Using scenarios to assess the future supply of NHS nursing staff in England

ABSTRACT: This paper examines issues related to the future supply of registered nursing staff, midwives and health visitors in the National Health Service (NHS) in England at a time when there are major public sector funding constraints and as more of these staff are reaching retirement age. Based on available workforce data, the paper reviews different possible scenarios for the supply of NHS nurses over a ten year period, assessing the impact of different numbers of new staff being trained and of varying retirement patterns from the ageing profession. The government in England has more policy levers available than is the case in many other countries. It determines the number of pre-registration training places that are commissioned and funded, it is the major employer, and it also controls the inflow of nurses from other countries through migration policies. Scenario models provide a picture of what the future might look like under various assumptions. These outcomes can be quantified and the results used to assess the risks and opportunities of alternate policy decisions. The approach used in this paper is that of the aggregate deterministic supply model. As part of this exercise, eight scenarios were selected and modelled. These were: A. "No change"- current inflows and outflows B. "Redundancies" - current inflow with higher outflow C. "Improved retention" - current inflow with lower outflow D. "Reduced training intakes A" - lower inflows with lower outflow E. "Reduced training intakes B" - lower inflow with higher outflows F. "Pension time-bomb"- current inflow with a higher rate of retirement G. "Pension delayed"- current inflow with a lower rate of retirement H. "Worst case" - lower inflow and higher outflow including higher retirement Most of the scenarios indicate that a reduction in the supply of nursing staff to NHS England is possible over the next ten years. Small changes in assumptions can make a substantial difference to outcomes and therefore emphasize the point that it is unwise to base policy decisions on a single projection. It is important that different scenarios are considered that may be regarded as possible futures, based on a realistic assessment of the available workforce data, policies and broader labour market and funding outlook.     

New labour and Britain's National Health Service: an overview of current reforms.

Britain's National Health Service (NHS) has been the subject of unprecedented market reforms, which have failed to solve its problems. The New Labour government elected in 1997 has halted the drive toward the marketization of health care and replaced cost with quality as the central concern of NHS administration and policy. Major changes are occurring in the regulation of professional activity, with profound implications for the medical profession and the health service. The authors discuss these changes and possible future problems for the NHS.     

Values in European health care markets: Values in European health care markets

The discipline of public health has played an important rolein showing that the health of populations depends on more thanthe amount and quality of the health services available. Therelationship between health services and health status has beena traditional theme within the discipline. This paper proposesthat public health has a part to play in current health reformdebates and research, which have been dominated by attentionto economic incentives and the technical operation of the systems.The focus has been on the inputs to and processes within healthsystems, with relatively little attention to the likely impactof these changes on outcomes and population health. The paperconsiders one aspect of health reforms which affects populationhealth status: the part played by the social values of choiceand equity. It gives an analysis of these concepts to help evaluatereforms, and as a basis for empirical research into the impactof reforms. It considers how the NHS reforms have affected choiceand equity and how to increase patient choice and uphold certaintypes of equity which many health service staff and the publicbelieve to be important. It shows how some types of choice conflictwith some types of equity and that different groups in societybenefit according to whether choice or equity is more prominentin health reform. The purpose of this paper is to help researchers,public health practitioners and policy makers consider, fora particular health reform, the following questions: i) willreforms increase the choices which are important to most people?,ii) what will the effect be on different types of equity?, iii)how will the changes affect population health?, iv) how shouldpublic health aims be pursued in systems with market competition?     

Do star ratings really reflect hospital performance?

The publication of performance ratings for NHS Trusts (star ratings) is an important part of NHS policy. There are significant benefits to a Trust in being awarded the top rating of three stars. The methodology for awarding stars to acute hospitals is explained. The most significant areas of performance in determining a hospital's star rating are identified. The Department of Health claimed that performance in 2002 was better than in 2001, against standards that are getting tougher. This claim is assessed but no clear evidence is found to substantiate it. An alternative performance rating system using the same data is developed and compared with the official version to illustrate the importance of methodology--this system used only the outcome measures of hospital services included within the star ratings system, and not process measures. Only 41 per cent of hospitals would have received the same number of stars as their official rating. Some implications of the system of performance ratings are discussed.     

Preparing to be Creative in the NHS: Making it Personal

There is currently a clarion call for the NHS to be more creative and innovative, as it moves into an increasingly quality focused agenda. But exactly how easy is it to do this when the NHS performance regime for the last 10 years has been more about delivering centrally driven, specific and detailed targets for improvement, such as reduction of waiting times, than promoting a culture that speaks of experimentation and possibilities rather than certainties. Can a workforce that may not have been all that prepared for creativity, be creative? And what does being prepared for creativity look like? This paper explores, briefly, the relationship the NHS has with creativity and the new agendas that are creating more fertile ground but then, drawing on practices and information from leading innovators and researchers in the business sector, it looks at the conditions the NHS might need to create in order foster creativity in its workforce. More specifically it looks at the role that a more personal approach to creativity might play in cultivating a workforce that is more comfortable entering into creative thinking and behaviour.     

Constructing notions of healthcare productivity: the call for a new professionalism?

Improving performance is an imperative for most healthcare systems in industrialised countries. This article considers one such system, the UK's National Health Service (NHS). Recent NHS reforms and strategies have advocated improved healthcare productivity as a fundamental objective of policy and professional work. This article explores the construction of productivity in contemporary NHS discourse, analysing it via the Foucauldian concept of governmentality. In this manner it is possible to investigate claims that the commodification of health work constitutes a threat to autonomy, and counter that with an alternative view from a perspective of neoliberal self‐governance. Contemporary policy documents pertaining to NHS productivity were analysed using discourse analysis to examine the way in which productivity was framed and how responsibility for inefficient resource use, and possible solutions, were constructed. Data reveals the notion of productivity as problematic, with professionals as key protagonists. A common narrative identifies traditional NHS command/control principles as having failed to engage professionals or having been actively obstructed by them. In contrast, new productivity narratives are framed as direct appeals to professionalism. These new narratives do not support deprofessionalisation, but rather reconstruct responsibilities, what might be called ‘new professionalism’, in which productivity is identified as an individualised professional duty.     

NHS Direct: managing demand for primary care?

This paper considers how NHS Direct is affecting demand for primary care in particular out‐of‐hours services from GPs. This is reviewed through a 3‐year study of NHS Direct and HARMONI, the integrated telephone health helpline based in West London. It describes the policy background and development of the services on the site, and some of the outcomes of the HARMONI commissioned research to answer the question ‘Has NHS Direct increased the workload for HARMONI doctors?’. The research adopted both a qualitative and quantitative approach using cross‐sectional and longitudinal analysis of the data collected. The analysis of the data reveals the issues as both complex and dynamic in nature. The research shows that while there has been no significant change to the total volume of activity, changes within patient groups notably the elderly and children, and in individual GP practices may be significant. In addition, the changes in organizational arrangements may influence significant changes in referral patterns such as GP out‐of‐hours visits. This was confirmed in the interview data indicating a link between the change in nurses' role from gatekeeper to patient advocate, which happened when they ceased to be employees of the part‐time co‐op and began to work instead for the 24 hours, 7 days a week NHS Direct service. The conclusions drawn are that behavioural and organizational changes are at least as significant as the evidence‐based computerized decision support software in changing the demand for primary care. Further evidence cited is that a different demand pattern of calls was experienced by those local GPs not integrated into out‐of‐hours provision at NHS Direct West London at the time of the study. Copyright © 2004 John Wiley & Sons, Ltd.     

Does the UK National Health Service need a fourth hurdle for pharmaceutical reimbursement to encourage the more efficient prescribing of pharmaceuticals?

Reform of the existing mechanisms that influence pricing for pharmaceuticals in the UK NHS is overdue. Currently, the prescribing pricing policy favours the needs of industry over those of the NHS and of individual patients. In a recent consultation document, the UK Government indicated an emerging policy that will provide for the assessment of the effectiveness and cost effectiveness of important pharmaceuticals in the NHS. In developing and implementing this policy, much can be learnt from the situation in Australia, where pricing of drugs is related directly to an assessment of their value for money in specific patient groups. In fact, the differing circumstances between the UK and Australia suggest that the progress achieved by the Australians may be supplemented by further reform to encourage a more rational relationship between the NHS and the pharmaceutical industry. Australia has led the world in demonstrating that a modest form of assessment of 'value for money' may be incorporated practically in the process of licensing and reimbursing new drugs. It is important that this finding is built upon in the UK NHS for the benefit of patients and for society as a whole. It is not clear that the current proposals for reform from the UK Department of Health go far enough to achieve the required changes in drug licensing and regulation.     

Patient focused care. Health management guide

Finding the holy grail which will deliver high quality care at lower cost is every NHS manager's dream, especially during times of severe resource constraint and intense competition. Reorganising units to provide 'patient-focused care' can, it has been claimed, make them simpler and slimmer, cutting costs and wasted time, while increasing patient and staff satisfaction. How is patient-focused care being implemented in the NHS, and how successful has it proved so far? Could it help your unit? This Health Management Guide looks at how patient-focused care originated and how it works, exploring a number of sites where it is in use, and identifying key points to consider before adopting a 'patient-focused' approach.     

Integrated health and social care in England – Progress and prospects

This paper reviews recent policy initiatives in England to achieve the closer integration of health and social care. This has been a policy goal of successive UK governments for over 40 years but overall progress has been patchy and limited. The coalition government has a new national framework for integrated care and variety of new policy initiatives including the ‘pioneer’ programme, the introduction of a new pooled budget – the ‘Better Care Fund’ – and a new programme of personal commissioning. Further change is likely as the NHS begins to develop new models of care delivery. There are significant tensions between these very different policy levers and styles of implementation. It is too early to assess their combined impact. Expectations that integration will achieve substantial financial savings are not supported by evidence. Local effort alone will be insufficient to overcome the fundamental differences in entitlement, funding and delivery between the NHS and the social care system.With a national election set to take place in May 2015, all political parties are committed to the integration of health and social care but clear evidence about the best means to achieve it is likely to remain as elusive as ever.     

Universal health coverage in the United Kingdom

This United Kingdom has had universal health coverage since 1948, provided through its government-funded National Health Service (NHS). In recent years, increasing workload and treatment costs have put a considerable strain on the NHS. The government has responded to these challenges through a controversial program of organizational changes in the NHS. In its most recent policy initiatives, the government proposes to increase the proportion of national income spent on the NHS and make much greater use of private-sector health care providers.     

Socialism and the British National Health Service

This paper examines some of the key characteristics of a socialist health care system using the example of the British National Health Service (NHS). It has been claimed that the NHS has socialist principles, and represents an island of socialism in a capitalist sea. However, using historical analysis, this paper argues that while the NHS claims some socialist ends, they could never be fully achieved because of the lack of socialist means. The socialist mechanisms which were associated with earlier plans for a national health service such as a salaried service, health centres, elected health authorities and divorcing private practice from the public service were discarded in negotiation. Moreover, even these would have achieved socialism merely in the sense of distributing health care, without any deeper transformation associated with doctor-patient relationships and prevention. In short, the NHS is more correctly seen as nationalised rather than socialised medicine, achieving the first three levels of a socialist health service identified here. It can be said to have socialist principles in the limited distributional sense and has some socialist means to achieve these. However, it lacks the stronger means to fully achieve its distributional goals, and is very distant from the third level of a radical transformation of health care.     

Exploring the human resource implications of clinical governance

In 1998, clinical governance was introduced in the National Health Service, UK (NHS) as a major policy initiative to improve the quality of clinical care. The implementation of clinical governance is crucially dependent on the skills, competencies and willingness of the NHS staff. In turn, clinical governance influences the way people work in health care organisations. Therefore, it is no surprise that the introduction of clinical governance has thrown-up new challenges for human resource management. However, what are these human resource management challenges under the clinical governance framework? The current literature on the subject provides no answer. This article attempts to fill this gap in the literature. A qualitative approach influenced by phenomenological case study approach has been adopted. A heterogeneous group of 33 persons identified through a purposive sampling procedure were interviewed using a semi-structured format. The results indicate that the staff members appreciate the crucial role of human resources management in the implementation of clinical governance. However, there is little evidence to suggest that senior management is paying attention to develop the human resources function around the clinical governance agenda. The seven major human resource implications of clinical governance that emerged from the data analysis are discussed. The author argues that a more proactive HR approach is needed to make clinical governance everyone's business in the NHS organisations.     

Patients�� Rights and the National Health Service in Britain, 1960s�C1980s

The language of rights has long permeated discussions about health care in Britain, but during the latter half of the 20th century, patients’ rights achieved a level of unprecedented prominence. By the end of the 1980s, the language of entitlement appeared to have spread into many areas of the National Health Service: consent to treatment, access to information, and the ability to complain were all legally established patients’ rights. Patient organizations played a critical role in both realizing these rights and in popularizing the discourse of rights in health care in Britain. “Rights talk,” however, was not without its drawbacks, as it was unclear what kinds of rights were being exercised and whether these were held by patients, consumers, or citizens.THE IDEA THAT PATIENTS HAVE rights in relation to health care is a powerful one, but it is a concept that has often generated problems when put into practice. As recent debates about health care reform in the United States make plain, both supporters and detractors of universal health care have been able to use the language of rights to make their case.1 The application of rights to health is no less challenging, however, in countries that do have systems guaranteeing population-wide access, such as Britain with its National Health Service (NHS). In January 2009, the Labour government introduced the NHS Constitution for England, a document that set out a series of rights, responsibilities, and pledges designed to embody the “principles and values” that guide the NHS. Patients were told that they had 25 rights, encompassing areas such as access to health services; quality of care and the environment; access to nationally approved treatments; respect, consent, and confidentiality; informed choice; involvement in their own health care and the wider NHS; and complaint and redress.2 The NHS Constitution, it was claimed, brought together “in one place for the first time in the history of the NHS what staff, patients and public can expect from the NHS.”3Although the introduction of the NHS Constitution was an important development in the reform of British health care under New Labour, it was certainly not the first attempt to formulate a list of patients’ rights, or to use these to shape the future of health services. From the 1960s onwards, a number of organizations claiming to represent the patient, such as the Patients Association, the Consumers’ Association, the National Consumer Council, and the Community Health Councils, drew on the language of rights to put forward their demands. Concerns about patients’ ability to complain, their access to information, and the presence of medical students during consultations and treatment were framed around the concept of rights. Patient organizations also expended much time and energy drawing up patients’ charters and guides to patients’ rights within the NHS. But where did this language of rights come from? What did it mean to talk about patients’ rights in the context of a collective health system like Britain’s NHS?In this article, I explore how the language of rights came to enter the discourse around British health care in the 1960s, and how it was developed and applied by patient groups in the 1970s and 1980s. Drawing on the papers of patient organizations, government records, newspapers, and medical journals, I suggest that although the language of patients’ rights held rhetorical power, putting such language into practice was to prove deeply problematic.     

Lansley sets out NHS vision

The detail behind the Conservatives' proposed redirection of NHS reform was revealed to HSJ by health spokesman Andrew Lansley (pictured) this week. But the manifesto--analysed on these pages--has come under attack from policy players and managers alike. Professor Chris Ham of Birmingham University commented: 'If that's not micro-management then what is?'.     

The eighties in perspective as a millenium passes

It has been a long and busy decade for the health service. But what of the years to come, the lead up to the turn of the millenium. Robert Jefford, planning administrator, Cambridge AHA(T) has stepped into an NHS time machine and sent us this report, first given as a talk to the IHSA, from 2001. The Government is a coalition, muddling through is a respectable art, and the service has survived twenty years in which computer planning has 'transformed strategic planning, not only by relating it to feasibility but by bringing together the isolated concepts that had previously been at war with each other. The NHS was saved'.     

Putting teamwork in context

Multidisciplinary teamwork is becoming more important in both the delivery of health care and in the organization and management of that delivery. The first of these has been accepted but traditional professional education has done little to address the challenge it presents to professionals. Recent reforms in the British NHS have made the challenge more urgent. Professionals must work together but in increasingly flexible and innovatory ways. They are also required to play more formal roles in NHS management and policy. Where teamwork has been addressed in professional education it has concentrated on the inter-personal dynamics of working teams. This remains important but to respond effectively to the new challenges curricula and educational practice will have to be clearer about the variety of teams involved and the importance of the context within which teams work. One view is offered as to how that context might be understood in order to map team diversity. Two models are offered to help develop multidisciplinary team learning. One of these deals with key aspects of the organizational setting and the other with factors that affect team processes. It is argued that both should help to facilitate multidisciplinary curriculum development but also suggest learning needs to be met within unidisciplinary professional education. Concentration on team dynamics alone will not deliver the teamwork required in the new NHS.     

Cocoa and health: a decade of research

It has been over 10 years since the first mention in a medical journal about cocoa and chocolate as potential sources of antioxidants for health. During this time, cocoa has been found to improve antioxidant status, reduce inflammation and correlate with reduced heart disease risk; with these results, and its popularity, it has received wide coverage in the press. However, after 10 years of research, what is known about the potential health benefits of cocoa and what are the important next steps in understanding this decadent source of antioxidants?