Written evidence submitted by Macmillan Cancer Support (RTR0102)

Written evidence to Health and Social Care Select Committee, January 2022

Workforce: recruitment, training and retention in health and social care

1. Macmillan Cancer Support is a registered charity providing information and support for people with cancer. There are around 3 million people currently living with cancer across the UK with 385,000 people receiving a cancer diagnosis every year.[1] The population of people living with cancer is projected to reach 4 million by 2030[2]. Macmillan plays a key role in supporting the NHS workforce. Over the past ten years Macmillan has invested £386 million in the NHS. Macmillan funds nearly 12,000 Macmillan nurses, doctors and other health professionals.[3]

2. Summary of recommendations

2.1.   The government must commit to producing an independently verified assessment of health and social care workforce numbers every two years, as well as a projection of workforce supply and demand (based on projected health and care needs) in the following five, ten and 20 years. A commitment to do this should be incorporated into legislation as part of the Health and Care Bill.

2.2.   NHS England and Health Education England (HEE) should urgently deliver a fully costed cancer workforce plan. This must be based on realistic estimates of the workforce numbers that will be required to meet the needs of people living with cancer and must be supported by long-term financial investment from the government.

2.3.   NHS England and HEE must urgently boost the supply and retention of the general adult nursing workforce to ensure all nurses have backfill for their clinical commitments to undertake continued professional development (CPD) and ensure a pipeline for specialist nursing roles to double the number of cancer nurse specialists required by 2030.

2.4.   If the announced merger between NHS England and HEE goes ahead, government should clearly set out and consult on the responsibilities and accountabilities of NHS England regarding workforce to ensure cancer nursing is an urgent national priority in national workforce planning. Government must also commit to appropriate resourcing for the new workforce functions of NHS England.

2.5.    The Government has made a welcome commitment to recruit 6,000 additional GPs by 2024, but it must urgently ramp up efforts to deliver on this promise, and further bolster our primary care workforce. This includes not just GPs, but also the wider primary care team who can offer vital support to people living with cancer, including nurses, link workers and Allied Health Professionals such as dieticians, physiotherapists and paramedics.

2.6.   HEE and NHS England, alongside local Integrated Care Systems (ICSs) and Cancer Alliances, should be accountable for ensuring that nurses across England have equal access to relevant CPD to end variation in access. Neither geographical location nor lack of charitable funding should prevent access to CPD.

2.7.   There should be clear and supported professional development pathways for a nurse to become a cancer nurse specialist. HEE, NHS England, ICSs and Cancer Alliances should work together to support this at the local level.

2.8.   ICSs, Cancer Alliances and local Trusts should undertake proactive workforce planning, which includes providing structured support programmes for the development of general adult nursing staff to gain insight and experience of cancer nursing.

2.9.   ICSs, Cancer Alliances and local Trusts should take a person-centred skill mix approach to workforce planning to ensure CNSs are able to focus on delivering the complex and specialist care they are trained to provide. This means having the right number of both specialist and support staff in the multidisciplinary workforce, in both primary and secondary care.

2.10.                      NHS England and HEE should develop and fund a comprehensive support package to promote cancer nurse specialist’ wellbeing, and time and funding to access CPD.

2.11.                      HEE should urgently implement a careers framework to support more nurses to become cancer nurse specialists, including developing structured pathways from general adult nursing into specialist cancer nursing and a greater focus on cancer care in the undergraduate syllabus.

3. What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

-          What is the best way to ensure that current plans for recruitment, training and retention are able to adapt as models for providing future care change?

3.1.   Recruitment of the adequate number of skilled staff, with the correct skills mix, is critical to ensuring that people living with cancer receive high quality, person-centred care throughout their cancer journey.

3.2.   We are currently aware of staffing shortages across many areas of the cancer workforce, which are impacting the care that people receive. With the population of people living with cancer projected to reach 4 million by 2030[4], significant increases in staff numbers will be needed to meet demand.

Cancer Specialist nurses

3.3.   Cancer Specialist Nurses (CNSs) in particular, are a vital resource, providing expert clinical and person-centred care. Cancer patients who report being given the name of a CNS are more likely to describe better care experiences[5] - but these staff are currently being stretched too thin. This is leading to severe health consequences for people with cancer. People who lack sufficient specialist nursing support are left with unanswered questions over their treatment and are over 50% more likely to report anxiety or depression[6]

3.4.   Prior to Covid-19, 44% of cancer nurses in England reported that their workload was negatively affecting the quality of care they can give to cancer patients[7].

3.5.   Macmillan research indicates that if the number of specialist cancer nurses stays at the current levels, the gap in the number of specialist cancer nurses in England by 2030 will be 3,371. We estimate that a financial investment of £124 million will be needed to train the cancer nurses needed to fill this gap[8].

3.6.   The government must ensure that the NHS has the sustainable nursing workforce required to deliver the care people living with cancer need.

The wider workforce

3.7.   Specialist cancer nurses sit within a much larger team of professionals, all contributing to the delivery of high quality, personalised cancer care. Workforce funding and strategy must quantify and address gaps in this wider group of professionals to ensure that the right skills mix is available to deliver the best care to people living with cancer.

3.8.   The impact of Covid-19 on staff working in cancer care has been significant. Some cancer professionals were re-deployed during the pandemic whilst others were required to take on new responsibilities. Interviews conducted by Macmillan in summer of 2020 indicated that a combination of staff needing to self-isolate or shield and staff being re-deployed meant the workforce to provide cancer services was depleted. We are very concerned that this has resulted in higher levels of burnout and a less resilient workforce.

3.9.   GPs and primary care teams also play a big role in supporting people across the cancer pathway, including cancer management, follow up care after treatment and at end of life. This role is set to increase as the number of people living with cancer grows. People with cancer require coordinated and personalised care from their GPs, in collaboration with secondary care teams, to support their health needs. Easy access to primary care services is a key component of this, but these services are currently under significant pressure.

3.10.                      Health Education England (HEE) has held a significant role in workforce planning and strategy since its creation. It has been announced that HEE is soon to be merged into NHS England. This could have significant impacts on workforce planning for the health service, particularly if the level of resource allocated for workforce functions is affected.

RECOMMENDATIONS:

3.11.                      NHS England and Health Education England (HEE) should urgently deliver a fully costed cancer workforce plan. This must be based on realistic estimates of the workforce numbers that will be required to meet the needs of people living with cancer and must be supported by long-term financial investment from the government.

3.12.                      NHS England and HEE must urgently boost the supply and retention of the general adult nursing workforce. This is necessary to ensure all nurses have backfill for their clinical commitments to undertake continuing professional development (CPD) and ensure a pipeline for specialist nursing roles to double the number of cancer nurse specialists required by 2030. Pay and reward is an integral part of ensuring adequate workforce numbers. Pay for the cancer workforce must be fair and reflect their value and contribution.

3.13.                       The Government has made a welcome commitment to recruit 6,000 additional GPs by 2024, but it must urgently ramp up efforts to deliver on this promise, and further bolster our primary care workforce. This includes not just GPs, but also the wider primary care team who can offer vital support to people living with cancer, including nurses, link workers, and Allied Health Professionals such as dieticians, physiotherapists and paramedics.

3.14.                      If the recently announced merger between NHS England and HEE goes ahead, the Government should clearly set out and consult on the responsibilities and accountabilities of NHS England regarding workforce to ensure cancer nursing is an urgent national priority in national workforce planning. The Government must also commit to appropriate resourcing for the new workforce functions of NHS England.

4. What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors?

4.1.   Ongoing access to training and professional development opportunities is vital to providing high quality care. Over three-quarters of cancer nurses in England (76%) have told us that having more time for Continued Professional Development (CPD) would help them improve care for people living with cancer[9]. Specialist cancer nurses and lead cancer nurses have reported three main barriers to accessing CPD – lack of protected time, lack of funding and lack of locally available courses.

4.2.   Even before the impact of the pandemic, research conducted by Macmillan in 2019[10], found only a third (36%) of specialist cancer nurses had protected study time to access and attend CPD training. One in five (22%) of CNSs had taken annual leave to undertake CPD.

4.3.   Individual workload was the most significant reported barrier to professionals being able to take time to access and attend training, with over half (58%) agreeing this was the case. Without backfill for clinical commitments many nurses are unable or unwilling to undertake CPD.

4.4.   Funding was also seen as a significant issue, with 43% of CNSs citing lack of funding as the main barrier to accessing CPD in the last 12 months. Funding from charitable or professional grants accounted for over half (54%) of the overall funding for CPD and one in five (22%) of CNSs had self-funded their CPD.

4.5.   A third of CNSs (33%) reported being unable to access CPD because of a lack of local courses.

4.6.   Many issues with access to CPD have been compounded by the Covid-19 pandemic. In further interviews conducted in early 2022, staff raised issues around reduced availability of training courses during the pandemic, increased workloads making it difficult to take time out for CPD and changes in format of courses (such as a move to virtual courses) resulting in a different experience of training.

4.7.   Local bodies like ICSs, Cancer Alliances and local trusts have an important role in workforce planning. However, their ability to engage in comprehensive workforce planning is currently constrained by the lack of a national workforce strategy, supported by projections of the future health and care workforce numbers.

RECOMMENDATIONS:

4.8.   Funding for CPD for cancer CNSs and for succession planning to support nurses to become cancer specialists should be ringfenced in Trust budgets. Without this investment in developing the workforce who have a significant role in offering such care, the commitment in the NHS Long Term Plan to deliver personalised care for everyone diagnosed with cancer in England will not be met.

4.9.   HEE and NHS England, alongside local Integrated Care Systems (ICSs) and Cancer Alliances, should be accountable for ensuring that cancer nurses across England have equal access to relevant CPD to end variation in access. Geographical location or lack of charitable funding should not be barriers to accessing CPD.

4.10.                      There should be clear and supported professional development pathways for a nurse to become a CNS. HEE, NHS England, ICSs and Cancer Alliances should work together to support this at local level. Local bodies should also undertake proactive workforce planning, which includes providing structured support programmes for the development of general adult nursing staff to gain insight and experience of cancer nursing.

4.11.                      ICSs, Cancer Alliances and local Trusts should take a person-centred skill mix approach to workforce planning to ensure CNSs are able to focus on delivering the complex and specialist care they are trained to provide. This means having the right number of both specialist and support staff in the multidisciplinary workforce, in both primary and secondary care.

-          To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?

4.12.                      The absence of an adequate systems for this purpose has led Macmillan Cancer Support to conduct independent modelling to estimate the projected shortfall in the specialist cancer nursing workforce over the next decade. It is not practical or possible for organisations like Macmillan to do this for all workforce groups on an ongoing basis.

4.13.                      RECOMMENDATION: The government must commit to producing an independently verified assessment of health and social care workforce numbers every two years, as well as a projection of workforce supply and demand (based on projected health and care needs) in the following five, ten and 20 years. A commitment to do this should be incorporated into legislation as part of the Health and Care Bill.

-          Do the curriculums for training doctors, nurses, and allied health professionals need updating to ensure that staff have the right mix of skills?

4.14.                      Macmillan Cancer Support are currently working with Health Education England and other stakeholders on an Aspirant Cancer Education and Career Development (ACCEnD) programme. This aim of this is to provide guidance and direction on the knowledge, skills and capabilities required by all nurses and allied health professionals who care for people affected by cancer in generalist and specialist cancer services, as well as roles that form part of multi-professional teams across the four UK nations.

4.15.                      The ACCEnD programme will seek to provide solutions to key issues that challenge the cancer workforce both now and into the future. This will include reviewing and recommending updated content to the undergraduate curriculums for nurses and allied health professionals in oncology, as undergraduate programmes across the professions vary considerable in the oncology content included.

4.16.                      This important programme must progress along agreed timelines and must not be delayed by the proposed merger between NHS England and HEE.

5. What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

5.1.   High retention rates of staff across health and social care are necessary to provide high quality, consistent cancer care. In February 2021, almost 30% of nurses and midwives in England (equivalent to 108,000 staff) said they were more likely to leave the profession, compared to a year ago[11]. A survey conducted by the Royal College of Nursing in October 2021 found that 57% of nurses state that they are either thinking about leaving their job or actively planning to leave[12].

5.2.   The impact of Covid-19 on staff has been significant, leading to stress and exhaustion. One CNS told us;

“I pride myself on the level of care I provide to my patients. However, at times I leave work feeling deflated knowing that if I had one less patient or there was one more nurse on shift those patients would have had an even better experience that day. There is only so much overwork, stress and heartache we can endure before we reach breaking point.”

5.3.   Even before Covid-19, almost half of cancer nurses in England (44%) told us that their workload was negatively affecting the quality of care they can give to cancer patients. Unmanageable workload is linked to increased levels of stress and sickness absence, and ultimately to more of the workforce leaving. The most important measure to mitigate the causes of workforce stress and burnout is to increase the supply across the health and care workforce so that workload is manageable.

RECOMMENDATIONS:

5.4.   NHS England and HEE should develop and fund a comprehensive support package to promote specialist cancer nurses’ wellbeing, and time and funding to access CPD.

5.5.   HEE should urgently implement a careers framework to support more nurses to become specialist cancer nurses, including developing structured pathways from general adult nursing into specialist cancer nursing and a greater focus on cancer care in the undergraduate syllabus.

6. Are there specific roles, and/or geographical locations, where recruitment and retention are a particular problem and what could be done to address this?

6.1.   It is difficult to make a full assessment of this using currently available data. As stated above, understanding of workforce shortages could be better facilitated by the central publication of an independently verified assessment of health and social care workforce numbers every two years, as well as a projection of workforce supply and demand (based on projected health and care needs) in the following five, ten and 20 years.

7. What should be in the next iteration of the NHS People Plan, and a people plan for the social care sector, to address the recruitment, training and retention of staff?

7.1.   The next iteration of the NHS People Plan must clearly set out the requirements for staffing of the NHS over the next decade, including a full and funded plan for how the service will meet those requirements.

7.2.   It must address the supply and retention of the general adult nursing workforce. This is necessary to ensure all nurses have backfill for their clinical commitments to undertake CPD and to ensure a pipeline for specialist nursing roles.

7.3.   In addition, a ring-fenced cancer nursing fund of £124 million should be established, to ensure the gap in the number of specialist cancer nurses in England by 2030 (estimated to be 3,371) can be filled.

8. 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?

8.1.   Integrated Care Systems will have a critical role in workforce planning for local systems. Devolution of workforce planning will better enable ICSs to ensure that local providers have the right skills and teams in place to meet the needs of their populations around cancer care.

8.2.   In order for local systems to be able to plan effectively, they will need the support of a comprehensive, fully-funded, national workforce strategy setting out the recruitment and retention measures needed to fulfil government policy commitments. This requires an independently verified assessment of staffing requirements based on projected health needs.

Jan 2022

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