Developing a shared vision for the workforce
In many STPs/ICSs, strong relationships and collaborative working are borne out of the recognition of shared goals and motivations to improve patient care and experience, grow the workforce to meet the population’s needs, and make best use of resources in a challenging financial climate. System leaders describe coming together around a shared aim, and recognising that despite different cultures and leadership, organisations across the system have commonalities which leaders can rally around to develop joined up workforce solutions which work for all system partners – across recruitment and retention, training, staff pipelines and skills gaps.
This should be underpinned by meaningful engagement with those who have a part to play in identifying and meeting the workforce needs of the system. This may involve trusts forming a coalition of partners to agree priorities and actions for the system, and may be supported by pooled resources, including training budgets.
Greater Manchester Health and Social Care Partnership
Following Greater Manchester’s devolution deal, ambitious plans were developed to transform the Greater Manchester health and care system, focused around integration and moving more care out of hospital and into the community. Workforce transformation was identified as a key enabler for delivering these ambitions. The Greater Manchester Health and Social Care Partnership (GMHSCP) developed the health and social care workforce strategy in 2017, designed to address workforce issues across the ten localities in Greater Manchester, with the aim of achieving a resilient workforce that feels sufficiently motivated, supported, empowered and equipped to deliver safe and effective services, drive improvements and positively influence the health and wellbeing of the population.
The strategy identified four priority areas, including:
- talent development and system leadership, ensuring the system attracts and develops people and has the right kind of leadership across health and care
- growing their own, widening access to a range of roles by investing in training and development, employing apprentices and supporting work placements
- employment offer, promoting the region as an attractive place to work in health and social care
- filling difficult gaps in the workforce and addressing.
The Greater Manchester workforce collaborative was created to support the delivery of the strategy. A core team has been established made up of colleagues from across GMHSCP and Health Education England (HEE), who alongside a steering group of key partners, work together to deliver the strategy. HEE and GMHSCP have agreed a memorandum of understanding (MOU) to coordinate allocation of HEE resources to meet local needs, enabling the workforce collaborative to allocate £1.6m to initiatives associated with the delivery of the workforce strategy.
A broad variety of stakeholders support the successful delivery of the strategy, including HR directors in trusts and local authorities, organisational development and equality and diversity colleagues, as well as professional networks, trade unions, education providers and the private sector. Enabled by strong governance of the GM health and social care strategic workforce collaborative board, key partners discuss and shape decisions to reach collaborative agreements, and through a variety of different forums engage with a diverse range of stakeholders including a trade union forum, an education transformation group as well as the steering group bringing together arm’s length bodies and support organisations.
Stakeholders come together twice a year to provide input and ideas for the future direction of workforce collaborative, looking to put in place plans to build on the outcomes already achieved beyond 2021.
GMHSCP faced the challenge of encouraging partner organisations to look beyond their own workforce challenges and take a collaborative approach to solving system-wide workforce issues. In May 2018 GMHSCP also launched the Workforce futures centre, an online platform which acts as a one-stop-shop for workforce teams across Greater Manchester to access resources and best practice to support the delivery of their local workforce plans.
Workforce planning in a place
This complex landscape of system working has implications for how trust leaders and their partners build workforce strategies and plan for the future. With a move towards collaboration, working across traditional organisational boundaries, and building relationships across sectors and organisations, people working in the NHS are increasingly being asked to work in a collaborative way. If systems are to join up to deliver on shared goals, it is no longer sufficient for individual organisations to work and plan in siloes, and there is increasing recognition of the value of carrying out this work at a local level to ensure the makeup of the workforce marries up with population health needs.
STPs and ICSs are likely to become pivotal in this process. The people plan raises questions about what elements of workforce planning and development should take place nationally, regionally or locally. However, as system partnerships mature, they will be expected to take on additional responsibility for workforce planning across a larger population and across organisational boundaries, with oversight from the new regional directors.
This is often more easily done on smaller footprints at the level of ‘place’ within an STP/ICS, in conversations between local leaders about skills mix and numbers. This is best supported by local level data, and a culture in which leaders and staff at the frontline have an understanding about where their challenges fit in with the wider system and how they can best support and develop their staff.
The Northumberland 'place' is part of the North Cumbria and Northeast ICS spanning a very large area across the north of England. Its constituent players are active within the ICS, as well as in the ICP arrangements across North of Tyne and Gateshead.
At 'place' level, Northumberland operates a system transformation board, chaired by the chief executive of Northumbria Healthcare NHS Foundation Trust, and over the past ten months has established a number of workstreams, including a workforce stream to help partners understand the specific challenges for Northumberland and progress workforce transformation at a place level.
The leader of this workstream engaged with the respective leads of each clinical and care component and with those directors responsible for workforce in individual organisations – including local council, clinical commissioning group, acute, mental health and ambulance providers – to identify what can be valuably carried out at a placebased level, without replicating work done by the ICS or merely aggregating up the work of individual providers.
The review raised some consistent themes across the providers and the system. This included the need to design and develop future workforce across the Northumberland specific clinical and care pathways. Alongside this, partners were keen to model demand and capacity across the place so as to effectively plan for future workforce needs, factoring in the impact of new roles.
The importance of this is reinforced by the commitment for primary care networks to employ additional roles including clinical pharmacists, paramedics, social prescribers and physiotherapists. This has generated a need to think carefully about required pipelines, ensuring a joined-up approach which enables the workforce to grow without destabilising the system. Equally, recognition of how creation of new roles in health can potentially destabilise home care, and the tendency for job creation opportunities linked to economic regeneration to result in domiciliary and residential care workers leaving the sector for more attractive jobs elsewhere is critical. Creation of accessible and attractive career pathways are essential.
Another area identified as benefitting from place-based emphasis is recruitment. ICS approaches have proved very successful for junior doctors and are being extended to nurse recruitment. Recruitment campaigning is as much about selling local lifestyle as it is the job: being able to showcase Northumberland as part of this helps greatly to differentiate us as a great place to work, live and train. Additional place-based campaigns, building on individual partner initiatives could offer tailored and flexible opportunities for attracting staff, their partners and families into the area.
System partners also identified the value of culture and relationships, with the need for all to gain a better understanding of the working context and challenges of partners. Breaking down siloes through job shadowing, co-location of teams, regular face-to face interactions and more joint training will help.
System leadership, clearly signalling the importance of day-to-day system wide working is seen as key, allowing teams to continue to progress transformation efforts even when the system comes under pressure. Creating cross-system teams focused on transformation, or dual roles with partners buying into their authority to lead collaborative working can facilitate this.
This engagement work has culminated in a report and nine themes and recommendations which will be used to develop a place-based workforce strategy and priority objectives:
- our future workforce should be designed and developed across our local
(Northumberland) clinical and care pathways and organisations
- workforce modelling is needed at local system level to identify gaps now and in the
future, and to model proposed new workforce solutions to address these
- work with local schools and other education providers is key to developing attractive
career pathways and our well-qualified workforce of the future
- systematic, proactive system-wide work is needed in some specific areas to secure
adequate local workforce supply and ensure service stability
- there is an important place for system-wide training schemes and support
- Northumberland-specific approaches to recruitment should be maximised
- consideration should be given to opportunities for increased shared back office functions
- development of system leadership which supports a cultural shift to embrace concepts
of integration, care closer to home and realistic medicine is crucial
- our use of technology should be an enabler currently, but will also significantly alter our
workforce of the future.
Building relationships across sectors
One of the fundamental drivers of system working is the role of individual relationships in enabling collaborative working. Trust leaders have expressed mixed views about the need for legislative change to enable system working, but consistently agree on the importance of building strong, local working relationships regardless of what is happening at a national level. Many systems are therefore working to break down the siloes between social care, primary care, the provider sector, commissioners and local government.
The workforce has a key role to play in this at all levels of leadership and frontline service delivery. While good working relationships at the top of organisations are important in building a culture where collaboration is the norm, connections need to be formed at every level, including at the frontline. Cultural norms, ways of working and different lexicons may vary across sectors, and, as such, new ways of collaborative working may take time to bed in. Leaders have a substantial role to play in granting the workforce permission to work in a different way, and promoting the benefits of working across boundaries. While funding pressures across the board may encourage system partners to retreat into their siloes, some systems have used these pressures as a burning platform to work in a different way.
Systems that have built strong relationships are often those where close working precedes formal STPs, and relies on a mutual understanding of system partners’ different ways of working, lines of accountability and challenges. Practical measures like co-location of teams and active efforts from leaders to build bridges often have a significant effect.
Mid Yorkshire Hospitals NHS Trust
Work to integrate services across Wakefield has been underway for a number of years under the Connecting care programme and when the system received vanguard pilot status, a number of initiatives were implemented which enabled them to test new models of care. The work has involved numerous system partners, including Mid Yorkshire Hospitals NHS Trust, the CCG, Wakefield metropolitan district council (Wakefield MDC), Wakefield district housing and the third sector.
Challenges across the whole system were identified, both in terms of delayed transfers of care, and levels of unmet need. Older people were visiting A&E with a variety of social needs, not necessarily social care needs, and some admissions to care homes were often a result of family carers not being identified and supported in time. Incompatible IT systems made it difficult for organisations to share information, meaning people had to tell their story multiple times. System partners convened the Wakefield Integrated Care Partnership board, where chief executives and directors of health, social care and third sector organisations in the system make decisions in collaboration with one another.
As part of the work, system partners have adopted multi-disciplinary team working, with teams co-located in two hubs and a satellite location. Staff work closely across organisations, and this has been done without changing employment terms and conditions to avoid distracting staff from the core aim of integrating care and generating an unwarranted focus on structures. A significant contributor to the success of the initiative has been drawing on the mutual mission of striving to provide the local Wakefield population with the best care possible at the right time, in the right way and in the right place. It has also been important to ensure staff have a good understanding of what colleagues across the system do and the challenges that they face.
The system has implemented a virtual leadership team between Mid Yorkshire Hospitals NHS Trust community team and adult social care Wakefield MDC, working as if they are one organisation, and giving staff permission to work across boundaries. Co-location of teams has been an enabler of this as it facilitates face-to-face conversations and relationship building. The virtual leadership team aims to lead by example, and working closely as leaders in the system enables other staff to do the same.
The ‘personal integrated care file’ enables sharing of records, so that all partners involved in a person’s care are working from the same basis, using the same electronic file to record information and make referrals, as well as follow up on outcomes.
Since the implementation of the system, all of the GP practices in Wakefield have joined the initiative and referrals are now received through one channel.
More system partners are expected to join the collaborative including Alzheimer’s UK, West Yorkshire Fire and Rescue Service and Yorkshire Ambulance Service with a view to looking more widely to other organisations which support vulnerable people, at the prevention end of service delivery.
One of the challenges has been demonstrating impact and value for money. Evaluating the impact of work in community services is more challenging due to the lack of concrete activity data. However, emergency admissions have reduced in the context of a nationwide increase. An independent evaluation of an integrated community services programme gathered evidence that patients felt more positive about their care as a result.
System leaders feel that having been part of the vanguards programme has facilitated collaboration and formed a basis for future system work including broadening people’s skill sets and the scope of people’s roles. The trust and the local authority are now part of conversations about how primary care networks in the system should look, with a view to sharing expertise from its own model of care in connecting care.
Working with primary care networks
New and more integrated models of providing care present opportunities for realising the value of cross-sector working including between secondary and primary care. Trusts are pursuing a number of models to integrate services with primary care, including the development of primary care networks (PCNs), structural integration and partnerships with primary care at scale via federations and super partnerships.
Each of these models brings challenges and opportunities with regards to the local workforce. There are clear opportunities for multi disciplinary teams, more integrated care, and better use of NHS estate through the co-location of different services. There are also challenges to be overcome through close partnership working particularly to develop new career paths and to avoid any one service facing increased vacancies because partners are recruiting. This is a particular concern with regard to recruitment and retention of key roles as PCNs begin employing staff which have traditionally worked in trusts such as paramedics, physiotherapists and pharmacists, alongside social prescribing link workers and physicians’ associates.
Many trusts are seeking to mitigate this risk, either through existing models or new ones. For example, ambulance trusts are seeking to promote the rotational model to develop their paramedic staff without sustaining a net loss to their workforce, while other trusts are lending their support to primary care networks to build a collaborative base for working in this new way.
Leeds Community Healthcare NHS Trust
Leeds Community Healthcare NHS Trust works closely with the Leeds GP Confederation, a membership organisation comprised of GP practices in Leeds and which exists for the benefit of its members, providing a unified voice for primary care in Leeds. The confederation and the trust share several roles, including the director of workforce, director of nursing, and medical director posts. This means that the post-holders for those roles sit on the boards of both organisations, facilitating joint working and the shift towards integrated care for the patients and communities of Leeds. In addition to this, the chief executives of the trust and the GP Confederation have a close working relationship and communicate regularly.
This joint working has been in development for several years, and before the NHS long term plan and the advent of PCNs, the Leeds GP Confederation and its predecessor organisations have been working alongside Leeds Community Healthcare Trust towards joint working and integrated care. The joint posts have been in operation for over a year to date.
The long term plan outlines plans for GP practices to join PCNs, which from July have had the opportunity to employ additional staff to support traditional primary care roles. These include community pharmacists, advanced paramedic practitioners, physiotherapists, and social prescribing link workers. It was evident from the work that the GP confederation undertook with PCNs that some needed support with the infrastructure necessary to employ staff – infrastructure which the Leeds Community Healthcare NHS Trust already had in place and could use to support PCNs.
The trust has made an offer to the PCNs in Leeds to be the employer of staff working for PCNs in these roles, handling HR functions such as payroll and employment contract – an employ and deploy offer. The PCNs will then determine how those staff will work and staff will be deployed and managed by PCNs locally and day-to-day, rather than the trust. This was agreed by the trust board within the context of the trust’s long term vision to integrate care across primary and community services, contribute to joint working as well as ensuring the best use of resources.
The GP confederation and the trust led a workshop with leads from a number of interested PCNs in the system to begin to develop a service level agreement (SLA) to define how the employ and deploy model would work. The funding for the new mandated roles was released at the end of July, and work is well underway to begin recruiting to the first tranche of staff, community pharmacists. To date, five PCNs have taken up the Leeds Community Healthcare NHS Trust employment offer with several already having appointed to their community pharmacist roles. At the time of writing, the trust with those PCNs are about to sign the SLA. It is hoped that this arrangement will create leverage for much closer working.
With 99 GP practices in Leeds, and multiple GPs working in each, a great deal of engagement across the Leeds system has been undertaken to gain buy in from the practices to facilitate this collaboration. Engendering understanding between the trust and the GP confederation as the voice of primary care in Leeds has been key within the context of differences in priorities and culture, given that GP practices are small businesses and function differently to an NHS trust. This has involved engagement with staff across primary care, supported by the chief executives of both organisations to broker communication with the relevant staff and build a shared understanding and vision to work from. There is always more work to do in this area both locally within Leeds, as well as the potential for national-level enablers to be put in place to facilitate collaborative working, including addressing the conflict between system working and organisation-level accountability for performance and finances.