Integration and Innovation: Where is the workforce in the White Paper?

Introduction

Once again, plans for the workforce are surprisingly absent from a major national plan to reorganise healthcare.  The Long Term Plan in 2019 famously abstained from addressing how the healthcare workforce would deliver its ambitions over the next 10 years, leaving this for the People Plan to address in 2020.  Now, in 2021, the White Paper has done the same, but without leaving time for a follow up plan.

The most specific the White Paper gets on workforce proposals is to say that:

“We also know that we need to support staff during organisational change by minimising uncertainty and limiting employment changes. We are therefore seeking to provide stability of employment and will work with NHSE and staff representatives to manage this process”.

Nevertheless, although “stability” is promised, there is no detail as to how, for example, thousands of CCG commissioning staff will magically emerge within the new ICS structures or in provider bodies.

Planning the Workforce elements is a fundamental part of delivering a complex reorganisation and this detail needs to be urgently elaborated upon if commitments to consult with staff are to be met in good time.  

Preparatory steps

Certainly some of the groundwork to implement many of the major workforce changes that will be needed, has been done in the last year.  The People Plan and the pandemic have paved the way for some of the major cultural shifts to more collaborative working. 

The pandemic response has quickly implemented reforms to reduce workforce bureaucracy, set up joint working and efficiently distribute leadership around place based systems.  Other changes have been developed under the auspices of the People Plan’s commitment to “New ways of working”.  In some cases, it may be possible to adapt some of these temporary changes to permanent fixtures.  For example, adjustments to the regulatory context for staff working collaboratively across organisational boundaries and sector boundaries, or to staff protection, such as the helpful temporary extension of indemnity cover for clinical negligence liabilities when working across boundaries. 

A few key Workforce challenges

1) Stamina for change

Arguably the biggest challenge will be motivating and energising the exhausted healthcare workforce to deliver these proposals.  There is a real concern about the collective mental and physical health of not only frontline staff, but organisational leadership and HR professionals who will need to drive and administer the necessary consultations in the aftermath of the pandemic response.  The unions and the shadow health secretary have already raised concerns about timing of this restructure. 

2) Flexibility

The success of ICSs is often based on expectations for staff to be more flexible in what they do, when they do it, and where they do it.  The White Paper focuses on collaborative working across “place” based systems, beyond traditional organisational and sector boundaries.  Whilst the pandemic has shown that this can be temporarily achieved in response to a crisis, it can’t be taken for granted that longer-term flexibility will automatically follow.  There is work to do here both in terms of engagement and in terms of the underlying contractual flexibilities. 

Movement of staff is going to be very dependent on what is defined as “place” within each system, which has been left to local discretion.  From both the engagement and contractual perspective, there is going to be a need to first consider reasonable expectations of staff in relation to the “place” in question.  For example, whether it is reasonable to flexibly deploy staff across a large rural ICS, or to deploy staff flexibly across much smaller geographical urban areas (such as multiple boroughs in London which might be more difficult to traverse).  A view of what is reasonable will then need to be built in to the staff engagement model and into contractual mobility clauses.  Both of these require plenty of time for consultation.

3) Staff contracting models

For every different partnership and collaboration arrangement, careful thought must be given to the best fit from a slightly bewildering array of staff contracting models.  At the moment, the pandemic response has given rise to numerous relatively informal models.  Memoranda of Understanding have been rapidly put in place, or placement agreements are being relied on for smaller scale situations.  These will need to be formalised or adapted in favour of more permanent models for joint working and staff sharing.

Some of the options available may include joint employment models, where each member of staff has a single employment contract with more than one employer; or dual employment models, where staff hold parallel contracts with separate employers (meaning less flexibility, but easier administration and separation); or secondment models where staff are retained by their primary employer and, usually temporarily, shared with host employers who have less control over them.  Crucially, any system should look to avoid models labelled as “Honorary Contracts” except in very specific circumstances for clinical academics, as this tends to be short-hand for “I don’t know what the right contract to use is”.

4) Organisational certainty

The risk here is that overlapping organisations or groups, whether place-based, system-based, or still based on old fashioned individual organisations will all be drawing from the same pools of staff.  There is some risk of staff being pulled in multiple different directions.  “Flexibility” is going to be the core expectation for staff in the new collaborative working systems.  Nonetheless, workforce leads will need to understand what those systems are, in detail, and how they are to interact, in order to adequately workforce plan.

5) Other practical challenges

More prosaicly, system working will require a whole host of practical complexities to be overcome.  These require investment in system-level workforce teams and expertise, with the vision to think strategically as well as fine-detail operational delivery.  High on the list of boring but important operational issues will be the difficulties of staff data sharing across organisations.  A large part of the White Paper focuses on “busting bureaucracy and data sharing” for patients and service users, but no mention is made of the challenges in relation to staff data.  Similarly, grappling with different staff terms and conditions across the “place” as defined in each system will be essential to avoid pockets of discontent and encourage engagement.  This includes the challenges presented by different benefits, particularly pensions, available across the system.

What next?

Systems and individual organisations would be well advised to start addressing and engaging with the wide variety of workforce challenges as quickly as possible.  April 2022 will come round very quickly indeed and, in the meantime, a great deal of clarification will be needed on system structures before the real workforce analysis and planning can begin, let alone the lengthy consultation processes needed to properly engage with unions and staff to achieve change without relying on the slow and adversarial mechanisms of enforced contractual change.  Nonetheless, organisations which get ahead of the curve by introducing flexible contractual models as quickly as possible will be in a significantly better place to negotiate.

To find out more about the White Paper and how it could affect your organisation, please visit our ICS webpage.