Refocusing the health and care system: workforce implications

The King’s Fund has recently published a major report calling for a wholesale refocusing of the health and care system to put primary and community services at its core.1 Our recommendations include actions for national leaders and politicians, but some thorny issues were raised around the way in which clinicians and leaders in health and care work and are trained which will be core to the refocusing that is required. These are particularly pertinent for us—a current GP and former NHS leader.

With an ageing population, multiple health conditions also affecting younger populations, and growing health inequalities, the need for practitioners to work effectively in the community, handle complexity, and cope with inherent risk is ever more pressing. While the NHS long term workforce plan sets out ambitions in this area, to date, the workforce growth in the NHS is centred on acute hospitals (the consultant workforce has grown by 18% in the past five years, compared to an at best static GP workforce).

Working in primary and community health and care settings is often seen as lower status than working in the acute hospital sector—a perception that often begins during training. One clinician we interviewed reported: “Acute was sexy, community was for failed clinicians or females who wanted to go part-time to have children.” But we also heard reflections that the reverse was true for previous generations: “If you moved to the community it was high status, you got paid more and you were recognised by your colleagues as having moved up in the world, in nursing, in your career, because you were autonomous as a practitioner, taking a risk out there.”

This perception of primary and community health and care services is not helped by a lack of effective data. The currency of community care is time rather than the number of transactions, but this is hard to measure and it is often easier for leaders to default to hospital-focused measures such as delayed discharges, and waiting times. Added to this, many of the most senior leaders in the NHS have backgrounds working in acute hospitals, partly because of the perceived high status of working in large teaching hospitals. This limited experience of primary and community health and care services, and limited data on those services, mean that leaders’ understanding of the issues can be lacking.

The perception of lower status is not helped by training programmes which do not explicitly require placements in primary and community services, and by differences in pay resulting from the way services are structured and commissioned. Arguably the nature of risk that practitioners working in primary and community settings face is more challenging, with more autonomous working and the need to manage uncertainty without the immediacy of other professionals or interventions, and yet this is rarely rewarded in financial terms.