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NHS faces its biggest challenge since the funding increases seemed like water to a parched flower - funding will cease to grow in 2011. Workforce is the area of biggest spend[1], so reviewing this using
workforce design techniques, and consulting with the staff to bring around culture development, are vital to achieve change in this area

But the 2002 Derek Wanless report (Securing our future health: taking a long-term view) already told us that if we carry on doing health the same way as we do it today, every able person in the country will be occupied looking after the less able - we have to change!

So how do you design a workforce fit for purpose?

And more importantly, how do you deliver such a workforce?

Firstly, understand that there are many ways to achieve the same end. A few very skilled, very highly paid people can provide a very fast service and deliver excellent outcomes: a larger number of less skilled, less highly paid people can spend longer with each patient and deliver equally good outcomes[2] - the choice really seems to depend on your starting point

• young skilled and well-qualified staff anxious for more responsibility, or
• the senior staff about to retire

Of course you need to match the workforce to the need in terms of activity and competency, and I've looked at this in different ways - see Resource & workforce planning for an overview, and more specifically Economic and workforce modelling in urgent & emergency, and workforce reprofiling in acute & mental health as well as the introduction of ECPs to the first contact team. There are more examples on the pages listed below:

And what about changing the culture?

So many culture change programmes attempt to align culture to the Chief Executive's view of what the culture should be. It's like getting a marketing company in to write you a vision and mission statement - it sounds great but nobody buys it.

We engage with all the staff, in a four stage approach:

1. understand the current culture(s), how they vary by top/ middle/ bottom[3], where the gaps and glass ceilings occur, reporting back not just to the board and project team but to the whole staff
2. helping front-line and support staff understand what is expected of the organisation, in clinical outcome and quality terms, volumes of activity, economically, politically, and the constraints. Help everyone to feel they belong (see one example, where feedback included "now I remember why I joined the NHS")
3. gaining consensus on where the organisation would like to be, culturally, and the activities each individual and team need to do to make this happen
4. monitoring: setting the performance measures (yes, for cultural development!) and showing a reporting mechanism and reporting which gives everyone feedback - each can see the difference their activity makes both to cultural development and the performance of the organisation in each of the areas it needs to perform

This can be very scary for an unconfident or over-controlling executive board. Are you willing?

Footnotes

1. NHS employed workforce represents around 70% of costs, but 15% goes on independent contractors (GPs, Dentists, Pharmacists, etc) who presumably have a similar proportion of staffing costs. This suggests workforce (NHS and independent) represents closer to 80% of the total NHS budget
2. A study on ward staffing and healthy outcomes for patients at Sheffield Teaching Hospital concluded that you could achieve the best outcomes for patients through a variety of different staffing models; meanwhile lowest wage bill was usually not cost-effective on a per-patient basis because of increases in complications, extended stays and readmissions.
3. Top - often bullish about a wonderful future and keeping on coming up with new ideas. May have forgotten that there's a service to deliver 24*365 in addition to any new ideas. Middle - fearing another new idea from the exec team. Bottom - getting on with the day to day mundanities and resenting any attempts to change their work

Further Reading

There are thousands of books on culture change, many assuming that you can apply the same change processes to public service organisations, and NHS in particular, as you would in the commercial world.

I've identified just three below which I think are the most pertinent, and that don't make these sweeping generalisations

As for workforce design, there's surprisingly little of use: I compiled a list of workforce design tools which is due to appear on the Skills for Health New Ways of Working workforce tools site.