Speaking in the opening ‘Workforce’-themed keynote at last October’s Healthcare Estates 2022 conference, Sir David Behan, Chair of Health Education England, and Nick Hulme, Chief Executive at East Suffolk and North Essex NHS Foundation Trust, gave their standpoints on some of the key workforce challenges facing both the healthcare engineering and estate management sector, and the wider NHS. They also looked ahead at some of the elements they believed would need to change. HEJ editor, Jonathan Baillie, reports
Preceding the two speakers, IHEEM’s President, Paul Fenton MBE, gave a President’s Address reflecting on his past two years in the role. Appropriately – given that the two speakers who followed him discussed workforce-related issues – he gave a particular ‘thank you’ to the healthcare estates management and healthcare engineering profession as a whole – recognising all that the professionals working in the field had achieved in the past three years. He said: “It has been your tenacity, drive, determination, and unyielding hard work – in assisting our clinical colleagues in delivering those clinical services – which have saved so many people’s lives.” Paul Fenton said that during the pandemic, the ‘importance and value’ of the EFM profession had been ‘demonstrated like never before – to our patients, to our Trust boards, to our staff, and to the population we serve’. He added: “When I look back at the hard work, effort, and support, our profession has given during that time, I look proudly on the Institute which I’ve had the greatest honour to lead as President over the past two years.”
Chair of Health Education England
After concluding his address, Paul Fenton declared the conference officially open, and introduced the first of two subsequent speakers – Sir David Behan, the Chair of Health Education England. He explained: “Sir David began his career as a qualified social worker, and has previously held the role of Director of Social Services in three local authorities. In 2003, he became the first Chief Inspector of the Commission for Social Care Inspection, and subsequently worked for the Department of Health as a Director General for Social Care, Local Government, and Care Partnerships. He was also a member of the NHS Management Board, and, between 2012 and 2018, Chief Executive of the Care Quality Commission. Now Chair of Health Education England, he is a member of the full Executive Board of NHS England.”
He continued: “Our second speaker, Nick Hulme, is Chief Executive of East Suffolk and North Essex NHS Foundation Trust, which was formed in 2018 with the merger of Ipswich Hospitals and Colchester Hospitals. Following the merger, he has fulfilled a number of roles, and in 2021 was seconded to lead the NHS England National COVID-19 vaccine effort for 12-15-year-olds. More recently, he was asked to join Norfolk and Suffolk NHS Foundation Trust part time, to help them through some difficult times. I’d like to welcome Sir David and Nick to the stage.”
Arguably the ‘number one priority in healthcare’
Sir David Behan began by saying how pleased he was to see that ‘Workforce’ was one of the key priorities in this year’s conference programme. He said: “It’s arguably the number one priority in health and care, not just in the UK, but globally.” In his presentation he said he would focus on three main points. He elaborated: “The first is the need to develop a more strategic, long-term approach to workforce planning. Secondly, we must regard workforce as our human capital, and invest in it over the long term, much in the way we have with the wider health service, and, thirdly, we will require more, but different, staff, as we move into the future.”
On becoming Health Education England Chair in 2018, Sir David said one of the things that first struck him about workforce planning was that it tended to focus on operational planning, ‘often at the cost of any long-term or strategic planning’. Secondly, service and financial planning had seemingly developed separately. He elaborated: “We thus often have a Service Plan, and the money to deliver it, without the necessary staff, because workforce planning has been separated. Thirdly,” he continued, “the debate about workforce planning focuses more on the supply, than on the demand side. I think we need both, and a clearer and louder voice on the demand side.”
A ‘much more strategic’ approach
Looking ahead, he believed that the service plans, the NHS Long Term Plan, and Dr Claire Fuller’s review (on the ‘Next steps for integrating primary care’), plus the ‘refreshed’ cancer and mental health plans, all presented opportunities ‘to develop a much more strategic approach to the workforce’. Equally, the merger of Health Education England into NHS England, and the creation of Integrated Care Boards, afforded ‘a real opportunity to integrate workforce planning into service and financial planning’. Sir David had also been interested to learn – from IHEEM and HEFMA’s joint Workforce Strategy, Future Leaders, published in March 2021 – that there are almost 100,000 staff working in healthcare estates and facilities nationally in England – representing about 8% of the total NHS workforce across England, in over 300 different roles. He said: “Having read the Strategy, my challenge to you – given what I said about my three priorities for this presentation – is: ‘Is it strategic? Do you take a long-term perspective alongside the immediate challenges you face? What will your workforce look like in 15 years’ time? – not only what will the hospital look like, and what will the workforce required to work in it be, but what will your workforce look like?’”
An ‘inspired’ Faraday Challenge
Sir David felt the IET’s Faraday Challenge for schoolchildren had been ‘inspired’, and had begun to ‘hint at the answer to that question’. He said: “But let me explore some of the more general issues across the workforce.” He explained that, having undertaken workforce planning over the past 3-4 years, in 2019 Health Education England worked on the People Plan with Baroness Dido Harding, which was still awaiting publication. He said: “Then, in 2021, we were asked by the then Health Minister to produce a strategic framework on the future, and in 2022, by Health Secretary, Sajid Javid, to create a Workforce Plan, projected for completion by November this year.” He continued: “You’ll all know – since those commissions were introduced – the uncertainty that has arisen as a result of the political changes, so I thought it interesting that in her plan for patients, the new Health Secretary, Therese Coffey, committed to publishing a Workforce Plan. Yesterday, speaking at the Conservative Party Conference, Robert Jenrick committed to produce a Workforce Plan. I regard it as significant that two senior government ministers have committed to such a plan.”
NHS workforce has grown
Here, turning to focus on ‘the current shape’ of the workforce, Sir David noted that while the NHS workforce had grown by over 20% between 2010 and 2020, demand had risen faster than supply, driven by demography – largely older people presenting with complex, comorbid conditions. While the pandemic had driven delays in treatment times, increasing waiting times, the speaker said he believed the sector was ‘overly focused on acute care in England’; the percentage of nurses and midwives working in acute Trusts was 80% – exactly the same as in 2001. He said: “So, we’re concentrating on responding to care, and not on prevention and early intervention. We have, however, created new roles. Take physician associates, for example, and in 2014 there were just 52 across England, but in 2022, there were 1250, with more set to graduate over the coming years.”
Increasing reliance on international recruitment
These new roles were, however, ‘only a small percentage of our current workforce’, with an increasing reliance on international recruitment – a factor he believes is ‘unsustainable long term.’ He said: “Taking a long-term perspective on workforce is incredibly difficult. It’s quite easy to predict the number of nurses and doctors we’ll have over the next 3-5 years – because they started at university this week. We can make the subtractions for attrition rates of students, and when people graduate, but anticipating how many obstetricians we’ll need in 15 years’ time is much more challenging, and when you get on to those services which will depend on technology, it becomes even harder.” Thus, rather than planning, Sir David said the sector needed to use ‘foresight’ techniques to look at different scenarios of how the future will develop. He said: “Just walking through the exhibition here, it is absolutely clear the impact technology is going to have on the tools and techniques that will be available for healthcare delivery.”
One of the most interesting visits he had undertaken in 2022 had been to the elective surgery wards in Exeter, designed through the conversion of a former Nightingale hospital, where hip and a knee transplant patients were now being discharged on the day of operation – really ‘pushing way beyond’ what the ‘Getting it right first time’ initiative had said about a three-day stay length, but with no diminution in outcomes. It was, he said, ‘really interesting how technology will drive changes in the way clinicians can respond to speeding treatment’. “But how,” he asked, “do we anticipate how many anaesthetists we’ll need in two years’ time with elective surgical hubs, where an anaesthetist, working with anaesthetic assistants, can operate in theatres simultaneously? How do those kinds of calculations work their way into future workforce projections?”
Drivers of change
Sir David next addressed some of the drivers of change. He said: “The first is demography; by 2037 there are projected to be 1.42 million more households headed by someone aged 85+. In Cornwall, Somerset, and Devon, people this age will account for over a third of the population, while two-thirds of them will have complex, comorbid conditions likely to drive demand for services.” It was also known that spending on a person aged 85+ was five times greater than for a 30-year-old. The relationship between health, age, and admission, was, he said, ‘neither linear nor inevitable’. He added: “We thus need a new paradigm of care, which focuses on health creation, disease prevention, and much more personalised care, supported by a workforce with more generalist skills, working in multidisciplinary teams, and providing much more joinedup care. Claire Fuller’s report sets out that direction incredibly clearly.”
Transformative factors?
The other key drivers of change were ‘science, data, digital, and technology’. Aspects such as remote consultations, and remote surveillance and support driving ‘virtual wards’, decision-making tools, machine learning and Artificial Intelligence, and precision medicine, would all ‘have a tremendous impact’. To what extent they would be transformative was an interesting question, but Sir David said he thought they would – ‘for many different reasons’. Health Education England had – he explained – asked Professor Sir John Tooke to analyse the impact that science, technology, and digital, would have on clinical care provision. One of his conclusions had been that technology will ‘provide clinicians with a gift of time, augmenting, rather than replacing, professionals’.
Sir David Behan explained that on visiting universities, one of his questions to both undergraduate and postgraduate courses was: ‘How far does the debate about technology, digital, and data, influence your undergraduate and postgraduate clinical curriculums?’ He said: “It’s very interesting how we’re creating space to ensure that the clinicians we’ll require in 15 years’ time are prepared for the future. One of my questions, though, is: ‘Are we preparing clinicians for today’s needs, and for the world of work they will enter when they graduate and begin to operate?’” Technology and digital would, he believed, ‘change the nature of the relationship between those of us receiving care and those of us providing care’, with citizens being ‘much more empowered’.
New roles emerging
Among the new roles he believes will emerge are those for data analysts, data scientists, bioinformatics, and biostatisticians, while there will also be a key requirement for healthcare engineers and healthcare architects. Here, focusing on ‘what people would want from a healthcare service in the future’, he said: “I’ve already said we need a much greater focus on health creation; how do we work to keep people healthy and well? How do we develop an approach where science and technology will emphasise, much more, the relationships between clinician and citizen?, and how do we develop much more joined-up and integrated care personalised around the individual?” He believes preventative and interventional surgery will become increasingly common.
One of the as yet less well-rehearsed debates was about how the world of work was changing, and how future generations’ expectations about work were altering similarly. Sir David said his children were ‘millennials’, whose standpoint on the optimal work / life balance was very different to his, and who, while caring just as much about their work, were not necessarily prepared to make the same trade-offs. He added: “It’s now all about how much flexibility we will offer in the way we employ people. Future generations will want much more. Equally, doing something that’s genuinely interesting to them will be much more important to them.”
Contact with universities
Sir David Behan explained that his role as Chair of Health Education England brought him into regular contact with universities. He said: “I was at Surrey University last week, looking at the inspiring educational and teaching work they’re doing using AI. One of the questions I’ve been asking is: ‘What will a university look like and offer in 15 years’ time, with artificial intelligence, virtual reality and assisted reality, and blended learning?’ ” His view was that AI would make education ‘much more bespoke’. He explained: “You’re not going to do things because the course requires you to if you’ve already done them on a prior degree.” Some universities would have more people undertaking medical degrees over four years, having already obtained a previous degree. AI would, he believed, ‘help emphasise what people are good at, what they’re less good at, and what they need to focus on’, and the areas they need to develop, ‘in a much more personalised way’. He asked, rhetorically: “So, how do we develop those things, and what does this all mean?”
Future workforce characteristics
Turning next to ‘What are the future workforce characteristics?’, he said: “The shape of work, and of education, will change, and indeed as we at HEE have developed some of our work over the past year, people have told us they want to see something different to what we currently offer. So,” he added, “we will need more clinicians with generalist skills able to provide personalised preventative, joined-up care, supporting flexible careers, alongside specialists. We do want specialists to undertake specialist interventions like the complex shoulder reconstruction I recently underwent, but will also need many more generalists to treat the complex comorbid conditions many older people will present with.”
Sir David Behan said there would be a need for ‘a greater focus on skills rather than roles’. He elaborated: “What got people into the multidisciplinary teams responding to COVID was their skills, rather than the roles they occupied. The ability to undertake airway management got somebody in a COVID team, rather than whether they were a consultant. We will need to deploy skills when and wherever they’re needed, and those skills will need to be developed and adapted. In 1950,” he told delegates, “the shelf life of medical knowledge was 50 years, but in the early 2020s, it’s 73 days, and falling.” Consequently, an approach to education based on knowledge retention was ‘limited’; it was more important that people knew where to obtain the knowledge they needed, and whether they could use it in real time.
A ‘pluripotential’ workforce
Sir David said: “So the problem/solution will be the challenge of the future, rather than physicians knowing every bone in the human body.” This shift would, he believed, require a ‘pluripotential’ workforce able to work in different settings, with roles including nurses, nurse associates, advanced clinical practitioners, physician associates, middle grade doctors, and allied health professionals, who could work in the community, in acute, primary care, and mental health settings, and in social care. To create the ‘conditions for success’ the sector would – the speaker contended – need ‘more and different’, requiring changes in how we recruit, educate, train, employ, and treat, our workforce. He said: “We’ve still got too many people leaving, because they’re not treated well, and to deliver these changes we’ll need a workforce that represents the community they serve.” This would mean widening participation and promoting social mobility approaches, and creating more routes into careers; the speaker said he really appreciated IHEEM’s work to date on apprenticeships.
Blended learning
He told delegates: “I would add to these various elements blended learning. We start our first Medical Apprenticeship Degree in 2024, and are going to develop a much greater approach to Continuing Professional Development and lifelong learning on multiple platforms. We need to enable people to learn and work together, because they will need to do so in adaptive teams. We also need to develop cultures that value people and lifelong learning. So, I hope I have clearly set out that we need to provide a workforce for the future. I’d advocate thinking about the long term alongside the short term, and taking the opportunity of the development of ICBs and Health Education England transferring into NHS England to develop an approach which takes a longer-term, more strategic, approach.”
With this, Sir David Behan concluded his address, and Paul Fenton asked Nick Hulme to join give his presentation.
EFM staff’s ‘invisible work’
Nick Hulme told delegates: “What I want to talk about is fundamentally all about leadership. I believe good healthcare has three major components – science, compassion, and environment. The science we get is from the incredible speed at which scientific developments are moving. A very good friend has pancreatic cancer, and she’s not well, but she says ‘if I just hang on for one more day, the cure might be around the corner’ – and increasingly, it is. So, the science is progressing.”
Importance of the environment
He continued: “Care and compassion is what you and your colleagues do every day, and a bedrock running through the NHS. Thirdly – and the least talked about by professionals – is the environment; the same warm, comfortable environment you ensure with your colleagues every day. It is ignored by so many, but if you look at my inbox – at what patients talk to me about – it’s about the care environment, and car parking, but it’s also about the invisible work that you and your colleagues do every day around safety.”
Nick Hulme said it was ‘a crying shame and a disgrace’ that ‘Estates and Facilities’ was ‘talked about so little by our leaders, right across the political and the executive spectrum’. He said: “I find it interesting that our new Secretary of State talks about ‘a, b, c, d’, but where’s the ‘E and the F’? Because the E and the F – the work you do – is often the difference between fantastic, and merely adequate, healthcare.”
An ageing workforce
Turning to ‘the challenge for workforce’ from his perspective, Nick Hulme said he knew that (according to the NHS Estates and Facilities Workforce Action Plan, published last June), 34% of the current UK healthcare estates and facilities workforce is aged over 55 (compared with around 19% of the overall NHS workforce). He said: “So, we know we have a major problem with recruitment and retention. We also know people don’t leave organisations, and don’t work for organisations either; people leave and work for their leader, their boss. The challenge we have as a profession is to provide that exquisite exceptional leadership – treating every employee as a valued member of our staff, with all the richness, diversity, compassion, and skills they bring every day to improve the lives of the people we serve.”
Leaders will make the difference
Nick Hulme said the ‘leadership challenge’ was ‘what you as leaders in the profession do’, adding: “To get the transformation David has talked about in terms of workforce will depend on the people in this room. Yes, the universities need to create the intelligence, skills, and science, but in terms of the people who rely on your care every day – you are as much caregivers as anybody else who wears a uniform or has a stethoscope round their neck – you will be the difference. For me, the biggest challenge we have around workforce transformation is encouraging more flexibility. We heard Sir David discuss the anaesthetist and the two anaesthetic assistants in that theatre space, but that will only happen if the Royal College accepts this, and if we get the flexibility as professionals and recognise the need for change. Sometimes the biggest challenge we have to changing workforce practices is ourselves, and our inability to accept that other people can do our jobs. During COVID, we saw extraordinary examples of people with skills just putting their hands up.” As the sector moved into what he dubbed the ‘most challenging and dark time, not just in the NHS, but for society’, the speaker said good leadership would ‘make the difference’
Wider challenges across the service
Nick Hulme told delegates that, on a wider front, there were ‘some real challenges’, as well as ‘massive opportunities,’ in the health service. He said: “For example, in one of the hospitals in the East of England, 30% of women with breast cancer don’t go through completely unnecessary chemotherapy, because we now know that due to the genotyping of their particular cancer, chemotherapy will cause huge disruption to their lives, and massive risk to them in terms of being immunocompromised, with absolutely no impact on their tumour. When we consider that survival rates for cancer are better than we’ve ever seen, and some of the stem cell work that’s happening, the future of healthcare is incredibly exciting.”
He had recently been talking to a medical student who was thinking about doing radiology, and had said to him: ‘Really? Are we really going to have people sitting in dark rooms in 10 years’ time looking at screens, or is it going to be AI?’ Nick Hulme said: “We now know that mammography software can identify tumours better than two specialist, consultant, breast radiologists. That software works 24/7, doesn’t talk to you about the BMA rate card, and never writes to me about car parking. So that’s undoubtedly the future.”
Waiting times and personal and professional challenges
Acknowledging the current ‘waiting times worse than we’ve ever seen, an exhausted workforce, and all sorts of challenges with people’s personal and our professional lives, plus pressures on the people healthcare personnel serve often much greater than we could ever imagine’, the speaker asked ‘how we then build that bridge from our current state – building on and talking about hope to our staff, patients, and leaders, to that future state’? He said: “How do we take our ward workforce with us?” EFM professionals were, in Nick Hulme’s view, ‘some of the most under-rated staff in the NHS, ignored by politicians, and often by leaders’. He said: “With this in mind, how do you make somebody feel valued, and that they’re making a difference to the lives of the people that we serve?”
A ‘life-saving’ role
He added: “At 2.00 am one day in the middle of COVID I was in Colchester Hospital, and there were some engineers installing pipes who had never worked in healthcare before. I just said to them: ‘You know you’re saving lives.’ They questioned this, and I reiterated: ‘What you’re doing this minute, today, is saving a life’, and they got quite emotional. You cannot remind your staff often enough that every single thing they do, every single day, is saving a life. It’s a crying shame that it took COVID for us to realise that – and I hope that now we never forget it.”
He concluded: “So, I just want to add my thanks for all the work you and your colleagues do every day. My grandmother trained as a nurse in this part of the world, later becoming a Director of Social Services in Leicester. She was still advising me when she was 99 about how I should be doing my job – and never got it wrong. When I got my first management role – the fantastically titled ‘Manager of Sexual Health and Counselling’ at King’s College Hospital, I phoned her – she was in her 80s – and asked: ‘Grandma, What are the two bits of advice you’d give me?’ She said: ‘Firstly, Nick, always treat your staff the way you’d like them to treat the patients.’ Her second piece of advice was: ‘Never manage car parks.’ For all those of you in the audience that do, thank you.” This closed an interesting session