Written evidence submitted by The CQC (RTR0100)

About CQC

1. The Care Quality Commission (CQC) is the independent regulator of health and social care in England. Our purpose is to ensure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care to improve.

2. We inspect services to make sure they are providing care that is safe, effective, caring, responsive and well-led. We publish what we find, including quality ratings, so that people can understand the quality of care of a particular service and can choose the right one for them. We also share good practice with providers and take enforcement action where necessary, to protect people from poor care and hold registered providers to account for failures in services.

Our evidence

3. This submission focuses on the question: What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

4. It is intended that ICSs will become increasingly important over the coming months and years, with significant responsibilities for planning services and managing NHS resources, and providing the basis for collaboration across health and care organisations. Crucially, ICSs have a key role in workforce planning. Additionally, our ICS assessments will examine whether there are enough qualified, skilled and experienced people, who receive effective support, supervision and development and work together effectively to provide safe care that meets people’s individual needs.

5. This submission draws on evidence from our Provider Collaboration Review (PCR) programme which ran between July 2020 and November 2021[1]. The PCR programme was commissioned as part of CQC’s COVID-19 response to explore how health and social care providers have been working together in local areas during the pandemic. Much of the evidence we draw on in this submission has not been published; instead it was used as the underlying data that supported the PCRs.

6. The purpose of the PCRs was to share learning between providers to support them:

1. to work together effectively and improve people's experiences and outcomes
2. as they re-establish regular services
3. to help drive improvement ahead of any future pressures (e.g. winter or COVID spikes)

7. The PCRs covered the following topics in five phases:

1. Care for older people
2. Urgent and emergency care
3. Cancer care services and pathways
4. Services for people who live with a learning disability in the community
5. Services for Children and Young people with a mental health condition

Key messages on how systems can address staffing pressures

8. Our PCRs identified a number of findings relating to staffing which include:

1. The relentless nature of the pandemic has meant that local systems have had to think about staff retention and the reskilling of staff, in response to worker burnout and a shortage in skills across different areas of service provision.

2. Additionally, providers have developed new collaborative relationships during the pandemic, and built on existing ones, to share staff and ensure that services with the highest demand were adequately staffed.

3. Strong, visible system leaders are important in ensuring that a local area has a sufficient number of staff with the right skills in the right places to support patients.

4. Our PCRs offered examples of staff being made to feel safe through remote working options and wellbeing initiatives and we encourage similar approaches are adopted by ICSs in the future.  

9. Additionally, there are broader points to consider as we look at the role of local systems in addressing staffing challenges:

1. Looking forwards, staff are increasingly going to be working in multidisciplinary teams that are not necessarily aligned to one organisation. Local systems will need to have clear accountability, governance and support structures to ensure that staff are supported and supervised in new roles and also are working within the limits of their competency. This is important for staff retention.

2. To further reduce staff turnover, there needs to be clear mechanisms for people working across a system to raise concerns, speak up and ensure the ICS is listening. System partners need to promote a culture, where staff feel they have freedom to speak up without fear, and that their views around care are taken seriously. We know from our recent DNACPR report[2] that often people did not know how to raise concerns with organisations.

3. There also needs to be a supportive culture that values teams in all settings and encourages improvement and learning cross system.

4. Finally, CQC is developing a new single assessment framework for our regulation of providers and systems which we intend to roll out over the next two years.  We will be considering staffing issues when assessing the quality and safety of services. These will include: safe and effective staffing, having capable, compassionate and inclusive leaders, and ensuring workforce equality. 

Defining integrated Care

10. It is useful to note that the definition of integrated care systems that we are using is the one provided by NHS England[3]:

1. Integrated care systems (ICSs) are new partnerships between the organisations that meet health and care needs across an area, to coordinate services and to plan in a way that improves population health and reduces inequalities between different groups.

2. Integrated care is about giving people the support they need, joined up across local councils, the NHS, and other partners. It removes traditional divisions between hospitals and family doctors, between physical and mental health, and between NHS and council services. In the past, these divisions have meant that too many people experienced disjointed care.

11. More fundamentally, integrated care is about joined up, proactive and person-centred care. Any future ICS arrangements need to go beyond governance structures, and they need to focus on delivering better care outcomes for their local populations.

Staffing shortages

12. Staffing shortages within health and social care systems are a major challenge. ICSs have a role in unpicking these challenges and working to develop pragmatic system-wide solutions.

13. ICSs need to understand their population need and should plan how to maintain capacity in their area. For example, areas with high levels of tourism may need to manage staffing pressures according to seasonal flows into and out of health and social care. In response, ICSs will also need to think about the innovative use of resources, drawing on support from a range of partners across the system to respond to their staffing issues.

14. Prior to the pandemic there were already challenges with recruiting and retaining staff across the NHS and social care systems - the pandemic has exacerbated these difficulties. During the PCR programme we found that there were a high number of staff vacancies across systems and that there were concerns around the ability of organisations to maintain their current level of service provision.

15. Furthermore, given the relentless nature of the pandemic there is a worry in some systems about the retention of staff that are critically needed within the system. We heard that COVID-19 exhaustion was a key factor in one system’s recovery plan to try and future proof their teams – “Staff are tired, emotionally drained and exhausted. The fear is what happens when they all stop with no break or recovery in-between.”

16. There was also acknowledgement around staff – regardless of whether they were frontline or not – having worked at “full tilt” for significant periods of time and the potential impact of this, specifically absence from work or fatigue induced performance issues. These risks have been exacerbated as the duration of the pandemic has increased.  

System-level collaboration

17. During the PCR programme we heard about collaborative working between providers, commissioners and other system partners (e.g. NHS England and NHS Improvement, Public Health England, Cancer Alliances, Education) around recruiting and redeploying staff, training, and wellbeing initiatives. This suggests a key role for ICSs in driving this type of activity going forward, both in terms of attracting (recruiting) and retaining (training and wellbeing initiatives) staff with the right mix of skills.

18. Strong, visible system leaders were important for ensuring that there were enough staff with the right skills in the right places to support patients and across the PCR programme phases we heard about system-level working to support workforce planning and monitoring. Providers developed new collaborative relationships during the pandemic, and built on existing ones, to share staff and ensure that services with the highest demand were adequately staffed.

19. Some specific examples of joint working around staffing challenges are listed below:

1. We heard about workforce cells that were established to support modelling and planning – they identified workforce and skill requirements and facilitated planning for COVID-19 surges ensuring that redeployment requirements were effectively represented within such plans.

2. Some systems indicated that they had started sharing their winter workforce plans with system partners prior to the pandemic. This was considered indicative of a system culture that values collaboration.

3. Staff working within one system had reflected on ways of working that had been initiated by the pandemic and recognised the importance of effective communication between staff working within different health care sectors.

“…having a primary care clinician on site working with the secondary care staff means there is a mutual respect in service provision between professionals and primary and secondary care”

20. This speaks to the aims of integrated care – removing traditional divisions between organisations – and further makes the case for ICSs to have a role in promoting similar ways of working to those described above. If there is staff buy-in to new ways of cross-sector working and the benefits are realised, then there are potential implications for staff retention.

Workforce strategies: training/upskilling, recruitment and redeployment

21. To ensure that local health and care organisations can successfully recruit staff with the right mix of skills for their services they should draw upon system-level collaboration. Within the Cancer PCR we were told that some systems were actively planning and managing staffing levels and skills for pandemic recovery. Similarly, system partners in one system were considering how to build a sustainable future in staffing, maintaining a flexible and skilled workforce.

22. In our Children and Young People’s Mental Health review we also heard that system leaders made decisions quickly to ensure there were enough staff with the right skills in the right places to support patients. Some of the strategies we heard about to ensure there were a sufficient number of staff with the right skills included:

1. ‘passporting’ of staff between NHS trusts
2. joint recruitment strategies
3. use of staff from private providers and agencies
4. redeployment within trusts/providers
5. upskilling/training

23. Training was provided across systems to staff who were in contact with children and young people (CYP). This included social care, paediatric staff, and other non-mental health staff including within the education sector, to allow staff in schools to better identify and support children and young people with mental health needs.

24. Within our Learning Disability PCR one system described the recruitment of staff to an urgent and emergency care provider that may not have had the required skills and knowledge initially but who were trained as a “Front Door Team”. Their role was to identify people with a Learning Disability that attended Accident & Emergency Departments (A&E) and make sure they were supported upon hospital admission. In one service we were told that due to staff shortages “the aim instead is to get people with the right values, and then ‘skill them up’”.

25. Training and upskilling of new and existing staff members was crucial to maintaining a workforce able to deliver high quality care during the pandemic. We heard that where staff had been redeployed to different services their employers were keen to make use of their newly acquired skills upon their return. This could benefit both the quality of care they deliver and their personal career prospects. Access to training and upskilling could be an attractive prospect to potential candidates and it could be argued there is a role for ICSs in supporting and facilitating this access for local health and care organisation staff.

26. Within the Urgent and Emergency Care review we heard that some oversight bodies, e.g. clinical commissioning groups (CCGs) and sustainability transformation partnerships (STPs) did not feel as though it was within their remit to set up system level staffing strategies. Yet as ICSs become the dominant model of healthcare from April 2022 there is an increased need to further break down siloed working.

27. During the Children and Young Peoples Mental Health Review we heard about innovative recruitment strategies across systems to recruit specialist staff. For example, recruitment and retention premiums and patients being invited to take part in interview panels. We were also told about the piloting of new roles such as digital practitioners to attract people to teams based in rural locations – moving towards a blended workforce of face-to-face and remote opportunities.

Opportunities and challenges presented by redeployment

28. The redeployment of staff into positions with higher patient demand was something we commonly heard about during the PCR programme. There were positive and negative impacts on service provision and on individual staff members. From a positive perspective redeployment helped to ensure that the right number of staff with the right skillset were working in the right areas to support the continuation of key health and social care services. However, we were told that the redeployment of staff within acute care to support the COVID-19 response meant that there was an impact on delivery of cancer services. Additionally, we heard that staff redeployment affected diagnostic services which meant that some cancer patients may have received a poorer diagnosis or prognosis.

29. In our review of Learning Disability services we also heard in one system that staff who were redeployed from a children’s team to a team supporting adults were left feeling deskilled and with an increased caseload upon their return to their usual role. Conversely, there were also examples provided where staff were given the opportunity to learn new skills as part of their redeployment – when community dental nurses were redeployed to the district nursing service in one system they were trained to administer insulin injections and wound care, potentially increasing their skill set.

30. All these competing factors should be taken into consideration when ICSs are deliberating their staffing strategies as the pandemic continues and recovery begins.

Staff retention

31. Ensuring staff feel valued is important to retaining staff with the right skill mix across health and care organisations. We heard that this was achieved when staff felt that they had been kept safe during the pandemic. Examples included:

1. Community teams and urgent care providers in one system we spoke to described the adaptation of some staff roles when people were not able to work face-to-face. Instead they undertook telephone support, patient triage and delivered remote training. We were told about changes to service delivery, such as the move to remote consultations, that was designed to keep both patients and staff safe.

2. We also heard in the Cancer PCR that the increased flexibility that came with home working could increase productivity. Similarly, we heard that one hospital had adjusted its shift patterns on chemotherapy units which was reported to have worked well from both the perspective of staff coverage and staff wellbeing.

32. In addition to being kept safe we were also told about a range of wellbeing initiatives that systems put in place to support their workforce. There was a strong focus on psychological and emotional support such as counselling, drop-in and reflection sessions and break out spaces. We also heard that supervision had become more regular for some staff during the pandemic. It is suggested that these things can contribute to staff feeling valued as people rather than simply as employees with a role to do.

33. We heard about the willingness and dedication of staff that have continued to adapt to changing circumstances. For example, care home staff volunteering to reside at the service when required. We also heard that staff were committed to continue to deliver services for the benefit of the people using those services despite the psychological impact that the pandemic might be having on them.

34. Some staff acknowledged the increased visibility and accessibility of their system leaders during the pandemic and this notion of them being just a call away enabled clinical staff to continue working with confidence.

Concluding remarks

35. The evidence presented above suggests that there is a role for ICSs in supporting local health and care organisations to work flexibly to aid staff wellbeing wherever possible. This could reduce the likelihood of staff burnout and exhaustion as the NHS and social care continue to be impacted by the COVID-19 pandemic. Minimising these detrimental impacts is important for ICSs to be able to maintain and expand their current workforces. If the concerns raised across CQC’s PCR programme around staffing shortages continue then service provision and delivery will reduce in access and quality.

36. Finally, local systems need to think about training beyond the current-day need. There needs to be a whole system approach that focuses on horizon scanning in order to meet the future delivery of care – this includes assessing and building the skills required as we move towards new models of care and technologies.

19 January 2022

For further information please contact Ayesha Carmouche, Senior Parliamentary and Stakeholder Engagement Adviser

Jan 2022

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