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We need a fairer division of NHS training budgets

We need a fairer division of NHS training budgets

A highly selective approach to training and development budgets is undermining estates and facilities at a time when a major investment in people and skills is long overdue, argues Jane Renton. 



We’ve heard a great deal about the funding crisis in the NHS, but that is likely to be eclipsed by a workforce crisis that has after all been bubbling away in the background for some time now. It will surely erupt unless meaningful action is taken. 


In fact, the staffing crisis is accelerating so quickly that the total shortfall in staff, currently reported to be running at 100,000 vacancies is likely to get a whole lot worse, with a predicted shortfall of 350,000 vacancies by 2030, according to a briefing paper published by The Health Foundation, The King’s Fund and Nuffield Trust last month. That assumes that the emerging trend of staff quitting the NHS at current rates continues unabated or that numbers of newly trained or international recruits do not rise sufficiently from their present levels. 


The paper, ‘The health care workforce in England: make or break?’ produced ahead of publication of the NHS long-term plan, urges the development of credible plans, all the sensible stuff that the service needs to get to grips with: cuts in funding for training places; restrictive immigration policies exacerbated by Brexit. There needs to be a strategy in place to deal with this, otherwise the long term plan will simply be an aspiration ‘wish list’ rather than a credible path to a sustainable future, the paper’s authors conclude.


The paper, like so many other such reports, is focused overwhelmingly on the current shortages of nurses and doctors, however. There is little mention of support staff and no mention of those who work on the estates and facilities (E&F) side of the service, whose own succession issues might not match the sheer numbers being talked about in nursing, but proportionately are as bad, if not worse than those affecting clinical staff.  


Estates shortages

No-one should downplay the significance of those clinical shortages - they are severe and problematic, with some 36,000 vacancies among nursing and midwifery - one in every eight such posts is vacant - but they should not be allowed to obscure pressing problems elsewhere, such as the skill and labour shortages afflicting the health estates and facilities’ services. One cannot work without the other. A holistic approach is required and urgently.


“NHS England understands this - and NHSI up to a point - but it does come down to individual Trusts to understand the importance of involving the totality of the workforce in training and development,” asserts Candace Miller, Executive Director of Learning Services for Health, which helps the NHS and other healthcare organisations with workforce development.


One of the problems identified by Candace is what she calls ‘the fear factor’ - the threat of litigation that prompts Trusts to prioritise clinical training ‘to the detriment of everything else’ in the service. She claims that invariably support staff either receive very limited time off work for training and development, or have to undertake training at their own expense and in their own time.


“Something pathetic like 3% to 5% of the total NHS training budget gets spent on the support workforce. I think someone once worked out this would be the equivalent of buying each member of the support staff a Big Mac quarterly.”


While the numbers may be rather smaller on the estates and facilities compared to nursing shortages, they are nevertheless proving equally perilous to overall service levels. Maintenance backlogs are growing at a time when the estates - the built environment and its ancillary support services - will be critical to improved patient services, through better use of technology and its workforce.


If anything, the scale of the problem in estates is even more pronounced because many jobs that are being vacated are either not being replaced, or there are difficulties attracting replacements because of underinvestment in skills training. The workforce is also ageing, as many are coming up to retirement over the next 10 to 15 years. 


This is reflected in the latest figures from NHS Digital for England. The figures, which are provisional and experimental, for March 2018 show a total of 895 vacancies in estates and ancillary jobs. While they are well below those in nursing and midwifery, which account for 40% or 11,483 of all total full time equivalent vacancies of 28,998, they are nevertheless worrying. They may suggest superficially that the level of vacancies are both proportionately low and relatively stable compared to other disciplines in recent years, but the facts dictate otherwise. The workload of estates and facilities has been increasing exponentially, while overall numbers are declining. This suggests that either productivity has vastly increased, which is unlikely given the state of disrepair of much of the English estate, or more likely that jobs are not being replaced.


Again provisional workforce figures from NHS Digital, which need to be treated with a degree of caution, are nevertheless revealing. They show that there were a total of 57,406 full-time equivalent jobs in the NHS in hotel, property and estates, plus an additional 1,768 managers in September 2009 compared to 53,586 in August 2018 as well as an additional 1,286 managers. While demands on the workforce have increased exponentially, overall numbers have fallen by 3,820 jobs, or 6.7%. Meanwhile manager numbers have fallen by 27% to 1,286, or one manager for every 42 workers, compared to one for every 32, nine years ago.


Acknowledging the problem

The difficulties faced by estates and facilities were clearly acknowledged by NHS Improvement at HEFMA’s annual Forum in May. “I think [the NHS] has had a real lack of focus in the estates and facilities arena, specifically over the last few years,“ acknowledged Fiona Daly, Head of Sustainability and the EFM workforce, when she spoke at the event. 


She said it was now time to take stock and look at how the estates and facilities could transition from an environment where people spent their time “bending and trying not to break” to the creation of a strong, resilient workforce for the future.


Fiona is right. There has been a great deal of bending and it is high time that the workforce strategy for the NHS also included the estates and facilities operations. One senior estates manager at a northern Trust, who recently had to contend with five coinciding retirements, only two of which were expected, was also increasingly resorting to external contractors for work that would normally be kept in-house as a result of ongoing labour shortages. It all adds to the cost of running the service, he says.


“We’ve also had to revert to overtime to fill gaps that would have otherwise disrupted service levels to patients,” the manager added.


Finding employees with the right skill levels is proving harder and harder, a situation one manager claims has been exacerbated by the withdrawal in many instances of the deputy or assistant posts in facilities. Those posts provided a well-trodden path to more senior management roles.  


Workforce succession planning is at best patchy and regional. For example, one senior manager from an electro-biomedical engineering background believes the issue has been flagged and managed “reasonably well”, at least as far as his own Trust is concerned. 


This resulted in a more proactive approach than in some other E&F areas, with his particular Trust being able to access a well-established apprenticeship model, some time before the current ‘trailblazer’ route came into operation.


“We have experienced recruitment issues and the ageing workforce problem was shared regionally and nationally via the Modernising Scientific Careers (MSC) programme some years ago,” he says.


But the same cannot be said of other areas of operation, such as hospital catering, warns another senior manager at the same Trust. 


“The current age profile of the chefs within our Central Production Unit averages out at about 55+ and potentially there will be issues with their replacement if succession plans are not put into place,” she warns.


One senior engineer complains that estates managers and engineers are now being expected to act as the ‘authorised person’ for as many as five different specialisations. Clearly this is neither practical nor safe.


Is anything being done?

To date, it seems that much of the initiative to redress such imbalances has been left to healthcare associations and professional bodies, or the initiatives of smaller concerned groups, such as porters at Leeds Teaching Hospitals NHS Trust, who established their own ‘porter huddles’ at St James’s Hospital, now also attended by clinical staff, to draw attention to patient safety issues along with recommendations on how to improve services, many of which have now been put into operation. 


HEFMA itself has not been idle on this front in its work to support and develop future workforce sustainability. It has developed a coaching and mentoring register accessible by members through its website and embarked upon a training programme to train individuals to become coaches or mentors who will support the register and help colleagues who want to develop their careers.


The organisation is also working to develop a partnership with Eastwood Park - the country’s long established centre for healthcare E&F training and accreditation.


“We discussed the heads of terms for this in late November and are now drawing together a memorandum of understanding to underpin the relationship,” announces Jonathan Stewart, HEFMA’s National Chair. 


This will enable the organisation to provide training across the range of E&F services in association with a professional training partner.


The organisation has also been heavily engaged in work with IHEEM, NHSI, NHS Scotland and others to develop standardised career route maps for individuals to identify their career goals and access appropriate education, training and accreditation with support at each key junction.


HEFMA is actively trying to find a way to get more apprentices back into the NHS and is keen to link with other healthcare associations to drive this forward.


Such a scheme would be welcome, as a quick scan of the latest apprenticeship completion figures are highly revealing. Just shy of 4,000 healthcare apprenticeships were completed according to data covering the period between March and October 2017, but only 11 of those involved worked in healthcare facilities, compared to 200 in business administration and 70 in accountancy. 


Money for E&F training clearly needs to be ring-fenced. While high level clinical apprenticeships are being developed, which could cost up to £27,000 each to the equivalent of degree level, there are inevitably concerns that apprenticeship funding could very quickly dry-up for other non-clinical healthcare services.


“There is a concern that the real drive will be to develop clinical apprenticeships, which are a good thing, but not if it comes at the expense of funding for wider NHS apprenticeships,” warns Candace Miller.


Meanwhile, the estates and facilities are running on goodwill, but even goodwill without sustenance eventually runs out of steam.