Liberating the NHS: Developing the Healthcare Workforce

The Chartered Society of Physiotherapy consultation response

To: Consultation Responses Workforce Education Policy Team Department of Health Room 2N12 Quarry House Quarry Hill Leeds LS2 7UE

By email: [email protected]

The Chartered Society of Physiotherapy (CSP) is the professional, educational and trade union body for the UK’s 50,000 chartered physiotherapists, physiotherapy students and support workers.

The CSP welcomes the opportunity to respond to the proposals published in the consultation document Liberating the NHS: Developing the Healthcare Workforce.

Our response is focussed on the areas of the consultation on which we feel we can most effectively contribute to the debate. We would be pleased to supply additional information on any of the points raised in our response at a later stage.

The contribution of physiotherapy

Physiotherapy enables people to move and function as well as they can, maximising quality of life, physical and mental health and well-being.

Physiotherapists use manual therapy, therapeutic exercise and rehabilitative approaches to restore, maintain and improve movement and activity. Working with a wide range of population groups (including children, those of working age and older people); across sectors; and in hospital, community and workplace settings. Physiotherapists facilitate early intervention, support self management and promote independence, and help prevent episodes of ill health and disability developing into chronic conditions. Physiotherapy supports people across a wide range of areas including musculoskeletal disorders (MSD); many long-term conditions, such as stroke, MS and Parkinson’s Disease; cardiac and respiratory rehabilitation; burns and reconstructive surgery rehabilitation; children’s disabilities; cancer; women’s health; continence; mental health; falls prevention.

Physiotherapy is both clinically effective and cost effective. Physiotherapists are ideally placed to keep employees healthy and fit to work. Illness and injury accounted for an estimated 29.3 million days off work in Great Britain in 2008/9. Investment in early intervention to physiotherapy, particularly for MSDs benefits individuals and businesses.

1 MSDs are the most common problems physiotherapists treat. 60% of people on long term sick leave cite MSDs as the reason. An estimated 9.3 million working days were lost through MSDs in Great Britain in 2008/9.

Physiotherapists also have a key role to play in promoting the health benefits of regular physical activity and in encouraging people to adopt and maintain a healthy lifestyle. The CSP is running a long-term public health campaign called ‘Move for Health’ to encourage people to build physical activity into their daily lives.

Physiotherapy delivers high-quality, innovative services in accessible, responsive, timely ways. It is founded on an increasingly strong evidence base, an evolving scope of practice, clinical leadership and person-centred professionalism.

As an adaptable, engaged workforce, physiotherapists have the skills to address healthcare priorities, meet individual needs, and to develop and deliver services in clinically and cost-effective ways. With a focus on quality and productivity, it puts meeting patient and population needs, and optimising clinical outcomes, and the patient experience, at the centre of all it does.

1. Introduction and overview

1.1 The Chartered Society of Physiotherapy (CSP) is supportive of the Government’s underlying principles of putting patients and public at the heart of everything the NHS does; delivering health outcomes that are among the best in the world; and increasing autonomy and accountability in the system. However, this is within the context of our grave concerns that the NHS reforms proposed in the White Paper Equity and Excellence: Liberating the NHS are the wrong reforms at the wrong time.

1.2 The CSP has severe concerns about the scope and speed of the structural changes proposed and believes these present a major risk to the quality of patient care and the future of the NHS, resulting in increased costs, fragmented care and an unacceptable postcode lottery of services across the country.

1.3 We do not believe that, at a time when the NHS is being asked to make unprecedented efficiency savings of £20bn, it should be focussed on implementing a costly reform programme which has no evidence base.

1.4 We are committed to an NHS that is free at the point of delivery, based on need, publicly funded, publicly provided and publicly accountable. We believe that collaboration and communication are the best ways to deliver services in the NHS and an over emphasis on competition between healthcare providers is potentially destructive to patient care.

1.5 All of our comments in relation to the proposals outlined in Liberating the NHS: Developing the Healthcare Workforce fit within this overall context.

1.6 The CSP welcomes the recognition of the importance of the whole healthcare workforce working effectively together, across sectors and care pathways.

1.7 We agree with the evidence which suggests that staff who are empowered, engaged and well supported provide better care, and therefore welcome the

2 aspiration in the proposals to support everyone in the healthcare workforce to realise their potential.

1.8 We support the alignment of service development with financial and workforce planning, as one of the fundamental weaknesses of workforce planning in the past has been these two issues being considered independently.

1.9 The lack of involvement of clinical service managers, such as physiotherapy service managers, in workforce planning is another fundamental weakness in the proposals. This is an issue in the current system, but we feel the proposals in the consultation are not strong enough to make the necessary improvements. We believe that strengthening the involvement of clinical service managers is imperative to achieving stronger, more effective workforce planning within the proposed arrangements. Service managers’ involvement is essential for supplying accurate data about the existing workforce and expert assessment of future staffing requirements. We wish to see effective channels to allow input from these staff in future arrangements.

1.10 We welcome the intention to consult with the Devolved Administrations as the physiotherapy workforce is a national workforce and a UK wide approach is needed.

1.11 The CSP broadly welcomes the six principles for workforce planning as outlined on page 15 of the consultation document. However, we have strong concerns that the outlined proposals for change will not enable these principles to be implemented, with the limited detail provided making it difficult to judge how workable and acceptable arrangements would be.

2. Vision

2.1 The CSP broadly agrees with the objectives outlined for workforce planning, education and design in chapter two of the consultation document.

2.2 We would argue for the inclusion of an additional objective: Commitment to demonstrating clinical effectiveness. We believe this commitment is under- represented throughout the whole consultation document. It has never been more important for healthcare professionals to engage in evaluating their practice and demonstrating safety, clinical outcomes, positive patient experiences and adhering to evidence based practice, and this should be reflected in the planning, education and design of the workforce.

2.3 The CSP is concerned that there is little recognition in the consultation of the crucial need to ensure staff providing NHS-funded services have access to appropriate forms of learning and development roles, in ways that support service development and delivery, meet changing patient/population needs and provide appropriate opportunities for professional and career development.

2.4 We would argue that under the High quality education and training objective, it is equally important to ensure that there is sufficient funding and access to time off and resources to enable staff to access continuing professional development opportunities, which are vital to ensuring they are up to date with the latest

3 developments and best practice in their field. We would strongly urge the Department of Health to build this into its priorities for workforce planning.

2.5 The CSP is also concerned that the consultation document makes very little reference to workforce planning in relation to support workers and developing the knowledge and skills of individuals in this category to provide timely, accessible services. We would welcome more detail on how this important part of the workforce will be supported in the new structures being proposed.

2.6 Moves towards increasing the opportunities for flexible local implementation and innovation should be done within the context of ensuring that there is consistency in service provision and workforce development at local level. This will help to prevent a postcode lottery in the range and quality of services available to any local population. We support the need for professional engagement at local and national levels, but have concerns that this could be dominated by the larger professions. It is very important that there is an opportunity for smaller professions to have a voice at both levels.

2.7 The CSP broadly agrees with the design principles outlined in chapter two of the consultation document. Again, however, we have concerns that the proposals for change will not deliver the principles effectively.

3. Context

3.1 The CSP agrees with the assertion made, in the consultation paper, that the people who work in the NHS are among the most skilled in the world and that securing and nurturing their talent in the service of public and patients is the responsibility of everyone who works in the healthcare sector or supports healthcare delivery. We believe it is vital that this responsibility is understood and accepted by everyone involved in providing NHS-funded care.

3.2 The CSP would like to see a stronger commitment to supporting continuing professional and personal development (CPD). The consultation paper asserts that, in the new NHS, the responsibility for investing in the existing workforce will sit with employers (paragraph 3.14). The CSP would like to see a requirement on all providers of NHS care to fund CPD for healthcare staff. This is essential to creating a sustainable workforce that can be responsive to changing needs and that is supported in providing professional leadership to make the proposed arrangements workable and effective.

3.3 Paragraphs 3.15 and 3.16 of the consultation paper outline the importance of ensuring high quality education and training. The CSP would argue that Higher Education Institutions (HEIs) need to have an expanded role in continuing professional development (CPD) to ensure the supply of high-quality, evidence- based learning that provides structured opportunities for professional and career development and the sustainable fulfilment of clinical service needs. The proposals, in the consultation document, to leave support for post-registration education to employers (see also paragraph 8.4 below) risks diminishing the quality of CPD opportunities available to the health care workforce that are required to meet service need. We are concerned that this may lead to a stronger reliance on unrecognised short courses that may lack educational rigour. A sustainable

4 approach to workforce planning has to recognise that the learning and development needs of the whole workforce (qualified and unqualified) must be addressed for the duration of individuals’ careers.

3.4 We welcome the acknowledgement, in the consultation paper, of the importance of an effective partnership between the NHS and education providers. The CSP would strongly argue for the need for providers to work more closely and directly with commissioners. We would also suggest that the new framework is an opportunity to strengthen partnerships between other healthcare providers (e.g. MOD, private sector) and HEIs, in addition to the NHS.

3.5 Paragraph 3.18 of the consultation states that the National Allied Health Professional Advisory Board has driven forward the development of advanced practice, changing roles and a research culture. While strongly welcoming the existence and work of this Board (see point 3.7), it is misplaced to assume that its work is complete and that the areas cited do not require further support to underpin their required onward development.

3.6 Furthermore, the security of advanced practice roles for allied health professionals (AHPs) and succession planning is of paramount importance. These senior, clinical roles are particularly important in providing clinical leadership, especially as physiotherapy manager roles are increasingly being subsumed by multi- professional roles, yet they are increasingly threatened in the current NHS climate for financial reasons.

3.7 The CSP strongly supports the continuation of the National Allied Health Professional Advisory Board, which gives a voice to all the AHPs. It provides a forum where profession wide workforce issues can be debated and fed through to the Centre for Workforce Intelligence (CfWI) by those with the expertise and knowledge of the roles and the future potential of this part of the NHS workforce.

3.8 We believe that the CfWI has an important role to play in providing leadership and expert advice on workforce planning in the NHS. In our opinion, it is critical for there to be overview of workforce supply and demand, particularly for the smaller professions.

3.9 The CSP would welcome any opportunity to further develop the links that it has already established with the CfWI as we believe that the professional bodies and trade unions have a major contribution to make to its work. We have unique access to information about our membership, of more than 50,000 physiotherapists, physiotherapy students and support workers, working both in and outside the NHS, which is currently not available elsewhere.

3.10 The CSP is concerned that there is little reference in the consultation document to professional bodies and trade unions and the vital contribution that these organisations can make to workforce planning.

3.11 We also have concerns about how the views and recommendations of the CfWI will be put into action locally under the proposed new structures. In the current system the Strategic Health Authorities (SHAs) have had a major, and in our view critical, role in overseeing workforce planning issues within each region, which it will be almost impossible to replicate within the proposed new structures. While we

5 strongly welcome the central role outlined for the CfWI in underpinning workforce commissioning decisions, we have concerns about how accountability to demonstrate use of the data will be ensured. Recent cases of significant cuts being announced to physiotherapy education numbers for 2011/12 suggests that CfWI data can be ignored.

3.12 In addition, we have concerns that some of the existing flaws in current arrangements – primarily that regionally-based commissioning misses that health care professionals are a national workforce – will be exacerbated by increasing fragmentation and devolution of decision-making to a local level.

3.13 Partnership working at national (via the Social Partnership Forum) and SHA level has been critical in solving countrywide employment issues – for example, the joint action plans which successfully dealt with high levels of unemployment among newly qualified healthcare professionals in England between 2006 and 2009. These action plans were produced by the national Social Partnership Forum, which brings together trade unions, NHS employers and the Department of Health to debate and resolve issues affecting the NHS workforce. Once these plans were developed, the SHAs provided a well structured means to relay messages about the causes of the problems and realistic solutions to those best able to work at local level to resolve them. The partnership fora at SHA level were able to meet to discuss the action plans with other stakeholders including trade unions, HEIs, and health care providers to develop effective solutions for their region and the SHAs were able to ensure that all relevant stakeholders were involved in contributing to solutions and took their fair share of responsibility to help tackle the problem. The combination of national and regional level partnership working made a huge difference, resulting in a dramatic fall in the number of newly qualified health professionals unable to find their first clinical post. The CSP is concerned that the loss of these regional and national mechanisms will mean that in the future such an effective response to a national issue will not be possible as the skills networks will not have the capacity, expertise or understanding of the national picture to be able to take on this role.

3.14 We are concerned that an unintended consequence of these proposals will be to dismantle arrangements at SHA level that manage issues of graduates struggling to secure initial employment. While the proposals are obviously intended to produce an approach to workforce planning that avoids this scenario arising, it clearly remains a risk. We are, therefore, seeking clarification of how an appropriately coordinated and sustained approach will be pursued, to avoid the potential of losing individuals from the professions for which their education has prepared them.

3.15 In August 2010, the CfWI produced a report on the physiotherapy workforce1. Having collected information from a variety of stakeholders, including the CSP, the report raised concerns that physiotherapy training course commissioning levels had dropped by 30% across England between 2005 and 2010 and that the number of places commissioned by the NHS in 2010 was lower than it was in 2000. The CfWI concluded that “If the number of training places commissioned significantly decreases any further, CfWI forecasts suggest the NHS physiotherapy workforce will decline in numbers from 2012” and that “… the likely future demand for physiotherapy services needs to be strongly considered in commissioning decisions.”

6 3.16 It is clear from the conclusions of the CfWI physiotherapy workforce report that the negative impact of cuts already made in physiotherapy training places is understood by all those responsible for commissioning across England in order for this trend to be reversed. The CSP believes that SHAs, with their responsibility for commissioning at regional level, provided a potential way of achieving this. The loss of SHAs, with their ability to co-ordinate and collate workforce information, recognising the limitations of this being done at a regional level (see points 3.11 to 3.13 above) will make it far more difficult in the future to ensure that a clear understanding of these regional and national trends reach all those involved in workforce commissioning.

3.17 The CSP believes that if skills networks are to be responsible for making decisions about the numbers of healthcare professionals being trained it will become increasingly difficult to achieve a national overview and avoid piecemeal cuts being made by an increased number of commissioners. There is a clear danger that a more fragmented approach to workforce planning will lead to a boom and bust in staffing provision which has been so damaging to the health service in the past, resulting in staff shortages, particularly at more senior levels.

3.18 The CSP agrees that that there is a need for consistent, high quality workforce information to provide the foundation for local and national workforce planning, as outlined in paragraph 3.19 of the consultation document. Advances have been made in the use of the Electronic Staff Record (ESR) to collate information about the current NHS workforce. However, there is still a lack of information available on details such as grade distribution by healthcare profession. The information gathered from the ESR only covers NHS employed staff and serious consideration needs to be given to how information will be collected about the workforce employed outside the NHS. With the planned increase in the number of non NHS providers it will be important that there is a clear and structured system in place to gather information about this section of the healthcare workforce. This information needs to include both those non NHS employed staff who are providing services to NHS patients and those who are providing health care services to patients outwith the NHS.

3.19 We also have concerns about the collection of workforce data on diversity, particularly information which is not a requirement under the ESR such as disability. It is important that trusts make greater efforts to ensure the quality and accuracy of their workforce data now, to help improve its robustness and value in the future. Non NHS providers should also be required to provide workforce data that is equally comprehensive and robust.

3.20 The current lack of information about the non NHS healthcare workforce has been a major obstacle to developing comprehensive and effective workforce planning in the past. The CSP welcomed the fact that the report on the physiotherapy workforce produced by the CfWI in 2010 did, for the first time, take account of the non NHS staff in workforce planning. This approach must be taken forward as a central element of future arrangements if the danger of failing to commission sufficient student numbers to projected meet patient and population needs through all providers is to be avoided.

3.21 The CSP has welcomed the, much needed, expansion of the NHS workforce over the last ten years. Since 2000, the number of qualified physiotherapists employed

7 by the NHS in England has risen considerably in response to a continuous growth in demand. According to the annual Department of Health Workforce Census, the headcount has increased from 15,608 to 21,984 – a rise of 41%. This growth is among the highest growth rates of any of the professions in recent years and it has been determined by demand from the public and the decisions of local commissioners and employers.

3.22 The CSP would not dispute the assertion that more could be done to improve productivity and release efficiency savings. Many physiotherapy services across England have successfully innovated and introduced initiatives to increase productivity. NHS Evidence has recently included self-referral to physiotherapy for musculoskeletal conditions in QIPP2, based on evidence of its ability to improve quality and productivity. However efforts to continue to develop such initiatives are being hampered by both the demand for significant efficiency savings and the speed with which the Government reforms of the NHS are being implemented. In our 2010 survey of NHS physiotherapy service managers 41% of respondents agreed or strongly agreed with the statement “Inadequate physiotherapy staffing levels are obstructing me from redesigning and modernising our service”.

3.23 Physiotherapy is ideally placed to provide solutions to current healthcare challenges. It can play a strong role in addressing healthcare priorities in a rapidly changing health and well-being economy, maximising productivity and efficiency while providing high quality care. Physiotherapists are already developing and focusing their practice, demonstrating both clinical and cost effectiveness. They are assuming greater responsibility for complex, non-routine caseload, taking on activity previously undertaken by medical colleagues and overseeing the delivery of care by others. There are areas where physiotherapy can extend its reach and deliver quality patient care and outcomes, in a clinically and cost efficient manner.

4. Developing a new system

4.1 The CSP welcomes the understanding in the consultation document that the core functions of workforce planning and development are integrated with the commissioning of service provision and financial planning. However, we feel that the scale of GP consortia will be too small to provide the big picture context needed to effectively plan the future demand and workforce need. It is also unclear how, at this level, the breadth of physiotherapy skills and practice could be preserved.

4.2 We support the acknowledgement of the need to design a framework for workforce planning which is clear in the duties and accountabilities of the different players involved. We would particularly welcome more clarity on how local decisions regarding workforce commissions will be made and mediated and crucially how the accountability for this very significant financial spend will be governed.

5. Increased autonomy and accountability for healthcare providers

5.1 The CSP would like to see alternative providers of healthcare services taking their fair share of responsibility for student placements, for the funding of both undergraduate training costs and CPD, and for providing rotation posts for newly qualified staff. This is essential in order to ensure that the policy of ‘any willing

8 provider’ is truly based on a level playing field. We would argue that the provision of education and training for the future workforce needs to be a standard to be delivered by any willing provider wishing to provide NHS services and therefore set and monitored within contractual requirements. We would also wish to see those health providers that do not currently provide NHS services contribute, as they benefit from public sector funding of all the costs involved in training and supporting healthcare professionals and support workers throughout their careers. It is important that funding costs include the costs of allowing staff time off to attend training and development particularly at a time when efficiency savings and cuts to staffing are making it increasingly difficult for staff to be allowed time off.

5.2 We support the principle of clinical placements being managed on a multi- professional basis across healthcare providers, with all providers of NHS-funded care contributing to placement provision. We also support the proposal that tariffs for clinical education should be nationally-set and relate to both medical and non- medical programmes to achieve a ‘level playing field’. Such an approach should be taken to redress inequities in funding that have long persisted and to ensure that the cost and value of providing clinical placements and supporting the development of the future and current workforce is explicit for all (rather than being hidden, as has been the case for AHPs). At the same time, the work and time required to achieve a multi-professional approach, by securing the contribution of all healthcare providers (ensuring that this is built into contractual requirements for ‘any willing provider’), and to base clinical placements on a common and fair tariff system, cannot be under-estimated.

5.3 It is unlikely all healthcare providers will volunteer to contribute in this way in an increasingly competitive provider market, so robust and transparent mechanisms must be introduced to ensure that each provider takes their fair share of the costs and responsibility. Smaller providers may not have the capacity to contribute directly in terms of providing placements, so we support the concept of a levy as an alternative means of contributing towards these costs.

5.4 We also envisage increasing difficulties in the provision of support for students and the newly qualified by existing NHS providers, who have always been the main providers of this support. Growing, acute pressure on budgets, cuts to staffing levels and freezing of vacant posts and an increasingly unpredictable future with no guarantees of levels of work or income will inevitably impact on their continuing ability to provide the same level of support. It will also make it far more difficult for managers to predict the numbers of staff and skill mix that they will require in the future making longer term workforce planning more susceptible to inaccuracy and incorrect predictions.

5.5 The CSP would highlight the fact that although newly qualified physiotherapists are autonomous practitioners, appropriate clinical supervision is needed to support new graduates to consolidate and develop their learning. Broad based rotations are needed to ensure that the newly qualified are able to develop their skills in a variety of clinical settings, including to support their subsequent progression to advanced and specialist roles. This ensures that the physiotherapy workforce will have the necessary transferable skills and flexibility needed to be able to adapt to changes in health care provision rather than specialising too early in their careers. For this reason, it is also vital that senior physiotherapy roles of band 7 and above continue to be funded in order that this support and supervision can be provided.

9 5.6 There is a worrying trend of qualified physiotherapists starting on ‘as- and when-’ contracts, which limits their access to regular training and consolidation of the skills learned during training. If workforce planning was more closely aligned to undergraduate training, this would reduce the number of graduates starting in these unsatisfactory situations.

5.7 The CSP believes that all healthcare providers should have a duty to consult patients, local communities, staff and commissioners of services about how they plan to develop the healthcare workforce. We would argue strongly that this duty should extend to consulting with trade unions. We believe there should also be a mechanism for regional and national oversight of workforce planning, as is currently provided by SHAs to avoid the potential for boom and bust in workforce numbers, which could arise from commissioning at the local level planned in the proposed reforms.

5.8 The CSP believes that all healthcare providers should have a mandatory duty to provide data on their current workforce and their future workforce needs. This duty should apply to all providers and not only those providing care to NHS patients. This is the only way to ensure effective workforce planning and training support in an increasingly fragmented provider environment. However, we acknowledge that there is potential for data about workforce to be misused and would argue that access and purpose will need to be explicit and regulated to ensure accountability.

5.9 As the proposals allow for the size and structure of ‘skills networks’ to be determined locally, it is difficult to understand how they will work in practice as this will depend to a large extent on the geographic area they will cover. We would also welcome some clarity on where the funding for the running costs will be drawn from.

5.10 The CSP is concerned that the term ‘skills network’ is misleading and does not adequately convey the critical and substantive work these organisations will be required to undertake, instead implying a much softer collaboration to facilitate skills development.

5.11 While we welcome the recognition that a range of stakeholders will need to be involved in the skills networks and the commitment that mechanisms will be put in place to ensure the whole workforce is considered and there is effective clinical engagement, we would like to see measures that will ensure the voices of the smaller healthcare professions are heard and that these professions, such as physiotherapy, have the opportunity to influence and contribute directly to the work of the skills networks.

5.12 The CSP is concerned that there is no mention of the role of trade unions and their representatives within the proposals for skills networks and would like to see provision made for them to be recognised within the skills networks in light of the important contribution that they can make. Trade unions and professional bodies have made major contributions to effective partnership working at SHA level via the regional social partnership fora and developing joint solutions to a range of problems.

5.13 The CSP is concerned that the consultation document seems to provide a list of functions a skills network might include, but is not mandating any activities. We

10 believe that without a mandatory core set of functions, there is likely to be inconsistencies in the contribution and effectiveness of local skills networks, which would lead, in turn, to inconsistencies in quality of patient care. The CSP would argue, for example, that the provision of high quality workforce data to the CfWI should be mandatory for all providers/skills networks.

5.14 The CSP believes that all healthcare providers should be expected to work within a local networking arrangement, as without this it will be significantly more complicated to ensure that all providers contribute to effective workforce planning, provide workforce data, provide student placements and graduate rotations or contribute financially to this provision (as outlined in 5.1 and 5.3 of this response).

5.15 The CSP is concerned by the proposed dismantling of existing workforce planning structures, particularly the loss of expertise at national and regional level as a result of this. We do not believe that the capacity and skills needed to take this forward currently exist at the local level and, if this proposal is adopted, we would like to see plans put in place to ensure these skills are developed within local networks. We are also very concerned that proposed skills networks will lead to extensive and unnecessary duplication in the commissioning process for student places (for those in commissioning roles, those informing the process and education providers). This will work against high-quality workforce planning and create added expense, thus working against the aim of increasing productivity and reducing cost.

6. Sector-wide oversight and support in developing the future workforce

6.1 The CSP welcomes the creation of Health Education England (HEE) to provide sector-wide leadership and oversight of workforce planning, education and training. We believe it is positive that the proposed structure should enable an integrated approach at national level (then cascading down through the local skills networks) to identify the education and workforce needs across the health professions and to achieve this across medicine / other professions for the first time However, we believe this raises questions about how the new structure will be set up and implemented in line with the principle of a ‘level playing field’, so that the contributions and needs across all professional groups are looked at in an equitable and measured way (rather than traditional domains of dominance distorting how strategic direction is set). The benefits achieved under the AHP Professional Advisory Board should not be lost.

6.2 The CSP is calling for Health Education England to have an independent Chair and a broad interdisciplinary membership, as well as service user involvement.

6.3 The CSP would like to see a greater role for professional bodies as it is vital that a national picture relating to the profession and of quality standards relating to education and training are enabled to inform developments. We do not believe it is possible for this to be coordinated primarily at a local level.

6.4 It is unclear from the consultation document how Health Education England will inform workforce decisions at a local level and how this will be co-ordinated effectively to ensure workforce planning and the commissioning of training places will fit with projections of national need – and how accountability for this will be

11 implemented. The CSP would like to see more clarity from the Government on how this will be managed.

6.5 The consultation document contains very little detail on the impact of the implementation of changes to higher education funding following the Browne Review3 of higher education funding and student finance. Changed funding arrangements are having a significant impact on individual HEIs in England and these need to be considered in the context of these proposed reforms. It is concerning that the proposals for workforce planning in the consultation document pay little heed to this, and presume a ‘steady state’ in the university sector. More specifically, we have concerns that the proposals do not appear to take account of the following:

6.5.1 The mismatch between the stated principle of avoiding creating a culture of instability for education providers and the nature of the commissioning proposals that it seems will inevitably lead to destabilisation.

6.5.2 The increasing culture of volatility and uncertainty within the university sector (which mirrors that within the NHS), which means that new arrangements for workforce planning will have the additional challenge of engaging institutions that are themselves in a state of flux.

6.5.3 The presumption that HEIs will remain ‘willing providers’ of NHS-funded health care programmes, while the reality of more complex and fragmented commissioning arrangements, uncertainty about the continuing security of contracts, and the potential for increasing differentials to arise in terms of the funding of health care and other programmes may well lessen the attractiveness of winning student commissions from an institutional perspective.

6.5.4 The central reference points of promoting equality and widening participation in the models being taken forward for student tuition fees; given that these requirements will be introduced at an institutional level and should therefore positively impact on NHS-funded programmes, it is important that the scope for linking policy in this area is maximised.

6.5.5 The central importance of Health Education England having reciprocal links with the Higher Education Council, not least to ensure that a streamlined approach is taken to the continued development of high quality standards relating to learning and teaching and the related formulation of quality measures and metrics.

6.6 We welcome attempts to avoiding creating a destabilising environment for the providers of pre-registration programmes; however, we believe that these proposals are very likely to have such a destabilising impact and create volatility in supply. For example, some HEIs are less likely to commit to hosting Department of Health funded programmes as the reliability of this as a source of income becomes increasingly uncertain.

6.7 The consultation paper outlines the key bodies that will be involved in professional and system regulation, and highlights the complexity of their inter-relationships. However, the CSP would like to see more detail on how these different

12 organisations will work together, in practice, to deliver the broad principles identified. It is also important that arrangements include integration with agents that assure the quality of learning and teaching provision in HEIs; for example, the existing Quality Assurance Agency and the new Higher Education Council, as proposed by the Browne Review.

6.8 We would highlight the important role that professional organisations have with regard to the development of education standards. The CSP works closely with the Health Professions Council (HPC) on education standards and projecting the future requirements of the workforce to meet the needs of services, patients and local communities, as outlined in 6.16 in the consultation paper. We would, therefore, like to see a requirement for HEE to engage with professional bodies, as well as professional regulators on these issues.

6.9 The CSP believes that the Government’s approach of expanding the policy of ’any willing provider’ for NHS funded services will undermine the intention to increase co-operation between NHS and non NHS providers in workforce planning and education provision. An increasingly competitive market is bound to have a detrimental impact on the willingness of providers to share data, good practice and innovation locally, as these things will be seen as competitive advantage.

6.10 Increasing fragmentation of service delivery, combined with a greater number of providers of NHS services ranging across the sectors and from the very large to the very small, will make it more difficult to co-ordinate workforce planning and training provision and to ensure that all stakeholders are able to have their voice heard.

6.11 The CSP believes that national oversight of the skills networks, through Health Education England (as outlined in 6.1 above), will also be vital to ensure that reporting links and accountability are overt. This will be important with regard to the need to enforce the duties on providers in relation to consultation, the provision of workforce information, and cooperation in planning the workforce and in the planning and provision of professional education and training.

7. Public Health Workforce

7.1 The CSP believes that the public health workforce must be included in NHS workforce planning and development structures and welcomes the involvement of the CfWI in providing data about the public health workforce and future workforce needs.

7.2 The CSP would argue that Local Authorities should be members of the healthcare provider skills network arrangements, as they will be directly employing healthcare staff working in public health roles, many of whom will be working across the boundaries between health and social care.

7.3 We therefore support moves to ensure that Public Health England and Local Authorities are integrated into the new framework for planning and developing the workforce, but foresee difficulties if the geographic boundaries of the local structures (GP consortia/skills networks) are not coterminous with Local Authorities.

13 7.4 We believe that it is essential that there are reciprocal links and representation between Health Education England and Public Health England.

8. Funding and incentives to support equity and excellence

8.1 We do not believe that adequate consideration has been given to how healthcare providers can be deterred from diverting funding away from training when they are urgently looking at ways to save money and we would welcome further information from the Government on how this will be managed.

8.2 Only a small part of current training funding is spent on postgraduate training programmes in areas such as leadership, skill mix and equality and diversity. All of these are areas which are vulnerable to cuts when finances are tight but are essential to develop the skills of managers, clinical leaders and others to enable them to contribute effectively to improvements in workforce planning.

8.3 We agree that it must be the responsibility of all providers of NHS funded services to provide development and training opportunities for all staff, but this must be accompanied by sufficient funding. A mechanism is needed to ensure that all professions and grades have equitable access to learning and development funding and there should be a requirement for providers to undertake equality impact assessments to ensure this is happening.

8.4 In addition, we are concerned that the proposal to leave employers to determine how they support the learning and development of the qualified and support staff, risks overturning the effective arrangements that have begun to be built up, via the SHAs, for the more systematic and sustained funding and planning of learning and development to meet service needs. This has included stronger partnership working with HEIs to identify CPD needs and to provide high-quality learning and development opportunities in direct response to these. The proposed arrangements threaten a return to a more piecemeal approach, within which learning and development provision – and therefore service delivery to patients – is compromised through local commissioning being based only on short-term decision-making and financial considerations.

8.5 The consultation paper states that MPET funding should only relate to pre- registration education, with responsibility for post-registration education and CPD for all staff will no longer cover post graduate training and CPD, and that responsibility for this will be transferred to individual healthcare providers. However, training budgets for NHS staff have suffered serious cutbacks in recent years and the CSP is concerned that with the increased pressure to cut costs and make efficiency savings, training budgets will continue to be vulnerable to further cuts and healthcare providers will not support postgraduate training or CPD. More fundamentally, the proposal appears to miss the central importance of addressing how a sustainable workforce can be achieved, with this needing to include attending to the development of the existing workforce to meet changing service and patient need, not simply the supply of the future workforce.

8.6 In August 2010, the CSP surveyed physiotherapy service managers in NHS organisations in the UK. More than half the managers who responded stated that they did not have sufficient funding for training to meet the CPD needs of their

14 physiotherapy staff. The CSP welcomes the commitment in the consultation document to provide high quality education and training that supports high quality care and greater flexibility which will enable staff to adapt quickly to changing models of service, but is concerned that unless mechanisms or checks are put in place, sufficient funding will not be available to meet these objectives.

8.7 In determining education and training tariffs, a broad range of metrics should be used to gauge and monitor quality and value for money, besides simply those relating to cost. In addition to metrics relating to learning and teaching quality, these should relate to institutions’ research profile and how this supports their learning and teaching; for example, in terms of research outputs, and quality, esteem and impact indicators as measured through the Research Excellence Framework (REF). As indicated in paragraph 5.6, it is essential that the approach led by the HEE links together with the approach to metrics developed by the Higher Education Council, including in relation to graduate destinations.

8.8 We would reiterate the points made above in points 5.1 and 5.2 in relation to the need for all healthcare providers to contribute to the funding and provision of student placements and clinical rotations for newly qualified staff.

9. Transition arrangements

9.1 The CSP is concerned that the rapid speed at which transition from the existing to new structures is too ambitious and could impact negatively on the ability of the service to continue to operate effectively during the transition period.

9.2 We are particularly concerned about the ability of Strategic Health Authorities to carry out their vital role in leading the transition in the final months before their abolition.

9.3 Furthermore, we believe it will be very difficult to manage a significant change in providers, as anticipated by the model presented in the consultation paper, at the same time as the commissioning structures themselves are in flux.

9.4 As highlighted in 6.5 above, the consultation paper does not consider the impact of the Browne Review, into higher education funding, on the changes proposed for the system of planning and developing the workforce. We believe it is important that the transition arrangements take into account the significant changes concurrently taking place in HEIs, as a result of the Browne Review.

10. Equality and diversity

10.1 The CSP strongly supports the underlying principle of fairness for patients and the NHS workforce espoused in the consultation document.

10.2 The CSP welcomes the intention to carry out a full equality impact assessment of the proposals.

15 11. Conclusion

11.1 Physiotherapy is an enabling profession, which can offer solutions to current healthcare challenges. It is both clinically and cost effective and can maximise productivity in a rapidly changing health and well-being economy, while providing high quality care and delivering the outcomes that patients value. Physiotherapists are already assuming greater responsibility and overseeing the delivery of care by others.

11.2 The CSP recognises it is vital to have a stable, well motivated and high quality NHS workforce to deliver high quality care for patients.

11.3 However, we remain concerned that the breadth and speed of the Government’s proposed NHS reforms will have a detrimental impact on staff morale and motivation as a result of uncertainty about job security and the future impact of potential changes to their pay, pensions and terms and conditions of employment.

11.4 We urge the Government to review its plans for workforce planning and development in light of the points made in this submission.

Phil Gray Chief Executive The Chartered Society of Physiotherapy 22 March 2011

- ends -

For further information on anything contained in this response or any aspect of The Chartered Society of Physiotherapy’s work, please contact: Donna Castle, Head of Public Affairs and Policy 14 Bedford Row London, WC1R 4ED Telephone: 020 7306 6624 Email: [email protected] Website: www.csp.org.uk

16 1References: CfWI; Physiotherapy Workforce Review; August 2010.

2 NHS Evidence (2011) Musculoskeletal physiotherapy: patient self-referral http://www.library.nhs.uk/qipp/ViewResource.aspx?resID=406806&tabID=289

3 Lord Browne of Madingley; Securing a sustainable future for higher education: An independent review of higher education funding and student finance; October 2010. www.independent.gov.uk/browne-report