Richard Griffin MBE is Professor of Healthcare Management, King’s Business School. (740 words)
Many years ago, I worked for an NHS Workforce Development Confederation (WDC), that had just been merged with a Strategic Health Authority (SHA). A few months into my role as Director of Education, a colleague asked me a question that has stuck with me ever since. “Who” she said, “owns workforce in the NHS?” A very good question. (1)
Consider the current situation. Is it the Department of Health and Social Care, or Health Education England, or NHS England and Improvement? Where do Public Health England, Skills for Health or NHS Employers or the Social Partnership Forum fit in? They all have roles. What about regional People Boards? How about Integrated Care System (ICS) People Boards? Or the workforce leads in Primary Care Networks? In Trusts is it HR, or clinical leads like Directors of Nursing or the Learning and Development? It gets even more complex when you consider individual occupations like maternity, where you have Local Maternity Systems, or Allied Health Professions, where you have Councils and Faculties.
From pre-employment to careers information, apprenticeships and beyond, all these bodies are doing good things but not always together. Also, there is no single NHS workforce plan – it is spread across numerous policy documents from the People Plans to the latest Operating Guidance.
Frankly, it is all a bit of a “kludge”.
Derived from computers a “kludge” is defined by the Oxford English Dictionary as “an ill-assorted collection of parts assembled to fulfil a particular purpose…a clumsy but temporarily effective solution to a particular fault or problem.”
The political scientist Steven Teles argues that a lot of public policy in liberal democracies is kludge. Initiatives are bolted on to already complex approaches, frequently in response to a specific current issue. (2) Every new assemblage, he says, further dents the policy’s original form and focus. Rather than starting from scratch, public policy delivery is often a make do and mend approach. Not surprisingly things don’t always work.
Vocational education in the U.K. is a perfect example of this. Since the early 1980s there have been 29 major pieces of legislation relating to vocational education, skills and further education. The policy area has been led by 49 Secretaries of State over that time.
I think NHS workforce planning shows signs of being kludge too. It is interesting, for example, that nearly two decades after my time with the SHA/WDC, to a large extent ICS, which should become legal entities next year, are essentially replicating their role. They largely cover the same geography and seek to align delivery of services with workforce planning, including the need to take account of local communities. The most recent NHS Operating Plan (2021) calls for ICS to – “…develop and deliver a local workforce supply plan with a focus on both recruitment and retention, demonstrating effective collaboration between employers to increase overall supply, widen labour participation in the health and care system, and support economic recovery”. Good stuff, but it is what we used to do in SHAs. Between then and now we have had Primary Care Trusts, Clinical Commissioning Groups, Health and Wellbeing Boards, HEE in various guises, NHS England, NHS Improvement and so on.
The NHS is the biggest employer in the U.K. Delivering safe and effective care is reliant on having the right number of staff with the right skills working in the right place. Workforce has long been the biggest challenge the NHS faces and the kludge like approach to organisation and structures has played a part in that crisis. The welcome news is that The NHS Interim People Plan of 2020 clearly set out the functions that will be carried out nationally, regionally, and locally and the recent NHS White Paper called The Future of Health and Care, signalled that there will be a central workforce plan, rather than somewhat arbitrary targets. It is essential though that this central plan does not hamper ICS’s ability to make decisions and build partnerships locally with local employment and skills’ partners including universities, colleges and councils.
My colleague’s insight, nearly twenty years ago, was that actually no one owns NHS workforce. Hopefully the new system being built (it is certainly not in place yet) will mean soon it will be much clearer.
Richard Griffin MBE is Professor of Healthcare Management, King’s Business School.
(1) Thanks to Gita Malhotra for asking the question.
(2) Steven M Teles (2013). Kludgeocracy in America. National Affairs, Number 17 Available from: https://www.nationalaffairs.com/publications/detail/kludgeocracy-in-america ]