How can we build a rural health and care workforce?

The NHS tuned 70 on 5 July 2018. This year has seen celebrations and appreciation of the vital role that the service plays. As the NHS ages the pressures and demands it faces are very different to those of 1948 – with the workforce under considerable strain to provide services. How can we plan, fund, recruit, train and retain health and care workers in rural areas that meet people’s (clinical and wellbeing) needs and the (professional/lifestyle) aspirations of staff? Jessica Sellick investigates.

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NHS England employs some 1.2 million people – in more than 350 different roles: from 140,000 doctors and 300,000 nurses and midwives through to physiotherapists and dieticians. Despite these numbers it is apparent to all that the NHS just doesn’t have enough staff. There are some 50,000 vacancies in different clinical areas, with a 5.9% shortfall between the staff needed and the staff in post. 

In November 2018 the National Institute of Economic and Social Research (NIESR) prepared a report for the Cavendish Coalition on the health and social care workforce (H&SC) in all parts of the UK – highlighting trends over time and across regions and job roles – and providing a number of simulations on the workforce in the next few years. By examining the pattern of leavers and joiners to the NHS over the year prior to June 2016 and the year post June 2016 the model suggests the UK may have an additional shortage of around 2,700 nurses. Projecting this shortfall over the remaining period of Brexit transition to 2021 suggest there may be a shortfall of 5,000-10,000 nurses in addition to current vacancies. While challenges around developing a sufficient workforce supply pre-date the Brexit referendum, and Government reforms to education and training routes, the report calls on Governments to urgently review their workforce planning approach.

What do these shortages mean for rural health and care staffing?

In July 2018 I was part of a research team commissioned by United Lincolnshire Hospitals NHS Trust (ULHT), funded by Health Education England (HEE), to apply a rural lens to the workforce challenges facing the NHS in England.  The research involved: 

• Applying the Rural Urban Classification – an official statistic used by Government to distinguish rural and urban areas – to the different units that health and care as a system is organised into.    
• Analysis of economic and labour market data: using the Rural Urban Classification to produce a demographic profile for different rural areas, their trends in employment and unemployment, qualifications, occupations and earnings data.
• An evidence review of academic, health and care charities, national and professional bodies that made reference(s) to rural health and care workforce matters.
• Analysis of a survey about adult social care involving 13 rural first tier Local Authorities commissioned by the All-Party Parliamentary Group (APPG) on Rural Services.
• A series of one-to-one interviews and focus groups with 20+ NHS staff in Cumbria, Northumberland, Lincolnshire, Herefordshire, Worcestershire, Kent and Cornwall.

The findings of the research were triangulated with a reference group. The group comprised individuals with different perspectives on workforce development at local, regional and national levels (e.g. representatives from rural general practice, acute care, clinical commissioning groups, professional clinical bodies, Local Authorities, charities and community groups). 

The golden thread running through the research is that securing staff to deliver high quality health and care in rural areas (now and in the future) is crucial.  The research identified the following 9 challenges around recruiting and retaining staff in rural areas:

1. Rural areas are characterised by the disproportionate out-migration of young adults and in-migration of families and older adults.
2. This means that the population is older than average in rural areas – this has implications for demand on health and care services and for labour supply.
3. Relatively high employment rates and low rates of unemployment and economic inactivity mean that the labour market in rural areas is relatively tight.
4. There are fewer NHS staff per head in rural areas than in urban areas.
5. A rural component in workforce planning is lacking.
6. The universalism at the heart of the NHS can have negative implications for provision of adequate, but different, services in rural areas.
7. The conventional health service delivery model is one of a pyramid of services with fully-staffed specialist services in central (generally urban) locations – which are particularly attractive to workers who wish to specialise and advance their careers.
8. Rural residents need access to general services locally and to specialist services in central locations to provide the best health and care outcomes.
9. Examples of innovation and good practice are not routinely mapped and analysed which hinders sharing and learning across rural (and urban) areas.

The research also identified 9 opportunities to maximise the supply of staff in rural areas: 

1. Realising the status and attractiveness of the NHS as a large employer in rural areas (especially in areas where there are few other large employers). 
2. This means highlighting the varied job roles, opportunities for career development and need for generalist clinical skills in rural areas. 
3. This means developing ‘centres of excellence’ in particular specialities or ways of working in rural areas that are attractive to workers.
4. This requires developing innovative solutions to service delivery and staff recruitment and retention. 
5. This may provide opportunities for people who need or want a ‘second chance’ – perhaps because the educational system has failed them, or because they want to change direction; their ‘life experiences’ should be seen as an asset.
6. Finding new ways to inspire young people about possible job roles and careers in health and care.
7. Drawing on the voluntary and community sector, including local community groups, to play a role in the design and delivery of services.
8. Promoting local solutions to foster prevention and early intervention.
9. Using technology so face-to-face staff resources are concentrated where they are most effective and needed.

Inherent in addressing these challenges and realising these opportunities are a number of trade-offs. These concern balancing centralisation and localisation (in the way health and care are organised); balancing the flexibility that the workforce desires with filling rotas (to meet required safety standards); balancing the number of clinical specialists with expert generalists; and balancing the use of technology with face-to-face provision.

The research report was published in October 2018. A copy of the report is available from the National Centre for Rural Health and Care (NCRHC) here.  There are three overarching points emerging from the research that may be of particular interest to RSN members: (1) spatial component, (2) staffing and (3) funding.

Firstly, the research highlights the lack of a spatial component in workforce planning. In 2016 the NHS and Local Authorities came together in 44 areas covering all of England to develop proposals to improve health and care. Called ‘Sustainability and Transformation Partnerships ‘(STPs) they have been set up to run services in a more coordinated way, agree system-wide priorities, and to plan collectively how to improve residents’ day-to-day health. NHS Shared Planning Guidance led to the publication of a document setting out how these 44 STP footprints should be formed. This highlighted five factors: (i) geography, (ii) scale, (iii) fit with existing footprints of change programmes, (iv) the financial sustainability of organisations in the area, and (v) leadership capacity and capability to support change. Since 2016 STPs have been publishing plans setting out proposals for how they will achieve these aims – with some STPs evolving into Integrated Care Systems (ICS).

The rural workforce research found 22 of the 44 STPs have a population share equal to, or greater than, the England average (of 17%). The research analysed 10 STP plans in detail – with these areas chosen because they have at least double the share of rural population than England as a whole. Across these 10 plans there are fewer than 50 references to ‘rural’. None of the plans makes a clear link between the rural area they cover and the workforce challenges that they face. That said, some of the plans do highlight how rurality impacts more generically on service delivery (e.g. time, cost and distance) – but these tend to be introductory and contextual remarks rather than integral to the documents. While RSN members recognise and champion the heterogeneity of rural areas– geographically and socioeconomically – this spatial component is not always taken into account in health workforce planning.

Secondly, the research highlights how there are fewer NHS workers per head of population in rural areas compared to urban areas. NHS Workforce Statistics publish monthly numbers of NHS Hospital and Community Service (HCHS) staff groups working in Trusts and CCGs in England (excluding primary care staff). This data on headcounts is compiled and published by NHS Digital. The research looked at the statistical bulletin published in April 2018 which included monthly headcount figures from January 2018. The headline figures show: 

• The headcount was 1,205,949 in January 2018. This is 7,711 (0.6 per cent) more than the previous month (1,198,238) and 21,068 (1.8 per cent) more than in January 2017 (1,184,881).
• The full time equivalent (FTE) total was 1,064,810 in January 2018. This is 6,910 (0.7 per cent) more than the previous month (1,057,900) and 19,252 (1.8 per cent) more than in January 2017 (1,045,559).
• Professionally qualified staff make up over half (54.0 per cent) of the HCHS workforce (based on FTE).

Analysis of this data reveals an overall difference in the ratio of NHS staff per head of population (excluding regional ambulance services) in the 11 most rural STP areas compared to England as a whole of 45%. This means compared to the national average rural areas have 45% fewer workers per head of population. And this picture does not appear to be improving despite the increase in headcount in some staff groups. In rural areas there are 10 key staff groups with shortages. They are: professionally qualified clinical staff, doctors, consultants (including Directors of Public Health), staff grade, specialty registrar, core training, foundation doctor year 1, midwives, scientific/technical and property/estates.

The research found recruitment poses a greater challenge than retention in many (but not all) rural areas. Achieving an optimal balance between mobility and immobility is important – some churn is valuable in stimulating new ideas, but too much churn is problematic. A segmented approach to recruitment is needed to focus on what makes rural areas attractive to different staff groups.

The research also highlights the need (in rural and urban areas) to think of workforce development in terms of an employment pathway: get in, get on and go further. For rural areas this could mean “grow your own”, i.e., finding ways to recruit, develop, cultivate and retain individuals from the local community to enter healthcare careers to help provide a long-term solution to addressing workforce challenges. For rural areas it could also mean thinking about health and care careers in terms of a ‘climbing frame’ rather than a ‘ladder’ because a career could include side-steps, changes in direction, entry into related or new specialisms and/or working for longer. For rural areas it could mean developing more innovative health and care service delivery models. For example, The Buurtzorg Nederland (home care provider) Model is based on small, self-managing teams of community nurses who have access to coaches for ongoing support and spend at least 60% of their time with patients – could a similar approach work in rural England? 

Thirdly, health and care funding formulas do not take into account the additional costs of delivering services in rural areas. From speaking with clinical and non-clinical staff the research identified additional costs associated with: staff joining towards the end of their clinical career rather than towards the start or middle (leading to higher wage bills); a lack of nearby acute centres to divert patients to if your own centre is full;  staff distance from training and continuing professional development and higher education opportunities; and poor road network (affecting ambulance response times, staff travel time).  In October 2018 The National Centre for Rural Health and Care (NCRHC) commissioned the Nuffield Trust to carry out ‘a rapid review of the impact of rurality on the costs of delivering healthcare’.  The review is considering how the NHS takes account of rurality in its funding allocations (e.g. unavoidable smallness due to remoteness). The Nuffield funding review will be available on the NCRHC website in December 2018. Given the announcement of an extra £2 billion for mental health services and £650 million grant for Local Authorities struggling to cope with rising care bills for 2019/2020 contained in Budget 2018 [NB: the budget for day-to-day running costs for NHS England is £114.6 billion for 2018-19]; it will be interesting to consider how the findings of the workforce research and the Nuffield review can be harnessed to inform future funding allocations to improve the ‘provider to population’ ratio?

Perhaps what this research reveals is the need for rural proofing in the funding, planning and delivery of health and care services. I am aware that Defra is looking at the guidance it provides to policymakers. There is also interest in rural proofing health and care policies in Northern Ireland and Wales. This also means understanding, in some detail, the character of rural populations and the health issues facing them (which are often masked by official statistics); and thinking through how we promote rural [as offering professionally fulfilling and rewarding careers with high quality of life] to health and care professionals. Can we do this? Watch this space…

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC). The NCRHC is a Community Interest Company, national in scope and with a Headquarters in Lincolnshire, and focuses on four principal activities: data, research, technology and workforce.

The NCRHC is providing the secretariat for a new Parliamentary Inquiry into Rural Health and Care.  The Inquiry is being led by the All-Party Parliamentary Group on Rural Health and Social care and is co-chaired by Ann Marie Morris MP and The Rt Revd and Rt Hon Dame Sarah Mullally. Eight key issues will be considered by the Inquiry over the next two years:

1) What are the needs of rural communities and how are they different from their urban counterparts?

2) How are rural health and social care needs currently met?

3) What is not working in rural communities and why?

4) Workforce challenges and opportunities

5) Education and training challenges and opportunities

6) Structural challenges of fitting current delivery models into a rural setting with different needs and challenges

7) Technology opportunities and challenges

8) Integration opportunities and threats

The first key issue was considered at a session on 30 October 2018 held in the House of Commons. Updates on the Inquiry and how to participate will be available on the NCRHC website and/or by emailing the Operations Director for the NCRHC Ivan Annibal via enquiries@ncrhc.org    

When Jessica’s not working at the NCRHC she is a researcher/project manager at Rose Regeneration. Her current work includes helping public sector bodies to measure social value; evaluating a hospital avoidance service; and undertaking a piece of work on migration.

In her spare time Jessica sits on the board of a housing association.

She can be contacted by email jessica.sellick@roseregeneration.co.uk or telephone 01522 521211. Website: http://roseregeneration.co.uk/ https://www.ncrhc.org/ Blog: http://ruralwords.co.uk/ Twitter: @RoseRegen

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