The Richmond Group of Charities – Written evidence (FFF0007)

 

 

House of Lords Public Services Committee inquiry on designing a public services workforce fit for future

 

About The Richmond Group of Charities

 

The Richmond Group of Charities[i] brings together a range of major national charities who are all key players in England’s health and care system, investing many millions as significant delivery partners for the NHS and other public services. Together we hear the concerns of and provide advice and information to millions of people. Our purpose and credibility flow from the shared insights we generate from our substantial individual contributions, through direct service delivery and our own staff and volunteers, our support for NHS services and staff, and our funding for research.

 

The Group has a particular focus on the needs of people with long-term conditions – especially multiple conditions. We use the power of our united voice to enable better value for money in the health and care system, helping decision-makers understand how to achieve the best outcomes for the people we support. We are striving, in a changing world, to develop our own services and activities so that together we can support people with multiple needs more collaboratively with services that recognise and respond to the realities of people’s lives and model the changes we want to see in others’ policy and practice.

 

Alongside the wider VCSE sector, Richmond Group members have invested significant resources as delivery partners for the NHS, in research, policy influencing and innovation activity as well as expertise to support the COVID-19 national effort. This contribution will also be critical to address longer term needs as a result of the pandemic, including the workforce challenge, and there needs to be an open and strategic conversation between Government, the NHS and the sector about financial sustainability of this support. Richmond Group members employ, fund, work with, educate, inform and support a wide range of health and care professionals and support workers as well as mobilising substantial numbers of volunteers. We are ready to play our part and committed to the collective effort to ensure the future workforce is fit for purpose.

 

Key themes of our evidence

 

Our evidence highlights the following overall themes and issues for the Committee to consider:

 

  1. The importance of planning for and training a workforce that can effectively respond to the ‘new normal’ of people living with multimorbidities
  2. The value to the system of incorporating relationships with VCSE organisations into workforce planning, and for this contribution to be understood and planned for
  3. Important issues that require prioritisation during workforce planning: tackling inequity, addressing the multiple conditions challenge, including and valuing the voices of lived experience, particularly underrepresented voices
  4. The necessity for additional workforce investment to secure delivery of the NHS Long Term Plan

 

 

 

 

 

QUESTION 1: It is difficult to predict accurately how the public services workforce will need to change in the long term, and yet it is necessary to prepare now for the future. What is an appropriate approach to long-term planning for workforce needs and demand on public services and how should current training adapt, not just at the point of employees’ entry into the workforce but throughout their careers?

 

OUR RESPONSE:

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1.1           An appropriate approach to long-term planning for workforce needs and demand on public services must recognise the ‘new normal’ of multimorbidity. The World Health Organization (WHO) recommends that awareness should be raised among policymakers and healthcare providers that multimorbidity is the norm and not the exception among people with long-term conditions[ii]. In England around one in four of us has two or more long-term conditions[iii] and this number is growing, yet research, clinical teams and training are organised mainly around single diseases or organ systems. As the number of people with multiple health conditions grows, meeting their needs will be one of the biggest challenges facing the NHS. Estimates for the percentage of people living with multimorbidity in England vary from 15 per cent to 30 per cent according to different national and local sources. In the UK this number is expected to rise to 68% in 2035[iv].

1.2           Workforce challenges are a health equity issue. Long term planning should ensure the workforce has the skills to understand both the social determinants of health and the impacts of health conditions that matter most to patients. People in more deprived areas develop multiple conditions 10-15 years earlier than in more affluent ones[v]. As well as specialists and a workforce with the skills to respond to complex conditions, we need people who understand interdependencies, multiple long-term conditions, the social determinants of health and health behaviours, and the impacts of health conditions. Social determinants include loneliness, social isolation, impact on day-to-day life of managing a condition, and common mental health conditions, while impacts of conditions include pain, mobility, breathlessness, fatigue and other symptom management.

1.3           Addressing the inverse care law to ensure that inequity is not further entrenched in workforce planning. Over the next 5 years, the rising number of people with multiple conditions is projected to increase total hospital activity by 14% and costs by £4bn[vi]. Therefore, a sustainable NHS workforce will need to improve both the quality and cost effectiveness of care for people with multiple conditions. GPs in England spend longer with patients who have more conditions, but, at all multimorbidity levels, those in more deprived areas have less time per GP consultation[vii] and are less likely to receive continuity of care, although they may be more likely to gain from it[viii]. This is understood as the “inverse care law”, where those who most need healthcare are the ones that are also least likely to receive it.

 

QUESTION 2: Conventional approaches to training have not enabled enough professionals to enter the public services workforce to meet demand. How might training change to maximise the number of public services professionals and improve their skills?

 

OUR RESPONSE:

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2.1           In response to the pandemic many NHS employers have been much more flexible in their approach to workforce planning and utilising skills. This flexibility has included things like easier movement between Trusts for health care professionals and better communication between different parts of the system. This good practice should continue as the NHS returns to operating in more normal times.

2.2           Healthcare professionals should be properly supported in their understanding of collaborative care planning. Medical and nursing education needs to change – we need specialists, but we also need people who understand interdependencies and managing multiple long term physical and mental health conditions. Evidence shows goal-setting conversations can be effectively led by non-medical staff and the voluntary sector, an approach which can allow more time and space for discussion and to identify appropriate support (and to identify informal carers and take action on their support needs too).

2.3           This requires moving towards team-based care. Care coordinators could reduce pressure on healthcare professionals, whether filled by the GP practice or via local voluntary groups. We would also like to see an increased focus on ‘life-course’ knowledge and skills, such as understanding the impacts of ‘empty nest syndrome’, frailty, dementia and the end of life. This move away from solely focusing on body parts, biomarkers and pathology is essential to the successful delivery of the personalisation agenda. E.g. Asking the right questions about how pain affects mobility, housing, work and leads to isolation, loneliness and anxiety – rather than solely discussing a tumour’s response to chemotherapy – will result in more effective personalised care and support planning that balances biotechnical rationales with patients' circumstances, priorities, and preferences.

2.4           It is also important to create opportunities for learners, including learning about interprofessional collaboration and gaining exposure to real-world models for caring for people with multimorbidity in outpatient settings and more exposure to non-traditional consultant models in order to care for patients with multimorbidity effectively.

2.5           The system needs to better support volunteers into jobs and careers in public services. In an PCP/RVS (2021) survey[ix] a 1000 volunteers were asked if volunteering made them ‘consider a career in health and social care or the NHS’; a) One in 5 of those who volunteered said that volunteering had make them think about pursuing a career health/social care/the NHS,  b) Over one in 10 of those volunteering stated they were actively seeking a job, and  c) One in 12 stated that thanks to their volunteering they now have work/career in health/social care/the NHS. Imagine what could be achieved if public services had more structured volunteer to job programmes.

 

 

QUESTION 10: What have been the effects of the COVID-19 pandemic and Brexit on the public services workforce? Have these events created opportunities for workforce reform?

 

OUR RESPONSE:

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10.1      There are significant workforce implications in meeting the challenges of addressing the elective care backlog. Prior to the pandemic, 4.4 million people were already on a waiting list for elective procedures, the highest figure since the referral to treatment pathway began in 2007. Around 700,000 people would normally receive elective procedures each month, most of which have stopped. Many people living with long term conditions are represented in these numbers. Addressing the backlog will require both maintaining workforce capacity to clear the backlog while also operating differently to make sure people requiring appointments for routine management of long-term conditions are not left behind. For example, there is a huge backlog of breast screening appointments with thousands of appointments cancelled during the pandemic. However, there is a workforce crisis within the diagnostic and imaging service. Prior to the pandemic, only 18% of breast screening units were adequately resourced with radiography staff in line with breast screening uptake in their area and over the next five years a quarter of consultant breast radiologists are forecast to retire.

10.2    The VCSE sector has played a vital role in plugging gaps in the system during the pandemic, and charities have been adapting services in order to meet the high demand of unmet need. It has also given us good examples of how powerful partnerships between the public sector and VCSE can be. For example, the highly impactful NHS Volunteer Responders Scheme was, and continues to be, delivered in partnership with our member, the Royal Voluntary Service.  When it launched, over 750,000 people signed up in just four days, three times the original target, demonstrating the willingness of a large number of volunteers to step forward and support the NHS.  There is now an opportunity for the NHS to think broadly and creatively about the volunteering workforce, recognising the value volunteering adds for people, staff and the volunteers themselves, as well as ensuring there is a permanent offer of joined up volunteering support available.

10.3      During the pandemic, large parts of the bureaucracy which has constrained the NHS from integrated working has been removed. The same willingness to remove bureaucracy needs to be applied to partnerships with charities. By working in partnership, the NHS, Local Authorities and the voluntary sector can develop the integrated approach required to  meet the future workforce demand effectively.  NHS and Local Authority Leaders need to understand the benefits of partnership working with the voluntary sector and work to reduce the bureaucracy around it so that the system is equipped to meet future demand more effectively.  We will return to this in our response to question 12 below.

 

 

QUESTION 11: Integrating public services can mean that they are delivered more effectively to users. What would be the outcomes of better integration between public services workforces?

 

OUR RESPONSE:

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11.1      For people living with multiple conditions, an integrated health and care workforce approach, including VCSE and volunteers, multi-sectoral teams and a focus on the outcomes that matter to people would have a major impact. People with multimorbidity frequently receive care from primary care physicians and multiple specialists. These health and care professionals may not communicate effectively with each other leading to disorganised and fragmented care, and medical error[x].

11.2      Research evidence consistently demonstrates that people with long-term conditions are two to three times more likely to experience mental health problems than the general population[xi]. For example, people with heart disease are at higher risk of dying in the short and medium term if they have depressive symptoms, compared with those who do not.[xii] Appropriate treatment for depression might be as important as treatment strategies for heart disease risk factors (and might help patients to adhere to those strategies). Addressing the institutional and professional separation of mental and physical health care workforce could have significant benefits for a very substantial number of people.

11.3      A further risk of continued silo working is that we continue to be unable to tackle challenges at their source. Integrated workforce planning has to go beyond more joined-up working within the NHS (acute/primary/community services) or even across health and social care and ensure the right links are made with housing, employment, welfare and education services.

 

QUESTION 12: How might voluntary and private sector workforces be involved in the delivery of integrated public services?

 

OUR RESPONSE:

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12.1      We need to grasp the opportunity to join up public services and VCSE services. As mentioned above in our response to question 10, the pandemic has highlighted the potential that lies in closer collaboration between the public and VCSE workforce. Realising that potential will require a focus on the leadership and management skills and capacity required to deliver transformational system and cultural change. This shift of mindset must include cultivating leaders and managers who understand the realities of partnership working and can build resilient relationships with the voluntary sector and others. It will also require a change of mindset at national level towards fostering and rewarding the use of these partnership skills.

12.2      Transforming and sustaining the workforce will mean taking proper account of social care and voluntary sector assets and making them central to the plan. For example, it will be important to take a comprehensive strategic approach to the development of social prescribing link worker roles and other support worker roles where voluntary sector capacity exists or could be developed. It is also likely to mean promoting flexible career development pathways that recognise people will increasingly move between the NHS, social care and voluntary sector employment over the course of their working lives.

12.3      The statutory sector cannot fully meet needs without engaging the voluntary sector. They’re absolutely crucial in knowing what people at the grassroots need. VCS organisations understand that being well is not just about being free of illness. They know how to support the whole person, beyond their medical treatments, in order to improve health and wellbeing. People’s financial stability, their living environment and how supported they feel by their families and communities are just a few of the wider determinants of their health and wellbeing. VCS organisations can address these factors and improve people’s health and wellbeing in a wide variety of ways; for example, by offering emotional support, information and advice, or by providing practical help, as well as through leading research, innovation and system redesign.

 

QUESTION 13: What are the barriers to achieving better workforce integration (including integration with the voluntary and private sectors), and how can any such barriers be overcome? How can leaders of public services drive and incentivise any cultural change necessary to achieve integration between organisations? Are there any examples of best practice?

 

OUR RESPONSE:

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13.1      Barrier 1: the perception of what effective partnership means.   To realise better workforce integration it will be necessary for the VCSE to be recognised as an equal partner and involved early in planning and design of services, including service user involvement in decision making, better utilisation of / referral to VCSEs’ assets and integration  into NHS pathways.

13.2      Barrier 2:  failure to take a multi-disciplinary approach.  Supporting people with multiple conditions requires a multidisciplinary approach, where partnership with the voluntary sector is an imperative. GPs ,as generalists and as the first point of contact for patients, are natural providers of person-centred holistic care. However, they face immense workload pressures as the demand for appointments and complexity of conditions grows.

13.3      Barrier 3: lack of consistent commissioning of VCSEs, including longer-term contracts which address full cost recovery (short-term contracts are time-consuming for all parties and hard to evidence long-term outcomes).  An example of excellent commissioning can be seen in the national award-winning Lincolnshire Stroke Service demonstrates workforce integration across health organisational boundaries to improve patient care and experience. Ten further case study examples of integrated working can be found in The Multiple Conditions Guidebook.

13.4      Enablers: Staff and system leaders need time to develop relationships and the space to think long-term about what is right for the communities they serve, rather than just what it will take to meet the next target. They need the capacity to build lasting collaborations and strategic partnerships with organisations across the system, including with and between VCS organisations. To put long-term plans in place, the system needs certainty about its funding and structures. It also has to be free to work across traditional organisation boundaries to innovate and invest upstream in prevention and other services that support people to stay well. We also want to see people with long-term conditions benefit from better collection and sharing of data.

 

QUESTION 16: Our previous inquiries have shown that public services are failing to deliver joined-up support that is centred on the user. What workforce barriers need to be overcome to bring about a more user-focused approach to public services delivery?

 

OUR RESPONSE:

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16.1      The best way of delivering bottom-up integration is by working outwards and upwards from how people and communities describe their needs and experiences and by using the potential of effective data analysis to add to that understanding in the context of reducing inequalities. In practice this will mean a range of approaches including a focus on working with trusted community leaders and commitment to meaningfully engage seldom-heard and under-represented groups in all aspects of service planning and delivery as described in our recent report: You Only Had to Ask: What people with multiple conditions say about health equity. This means championing patient participation groups, co-design, co-leadership and co-production and acknowledging that training, resourcing and a specific skillset is needed to do this well. Integration does not happen by accident: it requires leaders to create the right conditions for better communication and collaborative working.

 

 

23 February 2022

 

 


[i] The Richmond Group of Charities brings together the following members: Age UK, Alzheimer’s Society, Versus Arthritis, Asthma UK and British Lung Foundation Partnership, Breast Cancer Now, British Heart Foundation, British Red Cross, Diabetes UK, Macmillan Cancer Support, Rethink Mental Illness, Royal Voluntary Service and Stroke Association

[ii] World Health Organization. Multimorbidity: Technical series on safer primary care. Geneva: WHO, 2016. 

[iii] The Health Foundation, 2018 Understanding the health care needs of people with multiple health conditions.pdf

[iv] Kingston A, Robinson L, Booth H, Knapp M, Jagger C. Projections of multi-morbidity in the older population in England to 2035: Estimates from the Population Ageing and Care Simulation (PACSim) model. Age Ageing. 2018; 47: 374–80.

[v] Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: A cross-sectional study. Lancet 2012;380(9836):37–43. Search PubMed

[vi] Understanding the health care needs of people with multiple health conditions - The Health Foundation

[vii] Gopfert A, Deeny SR, Fisher R, et al. Primary care consultation length by deprivation and multimorbidity in England: an observational study using electronic patient records. Br J Gen Pract 2021;71(704):e185-e92. doi: 10.3399/bjgp20X714029

[viii] Salisbury C, Johnson L, Purdy S, Valderas JM, Montgomery AA. Epidemiology and impact of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2011;61(582):e12

[ix] https://www.royalvoluntaryservice.org.uk/media/yvhhp0zl/social_mobility_unleashing_the_power_of_volunteering.pdf

[x] Farmer C, Fenu E, O'Flynn N, Guthrie B. Clinical assessment and management of multimorbidity: Summary of NICE guidance. BMJ 2016;354:i4843. Search PubMed.

[xi] Long-term condition and mental health Chris Naylor February 2012 (kingsfund.org.uk)

[xii] Barth J, Schumacher M, Herrmann-Lingen C. Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosom Med. 2004; 66: 802–13.