You can’t workforce plan in health and care without population health management
Workforce Planning can be defined, as it was by Health Education England, as: “……to support the delivery of excellent healthcare and health improvement to the patients and public by ensuring that the workforce of today and tomorrow has the right numbers, skills, values and behaviours, at the right time and in the right place.” I appreciate that this is a health definition – but it is a good one nonetheless.
At its heart, workforce planning is about balancing the demand for health and care, with the supply of the right staff. You need to have the right amount of people with the right attributes to meet demand.
The trouble is, what we are normally talking about is not DEMAND, it is ACTIVITY. We often don’t have much information on demand – but we do know how much activity we did. The trouble is that activity just represents the patients that come through the door and are treated – it often does not include:
· People that were booked but did not turn up (Did Not Attends or DNAs). Those people may still need care.
· Cancellations that we made. Those people probably still need care.
· People that want care, but may not have been able to access it for some reason – not able to access care in the place it is delivered, queues too long for people to wait, etc. This is unmet demand for health and care.
· People that don’t even know that they need care.
And that is, unfortunately, a massive problem. Of course, we are worried about meeting activity – if there is a busy list or a queue of people out the door, we need enough of the right staff to deliver care to those people.
Even if we don’t always take them into account, obvious queues are also something we can see and know we need to do something about. Not enough GP staff to offer appointments quickly, hospital waiting lists, backlogs of social worker case load, these are all visible, if sometimes hard to quantify indicators of excess demand. We’ve developed models that have included these, but not all models have these included if they are not communicated or known.
Assuming we include DEMAND for healthcare, rather than just ACTIVITY, we could say that we are supporting the delivery of health and care to patients when workforce planning. But we aren’t meeting the needs of the public or population – we have no way of ensuring that we are delivering the right health and care to that population because there is absolutely no way of assessing the NEED for healthcare.
Luckily, in modern health and care systems there is a way – using proper Population Health Management information.
Population Health is defined by The Kings Fund as: “An approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people within and across a defined local, regional or national population, while reducing health inequalities.”
Straight away, we can see that this approach considers the population at its heart, as well as reducing health inequalities – inequalities that are produced by the way we are setting up services and workforce to deliver.
Population health management is driven by data. NHS England says that” The use of joined up data across local health and care partners and techniques like population segmentation and risk stratification can offer deeper insight into the holistic needs of different population groups and the drivers of health inequalities. Embedding this approach across all integrated care systems will transform the way we work and the way we care for people.”
It could (and should) also transform the way we plan workforce. Only by using population health management data can we truly understand the NEED for health and care in our population. No other way will get us beyond a reasonable understanding of DEMAND and stop us from planning based only on ACTIVITY.
PHM data is already being used to clearly identify workforce requirements, but it takes effort. Notably, it is being heavily used in Suffolk & North East Essex (SNEE).
Suffolk & North East Essex Experience
In SNEE, PHM data is helping understand population need and the workforce model. They are also actively tracking how PHM is influencing workforce within the system. Dr Mark Shenton picks up the story.
For us the use of PHM in workforce planning started by understanding the needs of the population from a bio-psycho-social perspective (the social part being of highest value as wider determinants of health account for 80% of our "health"). As we say “If we don't see this reflected in our data, we are missing a trick...”. This is our highest level of using PHM to workforce plan: to get the best outcomes for our population, how much of the staff need to be health and how much needs to be in education, housing etc.
Then, if we understand better the health and care need (the counted activity and understanding the scale of the missing (inequalities) data) of our population(s) we have a chance to look at what the teams of professionals required to meet those needs are. We need to understand what is required to prevent ill health, help people self-care when required, manage rising risks associated with ill health to prevent crisis and manage crisis effectively as close to people's home as much as possible.
By understanding this, we can then target (and grow) the right team elements to meet the need – starting with quite broad sweeps by determining how much VCSE sector we need, how much community services, PCN, hospital, council input is needed etc. This is the second level: working out what organisations or sectors within health and care need the staff to address the population need
By understanding this we can better know what effective sustainers are required - the training, education, workforce wellbeing interventions (coaching, mentoring, counselling, practitioner health etc). An example of this is the “One Team” approach – which aims to make integration of different disciplines and agencies really work for their benefit and the benefit of the population.
The classic way we start is back to front - we start with managing crisis care rather than prevention, we start by looking at workforce numbers, not what they are needed to provide and how.
In Suffolk we developed the concept of the INT (Integrated Neighbourhood team) as one that manages the health and care demand of a local geography of approximately 30-50,000 patients and integrates physical, mental health and social care teams functionality using one clinical record and colocation as One Team.
In addition, we developed the concept of Connect - the web of community-based assets of councils, communities and the VCSFE sector that can support that population with selfcare interventions and, more importantly, ill health prevention and health creation.
We then used the PHM data to influence our team make-up in Primary Care. This is the third level: determining our workforce needs in organisations/sectors using PHM information. We did this through:
· System demand and capacity modelling - using linked data alongside organisational data to model measured demand and use educated information to estimate unmet demand. Overlay with ONS and local population data predictions to model unmitigated demand for the next 20 years - apply this to organisational make up of the system, create the mitigation requirements and track using the data.
· Development of INT based healthcare priorities - traditionally we have used place-based needs assessments, derived from our JSNA and applied to Integrated Neighbourhood team populations to help steer thinking around priorities. PHM data uses up to date, regularly refreshed data and analysis to help direct teams more precisely to the current demands of their population based on activity and cost, whilst CORE20plus5 functionality helps them understand the hidden needs. INT priorities can therefore be checked against this data driven insight. Aggregating the INT priorities can help the place-based Alliance e.g. Ipswich and East Suffolk, West Suffolk, North East Essex make more informed decisions about what support those INT populations will need through the workforce.
· Identification of unmet needs - Hypertension case finding in deprived and ethnically diverse populations. Hypertension is the commonest long-term condition. Through early identification, the cardiovascular risk of those individuals can be assessed and managed better with monitoring of effective treatment and for emergence of other long term conditions such as diabetes and kidney disease. The PHM reporting suite through the use of CORE20plus5 functionality gives actual reporting on the scope of the missing population to assist thinking in how to identify them and, through the use of geographical analysis to ward level, help target interventions to improve equity of outcomes. The use of Faith groups, pharmacy, the VCSFE and community leaders to help in early health interventions was acknowledged and used in Covid vaccination to reach out to those who were easy to miss by health and care teams. Using that learning for ill health prevention for those with poorer outcomes from preventable disease is a natural progression (or so we hope!).
Finally, PHM data is used in front-line workforce planning to operationalise its use on a day to day basis. This is the final level: use of PHM data for front-line workforce planning.
Using the population needs model described above at Neighbourhood level. In Stowmarket, a town forming a significant part of the Central Suffolk Integrated Neighbourhood Team geography, the practices are working with their INT to segment their population so that they can identify and flag the sub-population who have the highest needs and poorest outcomes.
By doing this, they can move together on an integrated way of working using those needs to define the teams' make up and the work they will do e.g. Care home, housebound, those with multiple long term conditions, those with severe mental illness (SMI), Learning Disabilities (LD), those who are end of life and those needing proactive case management. PCN, practice and INT based workers have different backgrounds, different experience in managing risk and those strengths can be put to work in a coordinated way.
SystmOne will be the shared clinical record allowing real time access to and updating of the record. The current estate will be utilised more efficiently: The practices through the use of SystmOne and Ask My GP will identify and flag the population, directing them to the hub first time when those individuals contact them. Both practices currently use a demand led model of care so there is not a backlog. An evaluation module within the PHM reporting suite can track the effectiveness of the intervention when it goes live. The proposal will be optimised to ensure that the usual services of the practice to manage the needs of the rest of the population will not be undermined but that the needs of those with highest complexity and poorest outcomes get the time and expertise to meet their needs. This proposal is based on the work of the Foundry PCN in Sussex, written up by NHSE.
The other, often missed piece is in the training to work in teams that cross disciplines and agencies so that duplications are minimised, time is gained and the most expert approach is experienced by the person in need at the right time and place. If culture eats strategy for breakfast, it needs addressing - the limiting assumptions made by our workforce about each other is so often blown away by training together, using the data as a focus.
Conclusion
It isn’t just in the UK that it is being used. In Canada, teams can access the Population Grouper to identify the likely health needs of their population and convert this into the likely number of various clinicians that will be needed to meet NEED. This will have a fundamental impact on workforce planning across the country and puts them a step ahead in matching staff to actual need.
PHM data is revolutionising the way we plan workforce. Of course, short term pressures to deliver increasing activity – and the people queueing at the door – are always going to create the pressure to have enough staff to meet it, but there are big rewards for populations for doing it properly using PHM.
For the sake of population health, efficiency, fairness and staff - there should be no workforce planning without population health management!
(1) Health Education England
(2) Kings Fund - https://www.kingsfund.org.uk/publications/population-health-approach
(3) NHS England - https://www.england.nhs.uk/integratedcare/what-is-integrated-care/phm/