There has been some debate in Amicus on issues relating to skill mix. This is a debate that needs to be had particularly with the creation of a new pay system under Agenda for Change and the modernisation programme focusing on workforce development.
Unfortunately, this debate sometimes translates itself into colleagues claiming that the service is being diluted professionally or references to 'non-qualified colleagues'. This is unfortunate not only because of the personal sleight on some of our colleagues but it does miss the point about how we can both expand capacity whilst protecting the professional integrity of our professionally qualified membership.
The Government has set targets for increasing the numbers of health staff as detailed in the NHS Plan. However, whilst these targets are welcome, no workforce planning has been done on how this figure should be distributed throughout various professions and disciplines within these professions. Maybe this is an indeterminable objective. Amicus has met huge obstacles in trying to develop a robust model for community nursing and had to give up on a proposed research project in this area. However, we are convinced that we need to boost capacity in the NHS in order to meet Government health targets and improve healthcare in the long term. We are involved in a rigorous campaign to boost the number of practitioners across a range of professions.
Recruitment itself poses problems of national "intellectual capacity". Output from all forms of higher education, including internal NHS training, in 2005 is expected to be approximately 250,000. Demand from the NHS on present job mix is likely to be 60,000. 25% of the output, for 4% of the economy. Therefore other ways of resourcing staff requirements have to be found.
The most recent figures in England reveal a mixed picture in tackling the vacancy rate for a range of health professions. There is also the question of whether we accept the statistical premise that the vacancy rate is determined by the percentage of jobs that have been advertised and remain unfilled for a period of three months. In our work in pathology we have shown that this is a flawed approach as often Trusts claim there is no longer a vacancy if they use agency staff to fill a post albeit temporarily. This is without the added 'dynamic' of if and when the expanded number of posts envisaged in the NHS Plan come onto stream.
There is also an obvious gap between Government intentions and achieving the shift in resources that we know will improve health in the longer term. The problem for politicians is that they are faced with short-term political objectives and when the public responds positively to expanded numbers in effect they typically are doctors or nurses residing in the acute sector.
Genuine skill mix is a rational approach to workloads as it allows health professionals to concentrate on the core 'value added' competencies that are required for professional registration. At the same time this can facilitate a greater commitment to team working and multi-agency working. In this way skill mix is one way that capacity can be increased but at the same time we do need to protect against a dilution of a service based on grade mix. How can this be done?
GLOSSARY
| GOOD |
BAD |
| Skill mix |
Grade mix |
| Capacity increase |
Job substitution |
| Health needs driven |
Budget driven |
| Upskill |
Deskill |
| Invest |
Disinvest |
| Colleague |
Assistant or helper |
From the outset there is a need to address staffing from a service needs approach. Health professionals are the appropriate people to lead on this with support from the Trust management. Government policies and targets in a range of areas should inform this. Staffing levels and the required skill mix follows. The Trust is then required to make a qualitative decision based on health needs on priorities for expenditure.
Where this does not happen too often services respond by prioritising across policy initiatives and in effect create a form of the postcode lottery. This then becomes the starting point for any review of the service. As a result the Trust ends up determining the blend of grades - grade mix - in order to meet the Budget, allocating work accordingly.
One simple device to prevent grade mix is to keep track of the staffing complement and grading over a given time period. This information can be sought from management under trade unions rights to disclosure of information, although in small teams this is often well known. Through this approach it can be shown where positions at a lower grade - job substitution - have been introduced to replace those at a higher grade. If this has taken place we then need to ask on what health needs or service grounds this has been done. The purpose is to expose such decisions to scrutiny and prevent this being introduced by stealth.
We cannot avoid professional issues relating to this issue. Firstly, skill mix may seek to delegate work to other colleagues which is part of the professional development of the health professional or gives them job satisfaction. This is difficult to address but obviously the full range of duties must be part of a training programme and first years of practice. At the same time we should ensure that the work of the non-professionally qualified staff has its own resonance and not simply seen as one of a 'helper' to the health professional.
Our objective should be to create a policy of a skills escalator where all staff have access to paid time off and resources for continuing professional development. Often Trusts operate access to CPD based on a 'hierarchy of need' with the normal professions benefiting to the detriment of others. Our role as a trade union is to ensure that all staff have an agreed level of competency and they should not work outside that envelope. Also that skills enhancement is reflected in the level of pay our members receive, as this will prevent grade mix based on job substitution. Agenda for Change should provide this opportunity.
There is great opportunity for Amicus in this area. It is clear that as a result of the modernisation programme and the need to reduce workload pressures on doctors in order that the NHS can become compliant with the Working Time Directive new roles will have to be developed. This in turn raises the question of who undertakes the former work of those practitioners undertaking such new roles? Therefore this programme needs to be systematic and cover the NHS from top to bottom and from left to right. We have the professional expertise, either through autonomous sections or through links with professional bodies to make a big drive forward in this area.
The Knowledge and Skills Framework does have the potential to produce such an approach if operated honestly and fairly by Trusts. But if not done so could degenerate into a crude form of performance related pay. This points to new roles for local representatives as custodians of the KSF in the spirit in which it will be agreed as part of Agenda for Change.
Another issue is related to delegation and accountability. The CPHVA has produced a Professional Briefing: "Delegation and Professional Accountability" for community nursing. Further work is required to address this issue across the range of professions that we represent.
The key point is that health professionals in the main cannot delegate responsibility. They may come under pressure either because of a lack of staff or by management to delegate work that it is not safe to do so because it is beyond the competence of their colleague. The health professional should immediately record any concerns that they may have in this respect with their manager, keeping a copy for their personal files.
Finally, we have two organisational tasks to undertake. Firstly, we need to break down the regulatory obstacles to getting recognition. We need to ensure that the Health Professions Council delivers on the objective of the Government to ensure a broader range of health staff obtain professional status and become registered. We need to ensure that this takes place on a fair basis not the professional prejudices of Council members. Next we need to ensure a regulatory framework for health staff not covered by this arrangement, either through the HPC or a newly created body.
The other task is to unite all staff working in a particular Department or section of work e.g. pathology, pharmacy, community nursing in amicus MSF regardless of their professional status. This will prevent Trusts players of sections of staff against the other and allow us the opportunity to discuss the best way forward as equals in a collegiate manner.