2ContentsIntroduction …………………………… Lincolnshire Key Themes ……………………………………. 4 Workforce Demographics …………………………………… 5 Population Demographics …………………………………… 6 Future Service Demands ……………………………………..7 Workforce Opportunities …………………………………….. 9 Workforce Risks ………………………………………………10 Medical Workforce …………………………..……………….11 Nursing and Midwifery ……………………………………….12 Allied Health Professions …………………………………… 13 Healthcare Science and Pharmacy ……………………….. 15 Wider Workforce ……………………………………………… 16 Maternity and Newborn ……………………………………… 17 Mental Health and Learning Disability …………………….. 19 Children’s and Healthy Lifestyles …………………………...22 Urgent Care ………………………………………………….. 24 Planned Care ………………………………………………… 27 Primary Care …………………………………………………. 30 Frail Older People …………………………………………… 31 End of Life Care ……………………………………………… 32
3IntroductionThis plan has been developed in the context of emergent commissioning and education structures in the NHS and the focus and scrutiny on quality care delivery post-Francis. There continues to be scrutiny of healthcare provision in Lincolnshire and significant work is underway to address areas of concernNHS providers in Lincolnshire are committed to undertaking a sustainability review for the county to ensure that services are fit for the future, this will have an as yet unknown workforce impact, the LETC, the local workforce team and all partners will work together to ensure that workforce plans are regularly refreshed as the outcomes of the sustainability review become known.In April 2013, Health Education East Midlands (East Midlands Local Education & Training Board) was established as part of the new architecture for education and training in the health sector. Locally, the Lincolnshire Local Education & Training Council and LETB Workforce team was formed from the Lincolnshire Workforce Advisory Board. The LETC operates to the following principles:-Security of SupplyLocal Decision MakingInclusive Approach of providersGood GovernanceSound Financial ManagementStakeholder EngagementTransparencyPartnership WorkingQuality and Value-Year on Year ImprovementAccountabilityAll of the workforce plans received from providers indicate the continued need to meet increased demand on service against the financial constraints that remain in place. This is particularly relevant for the availability of LETB funds that support development for the existing workforce. The reduction of funds to support Learning Beyond Registration (LBR) will have an impact on the non-medical clinical workforce; particularly in terms of the ability to develop many of the advanced practice roles that are referred to in the planWorkforce metrics continue to be monitored by the Lincolnshire HRD Networks and whilst improvements have been made (particularly in respect of agency costs and sickness absence); it will be a challenge to achieve the sustainable improvements required by March 2014.MethodologyThe plan was developed through trusts’ internal workforce planning processes and was supplemented by a range of workshops which took place across the late spring/early summer. The workshops focused on the workforce risks and issues, workforce development and education training. Attendees were also asked to complete information prior to the workshop to support the intelligence gathering process. A range of partners and healthcare professionals were involved in the workshops and have provided a rich source of information for this overarching workforce plan for Lincolnshire.The plan will be supported by a commissioning plan for the county that will support the regional decision making process in regard to the pre-registration commissions for 2014/15
4Lincolnshire Key Themes The workforce and population demographics of Lincolnshire continue to be a risk in terms of ensuring the future workforce supply required to meet the needs of our local population.The continued development and widening healthcare provision at Lincoln University provides an opportunity for organisations to recruit locally and increased partnership working with senior academic staff enables the provision to directly reflect the health community’s needs.There is an immediate need to recruit a substantial number of registered nurses particularly to ULHT and as many acute trusts across the UK are also increasing nursing numbers (including several Trusts bordering Lincolnshire); there is a risk that there will be insufficient high quality applicants. The recruitment activity needs to be supported by a community wide recruitment and retention strategy that incorporates pre-employment, induction, preceptorship and career development programmes.As with previous years’ workforce plans there is an emphasis on developing new roles. This year there is focus on developing advanced practitioner roles; there is also repeated reference in the plan to confirming the roles, skills and competencies of the existing workforce in well established roles. Role clarity will ensure that the benefits realisation of new roles is achieved and supports the delivery of high quality, safe care by all staff.The supply of the medical workforce remains a concern particularly in some key specialities e.g. A&E; although across the health community some long standing vacancies have been recruited to in Psychiatry. There remains however a reliance on locum and agency doctors to deliver services. Lincolnshire will need to consider a range of options as part of developing a Medical Workforce StrategyThroughout the plan there is information regarding integration of teams and the ability to work and share information across professional, team and organisational boundaries as being essential to being able to deliver care to meet the needs of our population; particularly those with complex needs.
5Workforce Demographics The age profile of the existing medical/clinical workforce is shown below and indicates that there are significant numbers of staff (almost 50%) who are aged The clinical support workforce has an older age profile and relatively few numbers of staff aged below 35 which may impact on the ability to ‘grow our own’ in the future.In comparison, the rest of the East Midlands has almost 45% of its workforce over 45; however there is a better distribution of the workforce across the lower age groups, suggesting less future supply risks
6Population Demographics The population of Lincolnshire is currently estimated to be 697,900 (using local authority boundaries) and projected to rise to 838,200 by The GP registered population is 732,510.By 2033, all age groups are projected to grow with the largest increase in the group aged 75 and over. This age group is projected to more than double in size (109%) between 2008 and 2033The increase in the overall population is expected to be greater in Lincolnshire than in either the East Midlands or England. The greatest increase in Lincolnshire is expected to be in the West Lindsey area with the lowest increase in Lincoln.Estimates of people from non white British backgrounds living in Lincolnshire show that the numbers have doubled from 3% in 2001 to 6% in Districts with the highest number of people who are from non white British backgrounds are Boston, Lincoln and South Kesteven (also the sites of our three main hospitals)It is evident that the changes to the Lincolnshire population are caused entirely by the effects of migration movements into the County.Contrasting the numbers of births to the number of deaths in Lincolnshire shows that, were there no migration into the County, the population would be in decline. Since the 1980s, there has been an increasing trend of higher numbers of deaths than births.Inevitably, higher numbers of older people applies the effect to figures that younger people make up a lesser proportion of the population. However, it is not only the increasing numbers of older people which reduce these proportions. Across Lincolnshire, there is a reduction in the proportion of younger people in the population. There is evidence of outward migration of younger people.The live birth rate is currently 61.7 per 100 women age 15 to 44 years (2009 figure). This is higher than it has been for some time.
7Future Service Demands (1) The information below is from the 2011 Joint Strategic Needs Assessment. Many of the current health demands are as a result of deprivation and age factors and it can therefore be assumed that those areas below will continue to have a significant impact on the demand for healthcare services in at least the short – medium term; as public health interventions begin to impact in the longer term.Major DiseasesHeart DiseaseThere has been a 40% reduction in the number of deaths from coronary heart disease in Lincolnshire in the last 12 years.Despite this heart disease continues to be a key cause of premature death in the county with prevalence of the condition most noticeable in the East Lindsey area of the county. Premature death from heart disease can in many cases be preventable in terms of lifestyle issues such as smoking and poor diet and healthcare support to control high blood pressure and cholesterol. StrokeApproximately 2% of the population in Lincolnshire live with the consequences of stroke.The risk of stroke increases with age which may in part explain why East Lindsey has a higher prevalence and mortality from stroke in the county given the high proportion of people aged 65 and over in that area. Lifestyle can play a significant part in reducing the risk of stroke including issues such as smoking, excessive alcohol consumption, poor diet and low levels of physical activity. Association between these factors and deprivation lead to potential increases in health inequalities. CancerCancer accounts for approximately one in four deaths in the county with two thirds of cancers being potentially preventable. Incidence of cancer along with deaths from all cancers is highest in Lincoln and lowest in the East Lindsey area of the county. Higher rates of cancer diagnosis can be observed in those areas which are more deprived with patients from higher socio-economic groups more likely to take up screening programmes. Smoking and diet are also lifestyle risk factors associated with developing some cancers.
8Future Service Demands (2) DiabetesEstimated prevalence of Diabetes in Lincolnshire remains higher than actual recorded prevalence.Lincoln has the highest rate of emergency admissions for diabetes patients with South Kesteven having the lowest. Age is a key factor in diabetes prevalence and is also closely associated with deprivation. People with diabetes are also at an increased risk of having a stroke and dying from heart disease.Chronic Obstructive Pulmonary Disease (COPD)Estimated prevalence of COPD in Lincolnshire is significantly higher than actual recorded prevalence.Despite having the second highest estimated prevalence of COPD, South Kesteven has the lowest rate of deaths related to COPD in the county. Lincoln has the highest rate of deaths in the county. Lifestyle factors are closely associated with COPD and this is demonstrated by the fact that prevalence of COPD is higher in areas of deprivation which also have the highest rates of adults reported smoking. In Lincolnshire this includes Lincoln, Boston and East Lindsey
9Workforce Opportunities Work in partnership with service providers and commissioners to ensure effective use of training resourcesWork in partnership with education providers (schools, training departments, FE and HE) to secure future workforce and improve access to local delivered workforce developmentEnsure that scope, competence and training are clearly defined and recorded for staff (particularly those working in new/extended roles)Continue to explore opportunities for skill mix changesPrioritise education investment and measure return on investment
10Reduction of education investment funding from LETB Workforce RisksReduction of education investment funding from LETBAge demographics of the workforce (particularly GPs)Continued scrutiny of ULHT by the public and regulators; impacting on staff morale and recruitment of staff and traineesAbility to recruit to senior/specialist level posts
11Medical WorkforceThe LETC and Workforce team will be working with partners to develop a Medical Workforce Strategy for Lincolnshire in the coming yearMore positively; Lincolnshire Partnership Foundation Trust has been able to make appointments to Psychiatrist vacancies; some of which have been vacant for some timeThe future numbers of GPs in the county continues to be a risk; particularly as training capacity is constrained.Lincolnshire continues to struggle to attract both doctors in training and consultant workforce in key specialities; this leads the acute sector particularly to utilise a high number of both short and long term locum posts.In common with many areas of the country; medical cover in Urgent Care is a key concern and risk with only three substantive consultants out of 12 posts in A&EWhilst there have been some good international appointments, recruitment time is consuming and induction and initialisation into post takes longer due to lack of experience in the NHS
12Nursing & MidwiferyThe transition of adult and mental health field nurse training from the University of Nottingham to the University of Lincoln commenced in September The University of Lincoln were able to recruit fully to both fields and for mental health applications were high; reversing the trend from recent years where the programmes struggled to recruit.The publication of a number of key strategies and reports during the year has resulted in an active recruitment campaign for qualified nurses; particularly in the acute sector. There is a risk that high numbers of nursing vacancies in neighbouring counties may impact on the ability of Lincolnshire to meet its nursing requirements.There are a number of activities being undertaken to develop the nursing workforce and implement the 6 ‘C’s. Partnership with the University of Lincoln will support the development of joint appointments focused around frail older people. Additional nurse consultant posts are also planned.The impact of LD and child field having its academic centre in Nottingham (with utilisation of Lincolnshire placement circuits) and similar proposals for midwifery will require monitoring to assess the impact on the workforce supply for Lincolnshire.
13Allied Health Professions (1) All AHP GroupsReduction in education commissions for OT, Physio and Dietetics, there remains some graduate unemployment in physio and dietetics with high numbers of applicants to B5 posts. However there is potential for shortfall of applicants in 3 – 4 yrs as the impact of reduced commissions feeds throughDifficulties in recruiting to Band 6 senior staff across OT, Physio and Dietetics; additional training has been offered to B5 staff to support progressionSeven day provisionNeed improved clinical supervision and support for newly qualified clinicians and assistant rolesNeed local opportunities for quality CPDIdentify core skills for bands 1 – 4Increase in expectation at B5Inclusion of preceptorship for all professionsSafeguarding – training to a higher level for staffFewer band 5s and 8sLittle progression available for B6More profession specific training for support staff would be helpfulProvide career pathwaysTraining needsNeuro-rehabilitationCognitive rehabilitationOncology/palliative careHand therapyDementiaParkinson's diseaseWomen’s health physioPaediatric OTVocational assessment and rehab across a wide range of staffPaediatric neonatal dieteticsStudents typically attend placements in the west half of Lincolnshire impacting on recruitment in the EastPlacements offered and subsequently taken up are under-utilised impacting on ability of new educators to complete their APPLE accreditation process and staff not able to meet the standards for the amount of PPE offered per yearPre-registration training to include a foundation/generic year, generic skills and offer more joint postsMore AHP prescribingFewer patients seen but increased complexity and acuityMultiple routes into services e.g. self-referral, onward referral etc
14Allied Health Professions (2) DieteticsImpact of AQP yet to be determined and will result in the need for a more flexible workforce. More skill mix – staff with specific competencies and skills to carry out defined roles in dietetic services.Workload and activity are increasing; particularly around providing nutritional support both in/out patient and in place of care. Geography impacts on capacity to deliver home visitsCommunity PodiatryChallenge of delivering high quality service that is also cost effective and competitive financially (commissioned under AQP)Small reduction in front-line clinicians to match patient throughput combined with demand for increasing levels of specialist knowledge from generalist cliniciansIntroducing podiatry assistants to support toenail surgery in community clinicsRehabilitation Medicine/Acute therapy servicesIncreased number of in-patient bedsExpansion of rehabilitation medicine outreach serviceDeveloping therapy services within A&E/CDU/EAU to reduce admissions, length of stay and readmissions through early access to appropriate servicesDeveloping ambulatory care servicesEstablish a Paediatric OT service for children in hospitalDevelop of Palliative care beds at GranthamMental Health Therapy ServicesFully integrate OTs into MDTsBand 7 OTs not been replacedBand 6 OTs have little career progression unless they apply for generic clinical posts e.g. team coordinator
15Healthcare Science & Pharmacy Scientist WorkforceRisk to recruiting Practitioners into roles: audiologyTraining needs for existing staff to update not just in clinical/scientific skills but leadership and management – LBR route and Scientific framework being consideredTNA being undertaken currentlyRisk in service for competence in nuclear medicine/radiotherapy for the delivery of treatment in cancerThe collapse of the local PTP programme is a risk particularly for Medical PhysicsPharmacist WorkforceAgreed training model for medicines management technicians requires regional commissioning to ensure consistency across the East MidlandsNew service models for pharmacy may result in pharmacists leaving the service/taking early retirementCapacity for training may be impacted by new service models
16Wider WorkforceThere are a number of service areas that continue to view the Assistant Practitioner role as supporting the patient pathway; this is particularly the case where combined therapy/nursing skills would be of benefit. However the training model is expensive and alternatives should be sought where AP development continues.The workforce plan and workshops made continued reference to the need to ensure that healthcare assistant roles are clearly defined, consistent and that they have the appropriate competences and qualifications recorded as recommended in the Cavendish review. There is a drive to adopt the national minimum standards for healthcare support workersReview of administration and business support services are taking place across all organisations to ensure that these services are lean and efficient, but also provide a resource to release clinician time spent on routine administration tasksFor all staff in bands 1 – 4; there is a concern with regard to structured career development opportunities and career pathwaysThe LETB is a pilot site for previous healthcare experience in pre-registration students. Healthcare support workers in trusts may become ‘unofficial mentors’; so it is essential that we ensure this workforce have the appropriate behaviours and values
17Maternity & Newborn (1)Maternity services are delivered across 3 sites currently; although closure of midwifery led unit at Grantham has recently been announced. April saw the return of local neonatal unit at level 2, (toolkit guidance from DH). Special care unit remains in level 1. Two intensive care, three high dependency and 15 specialist beds. Change and ReconfigurationLouth community midwives are to be transferred to NLAG as they deliver care for women who birth at Grimsby.Maternity services have undergone an external review and the report from this review is awaited. This may inform of further changes/improvements that need to be delivered. Action plan will be shared once report received and reviewed.Marketing needs to be done around encouraging people to use our service rather than other local providers. Need to reinitiate joined up working between commissioners, maternity services and work force planning team – action to reinstate Maternity Programme Board.The increased population of immigrants impacts on utilisation and time: Use language line, information etc, interpreters. This activity increases length of time with patients (50% non-English speaking sometimes).Public health issues, obesity, drinking and smoking. A healthy lifestyles midwife is employed to support lifestyle change:10% of deliveries are expected to be neonates, activity showing an increases in this number, TCU increase of staffing Lincoln, for 24/7 cover rather than day care, turning to midwives in evening/overnight.Increase in birth-rate has tailed off, immigration increase impacted on births, might increase again but indications suggest steady state.MMU in Grantham is closing but need to establish MMU in Lincoln to help drive normalisation, more likely to happen when no medical input. Developing antenatal assessment centre.Risks and IssuesNeonatal services do recruit to roles from adult nursing if there is a problem, no recruitment issues currently but earlier in year advert went out 3 times, not able to recruit to practitioner level, 8a, can’t get trained. ANNP tier role when qualified.There is an aging workforce- potential for 8 staff to retire in next 5 years and 1 at Lincoln.Health visiting increases has led to loss of 3 staff at Lincoln 1 at Boston.Should have physio-paediatric respiratory staff, speech and language, have access, with intensive care coming back respiratory/chest clearance, new borns. Medical workforce not fully staffed at Boston but OK at Lincoln,Poor prescribing practice identified as part of medical external notes review, action plan leadership course but also commissioned neonatal prescribing update via DMUUnregistered, data clerk only works .6 WTE band 2 JDs being looked at. Band 4 nursery nurses, no opportunity to develop furtherThere is an increased demand for home visits.ULHT has 26% of its midwives that are over the age of 50 and could retire in the next 5 years. There is a further 24% over the age of 46. Development posts are now in place on both sites on Labour ward and maternity ward to ensure that when retirements occur we have staff ready to step into the vacant posts.
18Maternity & Newborn (2) Workforce Development Succession planning: Nottingham University QIS degree level, placements in Nottingham which could lead to loss of staff if Nottingham are recruiting.Maternity care support workers required to support rather than dilute midwifery workforce, Lincoln need uplift in midwifery, should be 1:30 but Lincoln 1:32. Both units need investment and uplift in services and MCS. 10 further WTE midwives would be recommended uplift.Move to increase new registered staff in Nocton ward. System not recognised ie working weekends.Education and TrainingQualified In Specialty required 80%. 70% Boston, fulfilled in Lincoln, drop to 66% in Boston August due to increase of staff.Neonatal services are planning sending 3 staff to Sheffield ANNP for January roll out.More requirement for specialist roles. Also more support roles e.. assistants at band 2:4.Community module for neonates -DMU has just stopped delivering. This is required for neonatal outreach who visit babies in community, train transitional care staff. An accredited qualification is required. To further discussions around commissioning of this module, possibly with University of Lincoln.NIPE (baby check) and practitioners need annual updates, Salford runs these, examination, Sheffield also deliver. The training needs analysis will drive local delivery of this course.Lots of competence required, equipment etc, takes staff away to train, staffing is to toolkit standards for present activity but doesn’t save staff input, care delivery more complex (Babies with birth asphyxia, monitoring machines, more observations etc).IT systems, changing, badger system, database for neonatal care, national collection, BAPM and National audit programme all use, every day input and again at night, EDD, staff taking on work, Nottingham has full time doctorNational blood spot screening bringing in IT system. Kicks off reviews sometimes by not hitting targets. Below 30% weeks should be transferred. Monitor on trial currently lessons learnt will CFAM.A development package has been put in place for B6 midwivesStudents – currently medical and midwifery but would like to reintroduce adult nurses into labour wards. Retirements coming up, new graduates want to work at Pilgrim, but are now on bank with preceptorship which will positively impact on retaining these graduates ready for permanent employment.Midwifery intense 18 months programme does have higher attrition; qualified and being a student is difficult but would like to retain the opportunity for this training.A move to increase the numbers of students from the adult nursing course into midwifery labour wards might drive interest to converting to midwifery later. Current activity is around children’s nursing students at pre-registration.Potential for the University of Nottingham to withdraw provision of pre registration midwifery: It has become apparent that much of the taught component is at Nottingham anyway although tutors do still come to Boston. This could be a risk for Lincolnshire if all training is delivered centrally within region. Consideration of options is underway to ensure that a high quality supply of midwives is maintained for LincolnshireNuchal translucency screening, research into blood components on women, might affect future training needs and choices for women.Uplift in clinical specialist roles ie drug and alcohol etc, midwifery rather than uplift for midwivesTop up in radiography for assessment for sonographers.Saturation monitoring will require training. Need to develop midwife/sonographer training programme.1:4 minimum standard for level 4 is NVQs 3.Leadership and management training is required, for higher bands, even at matron level.Access to Masters level degree programme related to the role would be preferred.
19Mental Health & Learning Disability (1) This section of the plan has been developed by Lincolnshire Partnership NHS Foundation Trust and it is recognised that over the coming years we will need to engage with non-NHS providers, the voluntary and independent sector to develop a system wide workforce plan for mental health and learning disabilitiesWorkforce PlanningThere is a need to ensure that workforce planning can become more effective within strategic decision making and to ensure workforce plans are focussed on results, actions and subject to constant review.It is clear that the successful implementation of the recommendations from the Francis report will hinge on the professionalism and commitment of the workforce as a whole and its motivation and capacity to deliver change.The following areas relating to the workforce implications of the inquiry will be implemented:contributing to the development of a shared culture where patients, service users and the public are the priority by examining how patient voice contributes to key workforce policiesensuring recruitment, training and retention policies and practices support the need for a workforce motivated to be compassionate and caring with shared values of transparency, honesty and candour.Workforce Plan to support IBP 2013/14 and LTFMWorkforce planning has been an integral part of the business planning process and services have been provided with robust workforce information to support the development of plans. Workforce plans which will deliver:A workforce that has sufficient workforce numbers to ensure that high quality services are delivered safely and efficiently.The appropriate skill mixes along care pathways.The planned reductions or additions in staffing for each area and the resulting redeployment, redundancy, retraining or recruitment requirements for the Trust as a whole.Taking into account patterns in turnover, recruitment and vacancy rates to maximise permanent staffing and a flexible workforce but reducing reliance on bank and agency staff.Highly skilled, competent staff who are clear about their role and the leadership qualities and behaviours required to deliver effectively.
20Mental Health & Learning Disability (2) Detailed Workforce ReviewsDuring 2012/13 detailed workforce reviews have been carried out within the services in all in-patient wards. The outcomes of the GAS in-patient review have resulted in a cost neutral plan to increase establishment staffing levels to support appropriate skill mix and staff per bed ratios. This has led to lower sickness absence levels and a reduction in bank and agencies spend.The following workforce reviews are on-going and will also support the achievement of cost improvement plans:Full workforce review to support new service developmentsTrust wide admin reviewReview of e-rostering and bank and agencies expenditureSkill mix analysis and identification of competency requirementsProductivity, efficiency and LEAN initiatives
21Mental Health & Learning Disability (3) Workforce RisksThe following identifies the workforce risks and their mitigating factors:Workforce Supply -Lincolnshire net exporter of young people. Recruitment difficult for specialist skills. National shortage of in psychiatry due to low recruitment into training posts.M - Funding through the LETB to develop a recruitment strategy to recruit vacancies and promote students undertaking professional education in Lincolnshire. The Trust is using external recruitment as well as NHS Jobs to recruit externally.Turnover –Annual turnover is 10.86% (85% of this being voluntary leavers) a turnover figure between 10 to 12% is considered ‘healthy’ for an organisation overall.M - Need to balance the cost of recruiting staff, and developing skills against the need to reduce staff and lose them through natural wastage.Vacancy Factor -The vacancy factor (percentage variance between establishment and contracted in post) is 7.06%, however 4.72% of these vacancies are being recruited to.M - The Trusts integrated finance and workforce plans need to address the correlation between turnover, vacancy rates and bank/agency usage.Age profile -The Trust has an ageing workforce in key professional groupsM - The impact of these age profiles will be analysed along with patterns in turnover.Maintaining safe staffing levels and achieving required efficiencies.CIPs have meant reductions in posts, there has been an attempt to reduce managerial and administration roles these make a modest contribution to the CIP’s.M -Skill mix, developing and enhancing roles and challenging variance in clinical practice. Staffing utilised more flexibly to increase efficiencies across integrated pathways both within the Trust and across the organisational boundaries.Key : Red = Risk Green (M) = Mitigating Action
22Children’s & Healthy Lifestyles (1) Change and ReconfigurationDevelop a paediatric observation unit at Lincoln County HospitalReduce in-patient beds as a result of the aboveEstablish paediatric OT service for children in hospitalImplementing community nursing review recommendationsActivity is increasing due to high numbers of complex cases and those where safeguarding is an issuesImmunisation programme in schoolsReview of community paediatric serviceHealth visiting – healthy child programme review will increase activity (implementation of universal service)Safeguarding/vulnerable children – a new model of safeguarding supervision is being implementedChildren’s therapies – increase in lower level activity to reduce need for higher level interventions. However specialist work increasing as a result of tribunal outcomesIncrease in domiciliary activity and referrals to specialist dental servicesIncrease in HIV patients particularly late presentation patientsDevelopment of the ‘Family House’ based on locality based operation multi-disciplinary specialist teams supported by separately managed skill mix teamsRisks and IssuesDependent on ability to recruit advanced paediatric nurse practitioners there may be a need to ‘grow our own’ over a period of timeRequirement to fill community nursing vacancies; some posts are being down-banded (7 – 6)Small numbers of children’s nurses seeking employment in LincsDifficulty in recruiting school nurses
23Children’s & Healthy Lifestyles (2) Education & TrainingMay need to train current staff to become advanced paediatric nurse practitionersIntroduce clinical educator roles in children’s wardsSome staff will undertake specialist practitioner training to increase numbers of school nursingIncreased places are being recruited to, to support required increase in health visiting numbers – 30 students due to qualify in 9/14 and a further 10 in 2015More training required for immunisation & vaccinations and sexual health (school nursing)Use of mobile technologyLeadership developmentWorkforce Development & TransformationSpecialist diabetes nursing staff required for paediatric diabetes serviceIncrease specialist paediatric dietician 1 wte for diabetes serviceAdvanced paediatric nurse practitioners to staff integrated OOH/emergency deptRecruitment of 2 consultants to deliver child protection and safeguarding service to service specificationTransfer of community paediatric nursing teams to LCHSPeer supporters for breast feedingHealth trainers0 – 19 skill mix team (ability to undertake brief interventionAdditional OT for paediatric inpatients
24Urgent Care (1)Urgent care is delivered in a wide range of Acute, Community, MH and Social Care services across the county. Demand for services continues to grow particularly in the acute sector’s A&E departmentsChange and ReconfigurationDevelopment of A&E front door, ambulatory care and chair centre modelEMAS engagement in redesigned pathwaysImprovements to GP accessDevelop GP skills in emergency care requirementsImproved access to services (times/days)Expanding scope of advanced practitionersDevelopment of FOP services, advanced care planning and access to information (for staff, patients and families/carers)Home care provision for increased acuityBetter integrated workingDevelopment of Nurse Consultant and Nurse Practitioner rolesSafer staffing project – linked to patient acuityImplementation of 24hr PCI unit in Jan 13Introduction of ambulatory/4th resus bed for trauma network workEstablish a Minors Stream modelDeveloping Pilgrim PPCI and development of ICD service in 13/14Pilgrim to become a hyper-acute stroke serviceSingle point of access for community referralsCloser integration of Urgent care and OOH servicesRapid response service (RRS) being established to provide immediate care and support to patients who can be safely managed at homeAssertive in-reach team (AIR nurses) will work alongside secondary care to prevent admission or reduce length of stayGP OOH, Walk-in centre and minor injuries units will provide unscheduled access to doctors and advanced nurse practitionersDevelop therapy services within A&E/CDU at Pilgrim to reduce admissions, length of stay and readmissions
25Urgent Care (2) Risks and Issues Education & Training No clear framework and role definition for B2/3 & 4Availability of education to support timely training (e.g. for advanced practitioners)Attracting staff from outside of Lincolnshire with urgent/emergency core skillsImplementation of telemedicineInvestment in terms and finance and time to support the workforce to developChange management and service redesign skillsPCI service reconfigured differently from original plans; shortfall in in workforce is being covered by ICU1 wte Stroke Consultant post currently out to international recruitment, middle grade covered by a trust locumAbility to recruit nursing staff with specialist skillsEducation & TrainingLocally trained workforceNeed better selection processes to pre-registration trainingPre-reg to include basic competence in emergency assessment and proceduresPost graduate training is too academic, not sufficiently focused on clinical skills; ideally multi-professional with Royal College approvalUrgent need to develop locally provided advanced practitioner programmes (perhaps in partnership with a nationally recognised centre e.g. Bradford) – ideally generic (multiple pathways) to support a range of disciplines within a general modelCoaching/leadershipEmergency care competencies locally delivered to national standards (all staff)Review of medical staff skills and training needsIncrease placement capacity in ED
26Urgent Care (3) Workforce Development/Transformation Create a culture of learning and governanceCareer framework for emergency nursingPhysician Assistant – no role as not able to prescribe and vacancies are generally at a higher levelPotential for more use of apprenticeships e.g. customer serviceGeneric healthcare support worker (B2)AP role not being fully utilisedDevelopment of Emergency Care Nurse PractitionersDevelopment of Nurse Consultant and Nurse Practitioner rolesPaediatric emergency department rotational post being createdIncreased resource (possibly acute care practitioners) to meet workforce requirements for stroke servicesA&E Consultant nurses in postReview of nurse practitioner team in MEAU/A&E to support ambulatory careRecruit to 2 wte consultant posts in A&E and fill 2 wte middle grade posts at BostonAdditional advanced nurse practitioners requiredIncrease therapist input in emergency care/ambulatory careMaximise the skills of the highly qualified workforce e.g Advanced Assessment Nurse Practitioners and Emergency Nurse PractitionersThe skill mix in the RRS will be enriched to ensure that service is available 24/7 to maintain people in their home until locality team availableRecruit additional OT, orthotist and Physiotherapists to provide additional cover at weekends to orthopaedic wards (part of trauma business case)Recruit additional Physio and OT to support extension of service to A&E/CDUIncrease B6 input to SEAU to improve co-ordination of patient flowIncrease B6 to support ambulatory area
27Planned Care (1) Change & Reconfiguration Many of the services included in organisational plans have been placed into the planned care section; although it is recognised that many services e.g. diagnostics provide urgent care services. Elective care is often impacted by emergency demandChange & ReconfigurationWork towards a 24/7 site working through Night team and outreach services using nerve centre IT system – electronic system for referring and prioritising the unwell patient out of hoursCardiac unit undertaking elective trans-oesophageal echocardiography (TOE)Review of rheumatology/biologics workload to assess potential for joint infusion suiteHaematology/oncology service redesign to create additional capacity (including extending hours)Introduction of chemotherapy CNS posts to support consultant activitySeek to appoint 3rd neurology consultant and substantiate the current locum into 2nd post to reduce waiting timesDevelop the epilepsy serviceImplemented a 7 day week consultant service for respiratory inpatientsLouth hospital to introduce 6 day case chairs; reducing the number of bedsMore acute care to be provided in community hospitals and in community nursingCommunity nursing catalogue implemented; planning exit strategies for unfunded activityPodiatry and MSK Physiotherapy expected to increase as AQP developsEstablished five community nursing locality teams of GP practice aligned district nurse case managers and staff; this maps onto integrated nursing and AHP rehabilitation and assisted discharge teamsTwilight services to be redeployed into either OOH or community nursingExtended core hours for community nursingDevelop rehabilitation medicine service at GranthamProvide orthopaedic 7-day therapy services for elective in-patientsEstablish nutrition teamsBed closures will reduce demand for inpatient therapy servicesEnhanced recovery programme for Urology, General Surgery and OrthopaedicsPain management serviceIncreased therapy support for Diabetes MDT clinics (dietetics/podiatry/orthoticsImplementation of e-prescribing system for chemotherapyExtend the hours within radiotherapy to meet demand and develop IMRT and IGRT treatmentsFurther roll out of weekend working in pharmacy, radiology and cardiac physiologyInvestment in additional diagnostic imaging equipment in radiology and cardiac physiologyLarger endoscopy unit (Lincoln) planned for 2014Procure an inpatient pharmacy service through ‘shop in shop’ service delivery modelDevelop a new surgical day unit at Grantham to repatriate work from Newark/NottinghamPhased reduction in opening days of Fotherby ward at LouthIncrease open access endoscopy service at LouthLouth will become an elective and diagnostic centre delivering services to patients from across Lincolnshire and North Lincolnshire
28Planned Care (2) Risks and Issues Increased demand for haematology/oncology services and no option to increase bedsInability to recruit staff with the correct skills and experienceNeurology has been carrying 2 consultant vacancies for 2 yearsDermatology has been carrying one vacant consultant post for 2 years which has been covered by speciality doctor and training grade posts which has worked well; however reduction in hours by a senior consultant has left a gap in senior level expertiseElective activities struggling to keep up with demand; particularly in outpatient referrals (gastroenterology)Locum cover has been sought but not successful (gastroenterology)Increase in elective activity at Skegness and Spalding impacts on capacity at Pilgrim (diabetes and endocrinology)Seasonal activity creates capacity issues in community nursingNurse practitioners, practice nurses and salaried GPs are difficult posts to recruit toBand 7 ANPs for RRS/Walk-in centre/minor injuries unit and OOH are difficult to recruit toIncreasing complexity of cases in the communityDemographic change e.g. ethnic diversity. People access services differently and require more public health inputInterface with IT services in working across agencies; inputting highlighted as time consuming.Ageing workforce combined with change fatigue may impact on future capacityCommunity specialist Speech & Language Therapists and Specialist Physiotherapists posts are difficult to recruit toOncology has no training middle grade posts at either Lincoln or BostonOOH is covered by locum middle grade shifts until 9pm when the Hospital at Night and medical rota takes overRecruitment plan for 2 middle grades approved in 11/12 but recruitment has been unsuccessful to date.Loss of PTP training in medical physics may impact on future workforce supplyLack of trainees in healthcare sciencesReluctance of oncology consultants to provide 7 day ward roundLack of suitably trained chemotherapy nurses and difficulty in recruiting themAdvertised twice a pain consultant post without appointment (out to advert again)Staff consultation re; more diagnostic services being 24/7TUPE of pharmacy and technician staff (or potential for staff to leave as a result of implementing ‘shop in shop’ modelFailure to recruit interventional radiologists to implement a viable on-call rota – impacting on the vascular serviceAbility to recruit consultant radiologistsNational shortage of sonographersUrological surgical emergencies, service is not integrated across Lincoln & PilgrimService delivery issues in urology (requirement to review service model) which is impacting on RTTPotential shortage of urology consultantsReduction in surgical training numbers will impact on future workforce supply
29Planned Care (3) Education & Training Specialist nursing skills in disease specific conditions maintained to provide access to expert advice and practical support in the management of palliative care, diabetes, respiratory disease management, heart failure, cardiac rehab, continence, tissue viability and infection prevention and control. The nursing element for stroke will be integrated with assisted discharge stroke serviceBusiness support staff to release clinician time spent on administration activityExploring options for different working patterns to ensure workforce available to meet service demandsIncreased staffing in rehabilitation medicine (Drs, nurses, dieticians, OT, physio, SaLT and psychologists7 day therapist input to orthopaedic wards will require additional registered and non-registered staffIncrease specialist nutrition support dietician 1 wteDevelop CNS posts in oncology to release consultant clinic time that will free up time for consultant ward workAdditional radiotherapy staffing as LINAC replacement is progressedAdditional medical physics staff for development of IMRT and IGRT serviceIncrease nursing, physiotherapist and clinical psychologists establishment for multi-disciplinary pain serviceIncrease technician grades in PharmacyExpansion of numbers in endoscopy and cardiac physiologyExpansion of non-medical consultant roles (diagnostics)Increase in assistant practitioners (diagnostics)Increase of surgical team, nursing and admin for surgical day unit at Grantham24/7 senior nursing on site at GranthamPredominantly nurse led endoscopy at LouthIncreased workforce at Louth as elective and diagnostic services expandB6 Occuplasty specialist nurse to be appointed as a training post to work towards B7Development of breast physician postsReview of specialist breast nursesOperational Head of Service role introduced for Urology at PilgrimEducation & TrainingSpecialist practitioner trainingNurse practitioner modulesLong term conditions management to include dementiaHigher level clinical skills e.g. venepuncture, cannulation, ECG interpretationExtending the scope of professional practice in non-registered workforceAffordable Assistant Practitioner trainingEngage with Productive Ward ProgrammeNon medical prescribingDysphagia assessment skillsLoss of provision for PTP training in medical physics (alternatives being developedDistrict nurse training needs updating to reflect increasing acuity in the communityOccuplasty trainingWorkforce Development & TransformationIntroduction of nutritional nurse on Lincoln County SiteOn-going increase of CNS over next 5 yearsAdditional specialist nurse required to support respiratory outpatientsReview community services, skill mix, competencies and establishmentAssistant Practitioners to support registered staff in the communityComplex case managers/clinical nurse specialists in disease/specific conditions aligned to locality structuresDistrict case manager acts as specialist generalist and key worker
30Primary CareIncludes a range of services delivered out in the community primarily by independent contractors e.g. General practice, dentistry, ophthalmology, audiology and community pharmacy. Although some information has been provided to support this section there is significant work required to fully understand and represent the workforceChange & ReconfigurationIncrease of services delivered in primary care particularly in pharmacy, audiology and optometryContinued development of diagnostics and procedures being carried out in GP practicesEducation & TrainingNeed to promote future cohorts of Foundations in Practice Nurse programmeDeveloping an Associate Trainers programmeRisks and IssuesDN/HV no longer often being co-located in GP practices which is impacting communications and ability to partnership workAge profile of GPs in LincolnshireParticipation rates of GP workforce is fallingTrends for recruiting practice nurses tends to be from practice to practice rather than a choice for a newly qualified nurseLack of sufficient GP trainees coming to Lincolnshire (9 out of 30 places recruited to)Workforce Development & TransformationAssociate Trainers programme will support nurses to take a teaching/training roleContinued development and utilisation of Nurse Practitioners
31Frail Older People Change and Reconfiguration This section of the workforce plan includes the full scope of services delivered to an increasing population in Lincolnshire. Many of the elderly population in Lincolnshire have one or more long term conditions and the incidence of dementia is predicted to rise in the future. This section also links to urgent care services and end of life services. The outcomes for better services for the frail elderly are; keeping people safe at home, responding rapidly at times of crisis and supporting safe and timely discharge from hospitalChange and ReconfigurationDevelopment of integrated locality teams, tier above this model is development of rapid response servicesLess acute activity, shorter hospital stays and specialist support provided in the communitySupport people by use of remote systems such as telephone follow upNeed the ability to share data across the health and social care communitySingle point of access and rapid targeted response3rd sector to single point of accessNeed to improve discharge process and ensure capacity in transitional careImprove discharge planning, particularly for complex dischargeEstablishment of a DTOC ward (pilot)Established 4.98wte Care of the Elderly Consultants (incl Consultant in Psychological Medicine)Wide of range of services offered incl. telephone advice, rapid access clinicsRisks and IssuesHow to think and work differentlyPatient focused mind setsSharing data across organisationsEducation & TrainingThinking and working differently, changing cultureLeadership at every levelConcept of a multi-skilled workforceCare management and care co-ordinationCommunicationDignity, respect and customer focusedWorkforce Development and TransformationDevelopment of combined organisational roles – community geriatrician (ULHT, St Barnabas and CCGs)More activity in the community, including therapy and nursing skills to support independent livingReviews of ways of working to compliment the FOP pathway workTeam working across professional groups and working across boundariesOption to review all levels of the workforce; roles, working practices, skills and competenceUse of CNS to assess relevant patients at the front doorStaffing of DTOC ward configured to take into account the dependency of patientsPotential role of Elderly Care Nurse Consultant
32End of Life Care (1) Change and Reconfiguration Education & Training There are a number of specialist end of life services in Lincolnshire in addition to the care delivered by a range of staff e.g. district nurses, acute care staff, home care support workers etc; who are supporting those at the end of their life and their families. There is a real enthusiasm to work differently and improve outcomes for patients. Workforce and skill mix reviews, including roles, responsibilities and ways of working are taking place across the health communityChange and ReconfigurationIncreasing co-morbidities and complexity of disease, but earlier intervention potentially delaying contact later in the journeyPartnership working essential for shaping future services in EOL careStrengthening links between organisation including outside the ‘traditional’ NHS familyOn-going development of specialist palliative care in IPU, hospitals and communityDevelop hospice operated community palliative care beds at GranthamStrengthening hospice palliative care teams on the three acute sitesDevelopment of acute oncology serviceReconfiguration of community MacMillan teamsElectronic Palliative Care Co-ordingation system (EPa CCS)TelemedicineRisks and IssuesAbility to work cross-boundaries (continued silo working)Equity of training across health and social careIncrease in dementia, frail older people and co-morbidities increasing acuity in the communityChange in family dynamics – still requirement for trained supportSafer care – timely sharing of informationWorkforce planning training for service managersMis-match between health promotion and screening and the impact on our client groupEducation & TrainingEquip staff to undertake role redesign and be solution focussedLocal training supports local recruitment but need to bring new people in tooInvest in potential future staffWider workforce need ACST skills training focussing shift to self-careCore skills, passport developmentMandatory training delivered in blocks (impact on smaller teams) . Blended learning approaches including webexMore exposure to 3rd sector in pre-registration training
33End of Life Care (2) Workforce Development/Transformation Role description required for ‘enhanced’ key worker roleNavigate patient through the systemAdvocacy skillsWork for an integrated service and system with authority to access resourcesCOMMISSIONER LED AND CONTRACTED: underpinned with service specification and KPIs. Role will be required to ensure patients are on an EOL pathwayMaking use of the potential workforce e.g. migrants and armed forcesConsideration of the knowledge, skills and competencies required by the whole of the workforceUtilising the wider workforce effectivelyGeneric assistant practitioner role – at the right place in the pathwayRe-enforce F1 rotation at F2 e.g. nausea and vomiting training programme for F2 palliative care – medical/surgicalPick up cover roles in the community – more difficult for acute trusts
34Prepared by East Midlands LETB Workforce Team (Lincolnshire)