Lincolnshire Workforce Plan 2013/14

1. Lincolnshire Workforce Plan 2013/14

2. 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

3. 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 post-Francis. 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:- 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 for 2014/15

4. 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.

5. 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

6. 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. • 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. • 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) • It is evident that the changes to the Lincolnshire population are caused entirely by the effects of migration movements into the County. • 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. • 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. • 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. 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 doublein size (109%) between 2008 and 2033

7. 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 • 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 • 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 • 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 socio-economic groups more likely to take up screening programmes. Smoking and diet are also lifestyle risk factors associated with developing some cancers.

8. 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

9. Workforce Opportunities

10. Workforce Risks

11. Medical Workforce

12. Nursing & Midwifery • 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. • 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. • 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. • 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.

13. Allied Health Professions (1) All AHP Groups • 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 • Neuro-rehabilitation • Cognitive rehabilitation • Oncology/palliative care • Hand therapy • Dementia • Parkinson's disease • Women’s health physio • Paediatric OT • Vocational assessment and rehab across a wide range of staff • 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

14. Allied Health Professions (2) Dietetics 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 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 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 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

15. Healthcare Science & Pharmacy Scientist Workforce • 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

16. 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

17. 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.   • Risks and Issues • 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. Change and Reconfiguration • 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.

18. Maternity & Newborn (2) • 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 pre-registration. • 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. Workforce Development • 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 • 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

19. 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 • 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 Plan to support IBP 2013/14 and LTFM • 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.

20. Mental Health & Learning Disability (2) Detailed Workforce Reviews • 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

21. Mental Health & Learning Disability (3) Workforce Risks The following identifies the workforce risks and their mitigating factors: • 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

22. Children’s & Healthy Lifestyles (1) • 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 Change and Reconfiguration • 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

23. Children’s & Healthy Lifestyles (2) • Workforce Development & Transformation • 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 Education & Training • 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

24. 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 • 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/4thresus 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

25. Urgent Care (2) • 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 multi-professional 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 Risks and Issues • 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

26. Urgent Care (3) Workforce Development/Transformation • 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

27. 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 • 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 Lincolnshire Change & Reconfiguration • 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

28. Planned Care (2) • 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 Risks and Issues • 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

29. Planned Care (3) • 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 Education & Training • 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 non-registered 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 • Occuplastytraining Workforce Development & Transformation • 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

30. 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 • Education & Training • Need to promote future cohorts of Foundations in Practice Nurse programme • Developing an Associate Trainers programme • Change & Reconfiguration • 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 • Risks and Issues • 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) • Workforce Development & Transformation • Associate Trainers programme will support nurses to take a teaching/training role • Continued development and utilisation of Nurse Practitioners

31. 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 • 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 • Risks and Issues • How to think and work differently • Patient focused mind sets • Sharing data across organisations • Education & Training • 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

32. 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 • 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 • Ability to work cross-boundaries (continued silo working) • Equity of training across health and social care • Increase in dementia, frail older people and co-morbidities 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

33. 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

34. Prepared by East Midlands LETB Workforce Team (Lincolnshire)