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Sector Skills Insights: Health and Social Care

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1 Sector Skills Insights: Health and Social Care
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2 Introduction The UK Commission is working to transform the UK’s approach to investing in skills to help secure jobs and growth. Key to our ambition is the need to encourage greater employer ownership of skills, working to secure long term sustainable partnerships. This slide pack and accompanying evidence report present the case for more employers in this sector to invest in the skills of their people. It does so by presenting real-life, skill-based business solutions that have been used by leading employers to tackle the performance challenges they face and by drawing on examples of the investments being made by the UK Commission through its investment funds. There are several determinants of employers’ skills needs and training behaviour including firm size, strategy and location but it is by sector which the strongest variations appear. Hence this work focuses on the Health & Social Care sector. Slide packs and reports are also available for a number of other sectors from: Each of the sectors are important to the economy in terms of employment, productivity or their future potential. For information about this slide pack and accompanying report please contact: Rebecca Jones, Source information can be found in the notes section of each slide

3 Storyboard What key skills challenges are being faced in Health and Social Care? The importance of Health and Social Care sector today Imagine where the sector could be tomorrow Performance challenge (1) doing more with less Performance challenge (2) attracting talented individuals Performance challenge (3) key skills shortages Further exploration in the accompanying evidence report Sector Skills Insights: Health and Social Care Performance challenge (4) management capability Tackling these performance challenges: Growth through skills Benefits to organisations

4 What services do the Health and Social care sector offer?
Residential care Hospital activities and nursing homes Child day care GP practices Social work activities SOURCE – GP and hospital photos supplied by Skills for Health Other photos purchased from Dreamtime Dental practices Specialist practices

5 What key skills challenges are being faced overall?
Doing more with less The NHS in particular is facing major restructuring including significant reductions in management and administrative costs and further efficiency savings are planned across all UK nations. Reduction in public spending is likely to result in significant cost pressures for the Health and Social care sector. Research has demonstrated that management skills are correlated with financial performance and better patient outcomes. Attracting and retaining the necessary talent An ageing population, and an ageing workforce produce a combination of increasing demand for services coupled with high rates of retirement of existing employees. Almost 1.7 million job openings are expected across health and social care by 2020 (both new demand and the replacement of retiring staff). This includes 881,000 job openings for managers, professionals and associate professionals (160, 000 new job openings). Some parts of the social care sub-sector have high staff turnover and vacancy rates. Sources: Job openings Wilson and Homenidou (2011) Working Futures , UK Commission for Employment and Skills Skills Gaps Davies et al (2012) UK Commission’s Employer Skills Survey 2011: UK Report, UK Commission for Employment and Skills Reducing skills gaps among the existing workforce A lack of proficiency has been reported in the areas of strategic management, team-working and communication skills. Skills gaps can typically make it harder for organisations to meet quality standards, increase the workload of other staff and create additional operational costs. At the same time, new technology is expected to have wide ranging impact across the sector with assistive technologies shifting the delivery of care towards the home and local providers. Technology will increase demand for high level skills, with potentially negative consequences for the skills gaps in the sector.

6 Health and social care matter: where the sector is today
D5 - Final The health and social care sector is fundamental to the success of the economy as a major employer employing almost 4 million people. Data suggests approximately 1/3 of health and social care employees work within small organisations (under 25 employees) and 1/3 work in large organisations (500 or more employees). The importance of health and social care lies in its contribution to all other aspects of the economy: a healthy population is more productive, and more economically active.   The health workforce is much better qualified than average. Almost a third work in professional occupations compared with a fifth in the labour market as a whole. Growth in output in the sector is projected to increase by 2.4% a year to When taking qualitative measures into account, productivity has increased over the last decade Employment in health is dominated by the NHS (over 75%), whereas 47% of employment in adult social care is in the private sector There is strong female participation in the sector (79%) and high rates of part-time working (40%), compared to an all-economy average of 47% and 28% respectively. The influence of health & social care extends beyond the sector: it provides a large market for UK life sciences industry and other industrial supply chains. However, the health and social care sectors have relatively low rates of innovation and investment compared to other sectors. Sources: Employment and employment by size of establishments, LFS 2010, ONS Number of establishments – IDBR, ONS 2010 Output, Working Futures , UK Commission 2011 Output, ONS 2010 Qualification Levels, Wilson and Homenidou (2011) Working Futures , UK Commission for Employment and Skills Gender, gender participation and public / private can be found in the accompanying Sector Skills Insights: Health and Social Care Influence of the sector and innovation are explore in the in the accompanying evidence report Sector Skills Insights: Health and Social Care, UK Commission for Employment and Skills 6 Exporting innovative ideas and expertise, provides business opportunities for UK-based companies. 6

7 Health and social care: imagine where we want to be tomorrow
The sector offers world-leading standards of care and public health supporting the well- being and economic activity of the population, so supporting the performance of other sectors World-class managers drive continuous improvement and maximise the contribution of employees to deliver service excellence Services are delivered in an efficient way that maximise value for money The UK leads the world in terms of efficiency and innovation in the delivery of Health and Social Care services The sector attracts the most talented individuals for both training and practice The sector recognises talent as a source of competitive advantage Firms and individuals invest optimally in their skills Employers collaborate on, lead and own skills solutions to the sector’s performance challenges in pursuit of mutual gain Further exploration of sector potential in the evidence report Sector Skills Insights: Health and Social Care

8 The sector tomorrow: increasing demand for skills in Health and Social Care
Employment overall is projected to grow by 1.3 per cent (social care +4.9%, health -1.3%) between 2010 and 2020 (below all sector average of 5.1 per cent). However, the expansion and retraction for different occupations reveals a more challenging picture. The majority of employment growth is projected among highly skilled occupations (9% across managers, directors and senior officials, professional occupations, associate professional and technical) but this is lower than across all sectors (16%), therefore competition for skills is likely to be high. Employment among positions using higher level qualifications (first degree level and above) is projected to increase from 28% in health, 26% in care in to 39% for both sectors in At both time points this is higher than the all sector average, 24% in 2020 to 32% in 2020 across all sectors New job openings due to retirement and employment growth is significant: 485,000 jobs in professional and 570,000 jobs in caring, leisure and other services occupations by 2020 Employment is also expected to increase among caring, leisure and other services occupations particularly in Social Care (12% for Social Care, but 9% for Health which is on a par with the all sector average) Positions are expected to decrease among administrative and secretarial (31%) and skilled trade occupations (33%), much more so than across all sectors (11% and 7% respectively). Source: Wilson and Homenidou (2011) Working Futures , UK Commission for Employment and Skills

9 The sector tomorrow: doing more with less
D5 - Final Doing more... The UK population is growing and ageing which is likely to lead to a 20% increase in demand for residential care, home care, day centres and meals per decade. The number of children referred to Social Services is rising in England (613K referrals year ending March 2011, 608K in 2010, 547K in 2009, 539K in 2008) Obesity is steadily increasing across the UK, associated with an extra 7 million cases of diabetes, 6.5 million cases of heart disease and stroke, and between 492,000 and 669,000 additional cases of cancer by 2030. Alcohol-related hospital admissions is rising as is the incidence of binge drinking With less... Targets of 5% in efficiency savings have been announced across the NHS, requiring annual savings worth £20 billion by 2014/15. The NHS is facing major restructuring (Health and Social Care Act 2012) including a challenge to reduce bureaucracy, and reduce the resulting management and administrative costs.     The pay freeze means salaries are under pressure, in the health sector especially: “the pressure to pay more in real terms will be immense; by GPs will have had their pay frozen for four years, consultants for three and everyone else for two years.” (John Appleby of the King's Fund) Further exploration in the accompanying evidence report Sector Skills Insights: Health and Social Care 9 9

10 The performance challenge Quality of management capability
Management practice in hospitals are strongly related to quality of patient care and better productivity. Improved management practices are associated with: Significantly lower mortality rates Better financial performance Quality patient care There is a general perception of poor management skills in the H&SC sector, however research* has shown that the UK delivers strong hospital-management practices relative to health expenditure. That said, variation in the quality of management and outcomes is evident; in that, better management scores can be found among: Hospitals with clinically qualified managers associated with better management scores. Higher-scoring hospitals give managers higher levels of autonomy Larger hospitals are better managed. Private hospitals (including not-for-profits) achieve higher management scores than public hospitals. Across both sectors the skills levels and training of senior staff are strong: Both sectors fare very well when compared to the all sector average for Managers and professional without L4 or above qualification (Health 15%, Care 30%, all sector average 39%) Equally, employees receiving training at Manager, Director and senior Official Occupations is well above the all sector average of 45%. (Health 61%, Care 60%) But, while on the whole skills shortage vacancies are lower than the UK average, the occurrence of skills shortage vacancies as % of all vacancies is concentrated in the managerial and professional occupations (for health, 42% of all vacancies for managers are SSV’s, and in care this is 24%) . Improved management practices are associated with: Significantly lower mortality rates: a one-point increase in management practice quality is associated with a 6.5 % reduction mortality rates (risk adjusted 30 days AMI) Better financial performance: a one-point increase in management practice quality is associated with a 33% increase in average income per bed Quality patient care: a one-point increase in management practice quality is associated with a 20% increase in probability that the hospital will score above- average in terms of patient satisfaction Management practices, Dorgan et al, Management in Healthcare; why good practice really matters, McKinsey & Co, LSE Skills levels , Wilson and Homenidou (2011) Working Futures , UK Commission for Employment and Skills Skills shortages and training, Davies et al (2012) UK Commission’s Employer Skills Survey 2011: UK Report, UK Commission for Employment and Skills A key outcome of the Health & Social Care Act is a reduction in bureaucracy and a consequent reduction in management and administrative costs. The challenge to do more with less means what is good now will need to be better.

11 The performance challenge Quality of management capability
Looking ahead at demand for management skills: Small growth is expected in the workforce in health and care sectors between However, the share of the workforce made up from the top three occupation levels plus caring occupations is expected to grow while others are expected to retract. Demand for skills at level from degree level to doctorate level is expected to increase during across all sectors including health and care But, demand for higher degree and doctorate level in expected to increase above the level for all sectors. In 2010 the share of employment at QCF 7-8 is around 9-10% for health and social care, in line with the all sector average. By 2020 this is expected to increase to just over 15% for health and social care and just under 15% for all sectors Meanwhile, the demand from other sectors for skills at the top three occupational levels is also set to increase, competition to attract these skills will be high which increase the need to nurture and promote from within the sector. Meanwhile, if we look at High Performance Working in the sectors the role of good management is important in enabling the execution of the four indicators used to measure HPW. Here both health and social care have variable strengths and some weaknesses in relation to the sector average Identifying talent is a strength for both sectors ( 20% health, 28% care and 214% all sectors) For both variety in work and discretion in tasks, health is lower than the all sector average (variety - 51% health, 59% care and 55% UK) (discretion – 42% health, 53% care and 52% UK) Flexible working is lower for both sector than the all sector average (27% health, care and UK) Looking ahead, Wilson and Homenidou (2011) Working Futures , UK Commission for Employment and Skills High Performance Working , Davies et al (2012) UK Commission’s Employer Skills Survey 2011: UK Report, UK Commission for Employment and Skills The increased demand for higher levels across the economy will mean increased competition to attract talent and nurture these skills. Key outcomes of HPW are effective skills utilisation and progression – this could help to nurture talent and meet future the demand for higher level skills from growth and replacement demand.

12 Case study - Front-line leaders programme
The problem MacIntyre found that managers in the Care sector were often lacking key management and leadership skills and also lacking confidence in the role. The approach The National Skills Academy for Social Care developed the Leader’s programme, designed for those working or leading to develop the language and values of leadership and peer learning. The course helped first-line managers respond to high rates of attrition (40% in first year, 60% in the second year). The benefits The programme helped managers better manage their role and gave them the confidence to cope effectively with the tougher, more personal aspects of the role. Feedback from attendees has been very positive generating high levels of enthusiasm, helping participants learn and think about themselves and their roles differently. Source - 12

13 The performance challenge Key skills shortages
In the Health sector, the over-whelming response from employers in regard to skills requirements was for greater levels of job specific skills (77% of health employers identified this as a need compared to 54% in Care and 66% across all sectors) In Social Care sector, employer skills requirements were highest for job specific skills. In addition to this employers reported similar levels of needs across: planning skills, communication skills (written and oral), customer handling, ability to work in teams and problem solving (all at higher levels than the all sector average for the skill type) Despite generally high proportions of well qualified staff overall (61% qualified to NQF Level 4 and above, compared to 36% in whole economy) there are still significant pockets of low qualified employees (e.g. 16% of employees in the sector have either no qualification, or are educated to NQF Level 1 or equivalent compared to a 19% economy average). Despite high instances of formal and informal training in both sectors In the Health sector, employees in skilled process, plant and machine operative roles were the only occupational category less likely to experience training than the sector average Whereas in the Care sector, employees receiving training was lower than the all sector average for professional occupations, associate professional and customer service occupations Across the three main implications of skills gaps employers in both health and care report similar experience of these implications as for all firms Increased workload for other staff (82 per cent for both health and care, 78% across all sectors), increased operating costs (40% health, 33% care, 45% all sectors), and difficulty in meeting quality standards (39% health 38% care and 40% all sectors) However, a particular issue for health and care employers is difficulties introducing new working practices (44% health and 48% care compared to 38% of all firms). Skills shortages, Davies et al (2012) UK Commission’s Employer Skills Survey 2011: UK Report, UK Commission for Employment and Skills The health of the workforce skills and experience of training is variable across occupations. The repercussions are felt more widely. In health and social care, new working practices and their consistent adoption are a fundamental to effective delivery. Investment in skills is key.

14 Case study – Creating new roles to reduce emergency hospital admissions
The problem Over 75% of 999 calls to the ambulance service result in admission to an emergency department. This is resource-intensive and creates trauma for patients. Skills for Health developed a competency framework for emergency, urgent and unscheduled care to devise a new role and learning programme for Emergency Care Practitioners (ECPs) The approach ECPs are up-skilled to assess and treat patients at the scene, provide clinical support and advice, support primary care staff in home visits or out of hours cover and work in minor injury units. The benefits ECPs have reduced emergency admissions: almost a third of patients avoided transfer to an emergency department when treated by an ECP at the scene. Almost a half of elderly patients suffering a fall and seen by an ECP did not need to be admitted. Patient satisfaction is higher; as generally patients prefer to be treated close to or in their own homes. The new competency framework provides staff with the opportunity to develop and progress. . ECP attendance costs less than sending an ambulance in response to a 999 call. Source Skills For Health New role has ‘phenomenal’ effect on Emergency Departments - published by Skills for Health

15 The performance challenge Attracting talented individuals
The share of all vacancies which are Skills Shortage Vacancies* are lower in Health (12%) and in Care (9%) compared to the (16%) average across all sectors, but on closer inspection the need to attract talent for specific occupations becomes apparent. In Health However, there is a concentration of Skills Shortage Vacancies reported among professional occupations in Health (47% compared to 16% for Social Care and 18% across the economy). There are skills shortages reported among Pharmacists, Dental Practitioners, Specialist nurses occupations and in other physiological sciences and respiratory physiology sectors. The share of skills gaps by occupation in health is higher for professionals 8% compared to 4 % for both care and the all sector average) Reliance on international recruitment is lessening, however employers need to think about alternative recruitment channels. In Care There are particular Skills Shortage Vacancies in personal service occupations in Care, of all the skills shortage vacancies in care 52% are in the caring occupations (compared to 29% for health) and 11% across the economy. Skills gaps** are also higher than average in skilled trades (8% compared to 4% in care and 5% all sector average) and caring occupations (6% versus 4% for health and 5% economy average). Social care also has a high staff turnover rate, of 18% in the private sector, and 11% among local authorities). Enhancing the attractiveness of jobs for new recruits improves employer’s ability to recruit and retain talented individuals. * Skills shortage vacancies are hard to fill vacancies caused by a lack of applicants with the skills, qualifications or experience needed ** Skills gaps are a lack of full proficiency amongst existing staff ie not able to do the job to the required level Skills shortages vacancies, Davies et al (2012) UK Commission’s Employer Skills Survey 2011: UK Report, UK Commission for Employment and Skills

16 Case study - Caledonia Healthcare: Improving recruitment and retention
The Problem As a healthcare recruitment company, specialising in recruiting and supplying care assistants, support workers and nurses, Caledonia Healthcare Limited wanted to attract, recruit, retain and motivate high calibre professionals and saw Investors in People (IiP) as a fundamental part of becoming an employer of choice and leveraging human capital. The Approach IiP helped Caledonia Healthcare understand what made their people happy through implementing a staff consultation process. The results revealed innovative solutions for business planning and new ways for senior managers to communicate with staff. The benefits In using a consistent approach to staff development, the firm experienced higher levels of staff engagement and retention. Gaining and retaining IiP has provided Caledonia Healthcare with a powerful way of demonstrating that they are a great company to work for – more people want to work for the organisation and more clients have provided positive feedback on the service they have received. Source: 16

17 Case study- A new foundation degree to improve recruitment and retention
The problem A rising elderly population led to increasing pressure on community nursing services to deliver routine care such as dietary monitoring, support for those with diabetes, wound dressing and other routine procedures. At the same time, care staff were not qualified to carry out these procedures leading to a resourcing issue for both time-pressured community nurses and care staff whose capabilities were being underutilised. For Carers, lack of suitable progression routes meant that retention was low. The approach A partnership between Skills for Health, Foundation Degree Forward, University Campus Suffolk and MOVE Lifelong Learning Network devised a new Foundation Degree to enable care staff to become qualified to offer basic care through a blend of work-based and theoretical learning. Credits can be accumulated and easily transferred via a structured pathway for career progression. The benefits Care homes recruit and retain the volumes of staff needed to meet future demand, benefitting from greater efficiency and reduced staff turnover. Patients would experience more timely treatment and greater continuity of care. The wider health sector experiences reduced pressure for community nurses and through reduced hospital admissions because of a lack of capacity in care homes to provide appropriate care. Source - Photograph also supplied by Skills for Health

18 Growth through skills Securing future success
Across the sector, raising skills is key to raising performance, but while there is no silver bullet, a mix of actions which push and pull in the same direction can help. Employer leadership in the development of solutions and then taking ownership of those solutions is fundamental to their success and sustainability. Sources of investment are available to support the implementation of solutions led by business on behalf of the sector. The Employer Ownership pilots offers employers in England direct access to up to £250 million of public investment over the next two years to design and deliver their own training solutions. The Growth and Innovation Fund (£9 million invested so far, £29 million to invest in ) gives priority to solutions for the sector e.g.: Employer commitment and investment in Apprenticeships Creation of employer networks to overcome skill problems Employer-backed proposals for other skills solutions such as: management and leadership; professional standards; high performance work practices incorporating people development (e.g. Investors in People). Information and business advice is also important as a solution. Ultimately this is trying to catalyse sustained investment in the development of the sector’s workforce led by employers which lies at the heart of an enterprising and dynamic nation. Sources - Employer Ownership – see GIF – see

19 Growth through skills Securing future success
Strong links between employers and colleges and universities have been cemented through the National Skills Academies. The National Skills Academy for Social Care offers leadership training to: Recent graduates through a National Management Trainee Scheme which seeks to attract people into the sector and develop future leaders. Front-line leaders which focuses on how the values and behaviours of leadership at the front line are crucial to excellent care delivery. Senior managers of the future An Aspiring Leaders programme focuses on leadership within the commercial reality of day-to-day operations. New Directors working with the Association of Directors of Adult Social Services (ADASS) to run a programme to support senior managers when they’re newly promoted to lead local authority adult social services. The social care academy also aims to raise the quality of provision by offering quality marks for organisations and individuals through awarding: Centres of Excellence: who demonstrate exemplary commitment to meeting the needs of learners, compliance with the social model of care, and understanding and measuring impact of provision on lives of service users. Recognised Providers: who demonstrate a professional approach to education and training in adult social care. Endorsed Practitioners: 'sole-trader' training providers who demonstrate a professional approach to education and training in adult social care. Source -

20 Growth through skills Securing future success
The National Skills Academy for Health seeks to raise skills in the sector by offering: Specialist Careers Advice and Information Brokerage for employers matching training providers to need Learning consultancy Apprenticeship, Youth and Pre-employment Programmes, including the management of the Joint Investment Framework Partnerships with various organisations delivering the diplomas, acting on their behalf, and providing a comprehensive menu of employment engagement activities Support to organisations on how to maintain standards both occupationally and through qualification requirements via our Skills for Health approval process Career development for those supporting learners with language, literacy and numeracy development needs Skills for Health are improving the talent pipeline of new entrants into the sector through: The Skills Passport will provide a framework for statutory and mandatory skills. to reduce training costs, improve productivity and increase quality of services. With investment from GIF, Skills for Health are offering to implement the framework within 60 organisations Skills for Health run a Cadet training programme to help young people start a career in the NHS, whilst continuing to study an academic or vocational qualification, a diploma and young apprenticeships. Source - Source -

21 Growth through skills Securing future success
Apprenticeships and Workplace learning – social care Case study research reports that employers believed that Apprenticeships and WPL, often alongside mandatory training, delivers a number of benefits: staff understanding of what care entails and consistency of standards; helping to develop staff confidence and capability to deliver a good standard of care; investment in training particularly beyond Level 2 offers (personal) development opportunities help to support staff motivation and retention when senior posts become vacant, a pool of suitably trained internal candidates for promotion will be ready to take up the opportunity to progress.* In addition, this study of 8 sectors the net cost of WPL in social care was found to be lower than in many other sectors for both L2 Apprenticeships and L2 NVQ . Partnerships with employers – Health Skills for Health worked with Whittington Hospital NHS Trust to pioneered a competence based leadership programme for front line managers. The benefits included: managers able to deal with issues without dependence on senior support , more proactive and raised confidence and morale. NHS Nottingham City and University of Nottingham have developed a ‘competency matrix’ to support staff development for End of Life Care. This has reaped benefits for: patient centred care, multidisciplinary approaches and increased competence and confidence in clinical practice. Source Social Care Apprenticeships - Partnership working , Health examples

22 Benefits of training to organisations
Evidence across a number of sectors suggests that employers who invest in training are more likely to survive than those who don’t ..... Training improves organisational survival rates. Non-training organisations in the Health sector are 1.2 times more likely to close compared to training organisations in Health*. And, what is more, the productivity gains for firms from investing in training are seen to be higher than the increase in wages experienced by employees Development of communication skills results in a demonstrable shift in staff behaviours towards patients. Staff show greater empathy, greater responsiveness to patient cues and better style of questioning. The evidence shows that change is sustained over the long term. Good people management practices are strongly related to lower patient mortality rates. The extent and sophistication of appraisal is particularly strongly related, but there are links too with the level of training for staff, and the way work is organised, for example the proportion of staff working in teams. Source Business survival and training *(2007) analysis of data drawn from the 1998 Cross-section and 2004 Panel component of the Workplace Employment Relations Survey (WERS). Both are based on stratified random samples of establishments and a sample employees from these. Productivity gains Management, Dorgan et al (2011), Management in Healthcare; why good practice really matters, McKinsey & Co, LSE Communication Back A L (2003), ‘Teaching Communication Skills to Medical Oncology Fellows’, Journal of Clinical Oncology, Vol. 1, Issue 12, pp Spiro H (1992), ‘What is empathy and can it be taught’, Annals of Internal Medicine, Vol. 15;116(10), pp Winefield H R, Chur-Hansen A (2000), ‘Evaluating the outcome of communication skill teaching for entry-level medical students: does knowledge of empathy increase?’, Medical Education, Vol. 34, p. 90 Effective Human Resource Management & Lower Patient Mortality. Carol Borrill & Michael West, Aston Business School, January 2003

23 Benefits of training to organisations
In the Social Care sector, better performing Care homes have: Higher proportions of staff with relevant qualifications including managerial and supervisory staff, senior care workers and care workers Greater proportions of workers with higher level qualifications (including care workers at level 3 and managers with professional and managerial qualifications) More experienced staff on hand. Christine Eborall , The Contribution of Worker Qualifications to Achieving High Inspection Scores in Care Homes (2011), Skills for Care, 2011,

24 Key messages The health and social care is a major sector in employment and economic terms now and demand for services is projected to grow over the next decade. Against a backdrop of fiscal constraint, several challenges exist which threaten the sector’s performance: attracting talented individuals to the sector overcoming skills gaps among pockets of low-qualified employees improving the quality of management capability across the sector Examples exist of where these challenges are being tackled successfully through employer-led skills solutions. If the sector is to realise its potential, this action must be scaled-up and employers must play a greater role in developing the skills needed by their respective workforces. By providing training and skills development in the context of an employment relationship which recognises the importance of career progression, there are benefits to both employer and employee . Work with employers to transform the UK’s approach to investing in skills of its people to secure growth and prosperity. The UK Commission is looking to work with employers to transform the UK’s approach to investing in the skills of its people to secure growth and prosperity. More information about the UK Commission’s investment funds is available here.

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