The Maynard Doctrine: Who is managing the NHS workforce?

Professor Alan Maynard points out the ludicrous state of NHS workforce planning.


The Department of Health usually has to hire some management consultancy to be told that the NHS is labour-intensive and the major cost pressure is the payment of wages and salaries.

'The NHS “tradition” is to extrapolate trends for doctors and nurses and assume that they can be funded. This is appalling bad practice, and perpetrators of such nonsense should be sacked.'

Currently, it is focused on re-cycling £20 billion over the next 4 years - i.e an unprecedented 4 per cent efficiency gain annually. Surely that pursuit of nirvana requires detailed workforce planning?

But who is planning the workforce for 2015, let alone 2020 and 2030? Training programmes now in place are determining the number of doctors and nurses that will flow into the NHS market place in the next decade.

Change management may be required
But where is the evidence that the supply and demand for these skill groups is efficient or consistent with the £20 billion “savings” game?

Can we afford linear increases of the consultant population ratio? With the gender of the profession changing radically, will the nature of contracts alter and/or will the work hours offered by practitioners decline?

If there is a decline, will the hourly price of labour alter, and if so how? How will such developments affect the provision of patient care?

Substitute
What is the scope for substitution of doctors with other types of practitioner? Thirty years ago, randomised clinical trials showed that nurse practitioners could carry out efficiently many tasks monopolised by doctors.

The “restrictive practices” of the medical profession have generally prevented the large-scale deployment of nurse practitioners; and where substitution has taken place, their roles have tended to be restricted. Is it not timely to re-visit this policy and invest in the production of nurse practitioners instead of doctors?

Nurses, horses and courses
Do nurse have to be graduates? The answer from the nursing profession is “yes”, and as a consequence large investments are being made worldwide.

Dare one suggest that you need “horses for courses”? That is for some nursing activities, highly trained nurses are essential. But is a high degree of university training needed by all nurses regardless of the skill complexity of their roles?

Such a simple question is not addressed by the “gnomes” in Whitehall even though they claim this is the age of austerity!

Nicholson on midwives: you can’t just turn them on
Sir David Nicholson this week declared to the Public Accounts Committee that there was a shortage of 4,500 midwives . What on earth does he mean? The language of “shortage” and “surplus” is basically political reflecting advocacy of interest groups anxious to play Oliver Twist and ask for “more”, regardless of opportunity cost.

Where is the analysis demonstrating that this investment would produce better healthy outcomes that buying more nurses or social workers?

Where is the consideration of retention issues? What is the wastage rate in nursing? Surely it is affected by 12- and 13-hours shifts and family-unfriendly contracts which bring despair to women with families. Why, despite claims about improved family-friendliness, are nurses still driven to distraction by insensitive managers?

The trade unions, ever-anxious to raise the status and pay of their members, do not like such issues raised - let alone to debate then openly and with evidence.

Workforce: key to NHS saveabilioty
Yet these issues are of course central to the survival of the NHS and the delivery of patient care.

Choosing expensive, evidence-free but politically convenient “solutions” uses scarce resources and deprives the NHS and patients of services which are urgently needed.

Pay progress
What assumptions are being made about NHS pay in the next decade? The Coalition is clearly anxious to “sort out” or reduce public sector pay. For many, the notion of annual increments is quaint - and although NHS contracts are supposed to allow progression on evidence of performance, this rule has been laxly applied.

With a two-year pay freeze and continued pressure to freeze increments, wage inflation is being reduced in the short term. Presumably the Coalition hopes that after two years, there will be limited bounce-back as staff fear for their jobs in a shrunken and parsimonious NHS? Once again, the planners should be setting out their assumptions and modelling the consequences. Where is the planning?

Sack them! (the old-school workforce planners)
The NHS “tradition” is to extrapolate trends for doctors and nurses and assume that they can be funded. This is appalling bad practice, and perpetrators of such nonsense should be sacked.

Workforce planning in healthcare is complex and supply and demand responses are affected by financial incentives. For decades, NHS workforce planning has been criticised as naïve and inadequate. Maintaining these qualities in these difficult times is indicative of weak leadership or a desire to undermine the NHS.

What nature abhors
Why is there this vacuum in analysis and policymaking? Surely Comrade Nicholson, in his pursuit of the £20 billion, must recognise that workforce issues are central to his success and job tenure?

Why is the Secretary of State not requiring more attention to these issues as he seeks to re-disorganise the NHS? Ignoring such issues is as extraordinary as it is dangerous for patients and NHS staff.