Lincolnshire
Workforce Plan
2013/14
Contents
Introduction ……………………………................................. 3
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
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Introduction
This 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 postFrancis. There continues to be scrutiny of healthcare provision in Lincolnshire and significant work is underway to address areas of concern
NHS 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:•
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Security of Supply
Local Decision Making
Inclusive Approach of providers
Good Governance
Sound Financial Management
Stakeholder Engagement
Transparency
Partnership Working
Quality and Value-Year on Year Improvement
Accountability
All 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 plan
Workforce 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.
Methodology
The 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
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for 2014/15
Lincolnshire 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 Strategy
Throughout 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.
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Workforce 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 45+. 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
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Population Demographics
The population of Lincolnshire is currently estimated to be 697,900 (using local authority boundaries) and projected to rise to 838,200 by
2033. 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 2033
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The 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.
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Estimates of people from non white British backgrounds living in Lincolnshire show that the numbers have doubled from 3% in 2001 to 6%
in 2007. 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)
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It is evident that the changes to the Lincolnshire population are caused entirely by the effects of migration movements into the County.
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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.
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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.
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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.
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Future 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 Diseases
Heart Disease
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There 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.
Stroke
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Approximately 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.
Cancer
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Cancer 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 socioeconomic groups more likely to take up screening programmes. Smoking and diet are also lifestyle risk factors associated with
developing some cancers.
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Future Service Demands (2)
Diabetes
• Estimated 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
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Workforce Opportunities
Continue to explore
opportunities for skill
mix changes
Work in partnership with
education providers
(schools, training
departments, FE and HE)
to secure future workforce
and improve access to
local delivered workforce
development
Ensure that scope,
competence and training
are clearly defined and
recorded for staff
(particularly those
working in new/extended
roles)
Work in partnership with
service providers and
commissioners to
ensure effective use of
training resources
Prioritise education
investment and
measure return on
investment
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Workforce Risks
Continued scrutiny of
ULHT by the public
and regulators;
impacting on staff
morale and recruitment
of staff and trainees
Age demographics of
the workforce
(particularly GPs)
Reduction of education
investment funding
from LETB
Ability to recruit to
senior/specialist level
posts
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Medical Workforce
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&E
• Whilst 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
The future numbers of GPs in the
county continues to be a risk;
particularly as training capacity is
constrained.
More positively; Lincolnshire
Partnership Foundation Trust has been
able to make appointments to
Psychiatrist vacancies; some of which
have been vacant for some time
The LETC and Workforce team will be
working with partners to develop a Medical
Workforce Strategy for Lincolnshire in the
coming year
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Nursing & Midwifery
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The transition of adult and mental health field nurse training from the University of
Nottingham to the University of Lincoln commenced in September 2012. 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.
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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.
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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.
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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.
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Allied Health Professions (1)
All AHP Groups
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Reduction 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
through
Difficulties in recruiting to Band 6 senior staff across OT, Physio and Dietetics; additional training has been offered to B5 staff to support progression
Seven day provision
Need improved clinical supervision and support for newly qualified clinicians and assistant roles
Need local opportunities for quality CPD
Identify core skills for bands 1 – 4
Increase in expectation at B5
Inclusion of preceptorship for all professions
Safeguarding – training to a higher level for staff
Fewer band 5s and 8s
Little progression available for B6
More profession specific training for support staff would be helpful
Provide career pathways
Training needs
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Neuro-rehabilitation
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Cognitive rehabilitation
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Oncology/palliative care
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Hand therapy
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Dementia
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Parkinson's disease
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Women’s health physio
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Paediatric OT
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Vocational assessment and rehab across a wide range of staff
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Paediatric neonatal dietetics
Students typically attend placements in the west half of Lincolnshire impacting on recruitment in the East
Placements 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 year
Pre-registration training to include a foundation/generic year, generic skills and offer more joint posts
More AHP prescribing
Fewer patients seen but increased complexity and acuity
Multiple routes into services e.g. self-referral, onward referral etc
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Allied Health Professions (2)
Dietetics
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Impact 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 visits
Community Podiatry
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Challenge 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 clinicians
Introducing podiatry assistants to support toenail surgery in community clinics
Rehabilitation Medicine/Acute therapy services
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Increased number of in-patient beds
Expansion of rehabilitation medicine outreach service
Developing therapy services within A&E/CDU/EAU to reduce admissions, length of stay and readmissions
through early access to appropriate services
Developing ambulatory care services
Establish a Paediatric OT service for children in hospital
Develop of Palliative care beds at Grantham
Mental Health Therapy Services
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Fully integrate OTs into MDTs
Band 7 OTs not been replaced
Band 6 OTs have little career progression unless they apply for generic clinical posts e.g. team coordinator
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Healthcare Science & Pharmacy
Scientist Workforce
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Risk to recruiting Practitioners into roles: audiology
Training needs for existing staff to update not just in clinical/scientific skills but
leadership and management – LBR route and Scientific framework being considered
TNA being undertaken currently
Risk in service for competence in nuclear medicine/radiotherapy for the delivery of
treatment in cancer
The collapse of the local PTP programme is a risk particularly for Medical Physics
Pharmacist Workforce
• Agreed training model for medicines management technicians requires regional
commissioning to ensure consistency across the East Midlands
• New service models for pharmacy may result in pharmacists leaving the
service/taking early retirement
• Capacity for training may be impacted by new service models
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Wider Workforce
There 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
workers
Review 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 tasks
For all staff in bands 1 – 4; there is a concern with regard to structured career
development opportunities and career pathways
The 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
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Maternity & 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 Reconfiguration
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Louth 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 Issues
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Neonatal 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 DMU
Unregistered, data clerk only works .6 WTE band 2 JDs
being looked at. Band 4 nursery nurses, no opportunity to
develop further
There 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.
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Maternity & Newborn (2)
Workforce Development
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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 Training
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Qualified 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 doctor
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National 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 midwives
Students – 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 preregistration.
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 Lincolnshire
Nuchal 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 midwives
Top 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.
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Mental 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 disabilities
Workforce Planning
Workforce Plan to support IBP 2013/14 and LTFM
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There 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 policies
– ensuring 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 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.
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Mental Health & Learning Disability (2)
Detailed Workforce Reviews
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During 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 developments
– Trust wide admin review
– Review of e-rostering and bank and agencies expenditure
– Skill mix analysis and identification of competency requirements
– Productivity, efficiency and LEAN initiatives
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Mental Health & Learning Disability (3)
Workforce Risks
The following identifies the workforce risks and their mitigating factors:
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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 groups
M - 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
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Children’s & Healthy Lifestyles (1)
Change and Reconfiguration
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Develop a paediatric observation unit at Lincoln
County Hospital
Reduce in-patient beds as a result of the above
Establish paediatric OT service for children in
hospital
Implementing
community
nursing
review
recommendations
Activity is increasing due to high numbers of
complex cases and those where safeguarding is
an issues
Immunisation programme in schools
Review of community paediatric service
Health visiting – healthy child programme review
will increase activity (implementation of universal
service)
Safeguarding/vulnerable children – a new model of
safeguarding supervision is being implemented
Children’s therapies – increase in lower level
activity to reduce need for higher level
interventions. However specialist work increasing
as a result of tribunal outcomes
Increase in domiciliary activity and referrals to
specialist dental services
Increase in HIV patients particularly late
presentation patients
• Development of the ‘Family House’ based on
locality based operation multi-disciplinary
specialist teams supported by separately
managed skill mix teams
Risks and Issues
• Dependent on ability to recruit advanced
paediatric nurse practitioners there may be a
need to ‘grow our own’ over a period of time
• Requirement
to
fill
community
nursing
vacancies; some posts are being down-banded
(7 – 6)
• Small numbers of children’s nurses seeking
employment in Lincs
• Difficulty in recruiting school nurses
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Children’s & Healthy Lifestyles (2)
Education & Training
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May need to train current staff to
become advanced paediatric nurse
practitioners
Introduce clinical educator roles in
children’s wards
Some staff will undertake specialist
practitioner
training
to
increase
numbers of school nursing
Increased 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 2015
More training required for immunisation
& vaccinations and sexual health
(school nursing)
Use of mobile technology
Leadership development
Workforce Development & Transformation
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•
•
•
•
Specialist diabetes nursing staff required for
paediatric diabetes service
Increase specialist paediatric dietician 1 wte for
diabetes service
Advanced paediatric nurse practitioners to staff
integrated OOH/emergency dept
Recruitment of 2 consultants to deliver child
protection and safeguarding service to service
specification
Transfer of community paediatric nursing teams
to LCHS
Peer supporters for breast feeding
Health trainers
0 – 19 skill mix team (ability to undertake brief
intervention
Additional OT for paediatric inpatients
23
Urgent 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 departments
Change and Reconfiguration
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Development of A&E front door, ambulatory care and chair centre model
EMAS engagement in redesigned pathways
Improvements to GP access
Develop GP skills in emergency care requirements
Improved access to services (times/days)
Expanding scope of advanced practitioners
Development of FOP services, advanced care planning and access to information (for staff, patients and
families/carers)
Home care provision for increased acuity
Better integrated working
Development of Nurse Consultant and Nurse Practitioner roles
Safer staffing project – linked to patient acuity
Implementation of 24hr PCI unit in Jan 13
Introduction of ambulatory/4th resus bed for trauma network work
Establish a Minors Stream model
Developing Pilgrim PPCI and development of ICD service in 13/14
Pilgrim to become a hyper-acute stroke service
Single point of access for community referrals
Closer integration of Urgent care and OOH services
Rapid response service (RRS) being established to provide immediate care and support to patients who can be
safely managed at home
Assertive in-reach team (AIR nurses) will work alongside secondary care to prevent admission or reduce length of
stay
GP OOH, Walk-in centre and minor injuries units will provide unscheduled access to doctors and advanced nurse
practitioners
Develop therapy services within A&E/CDU at Pilgrim to reduce admissions, length of stay and readmissions
24
Urgent Care (2)
Risks and Issues
Education & Training
•
• Locally trained workforce
• Need better selection processes to pre-registration
training
• Pre-reg to include basic competence in emergency
assessment and procedures
• Post graduate training is too academic, not
sufficiently focused on clinical skills; ideally multiprofessional with Royal College approval
• Urgent 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 model
• Coaching/leadership
• Emergency care competencies locally delivered to
national standards (all staff)
• Review of medical staff skills and training needs
• Increase placement capacity in ED
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•
No clear framework and role definition for B2/3 &
4
Availability of education to support timely training
(e.g. for advanced practitioners)
Attracting staff from outside of Lincolnshire with
urgent/emergency core skills
Implementation of telemedicine
Investment in terms and finance and time to
support the workforce to develop
Change management and service redesign skills
PCI service reconfigured differently from original
plans; shortfall in in workforce is being covered
by ICU
1 wte Stroke Consultant post currently out to
international recruitment, middle grade covered
by a trust locum
Ability to recruit nursing staff with specialist skills
25
Urgent Care (3)
Workforce Development/Transformation
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•
Create a culture of learning and governance
Career framework for emergency nursing
Physician Assistant – no role as not able to prescribe and vacancies are generally at a higher level
Potential for more use of apprenticeships e.g. customer service
Generic healthcare support worker (B2)
AP role not being fully utilised
Development of Emergency Care Nurse Practitioners
Development of Nurse Consultant and Nurse Practitioner roles
Paediatric emergency department rotational post being created
Increased resource (possibly acute care practitioners) to meet workforce requirements for stroke services
A&E Consultant nurses in post
Review of nurse practitioner team in MEAU/A&E to support ambulatory care
Recruit to 2 wte consultant posts in A&E and fill 2 wte middle grade posts at Boston
Additional advanced nurse practitioners required
Increase therapist input in emergency care/ambulatory care
Maximise the skills of the highly qualified workforce e.g Advanced Assessment Nurse Practitioners and
Emergency Nurse Practitioners
The 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 available
Recruit 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/CDU
Increase B6 input to SEAU to improve co-ordination of patient flow
Increase B6 to support ambulatory area
26
Planned Care (1)
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 demand
Change & Reconfiguration
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Work towards a 24/7 site working through Hospital @ Night
team and outreach services using nerve centre IT system –
electronic system for referring and prioritising the unwell
patient out of hours
Cardiac unit undertaking elective trans-oesophageal
echocardiography (TOE)
Review of rheumatology/biologics workload to assess
potential for joint infusion suite
Haematology/oncology service redesign to create additional
capacity (including extending hours)
Introduction of chemotherapy CNS posts to support
consultant activity
Seek to appoint 3rd neurology consultant and substantiate
the current locum into 2nd post to reduce waiting times
Develop the epilepsy service
Implemented a 7 day week consultant service for
respiratory inpatients
Louth hospital to introduce 6 day case chairs; reducing the
number of beds
More acute care to be provided in community hospitals and
in community nursing
Community nursing catalogue implemented; planning exit
strategies for unfunded activity
Podiatry and MSK Physiotherapy expected to increase as
AQP develops
• Established 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
teams
• Twilight services to be redeployed into either OOH or community
nursing
• Extended core hours for community nursing
• Develop rehabilitation medicine service at Grantham
• Provide orthopaedic 7-day therapy services for elective in-patients
• Establish nutrition teams
• Bed closures will reduce demand for inpatient therapy services
• Enhanced recovery programme for Urology, General Surgery and
Orthopaedics
• Pain management service
• Increased therapy support for Diabetes MDT clinics
(dietetics/podiatry/orthotics
• Implementation of e-prescribing system for chemotherapy
• Extend the hours within radiotherapy to meet demand and
develop IMRT and IGRT treatments
• Further roll out of weekend working in pharmacy, radiology and
cardiac physiology
• Investment in additional diagnostic imaging equipment in radiology
and cardiac physiology
• Larger endoscopy unit (Lincoln) planned for 2014
• Procure an inpatient pharmacy service through ‘shop in shop’
service delivery model
• Develop a new surgical day unit at Grantham to repatriate work
from Newark/Nottingham
• Phased reduction in opening days of Fotherby ward at Louth
• Increase open access endoscopy service at Louth
• Louth will become an elective and diagnostic centre delivering
services to patients from across Lincolnshire and North Lincolnshire27
Planned Care (2)
Risks and Issues
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Increased demand for haematology/oncology services and no
option to increase beds
Inability to recruit staff with the correct skills and experience
Neurology has been carrying 2 consultant vacancies for 2 years
Dermatology 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 expertise
Elective 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 nursing
Nurse practitioners, practice nurses and salaried GPs are difficult
posts to recruit to
Band 7 ANPs for RRS/Walk-in centre/minor injuries unit and
OOH are difficult to recruit to
Increasing complexity of cases in the community
Demographic change e.g. ethnic diversity. People access
services differently and require more public health input
Interface with IT services in working across agencies; inputting
highlighted as time consuming.
Ageing workforce combined with change fatigue may impact on
future capacity
Community specialist Speech & Language Therapists and
Specialist Physiotherapists posts are difficult to recruit to
Oncology has no training middle grade posts at either Lincoln or
Boston
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OOH is covered by locum middle grade shifts until 9pm
when the Hospital at Night and medical rota takes over
Recruitment 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 supply
Lack of trainees in healthcare sciences
Reluctance of oncology consultants to provide 7 day ward
round
Lack of suitably trained chemotherapy nurses and
difficulty in recruiting them
Advertised twice a pain
consultant post without
appointment (out to advert again)
Staff consultation re; more diagnostic services being 24/7
TUPE of pharmacy and technician staff (or potential for
staff to leave as a result of implementing ‘shop in shop’
model
Failure to recruit interventional radiologists to implement a
viable on-call rota – impacting on the vascular service
Ability to recruit consultant radiologists
National shortage of sonographers
Urological surgical emergencies, service is not integrated
across Lincoln & Pilgrim
Service delivery issues in urology (requirement to review
service model) which is impacting on RTT
Potential shortage of urology consultants
Reduction in surgical training numbers will impact on
future workforce supply
28
Planned Care (3)
Education & Training
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Specialist practitioner training
Nurse practitioner modules
Long term conditions management to include dementia
Higher level clinical skills e.g. venepuncture, cannulation,
ECG interpretation
Extending the scope of professional practice in nonregistered workforce
Affordable Assistant Practitioner training
Engage with Productive Ward Programme
Non medical prescribing
Dysphagia assessment skills
Loss of provision for PTP training in medical physics
(alternatives being developed
District nurse training needs updating to reflect increasing
acuity in the community
Occuplasty training
Workforce Development & Transformation
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Introduction of nutritional nurse on Lincoln County Site
On-going increase of CNS over next 5 years
Additional specialist nurse required to support respiratory
outpatients
Review community services, skill mix, competencies and
establishment
Assistant Practitioners to support registered staff in the
community
Complex case managers/clinical nurse specialists in
disease/specific conditions aligned to locality structures
District case manager acts as specialist generalist and
key worker
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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 service
Business support staff to release clinician time spent on administration
activity
Exploring options for different working patterns to ensure workforce
available to meet service demands
Increased staffing in rehabilitation medicine (Drs, nurses, dieticians,
OT, physio, SaLT and psychologists
7 day therapist input to orthopaedic wards will require additional
registered and non-registered staff
Increase specialist nutrition support dietician 1 wte
Develop CNS posts in oncology to release consultant clinic time that
will free up time for consultant ward work
Additional radiotherapy staffing as LINAC replacement is progressed
Additional medical physics staff for development of IMRT and IGRT
service
Increase nursing, physiotherapist and clinical psychologists
establishment for multi-disciplinary pain service
Increase technician grades in Pharmacy
Expansion of numbers in endoscopy and cardiac physiology
Expansion of non-medical consultant roles (diagnostics)
Increase in assistant practitioners (diagnostics)
Increase of surgical team, nursing and admin for surgical day unit at
Grantham
24/7 senior nursing on site at Grantham
Predominantly nurse led endoscopy at Louth
Increased workforce at Louth as elective and diagnostic services
expand
B6 Occuplasty specialist nurse to be appointed as a training post to
work towards B7
Development of breast physician posts
Review of specialist breast nurses
Operational Head of Service role introduced for Urology at Pilgrim
29
Primary Care
Includes 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 workforce
Change & Reconfiguration
Education & Training
• Increase of services delivered in primary care
particularly in pharmacy, audiology and optometry
• Continued development of diagnostics and
procedures being carried out in GP practices
• Need to promote future cohorts of
Foundations in Practice Nurse programme
• Developing
an
Associate
Trainers
programme
Risks and Issues
Workforce Development & Transformation
• DN/HV no longer often being co-located in GP
practices which is impacting communications and
ability to partnership work
• Age profile of GPs in Lincolnshire
• Participation rates of GP workforce is falling
• Trends for recruiting practice nurses tends to be
from practice to practice rather than a choice for a
newly qualified nurse
• Lack of sufficient GP trainees coming to
Lincolnshire (9 out of 30 places recruited to)
• Associate Trainers programme will support nurses to
take a teaching/training role
• Continued development and utilisation of Nurse
Practitioners
30
Frail Older People
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 hospital
Change and Reconfiguration
Education & Training
• Development of integrated locality teams, tier above
this model is development of rapid response services
• Less acute activity, shorter hospital stays and
specialist support provided in the community
• Support people by use of remote systems such as
telephone follow up
• Need the ability to share data across the health and
social care community
• Single point of access and rapid targeted response
• 3rd sector to single point of access
• Need to improve discharge process and ensure
capacity in transitional care
• Improve discharge planning, particularly for complex
discharge
• Establishment of a DTOC ward (pilot)
• Established 4.98wte Care of the Elderly Consultants
(incl. 0.98 Consultant in Psychological Medicine)
• Wide of range of services offered incl. telephone
advice, rapid access clinics
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Risks and Issues
• How to think and work differently
• Patient focused mind sets
• Sharing data across organisations
Thinking and working differently, changing culture
Leadership at every level
Concept of a multi-skilled workforce
Care management and care co-ordination
Communication
Dignity, respect and customer focused
Workforce Development and Transformation
• Development of combined organisational roles –
community geriatrician (ULHT, St Barnabas and
CCGs)
• More activity in the community, including therapy and
nursing skills to support independent living
• Reviews of ways of working to compliment the FOP
pathway work
• Team working across professional groups and
working across boundaries
• Option to review all levels of the workforce; roles,
working practices, skills and competence
• Use of CNS to assess relevant patients at the front
door
• Staffing of DTOC ward configured to take into
account the dependency of patients
• Potential role of Elderly Care Nurse Consultant
31
End of Life Care (1)
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 community
Change and Reconfiguration
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Increasing co-morbidities and complexity of disease,
but earlier intervention potentially delaying contact
later in the journey
Partnership working essential for shaping future
services in EOL care
Strengthening links between organisation including
outside the ‘traditional’ NHS family
On-going development of specialist palliative care in
IPU, hospitals and community
Develop hospice operated community palliative care
beds at Grantham
Strengthening hospice palliative care teams on the
three acute sites
Development of acute oncology service
Reconfiguration of community MacMillan teams
Electronic Palliative Care Co-ordingation system
(EPa CCS)
Telemedicine
Risks and Issues
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•
•
•
Ability to work cross-boundaries (continued silo
working)
Equity of training across health and social care
Increase in dementia, frail older people and comorbidities increasing acuity in the community
Change in family dynamics – still requirement for
trained support
• Safer care – timely sharing of information
• Workforce planning training for service managers
• Mis-match between health promotion and
screening and the impact on our client group
Education & Training
• Equip staff to undertake role redesign and be
solution focussed
• Local training supports local recruitment but need
to bring new people in too
• Invest in potential future staff
• Wider workforce need ACST skills training
focussing shift to self-care
• Core skills, passport development
• Mandatory training delivered in blocks (impact on
smaller teams) . Blended learning approaches
including webex
• More exposure to 3rd sector in pre-registration
training
32
End of Life Care (2)
Workforce Development/Transformation
• Role description required for ‘enhanced’ key worker role
– Navigate patient through the system
– Advocacy skills
– Work for an integrated service and system with authority to access resources
– COMMISSIONER LED AND CONTRACTED: underpinned with service specification and KPIs. Role
will be required to ensure patients are on an EOL pathway
• Making use of the potential workforce e.g. migrants and armed forces
• Consideration of the knowledge, skills and competencies required by the whole of the workforce
• Utilising the wider workforce effectively
• Generic assistant practitioner role – at the right place in the pathway
• Re-enforce F1 rotation at F2 e.g. nausea and vomiting training programme for F2 palliative care –
medical/surgical
• Pick up cover roles in the community – more difficult for acute trusts
33
Prepared by East Midlands
LETB Workforce Team
(Lincolnshire)