop and test both simulated and peripatetic models of learning and assessment in primary care are also being explored and show real promise for enhancing participation of the workforce in competency based training, in a highly pressured working environment. This could form part of a solution to the key challenges of insufficient time and resource to train, motivate and retain the workforce.

References

Centre for Workforce Intelligence (2014) In-depth review of the general practitioner workforce. Centre for Workforce Intelligence

Deloitte (2012). Primary care: Today and tomorrow. Improving general practice by working differently. Deloitte LLP

Department of Health (2014). A mandate from the government to Health Education England: April 2014 to March 2015. Department of Health

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The Core Skills Framework provides a consistent and transferable approach to standardise statutory and mandatory training across providers in the North West

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Page | 11 Quality education for quality patient care, transforming our workforce Department of Health (2014) Transforming Primary Care. Department of Health

Health and Social Care Information Centre (2013)

http://www.hscic.gov.uk/searchcatalogue?productid=14458&topics=2%2fWorkforce%2fStaff+numb ers%2fGeneral+practice+staff&sort=Relevance&size=10&page=1#top [Accessed 16.01.2015] Health Education England (2014) Strategic Framework 15. Health Education England

NHS (2014) The NHS Five Year Forward View. NHS England Office for National Statistics

http://www.ons.gov.uk/ons/taxonomy/index.html?nscl=Population+Projections#tab-data-tables