Intended for healthcare professionals


Reshaping the NHS workforce

BMJ 2000; 320 doi: (Published 15 April 2000) Cite this as: BMJ 2000;320:1023

Necessary changes are constrained by professional structures from the past

  1. Lesley Doya, professor in health and social care,
  2. Ailsa Cameron, research fellow
  1. School for Policy Studies, University of Bristol, Bristol BS8 1TZ

    Education and debate p 1067

    The staffing problems of the NHS continue to make headlines.1 Junior doctors are threatening to strike, consultants are voicing their frustration, and nurses are voting with their feet.2 Though their concerns are less visible, physiotherapists, radiographers, occupational therapists and other members of the professions allied to medicine are also facing major challenges.3 The problems have been well rehearsed but solutions seem as far away as ever.If the healthcare needs of this new millennium are to be met, more radical approaches to collaborative working will need to be explored.

    By its very nature the healthcare labour force is an interdependent one. The different occupational groups did not develop in isolation from each other but as part of a complex and interdependent system capable of carrying out the many activities that make up a modern health service. Yet despite this obvious reciprocity, the different elements of the NHS labour force are still planned and managed in isolation. This continuing fragmentation has a major impact on the quality of patient care and on the wellbeing of health workers themselves.4

    Since the 1970s there have been irresistible pressures towards collaborative working across traditional boundaries. More health workers are now organised into multiprofessional teams, and many nurses and those in the professions allied to medicine have taken on innovative roles which sometimes include work previously done by junior doctors.5 6 These developments have led to some lowering of barriers between different professional groups, but major obstacles still remain.

    Structural problems

    Much effort has been put into team building and improving communication skills, but attempts at working together continue to be constrained by differences in styles of learning, in career patterns, in models of working, and in regulatory mechanisms. Moreover, there is still little or no movement of individuals between professions. It is no easier for a highly skilled nurse to become a doctor, for instance, than it was 30 years ago. If the appropriate human resources are to be available to meet the healthcare needs of the coming decades these structural problems need to be addressed.

    Current social and demographic trends are likely to continue into the foreseeable future, with the ageing of the population and the rise in chronic diseases leading to greater demand for health care in both hospitals and the community. At the same time, the development of new technologies will require more practitioners willing and able to pioneer new ways of working. The emphasis on evidence based practice will also continue so that each occupational group will have to justify its place in the healthcare team. The likely overall effect of these trends is to intensify the pressures towards reconfiguring clinical care.

    Moves towards even greater flexibility in the labour force will have obvious advantages for those responsible for managing the delivery of services. However, they will also pose significant problems. As the “core” skills and responsibilities of the different groups change, the organisation of the NHS labour force will be increasingly out of line with the traditional map of the healthcare professions. The resulting tensions will not be amenable to solutions devised by individual directorates or trusts or by the different professional bodies working alone.7

    Need for better planning

    New mechanisms of workforce planning will be required to develop integrated strategies for the different occupational groups.8 These will need to include not just nurses, doctors, and professions allied to medicine but all the other groups (including some social workers) who play an increasingly important role in the complex mosaic of healthcare delivery. Particular attention will need to be paid to new categories of worker such as the healthcare assistants emerging to fill gaps left as “task drift” alters patterns of work among traditional professionals. This need for better workforce planning at all levels is emphasised this week by Buchan and Edwards in their article onthe nursing workforce (p 1067).9

    There will also need to be a rethink of education and training as health workers are increasingly engaged in work whichwas not part of their original mandate. Several studies have already identified the lack of appropriate courses for those taking on innovative roles that cross historical boundaries. Where nurses take on the work of junior doctors, for example, there may be no supporting educational programme.5 6 Under these circumstances health workers themselves report considerable stress, and the dangeris that patient care will sometimes be compromised.

    Clinical governance is currently receiving considerable attention as a means of managing resources (including staff) attrust level to ensure quality, but again there are structural barriers that limit what individual management teams can achieve. Patterns of accreditation and regulation continue to be based on traditional models of the separate professions and on their definitions of “appropriate” practice. Each group has the major responsibility for regulating itself, with relatively little crossover between them. As the pattern of service delivery changes, these processes will need to be harmonisedto facilitate cooperation between practitioners from different backgrounds and also to make professional mobility easier for individuals.

    If quality of care is to be maintained within existing resource constraints, there will clearly need to be a more integrated approach to planning and managing human resources in the health sector.10 It will require not just teamwork between the individuals providing the service but also institutional cooperationand negotiation at several levels. Some of these developments are already beginning to happen. This week's consultative document from the Department of Health suggests a major step forward in the form of “a more holistic approach to workforce planning than has been the case hitherto.” 1011 It criticises the existing “policy vacuum” and calls for “a major programme of action” to remedy this deficiency. This is a significant intervention which offers an opportunity for much needed debate. However, past experience indicates that they will not be easy to achieve.

    As health care is transformed, some professions are likely to gain power and status while others lose. Indeed some professions may not be sustainable in their current form while other groupings are already emerging to meet new needs.3 Occupational therapists, for example, face increasing difficulties in sustaininga specific role in acute care. At the same time a number of other groups, including paramedics, are moving towards professional status through the Council for Professions Supplementary to Medicine. Against this background of complex and sometimes threatening changes, the challenges of “working together” are likely to be greater than ever before. But solutions willhave to be found if the health labour force is to be reshaped to meet the challenges that lie ahead.


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