Recognition that growing the community workforce is key to the future of the NHS and to help people stay healthy for longer, closer to home, is certain to be welcomed by leaders of community providers. But what does the NHS Long Term Workforce Plan deliver for the community workforce, and where is there more to do?
This article was first published in Healthcare Leader on 11 July 2023.
The pressures facing community health services are extensive and immediate as we have highlighted, staff shortages are significant, particularly in key services such as health visiting, podiatry, speech and language therapy, and community dentistry.
This means concerning backlogs of care and long waits for patients for some key services, particularly for children and young people.
The supply of community health staff has also failed to keep pace with increases in demand. The number of district nurses fell by almost 43 per cent between 2009 and 2019.
There are crucial issues around pay parity too, with promised uplifts for those on Agenda for Change contracts not centrally funded for staff delivering NHS community services in the non-statutory sector, such as for community interest companies or local authorities. This means that these organisations either have to stretch even further, potentially cutting elsewhere, or fail to pass on the pay rise.
Addressing shortages is vital for community health service leaders, who will welcome the plan as a step towards greater stability for the sector. The ambition to grow the proportion of mental health, primary and community care staff to deliver more preventative and proactive care across the NHS, is significant, with the total community workforce expected to nearly double in size by 2036/7. The forecasts of delivering 74 per cent more health visitor training places by 2030/31, as well as more district nursing and school nursing places, will go a considerable way to addressing the challenges we faced.
Implementation strategy needed
…while the ambition behind the plan is important it will need to be accompanied by a robust implementation strategy
Our members are clear that while the ambition behind the plan is important it will need to be accompanied by a robust implementation strategy to break down the existing barriers to recruitment and retention in the community sector. Meeting the targets set out in the plan will require greater prioritisation of community roles, particularly early in education and over new career pathways. This means encouraging students to take placements in community settings and developing community-focused degree pathways.
Although there will be a need to ensure clinical standards are not diluted, and new recruits are well supported, leaders of community providers will welcome the opportunity to expand and develop new or blended roles which will attract more people into the community sector, help reduce duplication between services and enhance the patient experience. This is something the Community Network has been calling for. Apprenticeships, too, will play a role in increasing the numbers of community nurses, particularly by supporting non-registered staff into registered roles. Of course, to deliver this, it is also important that government offers funding to backfill more senior time engaged in supervising or training apprentices.
Upping the ante
Community providers will also welcome the emphasis on developing core skills to deliver care for people with multi-morbidities. This is critically important in community settings, particularly as people are living at home with more complex care needs.
The focus on multi-disciplinary teams, which play an essential role in delivering more integrated care for patients, is also welcome, as is the commitment to increase the number and type of senior clinical decision makers. Community providers tell us that clearer progression pathways would better support retention and that more senior level decision making capacity is important in allowing more complex and acute care needs to be supported in the community.
More needed on staff retention
In fact, while the focus on expanding training and workforce numbers is welcome, it is essential we do not lose sight of what can be done to retain existing staff in community services. Although the plan contains a number of helpful initiatives, I noted there was little that felt really new.
That said, our network will support the plans to allow people to work more flexibly to encourage staff morale and proposed flexibilities for retirees.
Existing staff must also be backed to have the right skills to ensure they feel confident in supporting people safely in the community, particularly given increasing levels of complexity being managed out of hospital. For example, the focus on artificial intelligence and technology to improve productivity must be matched by the right training to give staff the confidence to use it. This will require upskilling and retraining staff as well as further investment in the community sector the avoid variation in digital maturity.
Parity of pay and investment is essential
Looking ahead, I am optimistic but it will be essential for the plan to be refreshed every two years as promised given that patient and workforce needs will continue to evolve. We understand that the £2.4 billion of funding to 2028 is additional money and that this will be formally announced in the next fiscal event. This is very welcome, and we look forward to seeing further details of how the funding will be profiled over the next five years.
Questions about pay parity persist in the community sector
Perhaps the most glaring issue for staff delivering community services could not be addressed by the publication of the long-term workforce plan. Questions about pay parity persist in the community sector with colleagues in community interest companies and voluntary and independent organisations providing NHS commissioned care, unable to access the same government support for the pay uplift for colleagues on Agenda for Change. Yet pay parity will be essential in maintaining effective, caring and stable community services in local systems.
More broadly there is an opportunity for greater coordination within ICSs, working with local partners, to ensure a pipeline of talented staff. This is particularly important for community providers who often work in multidisciplinary teams spanning health and social care. However, community providers tell us that a key challenge is lack of parity of pay between staff in similar roles across social care, primary care and NHS community services, which will persist without concerted government action. While this plan focuses on the NHS workforce, a key and explicit dependency will be reform and similar support for social care.
Now the focus must move to implementation
Alongside the necessity of social care reform is the need for extra capital investment if this bold and ambitious plan is to succeed. Community services require substantial upgrades in facilities and equipment, including investment in digital infrastructure, interoperability and virtual wards which will hold back progress even with more people. Community services will be key to the future of the NHS and building a sustainable health service fit for another 75 years, and cracking numerous workforce challenges will be integral to that. The long-term workforce plan offers hope and resets the terms of the conversation about our workforce needs. Now the focus must move to implementation.
Siobhan Melia is chief executive of Sussex Community NHS Foundation Trust and chair of the Community Network, which is hosted by the NHS Confederation and NHS Providers.