Scottish Government

Scottish Health Workforce Plan - 2004 Baseline

3 Where we are now: Current staffing position

Background

Three fundamental characteristics of NHSScotland make strategic workforce planning critical to its success:

• the scale of the NHS as an employer;

• the diversity of career choice within health and care; and

• the central role of staff to delivery of its business objectives.

The NHS is one of Scotland's major employers. With over 147,000 staff (plus over 10,000 practice staff employed directly by GPs) NHSScotland accounts for around 6% of the workforce in Scotland directly and provides employment for a considerable number of people in industries that supply goods and services to it. In addition, most health professions have staff working in private practice as well as in the NHS. Given the changing demography of Scotland, the scale of NHSScotland as an employer raises labour market supply issues, especially around the interface with social care - where there is an increasing overlap in the nature of care provision.

The 147,000 staff of NHSScotland are employed in a wide range of careers covering both clinical and non-clinical roles. Clinical staff are, predominantly: doctors, dentists, nurses, midwives, allied health professionals, scientific and professional staff and technical staff. (The traditional way of categorising clinical staff by professional group - qualified and unqualified - is, however, increasingly showing limitations as a way of analysing and planning for a more integrated workforce whose capacity is measured in terms of skills and competences.) Non-clinical staff groups include senior managers, administrative and clerical staff as well as ancillary, trades and works staff - all of whom support the infrastructure necessary to deliver high quality patient care. This diversity of career opportunity reflects itself in the differing profiles each staff group has in terms of working pattern, gender, age and ethnicity and presents increasing opportunity for diversification of roles in the quest to maximise both patient care and staff potential.

NHSScotland attaches a high priority to staff governance and aims to be an exemplar employer: many of the family-friendly policies (such as part-time working) impact on both training numbers and staffing requirements for the future. Another defining characteristic of this workforce is the high proportion of staff that require specialist training in order to fulfil their role. This creates the need to carefully plan training requirements today, in order to meet the service needs of the future.

Against this background, this chapter describes the key trends in NHS staffing over the past decade and highlights some issues of interest in the context of workforce planning for three of the clinical staff groups: medical and dental, nursing and midwifery and allied health professionals (AHPs). This, together with the array of drivers of change discussed in Chapter 2, sets out the baseline from which projections of future staff requirements
will flow.

A number of the tables and charts have been replicated for the three workforce planning regions; these can be found in Appendix B.

Profile of NHS Staff by Group

As at September 2003 NHSScotland employed 147,450 people, or 123,937.3 on a Whole Time Equivalent (WTE) basis. Seventy-two per cent of the WTE count are front line staff involved in direct clinical care, whilst 28% provide the infrastructure support. Chart 1 gives an overview of the WTE staff count by group as at 30 September 2003.

Chart 1: WTE Staff as at 30 September 2003 by Group

Source: ISD Scotland

Over the past decade there have been considerable changes in service design and delivery. Table 1 shows the changing profile of NHS staff by group over this period.

Table 1: Profile of WTE Staff by Group: as at September 1993 and 2003

Note: Data provided by ISD Scotland
GPs: includes GP principal, GP registrar and other GP
Medical: Hospital and Community Doctors including doctors-in-training

• Nursing and midwifery remains the largest single staff group with 54,120.0 WTE staff (around 44%) as at September 2003. This is an increase of 1,485.3 (2.8%) compared with 1993 (or a 3.3% increase adjusting for the re-categorisation of senior nurse manger grades out of the nursing category and into other non-clinical categories over the 10 year period).

• For registered or qualified nurses and midwives the increase over the 10 year
  period is much higher, rising by 8.5%, from 35,270.1 in 1993 to 38,262.5 as at September 2003.

• A further 12% of the workforce are medical or dental practitioners (15,334.3 WTE). This group includes hospital doctors and dentists as well as those working in primary care - and has increased by 23% since 1993.

• In total 19,480.7 WTE staff (16%) work in the other clinical staff groups: allied health professionals, ambulance, and scientific, professional and technical staff. AHPs have seen significant growth over the past decade; at 8,141.4 WTE their numbers are up by some 52% compared with 1993. Scientific and professional staff numbers have increased by 56% over the same period - to 2,089.3 as at September 2003.

• By far the largest non-clinical staff group is administration and clerical staff at 20,960.3 WTE (17%), many of whom also have specialist training needs - such as medical records staff (who may qualify for the Institute of Health Records and Information Managers (IHRIM)), medical secretaries, clinic receptionist and practice managers.

• The senior manager group has gone through a significant period of change over the last 10 years, with a number of posts both clinical and non-clinical now falling into this category.

• Over the past decade the contracting out of ancillary, trades and works staff has had a significant impact on the scale and mix of the non-clinical staff group - as reflected in table 1.

Charts 2 and 3 show the changing scale of each staff group since 1993 within the clinical and non-clinical areas. Following the changes in reporting of nursing staff, this group now accounts for a smaller proportion of the total - offset by greater increases in the other staff groups such as AHPs. However within the nursing and midwifery staff group, the proportion of qualified nurses and midwives has increased from 67% to 71% over the period.

In each of the clinical groups there has been an increase in staff numbers, whilst among the non-clinical groups the balance has been considerably affected by contracting out.

Chart 2: Percentage Change in WTE Clinical Staff: between 1993 and 2003

Source: ISD Scotland

Chart 3: Percentage Change in WTE Non-clinical Staff: between 1993 and 2003

Source: ISD Scotland

Given the fundamental change in delivery of ancillary, trades and works services, it is useful to consider the overall trend in WTE staff numbers excluding these groups. As Chart 4 shows, on average there has been just over 1% per annum growth in WTE staff numbers over the past decade: from 97,503.0 in 1993 to 111,596.2 in 2003. The largest increases have been in the most recent period - in line with the relatively large increases in NHS funding.

Chart 4: Trend in WTE Staff (excluding Ancillary, Trades and Works) together with the Breakdown of Clinical, and Senior Management and A&C

Source: ISD Scotland

Staffing levels compared to England

As Table 2 shows, over the last six years NHSScotland compares favourably with England on provision of hospital and community doctors and dentists and for qualified nurses and midwives staff on a per head of population basis. This partly reflects Scotland's higher levels of morbidity and remoteness, both of which place greater requirements on NHSScotland.

Table 2: WTE Staff as at 30 September (Rate per 100,000 population, mid-year population estimates)

Note: Data provided by Department of Health and ISD Scotland
¹ Hospital, Community and Public Health Services staff only
* Rate calculated using mid-2002 population estimate

Trends in working patterns

When describing the overall capacity of the NHS it is helpful to consider trends in WTE numbers. ² However, from a workforce planning perspective it is also helpful to look at the headcount as different groups of staff will be more or less likely and/or able to opt for part time working. This has an impact on planning for the numbers required to deliver services. Indeed as Chapter 2 discussed, the improved opportunities for managing work/life balance are expected to further impact on working patterns. For example, additional staff are likely to be required to cover for parental leave allowances for all types of work pattern.

Chart 5 shows the long-term trend in flexible working - expressed as the ratio of WTE to headcount. As the chart shows, over the past decade the ratio has not changed substantially, rising from 82.9% in 1993 to 84.0% in 2003 (a difference of 1.1 percentage points). If ancillary, trades and works are excluded to make the trend more comparable the difference drops to only 0.3 percentage points - suggesting very similar working patterns overall, although there are interesting changes by staff group as discussed below.

Chart 5: Ratio of WTE to Headcount - All Staff, Clinical and Non-Clinical

Source: ISD Scotland

Table 3 shows the profile of whole time equivalent staff by group as a percentage of the Headcount. Chart 6 shows the percentage change between 1993 and 2003.

Table 3: Profile of WTE Staff by Group expressed as a percentage of the Headcount 1993 and 2003

Note: Data provided by ISD Scotland

• At 30 September 2003 the WTE clinical staff constituted 86.3% of the headcount total for this staff group. The equivalent figures for the non-clinical staff group are 78.6%.

• Ambulance, medical and dental staff tend to work full time, each having over 94% of WTE to headcount. AHPs have the most propensity for part time working - with WTE accounting for 82.3% of headcount in 2003.

• For non-clinical staff the overall average was 78.6% but this was largely driven by the very high rate of part time working among ancillary staff - where WTE accounts for only 65.2% of headcount.

• The majority of senior management, trades and works staff were working full time at September 2003.

Over the past decade there have been some interesting shifts in working pattern. For example, as Chart 6 shows, nursing and midwifery and dental staff saw more full-time working in 2003 than in 1993, whilst there has been a reduction in full-time working among GPs and scientific and professional staff groups.

Chart 6: Percentage point change in WTE/Headcount ratio - Clinical and Non-Clinical Staff as at 30 September 1993 and 2003

Source: ISD Scotland

Different issues will have driven each of these changes, and the policy changes to facilitate work/life balance and to modernise medical careers may increase the propensity of part-time working, reversing some of these movements. Indeed evidence suggests that a substantial proportion of both male and female staff would be interested in part-time working at some point in their career ³.

Gender

Over three-quarters of the workforce are female (78.2%) - largely accounted for by nursing and midwifery, AHP and A&C staff. Given that in many areas of employment females are more likely to work part time than males, this has links to the ratios of WTE to headcount described above.

As Chart 7 shows, the percentage of each staff group that is female ranges from under 1% among trades and works and 24% of ambulance staff - to 90% of nursing and midwifery staff and 91% of AHPs. Forty-eight per cent of current senior management are female.

Chart 8 looks at the changes in gender mix across the staff groups over the last
10 years. Although the number of female hospital doctors and GPs is currently just over 40%, the proportion of females has grown over the 10-year period, particularly in the
GP group. A similar pattern is to be found with dentists.

Chart 7: Percentage male/female staff (Headcount) per staff group: as at 30 September 2003

Source: ISD Scotland

Chart 8: Percentage point change in female staff (Headcount): between 1993 and 2003

Source: ISD Scotland

Age profile

Just under one-quarter (24%) of NHSScotland staff are aged 50 or over, and there is considerable variation in age profile by staff group. Chart 9 shows the age profile of clinical and non-clinical staff - with 32% of non-clinical staff aged 50 and over compared with 21% of clinical staff.

Chart 9: Age profile of all staff groups (Headcount): as at 30 September 2003

Source: ISD Scotland

However, given the long training to qualification time for certain clinical staff, succession planning is a critical aspect even for the relatively younger age profiles. Indeed as Chart 10 shows, a key issue for workforce planning is the bulge in the age profile at around 40-49.

Looking at the age profile of the economically active population in Scotland, 25.4% are in the age group 40-49 years, with a further 19.2% falling into the 50-59 years group. This compares with 32.1% and 21.0% of the NHSScotland workforce falling into the 40-49 and 50-59 age groups respectively.

Chart 10: Age profile of Clinical Staff Group (Headcount): as at 30 September 2003

Source: ISD Scotland

Chart 11: Age profile of Non-Clinical Staff Group (Headcount): as at 30 September 2003

Source: ISD Scotland

As with other staff groups, a particular issue for GPs in Scotland is the increasing age profile. As Chart 12 shows, the majority of GPs are aged 40 and over. As Chapter 2 describes, both Modernisation of Medical Careers and pay modernisation will have a key impact on shaping future trends.

Chart 12: Changing age profile of GPs (Headcount)

Source: ISD Scotland

Ethnicity

Around 95% of Scottish residents described their ethnic origin as White at the time of the 2001 Census. In the ethnic data derived from the annual medical and dental census and the equivalent non-medical census, 97% of NHSScotland staff who completed the ethnicity question described themselves as White. Chart 13 shows the overall profile of staff replying to the survey by ethnicity.

Chart 13: Ethnicity (Percentage of each Ethnic Group: All Staff Groups)

Source: ISD Scotland

Table 4 shows the profile of staff by ethnic origin for medical and dental and non medical and dental staff.

• Just over 17% of medical and dental staff were of non-white origin; within this total 8.5% were Indian and 4.1% were of "Other" groups.

• In the non medical and dental staff group, less than 1% described themselves as
  non-white.

Table 4: Ethnic Origin: 2003 Survey

Source: ISD Scotland

Since 1994 there has been a small but steady growth in the percentage of medical and dental staff who described themselves as Indian in origin, rising from 5.9% in 1994 to 8.5% in 2003. (Note that this figure relates to only those staff who provided data on their ethnic origin and is self reported.) The profile of doctors-in-training is slightly different with 73.3% describing themselves as White and 12.5% as Indian.

There has been very little change over the last nine years in the ethnic origin distribution in the other staff groups.

Nurses and Midwives, Doctors and Dentists, and Allied Health Professionals

Many analyses of the workforce relate to the number of staff in post on a given census date. In order to fully understand the dynamics of the workforce one has to look at the establishment as a whole:

• staff in post;

• posts under review (in the context of nursing and midwifery and AHPs where regrading or restructuring are being considered); and

• vacancies.

Information is collected at a national level on these aspects for, nursing and midwifery, medical and dental and AHPs. This section sets this information for each of these three groups in the context of the overall establishment. In future editions of the Workforce Plan other staff groups will be featured.

Vacancies can arise either as posts that were filled and are subsequently vacated, or as a result of a delay between the expansion of an area of service and the filling of those new posts. Given past trends in growth within NHSScotland it is therefore important to look at what is termed "harder to fill" vacancies - nursing and AHP vacancies of 3 months or more; consultant vacancies of 6 months or more. Although the recruitment process can take some time (potentially longer than 3 months), these measures attempt to get a better understanding of longer term gaps.

Nursing and Midwifery

Nursing is the largest source of professional employment for women in Scotland, with some 54,120.0 WTE nurses and midwives in NHSScotland as at September 2003. This section describes the key issues for this section of the workforce.

As chart 14 shows, the largest proportion of nurses (42.2%) work in the Acute sector, and this group has been rising steadily over the last decade, with the proportion of qualified nurse increasing from 13,645.8 WTE to 16,766.4 WTE (a 22.9% increase). The changes in the trend for care of elderly and learning disability nurses are likely to reflect the move to more community and primary care based services.

Chart 14: Trend in WTE Nursing Staff (NHSScotland) by Specialty: as at 30 September

Source: ISD Scotland

Table 5 shows that there has been a steady rise in the total number of pre-registration nursing and midwifery students commencing training in the period 1997/98-2002/03. Midwifery students have remained relatively constant during this period, taking account of the falling birth rate and reduced demand, although numbers are beginning to rise again in 2002/03 with a move to more midwife-led care.

Table 5: Nurse Training numbers

Source: NHS Education for Scotland (NES)

Table 6 below shows that the percentage of vacancies for nursing and midwifery has remained fairly stable as establishment has grown, with the key indicator of percentage vacancies of 3 months and over remaining steady at 1%. There are variations in vacancy rates across the specialties, with ITU having the highest 3 month rate of 2.9%, and district nursing the lowest 3 month rate at 0.4%

Table 6: WTE Trend in Nursing and Midwifery Vacancies: as at 31 March

Source: ISD Scotland
Note: Estimated figures for establishment and vacancies are used at Scotland level. This is to compensate for under-reporting.

Agency nurses are used as a last resort by the NHS to deal with specific pressures; the preferred approach is through the use of nurse bank arrangements. The Partnership Agreement included a commitment to 'implement nationally co-ordinated nurse bank arrangements to assist nurse placement across Scotland, to improve patient services and cut costs of agency nursing'. Table 7 below summarises the use of Bank and Agency Nurses by the NHS, which account for only 2.9% and 1.5% of WTE nurses in 2002. Spending on bank and agency nurses was 39m and 28.1m respectively in 2002/3.

Table 7: WTE Nurses by Grade 2002

Source: ISD Scotland

Medical and Dental

As at 30 September 2003 there were 15,334.3 WTE medical and dental staff, including just under 4,000 GPs (GPs includes principals, registrars and other GPs) and just over 2,000 NHS dentists. Those who choose to become consultants presently take around 14 years to train from leaving university to qualifying. Key issues facing this group are: the impact of new working patterns for doctors-in-training (on working hours and on the supervision requirements); clinical governance; career structure modernisation; pay modernisation; and shortages in some specialties compared with service needs.

Chart 15 shows trends over the past decade in the five main groups of medical and dental staff: doctors-in-training, consultants, general medical practitioners, general dental practitioners and other career grades. Over this period consultant numbers have grown most rapidly with a steady increase of around 3.5% per annum since 1993. In the most recent period there has also been a sharp increase in the number of doctors-in-training.

Chart 15: Trends in Medical and Dental Staff: WTE as at 30 September

Source: ISD Scotland

Table 8 shows the trend in doctors in the current training structure, with large increases in WTE across the three training grades. As discussed in Chapter 2, Modernising Medical Careers will be a key driver of change for this group - impacting not only on the length of time to progression to consultant, but with the potential to impact on the specialty that doctors elect to join.

Table 8: WTE Doctors-in-training

Source: ISD Scotland

Table 9 shows trends in the ratio of training grade doctors to consultants - the recent rise in junior doctor numbers in the drive to comply with the New Deal is reflected in this ratio, and Chapter 4 explores some of the related issues in more detail.

Table 9: WTE Trend in Ratio of Doctors-in-training to Consultants

Source: ISD Scotland

The most recent figures published on doctors-in-training in relation to compliance with 'New Deal' show a compliance rate of 81.7% (as at January 2004). Specialist Registrars had the lowest compliance rate of 78.8%, and Pre-Registration House Officers the highest at 92.3%. In addition there is variation in the compliance rate across the different specialties. For example Obstetrics and Gynaecology had an overall compliance rate of 70.7%, Trauma and Orthopaedics 71.8% and Paediatric Surgery 51.7%.

Table 10 looks at the vacancy rates for consultants over the last three years (only three years' data are available for the WTE trend), the overall vacancy rate as at 30 September was 6.7%, with the 6-month rate at 3.5%.

Table 10: WTE Trend in Consultant Vacancies

Source: ISD Scotland

These national rates mask variation both at a regional and specialty level. The West region has the highest vacancy rate at 7.9%, with the over 6 month rate standing at 4.1%. Particular pressure points in the over 6 month vacancies are in Geriatrics, Psychiatry, Clinical Radiology and Trauma and Orthopaedics. Both the East and North regions have similar long-term vacancy issues for Clinical Radiology and Psychiatry. (See Appendix B)

A related issue to vacancy rates is the use and cost of locums. For the year to March 2003, 17.4 million was spent on all grades of locums, of this 9.9 million was spent on consultants and 3 million on senior house officers.

Allied Health Professionals

Allied Health Professionals (AHPs) are a group of clinical staff which include a wide range of specialists including: chiropodists/podiatrists, dieticians, occupational therapists, orthoptists, physiotherapists, radiographers and art/music/drama therapists.

AHPs provide services to people of all ages across all health specialties. They work in acute, primary care, public health, education and social care settings. AHP expertise is required in increasingly pivotal roles in clinical teams that are delivering care in priority areas such as cancer, CHD/stroke/mental health, maternity services and primary care modernisation. AHPs are also helping to achieve access, waiting times and working times targets through development of new roles and extended scope of practice.

Chart 16 below shows the increase over the last decade in the six largest staff groups. Physiotherapists, Radiographers and Occupational Therapists show large increases of between 35% and 45%.

Chart 16: Trend in WTE Allied Health Professionals for selected staff groups: as at 30 September

Source: ISD Scotland

Table 11 shows the significant increases in the number of qualified AHPs over the last seven years. As shown earlier on in this chapter, AHPs have the most propensity for part-time working, with the majority of the staff (91%) female.

Table 11: Qualified AHPs as at 30 September

Source: ISD Scotland

Limited data are available on the number of students who are currently undertaking AHP courses, table 12 below show the number of students who have commenced training courses.

Table 12: Commencements in AHP courses

Source: NHS Education for Scotland (NES)
* 2002 figures are for places filled at the time of returning questionnaires rather than actual student commencements.
** Dietetic intakes all exclude the Robert Gordon University for which information was not submitted.

Table 13 shows a small increase in the number of AHP posts which have been vacant for
3 months or more. As establishment figures have increased - by 33.9% over the eight-year period - vacancies have risen as delays are experienced in filling posts. As with other staff groups, vacancy rates vary across specialties. Radiography (qualified) has the highest rate, 4.9%, for vacancies of 3 months or more, and Podiatry and Dietetics have the lowest at 0.4% and 0.7% respectively.

Table 13: WTE AHP Vacancies: as at 31 March

Source: ISD Scotland
Note: Estimated figures for establishment and vacancies are used at Scotland level. This is to compensate for under-reporting.