The recent dramatic expansion of new healthcare roles in the
English NHS, including physician associates, has failed to take
account of lessons from history about how to embed and integrate
them effectively, a new report says today.
Expanding the balance of professions is a core part
of any evolving healthcare system and has been central to the NHS
since its inception, but too often in recent years these changes
have happened before issues to do with regulation, training,
supervision, and communication have been resolved, meaning action
is needed from NHS organisations to manage this transition.
That's according to a new report published by the
Nuffield Trust, an independent think tank. The study, In the balance,
commissioned by NHS Employers, looks at the history of how
distinct and different roles - including physician associates,
nursing associates and advanced nurse practitioners - have been
brought into the NHS; how the mix of staff skills in the NHS in
England compares to that of other countries; and what issues need
to be addressed if the government's plans to expand the workforce
and invest in new and emerging roles are to succeed.
The Nuffield Trust's report draws on published data
from across England and the OECD, a literature review, focus
groups with NHS employers and a short survey. It does not offer a
view on the right level of new and emerging roles, or what a good
balance between doctors, nurses and other staff should be. It
comes as an independent review is underway, examining the safety
of physician and anaesthesia associates and their contribution to
multidisciplinary healthcare teams.
Key findings from the research include:
- There has been a huge shift in the balance of roles in the
NHS in England in recent years. This has been particularly
apparent in general practice where a decade ago there was one
other clinician for every fully-qualified permanent GP, whereas
now there is an average of 2.6.
- The hospital sector in England has a higher proportion of
staff other than doctors or nurses than other OECD countries:
doctors and nurses account for just two-in-five hospital staff in
England (39%), compared to nearly two-thirds (63%) in Italy and
almost three-quarters (72%) in Austria.
- The government's Long-Term Workforce Plan assumes significant
growth in the numbers of these different roles, with nursing
associates reaching 14 times the current level by 2036/37. The
proportion of the workforce filled by physician and anaesthesia
associates would remain small (at 0.6%), but their numbers are
projected to grow to around six times the current level.
- Financial subsidies from the government for new and emerging
roles has been a key factor in their growth. For example,
three-quarters (78%) of the growth in staff in general practice
over the last five years has been through the Additional Roles
Reimbursement Scheme, a central scheme to increase direct patient
care staff in general practice.
The study draws on review papers looking at how nursing
associates, medical associate professions and an array of other
new and emerging roles have been embedded, and how the non-GP
workforce has been expanded in primary care to identify key
insights and lessons for NHS employers, policymakers and
professional groups involved in reshaping the NHS workforce.
These include:
- Plans to grow some emerging roles may be jeopardised by a
lack of capacity in the education sector and in over-stretched
services that provide practice learning opportunities.
- While regulation is now being rolled out for physician
associates, the previous lack of regulation has been a concern
for staff: over three-fifths of doctors and staff in emerging
roles, and four-fifths of managers, said regulation or
certification requirements stood in the way of implementing
physician associates.
- Ongoing support like clinical supervision, mentorship and
peer support is important for the successful embedding of these
roles. But workforce expansion puts senior doctors under
particular pressure to educate and supervise, with high
workloads, lack of time, and disrupted line management making
this difficult to achieve.
- Careful planning is essential when introducing new roles to
ensure they integrate with existing staff. In the absence of
sufficient national leadership and guidance, more responsibility
falls on already overwhelmed hospital, community and GP services
who may struggle to develop a sufficiently detailed understanding
of the skills, knowledge and scope of practice of the wide array
of professions.
- Existing staff can have concerns about the quality and safety
of care, the negative impact on their own training opportunities,
or fear of substitution or replacement. Failing to address
inconsistencies in pay across professions, with some new roles
having relatively high starting salaries compared with
established professions, risks worsening tensions.
- Public understanding of most emerging roles is limited, and
evidence shows patients are more likely to support these roles
when they see a positive impact on timeliness, quality or
experience of care.
The Nuffield Trust report calls upon NHS England to urgently
review the principles and impact of schemes where local NHS
organisations are reimbursed for the salaries of emerging staff
roles, which it says can distort local decisions about what staff
to invest in.
It also calls upon NHS England to openly outline governance
arrangements for new roles and publish up-to-date guidance on the
scope and development of these roles; national bodies to
commission research on the impact of different staffing mixes on
patient outcomes; and local employers to take steps like ensuring
that job descriptions reflect the latest guidance on the scope of
such roles.
Commenting on the report, Nuffield Trust Senior Policy
Fellow Dr Billy Palmer said:
“Introducing new and different staff roles to work alongside
doctors and nurses has been a well-worn path for the NHS for
decades. But in recent years, there has been a particularly
dramatic shift in the size and shape of the NHS workforce, and
future plans to expand staff numbers rest heavily on new and
emerging roles.
“This report shows that there are big challenges to overcome in
bringing on any new role –ensuring existing staff have time to
supervise them, having clarity on the scope of the new role,
having the right checks and balances in place if things go wrong,
to name a few.
“These challenges can be overcome with careful planning, time and
attention at all levels in the health system. But the NHS must
take heed of the well-established lessons from history. The
government's review of physician and anaesthesia associates, and
its wider refresh of the Long-Term Workforce Plan provide an
important opportunity to set out some clarity over the transition
and avoid further repeating the mistakes of the past.”
Caroline Waterfield, Director of Development and
Employment at NHS Employers, said:
“Over recent years there have been many changes to roles and the
composition of teams delivering patient care. Change has been
evolutionary over several decades, rather than a recent
phenomenon, and we expect to see this evolution continue. It is
therefore critical to understand what has worked well, what has
not been implemented well, and why.
“We are grateful to the Nuffield Trust for their work to explore
this and identify tangible and practical actions which we can all
work on to ensure that we deploy best practice change management
approaches and reap the intended benefits for staff and
patients.
“As the NHS develops a 10 year plan and revises the workforce
plan to support it, it is critical that the findings from this
work are central to the current design work and any future
implementation plan.”
Ends.
Further information
To read the embargoed report In the balance:
Lessons for changing the mix of professions in NHS services
click here.
