WF 19

Ymchwiliad i gynaliadwyedd y gweithlu iechyd a gofal cymdeithasol

Inquiry into the sustainability of the health and social care workforce

Ymateb gan: Cyfarwyddwyr Therapïau a Gwyddorau Iechyd

Response from: Directors of Therapies and Health Science



Inquiry into the sustainability of the health and social care workforce

Consultation Response from Executive Directors of Therapies and Health Science

1.       Do we have an accurate picture of the current health and care workforce? Are there any data gaps?

The data available on the current health and social care workforce across Wales covering professionally registered and unregistered staff is not joined up. Whilst there are certainly gaps, because the workforce intelligence is incomplete is difficult to accurately say where the gaps are.

Form must follow function and it would be helpful if there was a nationally described service specification for an integrated health and social care system. If we can accurately describe the outputs required to meet the needs of the people of Wales, we could then describe the workforce as an input to deliver the required system level outputs. The health and social care workforce must be described in terms of tasks and competencies rather than solely professional roles to enable the development of a truly integrated workforce. We could then benchmark our existing workforce against the required workforce and develop a workforce plan to bridge the gaps

The future health and social care workforce will certainly have portfolio careers with supporting skill sets and knowledge bases to allow them to flex to support areas of need across the entire health and social care system. This would provide an element of system level resilience and support the continued migration of care from secondary care settings into settings closer to people’s homes.

Care pathways must seamlessly join up public, private and third sector provider care delivery. To make this a reality the health and social care workforce must straddle traditional sectoral and organisational interfaces to ensure that individual care is joined up and effective.

There is a significant degree of unwarranted variation in practice across the whole health and social care system. The role of the hybrid/multi-competency support worker is not defined, nor are national competencies in place.  We’ve got clear delegation guidelines and examples of competencies e.g. Occupational Therapy and Physiotherapy Level 3 diplomas but these are not routinely utilised across Social Care and in residential care other than in in a few discrete localities. NHS Wales CEOs have recently commissioned a piece of work to develop a multi-competent support worker workforce. There are numbers of roles in the community already undertaking this function but they differ across Wales, some more effective than others, and assurance of governance is not always robust.

2.       Is there a clear understanding of the Welsh Government’s vision for health and care services and the workforce needed to deliver this?

The information is out there but it may benefit from further streamlining or finessing to improve clarity and reduce ambiguity. The triple integration agenda described in England (primary: secondary, mental: physical health and health and social care) does not appear to be articulated at all in Wales in an easily digestible way.  A workforce that is competent to operate across all three domains of integration should be a fundamental tenet of our vision in Wales.

However it would appear there is a fundamental lack of understanding by existing professional groups on what they are required to do, to make this step change happen. Professional groups are not always motivated to work in new ways when it is perceived that the change will undermine their professional standing, and ways of engaging them in a collaborative manner is required.



3.       How well-equipped is the workforce to meet future health and care needs?

The focus on RTT and patient flow has shaped the secondary care workforce, making it difficult to respond to the necessary paradigm shift required to continue to deliver safe and sustainable high quality care. Largely workforce is planned in sectoral, organisational and professional silos with impermeable boundaries. This has been further strengthened by the “Nurse safe staffing Act”, which has looked at a profession in isolation, rather than the needs of patients which may be better met by a truly integrated workforce approach, which would also make it more sustainable. The vast majority of our current health workforce is designed to meet secondary care challenges, and not the challenges of delivering coproduced, patient activated care in non-traditional healthcare settings. We have a workforce which requires re- configuring to deal with the challenges we face going forwards.

The Career Framework 2-4 healthcare support worker workforce will be critical to successfully integrating the existing fragmented workforce across, and within, health and social care. The move to portfolio skill sets based on competence rather than professional affiliation will enable the required integration of the workforce across the 3 domains. It is important that these roles are not just seen as part of the nursing workforce. Enablement and rehabilitation are therapeutic activities and require therapist direction and supervision.

This will require a significant shift of thinking from existing professional groups. Workforce models must include a support worker cohort which can maximise their input into a broad range of professional services. We will need to create bespoke training and competence frameworks  and apprenticeships to support the development of support workers aligned to pathways rather than professional groups. Already we have examples of professions creating associate roles, with proposals to develop more, rather than boundary spanning multiprofessional re-ablement roles.

The medical model needs to be refocused in many areas to a social model of healthcare. Medicine as a profession has not been subject to the paradigm shift that is required, at the scale that is required. There are pockets of change, but integrated workforce planning and service provision that includes all professions,, including medicine is required. 

4.       What are the factors that influence recruitment and retention of staff across Wales?

Recruitment and retention are significantly impacted by job satisfaction, including access to and funding for training, access to peers with specialist knowledge, career progression, R&D opportunities as well as remuneration and terms and conditions of employment.

 The Primary care workforce plan did not go far enough in defining the new models due differential incentives for private and public care providers. Safe staffing levels for particular professional groups are not helpful as it prevents diversification in the workforce and is a barrier to integration. Safe staffing levels are essential in some areas but this should not be prescriptive about the profession but more about the availability of service and the supply of tasks based on competence.

Funding in all sectors is going to be a constraint to change. Strategic budget setting, integrated training and development budgets and integrated service modelling and commissioning will start to unpick these issues. However without pump priming it may be difficult envisage how the move from the current state to the desired state will happen at the pace required.

4.1   The opportunities for young people to find out about/experience the range of NHS and social care careers;

Career events tend to be profession specific. It is difficult to promote new ways of working and supporting roles with confidence when they are poorly understood and may not be universally supported by traditional professional groups.

       4.2  Education and training (commissioning and/or delivery);

Organisational Workforce and OD functions should be linked across organisations and sectors and able to respond to WG directives. Again existing local governance frameworks inhibit this and there is a requirement for a simplified national system level governance framework. This will allow all organisations to interpret the ‘rules of engagement’ in similar ways.

An integrated training and education budget will be essential to allow tasks to be transferred safely from one professional group to another in services where shortage profession are creating bottlenecks in care.

An effective integrated workforce commissioning model will be fundamental, as will access to an integrated staff budget for training and development. The workforce will have to be commissioned at a national system level and deployed locally based on need rather than organisational budgets and boundaries. Outreach models and ‘push and pull’ workforce models will need to be considered along with the supporting integrated governance framework required to enable this change to happen

4.3  Pay and terms of employment/contract;

There will be requirements for staff to work across public, private, third sector and even industry sectors. These types of appointments and developments are not easily enabled by the current configuration of healthcare providers in Wales. Agenda for Change banding lacks consistency of application across Health Boards and can be demotivating for staff. In addition delays in the banding approach often delay recruitment. A consistent national approach would be welcomed. Social care staff are on different terms and conditions which can cause tension between front line staff working side by side – the same system for health and social care would be beneficial. The different terms, conditions and pay scales across health and social care can be a barrier and greater integration of education and training departments would be welcomed.

Professional regulatory issues are not consistently understood and therefore interpreted. This leads to inconsistencies in workforce models and de facto barriers to integration. Further work on a standard multi-sectoral and multi-professional scheme of delegation will be required to enable better integration of cross-sectoral workforce and adoption of standard workforce practices.

4.4   Whether there are there particular issues in some geographic areas, rural or urban

areas, or areas of deprivation for example.

Having stated that there is a pressing need to create an integrated workforce with a broad range of multi-professional skills particularly at career framework 2 - 4 there will also be a requirement for highly specialised workforce with expert knowledge bases and skill sets. There are particular therapies and healthcare science skills gaps such as MRI expertise which need to be addressed on a national networked level rather than by an individual healthcare organisations. Also many highly specialist workforce groups face acute recruitment, training and retention issues when managing risks associated with an aging workforce.

A greater focus on intermediate care and the potential this offers at undergraduate level would probably be helpful. All therapy staff should have a community clinical placement at undergraduate level. 

We need to work harder to raise the profile of the support workers and to make it a career of choice and alternative to nursing for some of the students at our local schools/colleges undertaking Diplomas in health and social care who don’t wish to pursue the professional route. Apprenticeships appear to provide an ideal opportunity to recruit and develop a local workforce in some of the most deprived areas in Wales.