CHANTRY DEVELOPMENT CONSULTING
Consultant Report
Telephone:07973984683 Email
Dudley Clinical Commissioning Group
Brierley Hill Health and Social Care Centre,
Venture Way,
Brierley Hill,
West Midlands
DY5 1RU
Investigation and Report
Dudley Clinical Commissioning Group (CCG) Integrated Education Strategy
Client: Mr D King - Head of Membership, Dudley Clinical Commissioning Group
1. Background
Primary Care in England is facing many challenges over the coming years. This has been put into sharp focus recently by the publication from Simon Stevens, NHS England, of a five year plan which, although promising investment, will require vast change by primary care providers.
This is at a time of severe pressures in primary care which appear to be multifactorial and reflect increased patient load, increased expectations, increased administrative workload and increased auditing and data collection. This on a foundation of primary care funding being at an all time low, at 8.3% of the NHS budget.
There is supporting evidence from the Centre for Workforce intelligence (CWFi), stating the GP workforce is under considerable strain and current levels of activity may not be sustainable. The Seventh National GP Work life Survey (Hann, et al. 2013), found falling job satisfaction among General Practitioners (GPs), with the highest levels of stress since the start of the survey series in 2006 and a substantial increase in the proportion of GPs intending to cease direct patient care within the next five years.
This evidence can be replicated in other areas of the primary care workface. A 2014 Medeconomics survey of 210 practice managers found that many felt the complexity and intensity of the work has increased.They reported increased workload (96%) increased work intensity (95%) increased stress (90%).Recent workload changes had prompted 67% to contemplate leaving their job, 64% had thought about moving away from working in general practice, 42% about leaving the NHS and 35.3% had contemplated either retiring or reducing their hours.
Furthermore the Practice nurse workforce is not immune. Deloitte (2012) estimates that 1 in 5 General Practice Nurses were over 55 years old in 2012 and that between 20-33% of them were likely to retire in the next few years.
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There is numerical evidence to support the feelings of the workforce with patient demand for general practice services showing strong growth in recent decades. The latest available GP workload survey activity and consultation rate data points to longer average consultation times, more consultations per patient (particularly for older people), and more case complexity than a decade ago. The population has an increased life expectancy and 53% of population self report a long term condition- this is increasing and often underreported. In addition, the government is emphasising the importance of transferring facets of patient care from hospitals into the community. This has significant implications for future GP workload, added onto the recent 7 day access drive, requiring increasing hours at evenings and weekends and the raft of new requirements of service provision.
At the same time however, growth in the GP workforce has not kept pace with the change in requirements. The number of GPs rose by 23% on a full-time equivalent basis (excluding registrars, retainers and locums) between 1995 and 2013. By contrast, the number of consultants in other medical specialties more than doubled over the same period. Failure to implement the Doctors and Dentists Review Board recommendations and recent pension changes are contributing, together with the factors above, to highly experienced and skilled GPs looking to leave the profession at age 55 onwards. The workforce pressures have also been exacerbated by the feminisation of the GP workforce, together with clinicians fulfilling CCG commitments and other external non clinical work all contributing to less clinical face to face time. A further relevant feature is the increase in the number of GPs requesting a certificate of good standing from the GMC to emigrate, which has increased by over 50% over the last 4 years to 529 in 2013.
The CfWI has also concluded that the current level of GPs being trained is inadequate and likely to lead to a major workforce demand-supply imbalance by 2020 unless action is taken. The CfWI recommends that Health Education England (HEE) consider a substantial increase in GP training numbers and also proposes a number of measures to help boost workforce supply, particularly in the short term, given the significant lead-in time in training new GPs.
So part of the political agenda is to train more GPs but the number of young doctors looking to train as GPs is under pressure, with 12% of the training posts for GPs in England this year unfilled, despite an unprecedented 3rd round of recruitment. Wilkie in the BMJ suggests that a lack of fulfilled happy GP role models is partly to blame with students and trainees witnessing stressed and burnt out GPs who feel isolated and unsupported hence are unlikely to choose general practice as a career. She felt that preventing attrition in the workforce to be as important as recruiting new trainees.
This description is of great tension in a workforce with an evidence base supporting this assertion and yet a requirement for a massive change programme with primary care required to make new partnerships, support a radical upgrade in public health and prevention and to support patients to gaining more control of their own care. The barriers between secondary and primary care and social care need to be revisited and all this is to be delivered by the existing workforce without a current cohesive training and education programme to support them. It seems little wonder the workforce is expressing strain.
Simon Stevens has stated ‘HEE will work with employers, employees and commissioners to identify training needs and education of our current workforce. This strategy it acknowledges requires greater investment in training for existing staff and the active engagement of clinicians and managers who are best placed to know what support they need to deliver new models of care’ The agenda for HEE is massive and there is currently a lack of clarity how this strategy translates into practice for Dudley Primary Care providers and their workforce.
There is no statutory requirement for Dudley CCG to involve itself in the education provision of the provider workforce, but the Health and Social Care Act does create a statutory duty for clinical commissioning groups to ‘promote research, innovation and the use of research evidence’ Furthermore, recent important reviews, such as the Francis report, questioned the quality of care provision in the NHS with the conclusions all highlighting the need for more consistent and higher standards of patient care. These reports conclude that ensuring a skilled and effective workforce to be of paramount importance.
It would appear that a training and education agenda should form a crucial part of the development strategy for Dudley CCG. The possibility of a co-commissioning agenda would bring an education and training strategy for Dudley into even sharper focus and should look to achieve;
o A skilled workforce for Organisational Development
o Improved recruitment and retention
o Support for succession planning
o Support for the increasing quality agenda
o Reduction in variation of care
The Dudley CCG vision states ‘We want Dudley to be a place where people want to come and work, because they will get the best possible training support and satisfaction for a job well done by extension our population will get the best possible care. So investing in the workforce is mission critical’.
The crucial area for consideration is how this will be achieved.
This provides the background for this report.
2. Terms of Reference
Purpose/ Aim
The purpose of undertaking this project was to clarify and define the feasibility of establishing a collaborative and co-ordinated approach to the provision of education services to support the Dudley CCG strategy.
The aim is to establish a sustainable framework to encompass the multifaceted requirements of an education strategy that can be practically implemented and managed in support of the broader Dudley CCG aims and objectives.
Objectives:
- Determine the key stakeholders associated with this strategy.
- Evaluate the ‘appetite’ of stakeholders for an integrated strategy.
- Define the broad scope and terms of reference for ‘Education Services’.
- Identify wants and needs of stakeholders and key success factors for the strategy.
- Define the scope of activities to be included within DCCG Education Strategy.
- Research and evaluate ‘best practice’ from other areas.
- Present alternative operating frameworks for the service.
Deliverable:
a) Report with clear recommendations for consideration by Dudley CCG board.
3. Research Methodology
The research underpinning this report was conducted using three interrelated methodologies to provide;
a) A wider perspective of the range of approaches to education across the primary care sector.
b) General perspectives from with the Dudley CCG operating area.
c) Focused consideration of the priorities and challenges faced by GP Practices.
The three methods used were desk research of the internet and printed published material, surveying via email based questionnaires and telephone and face to face interviews of key stakeholders.
Desk research sought to identify the key stakeholders within the project and to investigate the national drivers and priorities for education in Primary Care. This was also a valuable source of alternative strategies adopted or proposed in other CCG areas. Questionnaires were issued via email to all GP partners (Appendix 1) and Practice Managers (Appendix 2) working within the Dudley CCG area to enable all key stakeholders within GP practices to provide feedback and comment on priorities and challenges.
Focussed interviews were also undertaken with the following stakeholders
o Seven GP Partners
o Seven GP Practice Managers
o One Primary Care Education representative
o One Health Education West Midlands representative
o Two West Midlands Academic Health Science Network representatives
o One Secondary care Education lead
o One Health Education Primary care leadership
o Two CCG representatives
These interviews provided the opportunity for further exploration of the critical elements governing the development of the strategy and allowed gathering of ideas from each of the parties.
4. Findings
a) Key Stakeholders
For the purposes of this report a stakeholder has been defined as any party whom may be interested in or impacted by the development of the strategy or could exert influence on the future direction.
The primary stakeholders were identified as
Dudley CCG / Responsible for the development and funding of an integrated strategy. It was considered that the funding and promotion of the strategy would be critical in securing sufficient engagement of GP practices.Dudley CCG GP members / Responsible for the development and prioritisation of clinical education at both individual and practice level.
These were considered to be the key decision makers and therefore their commitment was seen as being central to the effective implementation of any strategy.
GP Practice Managers (DPMA) / Currently taking responsibility for the development of local education policies and procedures for managerial and non clinical staff. They would also be important in the functional scheduling and accessing of education and training for all practice staff.
Black Country Local Education and Training Committee (LETC) / Responsible for delivery of plans for training and development locally after agreement with LETB
Secondary stakeholders were identified as
Health Education West Midlands(HEWM)Local Education and Training Board (LETB) / Establish regional priorities for education within a national framework and represent significant opportunities for access to development funding.
West Midlands Academic Health Science Network / A young organisation that are enthusiastic about working with primary care in the development of learning The role of this organisation is evolving and their remit will develop to meet the needs of its stakeholders.
University Medical Schools / Current relationships with practices undertaking education and also development of new programmes like Physicians Assistant
Training providers eg Blue Stream Academy, Palm Training, Skills for Health / Providers will be important in developing course content and models of delivery and assessment of learning within the workforce.
Secondary care / Primary care education needs to be aligned to development in secondary care and they offer an opportunity for collaborative working within the development arena. Crucial to current NHS agendas and to affect change in workload
Clinical senates / Mainly currently supportive agenda regionally will direct specialist clinical care
b) Review of current education structure
Health Education England
The role of Health Education England (HEE) is to provide leadership for the new education and training system and its business plan states it will ‘ensure that the shape and skills of the future health and public health workforce evolve to sustain high quality outcomes for patients in the face of demographic and technological change’. They aim to ensure that the workforce has the right skills, behaviours and training and ensure sufficient workforce capacity to support the delivery of excellent healthcare and drive improvements.
HEE will support healthcare providers and clinicians to take greater responsibility for planning and commissioning education and training through the development of Local Education and Training Boards (LETBs), which are statutory committees of HEE, the local one being Health Education West Midlands (HEWM)
HEE is required to deliver against the Education Outcomes Framework outlined in the guidance from ‘Design to Delivery’ published January 2012 which has 5 high level domains
o Excellent education
o Competent and capable staff
o Adaptable and flexible workforce
o NHS values and behaviours
o Widening participation
HEE states the Priorities for Primary care in their 2014-15 business plan to be
o Build capacity and capability in primary care workforce
o Increase placements in primary and community care
o Strengthen leadership in primary care settings
These plans are on the background, however, of HEE recently launching a consultation on planned changes to its structure which are designed to reduce running costs and reduce numbers of senior staff. The aim is to cut running costs by 20% and it is suggested this may impact for the short term on the effectiveness of the LETB (HEWM).