(Item 8c) Argyll and Bute HSCP draft workforce plan - 17th Oct
Argyll and Bute Council · 23 November 2022
Back to Argyll and Bute HSCP Integration Joint Board (IJB) — 23 November 2022 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 Strategic Workforce Plan 2022-2025
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2 Contents 1. Introduction ...................................................................................................................... 3 2. Background and Context .................................................................................................... 3 3. Methodology..................................................................................................................... 4 4. National Workforce Strategy for Health and Social Care....................................................... 5 5. Overview of A&B ............................................................................................................... 5 Geography ............................................................................................................................ 5 Services ................................................................................................................................ 6 Joint Strategic Plan ................................................................................................................ 7 Financial Position .................................................................................................................. 9 Approved Budget 2022-23 ................................................................................................... 10 6. Demographics ................................................................................................................. 10 Life Circumstances............................................................................................................... 11 Health and Wellbeing Status ................................................................................................ 12 7. Labour Market Analysis.................................................................................................... 12 8. Workforce Analysis .......................................................................................................... 13 Vacancy Data ...................................................................................................................... 18 Supplementary Staffing ....................................................................................................... 19 Sickness Absence................................................................................................................. 20 Turnover ............................................................................................................................. 20 Culture, Health, and Well-being ........................................................................................... 21 9. Common Workforce Drivers ............................................................................................. 24 10. Strategic Workforce Risk .................................................................................................. 25 11. Strategic Workforce Action Plan ....................................................................................... 31 Appendix 1: Key Detail by Profession (NHS Argyll & Bute Workforce) ......................................... 38 Appendix 2: Workforce Drivers, Challenges, Risks by Service Area ............................................. 46
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3 1. Introduction Welcome to Argyll and Bute Health and Social Care Partnership’s (ABHSCP) Strategic Workforce Plan for 2022-2025. The Plan is intended to support the Joint Strategic Plan for ABHSCP covering the same time period with a view to ensuring we have the right people with the right skills in place to deliver remobilised services following the pandemic. The workforce plan reflects the impact that COVID 19 has had, and continues to have, on services and the workforce in particular. Whilst the pandemic has had a significant impact on the workforce there are a number of positive opportunities that have made, and continue to make, a difference in how we can work within a remote and island health and social care partnership. This Strategic Workforce Plan also reflects the recently published National Workforce Strategy for Health and Social Care and will contribute, where possible, to the implementation of many of the actions included in that strategy. The action plan at the end of this document will mirror the 5 Pillars approach outlined in the National Workforce Strategy. The actions set out in the workforce plan are the starting point in ensuring that we have the required workforce to achieve the strategic ambitions laid out in the Joint Strategic Plan enabling People in Argyll and Bute to live longer, healthier independent lives. The plan will be refreshed on an annual basis as actions are fulfilled and new actions are developed. As we build towards a more refined partnership approach to workforce planning across ABHSCP the action plan will be updated and refreshed. 2. Background and Context In common with all employers, employees within the Argyll and Bute Health and Social Care Partnership are critical to the delivery of services and our strategic ambitions. One of the highest level risks within the Corporate Risk Register, therefore, is focussed on workforce recruitment and retention: inability to recruit and retain the required workforce because of national workforce challenges and local challenges particularly in remote and rural areas and for clinical specialties. This leads to increased costs from reliance on medical locums and agency staff, not only for the IJB but also for commissioned service providers. Effective workforce planning across the partnership is vital to mitigate this risk and this workforce plan is the starting point. Health and Social Care Partnerships are required to publish a 3 year workforce plan by 31 October 2022 which aligns with both the NHS Scotland Recovery Plan and the National Workforce Strategy for Health and Social Care. Whilst the publication of a workforce plan is a requirement, it is vital for the delivery of the Joint Strategic Plan 2022-2025 that a strategic workforce plan is developed that supports the attraction, recruitment, development and retention of the workforce required to deliver the Joint Strategic Plan and enables the ongoing sustainable delivery of services in the future. Workforce planning is a key part of the Strategic planning process, with workforce development and mitigations to workforce risks being seen as a key driver for strategic change.
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4 3. Methodology Workforce planning within the ABHSCP has hitherto been led by the individual employer for a particular workforce. Through the development of this plan we have begun to work together as employers within the partnership through workforce planning discussions with managers and the development of engagement sessions with leaders in the ABHSCP. The national workforce planning guidance issued in the Scottish Government Directors letter of 1 April 20221 does not prescribe a specific workforce planning methodology. Both employers within the partnership, however, adopt a similar approach to workforce planning that: Assesses the current workforce Assesses future workforce requirements Develops an action plan to fill the gap between present and future. Argyll and Bute Council workforce planning colleagues also adopt a risk based approach to future workforce planning based on an assessment of impact and likelihood in relation to: Ageing workforce Recruitment Succession planning Skills This provides an overall risk rating with the higher risk services receiving more targeted and frequent workforce planning support. This approach will be adopted across both employers within ABHSCP in the future as we continue to develop a more refined partnership approach to workforce planning. The development of this workforce plan has been based around engagement sessions with managers, independent sector providers, professional leaders, staff-side representatives and the Integration Joint Board. These sessions identified the strategic drivers for change, challenges and risks to stabilising and retaining the existing workforce, as well as any workforce changes expected in the future and actions required. The aim of the workforce plan is to summarise the key points from those engagement sessions and develop an action plan. Delivery of the actions contained within will be overseen by a Strategic Workforce Planning group that will be developed within the governance structure of the Transformation Programme, detailed later in this plan. This Strategic Workforce Plan covers the workforce involved in providing all the services delivered or purchased within the remit of the ABHSCP and therefore includes independent providers within both primary and social care. It does not, however, include services commissioned from NHS Greater Glasgow and Clyde. 1 DL 2022 (09) National Health and Social Care Workforce Strategy: Three Year Workforce Plans https://www.sehd.scot.nhs.uk/dl/DL(2022)09.pdf
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5 4. National Workforce Strategy for Health and Social Care The Scottish Government published the National Workforce Strategy for Health and Social Care on 31 March 2022 that sets out a national framework to achieve the vision for a sustainable, skilled workforce with attractive career choices where all are respected and valued for the work they do. The strategy outlines an overarching framework for activity at national level that supports boards and HSCPs to plan and deliver the workforce required for the future. It sets out the changing demands on the health and social care workforce and uses the 5 pillars of the workforce journey as a framework for action. The 5 pillars are: Implementation of the National Workforce Strategy will take place at both national and local levels, with local implementation being driven through the workforce plans developed by HSCPs and NHS Boards. The action plan within this workforce plan, for example, will by laid out using the 5 pillars as a framework for action. Where input to national actions are required, or relevant, they will be included in the actions within this plan. Some key national actions with direct relevance to this workforce plan are: 5. Overview of A&B Geography Argyll and Bute is the second largest Council area in Scotland by area (after Highland), with the third lowest overall population density in Scotland (after Highland and Na h-Eileanan Siar). Our geography covers some 2,500 square miles and encompasses a range of rural, very remote rural and populated islands. This presents a variety of challenges to the sustainability of health and care services as well as an increase in the cost of service delivery. Working with our communities and staff we strive to provide the vast majority of our health and care services within Argyll and Bute close to people’s communities. ABHSCP is divided into four locality planning areas:
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6 Within three localities, there are further divisions into ‘local areas’ which consist of groupings of natural geographical communities and/or service provision. Workforce challenges and risks can often vary across different localities with western and Island areas being particularly difficult to recruit to, although Helensburgh being more relatively well connected with the central belt faces competition from the Greater Glasgow HSCPs. Planning may sometimes be necessary for smaller areas within a locality e.g. for one island. Helensburgh is relatively well-connected via land transport links with the central belt and is the only settlement classified as ‘Urban’. The geography includes 23 inhabited Islands connected to the mainland through ferry and air services. 69% of the population live in ‘very remote’ areas (either rural or small towns). Services In Argyll and Bute, the HSCP delivers and purchases a broad range of services covering all aspects of health and social care. Our main health and care facilities in Argyll and Bute include 6 community hospitals, an Acute Hospital and 21 Care Homes for older adults. The full range of children’s, adults and justice social work services are also provided along with a wide range of social care services. Included in the remit of the HSCP are: NHS services; Community hospitals; Acute Care; Primary Care (including GPs); Allied Health Professionals, Community Health Services, Maternity Services Public Health services including the Prevention agenda Adult services including care homes, care at home and other services for older adults; Services for people with learning disabilities; Mental Health Services Children & Families social care services
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7 Children’s Health Services and Child and Adolescent Mental Health Services Alcohol and Drug Services Gender Based Violence Child and Adult Protection Justice Services In bringing together all these services within one partnership and one strategy we aim for services to work closer together so that people receive the right level of care at the right time from our workforce of professional staff and can move through services easily. Argyll and Bute HSCP works very closely with NHS Greater Glasgow and Clyde Health Board, from whom we commission acute hospital and specialist services for emergency, elective and outpatient services. Joint Strategic Plan2 2 It should be noted here that NHS Highland is currently developing a 5 year strategy (Together We Care). The people ambitions within that document will have a positive impact on health staff within Argyll and Bute with actions taken under that strategy feeding into actions contained within this workforce plan. For further information see the NHS Highland Workforce Plan.
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8 Argyll and Bute Health and Social Care Partnership published its 3 year Joint Strategic Plan in June 2022 which lays outs the vision, priorities, commissioning intentions and strategic objectives for the partnership as shown below.
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9 The Joint Strategic Plan also outlines the objectives and priorities for the next three years for each of the service areas, with the intention that each employee and every service will work towards our ultimate vision. This workforce plan contains key workforce drivers, challenges and actions for most of these service areas, which will support the workforce in meeting the objectives and priorities. Financial Position The Argyll and Bute Health and Social Care Partnership is required to operate within the resources it has available to it and on a financially sustainable basis. The partnership has set a balanced budget for
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10 financial year 2022/23 and is currently developing longer term finance and investment planning. It is important that the strategic priorities and objectives of the HSCP align with its budget. Overall the HSCP has faced significant financial challenges in recent years and these are now being addressed. The financial position is improving and our services are being better funded by government, this gives us increased scope to consider how we develop and transform our services and invest in the longer term. Approved Budget 2022-23 The approved budget for 2022-23 outlines our plans to spend the funding allocated to us, totalling £320.9m for the year. The HSCP is benefiting from recent commitments from the Scottish Government to better fund and priorities Health and Social Care Services. Almost all of our funding comes from Scottish Government to the two partner bodies, NHS Highland and Argyll and Bute Council who then allocate it to the HSCP. The HSCP has set an expenditure budget for the year which balances to the available resources. However, this requires £3.9m of savings to be delivered in year in order to achieve financial balance. This on-going need for efficiency and cost improvements is driven by on-going inflation, demand increases and the introduction of new interventions and treatments. The impact of demographic change is an important aspect of this challenge, as our population ages health and care needs increase materially while the working age population is reducing in our area. We seek to ensure that our savings plans improve efficiency and reduce costs in ways which minimise the impact on service users and the wider community. The expenditure budget is allocated across a wide range of services throughout Argyll & Bute and with external providers, particularly related to Hospital Services in NHS Greater Glasgow & Clyde. The financial plan assumes a level of growth in workforce numbers. This is difficult to quantify at present but includes: Increase in workforce size to narrow gap between current budgeted establishment and actual staffing (reduced vacancies); Reduce reliance on temporary and agency staff to implement more cost effective, stable and sustainable staffing models; Some transition from commissioned services to direct delivery of service; Additional growth in 2022/23 budget and use of non-recurring reserves balances not yet fully reflected in staffing establishment; and Cost and demand pressures allowed for will require additional staffing. It is likely to be the case that some of the savings programme will require reductions in staffing which will in part offset the increases referred to above. The Workforce plan seeks to outline how the HSCP can seek to address the workforce challenge over the medium term. 6. Demographics The Joint Strategic Plan contains an analysis of the demographics, life circumstances and health and wellbeing status of the Argyll and Bute population. The following is a brief summary of that analysis.
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11 The 2020 mid-year population estimate for Argyll and Bute is 85,430, a 3.6% decrease since 2010, with the number of deaths registered higher than the number of births each year since the early 1990s. In particular, the population of working age has decreased and is projected to continue to do so. Alongside this, the population of those under 16 has decreased and this is also projected to continue. There is a lower ratio of people of working age to other ages in remote and rural areas In contrast, the population of those aged 75 and over has increased each year since 2002 with 11.7% of the population aged 75+ compared to 8.6% in Scotland as whole. The number of people aged 75+ and 85+ is projected to continue to increase over the next 10 years. Bute and Cowal have the highest proportion of people aged over 65 Life Circumstances Within the Argyll and Bute population 9.7% are estimated to be income deprived and, therefore, more likely to experience poorer health and wellbeing. Deprivation within rural areas is likely to be hidden by the mixed socio-economic status of small rural areas. 17% of those under 16 are estimated to be living in relative poverty. Minimum income standards are high in remote, rural and island areas, largely due to fuel costs, currently a significant issue for those living and working in Argyll and Bute. There are increasing numbers of those living alone, currently over 1 in 5 people. Lack of affordable housing is a significant problem in some areas with high rates of second homes, empty properties and older housing stock in some areas. Seasonal differences in population due to high levels of tourism and increased length of stay in second homes mean fluctuating demand for services across the year. Increases in the numbers within the population with limiting conditions means an increase in the number of unpaid carers, with a potential impact on their own health and wellbeing. As many as 12,000 people aged 16+ provide unpaid care within Argyll and Bute. In addition, there is a high and increasing rates of dependency (looking after younger or older relatives) compared to the rest of Scotland. This has potentially significant issues for workforce retention in the area.
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12 Health and Wellbeing Status Alongside behavioural issues such as drug/alcohol use and smoking which are more prevalent in deprived areas, the increasing proportion of the population in the older age brackets provide a number of challenges. Increasing numbers of people with care needs Tackle (reduce) inequalities in health and wellbeing Management of people with one or more long-term conditions Prevention of long-term conditions Under-diagnosis of certain conditions Accessibility of services for those with sensory conditions Mental health support e.g. through mental health first aiders, trauma informed communities and training in suicide prevention. 7. Labour Market Analysis As with many economies in the developed world, Scotland’s population is ageing. By 2045, the number of people of pensionable age in Scotland is expected to increase by 20.6% (205,800 people), whilst the working-age population is projected to decline by 2.4% (84,400 people). This suggests the possibility for a tighter labour market in future and an increasing dependency ratio. As noted above the number of people aged 65 and above is increasing in Argyll and Bute at a greater rate than the rest of Scotland. In addition, based on population projections, the Argyll and Bute dependency ratio will be 81% in 2043, compared to Scotland’s 60%, creating a tighter labour market in the region compared to the rest of Scotland. Ongoing Brexit concerns, and COVID-19 considerations, create heightened uncertainty regarding the supply of migrant labour from the EU and further afield. Argyll and Bute with its large Tourism and Agriculture, Forestry and Fishing sectors, has faced challenges replacing migrant labour in certain sub- sectors and locations. In 2019, EU citizens were 4% of all employees, compared to 6% for Scotland as a whole.
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13 The impact of short term holiday lets on the labour market cannot be over-estimated, both in terms of lack of available/affordable housing and long term lets for inward migrating workers, but also in terms of removing local residents from the labour market who can make more money from holiday lets than working, for example, in social care or health care support roles. In the Argyll and Bute Growth Deal, 4,400 job openings are forecast to be created across all sectors from 2021 to 2024. The number of people required in the region is forecast to increase by 900 from 2021 to 2024 due to expansion in the labour market. The replacement requirement of 3,500 people will also create a need for labour. The working age population (16-64) within the region has decreased by 4% (2,200) over the last 10 years to 50,500, of which 13.2% are aged 60-64. This decrease is projected to continue. 1,400 people were unemployed with a further 1,700 economically inactive but declaring they wanted to work, this being a potential labour market to be explored. Net out-migration of young people is a long-standing and significant issue as young people move out of the region to pursue education and career opportunities in the rest of Scotland and further afield. HIE’s research (including Argyll and Bute) on the attitudes and aspirations of young people aged 15- 30 illustrates an increasing commitment to staying in the region (55% want to stay in the region up from 43% in 2015). Around three in five (59%) believe that young people who leave will return to the region when the time is right. Almost two-thirds (64%) would like to work in the Highlands and Islands (including Argyll and Bute) in future but cite a number of economic and social factors that need to be in place to facilitate this. The top four economic factors cited by young people were good pay levels, high quality jobs, a low cost of living and opportunities for career progression. Quality of life, availability of affordable housing and access to good healthcare are the top three social factors. In the Highlands and Islands (including Argyll and Bute) 57 per cent of businesses overall had experienced some form of labour shortage. Labour shortages across the region were felt most acutely in the Tourism sector with 68 per cent experiencing some form of shortage. In summary, the reducing working age population, will impact on replacement labour across Argyll and Bute, including staff working within ABHSCP and commissioned services, as well as our ability to recruit to existing vacancies. Young people are more inclined to stay in the area which is good news for recruiting a younger workforce, but we must adapt our entry and career pathways to take advantage of the opportunity this represents, enabling them to become qualified professionals within health and social care where required and providing them with a career in health and social care to whatever level they are able or wish. 8. Workforce Analysis We have tried wherever possible to deliver an integrated dataset for the whole of the ABHSCP workforce in this analysis. Where that has not been possible we have shown the data for each employer separately but are committed to working towards a holistic integrated data set. The total ABHSCP workforce extends beyond NHS Highland and Argyll and Bute Council as the two main employers within the partnership, and includes the workforce employed across both primary
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14 and social care by commissioned service providers. Below charts demonstrate an approximate breakdown of the workforce in ABHSCP across employers, with around half being employed by the independent sector.3 The makeup of the ABHSCP workforce is shown below. 3 Note this only includes independent social care providers. There is insufficient information available in relation to the primary care workforce, an issue Scottish Government has committed to addressing the National Workforce Strategy for Health and Social Care.
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15 4 The ABHSCP workforce as can be seen is predominantly female with a high proportion of part time hours on permanent contracts. The largest proportion of the workforce is the nursing and midwifery job family, closely followed by social care and administrative services. Social Work and Allied Health Professions are key professional groups with relatively small numbers spread across small, dispersed teams in remote and island locations. In common with the wider population with Argyll and Bute the workforce within ABHSCP is increasingly concentrated in the higher age ranges. The risks this poses to the ongoing delivery of services are significant and include Loss of knowledge, skill, and experience. Increased absence rates due to a greater potential for long term conditions Greater tendency to have a dependency for older parents who are living longer or grandchildren It is vital that the employers across the ABHSCP are aware of the current age profile, average retiral age across job families and projected retirals, in order to deploy targeted retention or succession planning work in good time to avoid shortfalls in service, particularly in remote and island areas where the fragility of small teams is high. Graph below shows that over 50% of the workforce are over the age of 50 with a third over the age of 55 and over 14% over the age of 60. 4 Note Social Work has been added as a job family in its own right here and includes social workers, social work assistants and referral assessment officers. Job Family Headcount WTE ADMINISTRATIVE SERVICES 416 336.75 ALLIED HEALTH PROFESSION 179 138.37 DENTAL SUPPORT 43 29.98 HEALTHCARE SCIENCES 29 25.73 MEDICAL AND DENTAL 48 28.84 MEDICAL SUPPORT 2 1.43 NURSING/MIDWIFERY 668 556.88 OTHER THERAPEUTIC 41 35.79 PERSONAL AND SOCIAL CARE 475 356.44 SENIOR MANAGERS 6 6.00 SOCIAL WORK 166 150.41 SUPPORT SERVICES 273 194.67 Grand Total 2346 1861.30
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16 Those age over 55 by job family with high numbers in both nursing/midwifery and within social care. As a proportion of the overall headcount of each job family, support services has the highest percentage of employees aged over 55 with over 50%. These roles tend to be in lower pay brackets with significant levels of manual labour and also tend to have higher average retiral ages. This may be further impacted with the current and ongoing cost of living crisis and the subsequent impact on workforce availability noted above.
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17 Private Sector Age Profile There is a similar age profile issue within the independent social care sector in Argyll and Bute, with roughly a quarter of the workforce over the age of 55. Average retiral ages vary across the professions and job roles. Homecarers, for example had an average retiral age of 68 with social workers, nurses and allied health professionals retire on average at the age of 62. Currently 93 employees across the HSCP are over the average retiral age for their job family/profession and at risk of leaving immediately, with a further 226 at risk of retiral over the next 4 years, with the biggest numbers in nursing, social care and administrative services. Row Labels <20 20 - 24 25 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 65 + Under 20 Grand Total ADMINISTRATIVE SERVICES 12 25 33 45 38 50 76 71 52 14 416 ALLIED HEALTH PROFESSION 5 12 19 18 32 32 25 23 11 2 179 DENTAL SUPPORT 1 2 5 4 6 7 7 7 4 43 HEALTHCARE SCIENCES 2 3 5 5 2 4 4 2 2 29 MEDICAL AND DENTAL 1 1 7 4 7 10 10 6 2 48 MEDICAL SUPPORT 1 1 2 NURSING/MIDWIFERY 16 44 58 64 58 92 125 130 74 6 1 668 OTHER THERAPEUTIC 1 1 6 4 4 6 6 8 3 2 41 PERSONAL AND SOCIAL CARE 1 4 14 27 51 43 62 97 109 71 33 512 SENIOR MANAGERS 2 1 3 6 SOCIAL WORK 2 2 10 6 26 9 24 25 17 8 129 SUPPORT SERVICES 2 2 8 5 21 24 20 46 70 51 23 1 273 Grand Total 3 43 111 167 225 240 290 421 461 287 96 2 2346
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18 Vacancy Data On average throughout May, the independent care home sector was running with vacancy rates of roughly 7%, based on a census of care homes, adult care home and care homes for older people. This equates to approximately 140 employees. A snapshot of current vacancies within Argyll and Bute is shown below. The vacancy snapshot shows the biggest number of vacancies are in social care and nursing with relatively high levels in Allied Health and Administrative Services. There are currently significant numbers of social worker (29.2 WTE), home carer (42WTE) and social care workers (12WTE) as well as nursing and midwifery vacancies across ABHSCP. The ABHSCP has ongoing recruitment challenges across all job families and roles. The list below highlights some of the most critical and challenging recruitment areas but is by no means exhaustive. Mental health nursing Consultants in Psychiatry specialties General Practitioners Social workers Social care workers (in house and independent sector) Physiotherapists Occupational Therapist Care at home workers (in-house and independent sector) Consultants in both general medicine and general surgery Recruitment challenges are driven by a number of different factors, some unique to different job roles, others unique to different localities, but there are many commonalities. A number of challenges have been noted in the labour market analysis above, a shrinking working age population, reduced numbers of young people entering the labour market (with the notable exception of Oban where the younger population is growing), and general competition across the labour market. Specific issues for recruitment within the ABHSCP include Reputation and misconception of social care as a career Job Family WTE Vacancies Administrative Services 67.08 Allied Health Professions 29.69 Healthcare Sciences 2.00 Medical and Dental 12.30 Nursing and Midwifery 94.25 Other Therapeutic 7.00 Senior Managers 2.20 Social care 146.33 Social Work 29.20 Support Services 23.87 Grand Total 413.92
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19 Lack of affordable housing, higher proportion of second homes and competition with high earners re-locating to A&B for lifestyle The out of hours/on-call commitment across all professions in smaller remote/island teams can be onerous, although work has been done within Social Work to improve the position Funding models for particular roles, particularly in social work, fail to take account of the challenge of recruiting to part time, fixed term roles within small and remote teams. Interest over time in specialist roles when remote and Island areas need generalists with a broad range and depth of experience. Supplementary Staffing There is a clear reliance on supplementary staffing, shown below, caused by an inability to recruit substantively linked to national shortages in across job families as well as ongoing sickness and covid related absence. There will be continued scrutiny of the appropriate use of bank and agency staff and use of overtime and additional hours. NHS Highland is actively progressing initiatives, both locally, regionally and nationally to ensure better workforce supply and the creation of a more resilient workforce.
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20 Sickness Absence STILL WORKING ON AN INTEGRATED DATA SET Absence rates across the HSCP are shown above both for the individual employers and for the HSCP as a whole. ABC employees within the HSCP had a 6.59% absence level for the year to March 2022 compared to 5.11% within NHS Highland. Work is ongoing to provide comparator data at a more granular level within the HSCP. We do know, however, that absence rates vary across professions and when combined with COVID absences (excluded from the above figures due to recording differences) a significant issue with sickness absence becomes more apparent. Work continues across both employers to support managers with both long and short term absence issues within their teams. Turnover The turnover rate for the ABHSCP is shown below sitting at 11% overall. The higher level of turnover within A&B Council is driven largely by turnover within social care with two thirds of leavers working in that area. Argyll and Bute Council have recently launched an online exit questionnaire which will improve data on reasons for leaving enabling issues to be identified and addressed. NHS Highland will be launching a similar approach later this calendar year. 0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% ABHSCP Absence Rates Series1 Series2 Series3
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21 Culture, Health, and Well-being At the start of summer 2021, the ABHSCP undertook a Listening and Learning Survey as part of the response to the Culture Review. Employees from both employers were given the opportunity to take part in the survey, although the response rate was low at 38%. The high level results of the survey are noted below.
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22 A Management Reflections exercise was undertaken in response to the results from the Listening and Learning Survey, in addition to the establishment of a Culture and Wellbeing Group. A detailed action plan has been developed by the senior leadership team based around three themes as follows Joint Working, Communication and Governance Roles and Responsibilities Capacity Employees across the Partnership have access to Employee Assistance Programmes that support employees across a number of areas. The Guardian Service is available for all employees working in Argyll and Bute – both from the Council and the NHS. The service is independent and confidential and is for staff to discuss matters relating to patient and service user care and safety, whistleblowing, bullying and harassment, and workplace grievances. The guardians are external to the HSCP and provide information and emotional support in a strictly confidential, non-judgemental manner. The ‘Speak Up’ Guardian Service can be accessed 24/7. A further Listening and Learning survey will be undertaken in January/February 2023. Another focus area for both employers since 2019 has been to ensure colleagues are supported to stay physically and mentally healthy and have access to services when they become unwell and are helped to stay at work or return to work successfully when they are able to. For NHS Highland, throughout the pandemic, much focus has been on supporting the tactical elements, such as our Employee Assistance Programme, investing in additional psychology resources within our Occupational Health Team and practical support for rest, nutrition, and fluids. We’ve developed our Menopause policy and resources and are working on a Toolkit to support colleagues and managers. Our Together We Care strategic ambition to Nurture Well will see us deliver our holistic
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23 health and wellbeing strategy and plan, around 3 key areas of Mental Health, Physical Environment and Stress and Workload with a diagnostic currently underway, working with colleagues and key partners to ensure this meets the current and future needs of our workforce. For Argyll and Bute Council
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24 9. Common Workforce Drivers In common with many HSCPs and Boards, ABHSCP faces a challenge in maintaining a suitably trained workforce over the next 5-10 years. Demographic patterns have a direct impact on the available workforce and have created an imbalance between the supply and demand in critical services. For certain professions it continues to be extremely difficult to recruit the right staff in the right quantities. Direct engagement with a range of professional leads and managers either through workforce plans, workshops, one-to-one meetings and workstreams we have enabled the identified key drivers and the workforce challenges that need to be addressed through this strategy. Common workforce drivers and challenges that span multiple job families have been themed below: Common Drivers Common Challenges/Risks Embedding the NHS Highland Workforce Planning Cycle Defining key data metrics and associated outcomes Delivering new models of care services and within financial limitations Diversification of workforce Roster efficiencies Post covid treatment backlog Embracing changes in technology Changing demographics, both workforce and population Health and Care (Staffing) (Scotland) Act 2019 Increasing the future workforce pipeline/grow our own Alternative roles in areas experiencing long term vacancies Attraction & Recruitment Retention – high turnover / staff moving between services Lack of succession planning and workforce planning Accommodation both for employment and placements (lack of affordable housing) Age profile of workforce Work/life balance Lack of career entry pathways / apprenticeships Reduction in student numbers Poor utilisation of the careers framework to support career long learning and development and transitions between roles Financially constrained environment / management of fixed term posts Reliance on supplementary workforce / roster gaps / pressures on existing staffing The availability, validity and reliability of workload tools Predicated Absence Allowance (PPA) only allocated to Nursing Lack of ability to support staff training and development, no protected learning time Impact of inability to sustain independent contractors’ services
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25 10.Strategic Workforce Risk Following engagement with services across geographical areas and professional job families we have identified common themes where there are areas of challenge that will impact on our current and future workforce and the way we plan our services. Taking into account the data nationally, regionally and locally the key themes below outline strategic risks that span multiple job families and working environments. Risks Island Challenges Argyll and Bute has 23 inhabited Islands, none of which are connected by road to the mainland and require ferry or air services to reach. This poses a number of significant challenges in the delivery of health and social care services for the partnership, including the availability of accommodation for incoming employees noted above. Further workforce specific issues include Professional isolation and difficulties in providing support and professional supervision Skills maintenance through narrow breadth and depth of caseloads across all registrant job roles. Different personality of Islands not taken into account when recruiting Sustainability of teams due to size, age profile and ongoing vacancies on, for example, Coll, Tiree and Mull •Island Challenges •Accommodation •Flexibility in retirement •COVID impact and aftermath •Cost of Living crisis •Population demographic •Employee health and wellbeing •Recruitment challenges
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26 Service and workforce model that works on the mainland not always suitable for Islands. Temporary funding models do not support service delivery and workforce recruitment to Islands. The partnership has explored a number of different initiatives to support recruitment and workforce development over the last year. Community engagement sessions with prospective candidates were held in Mull, giving the candidates the opportunity to experience Island life and recognise that the community are willing to invest in them. Specific work is being led by the Chief Officer to deliver a sustainable service delivery model for the Isle of Coll. This includes scoping alternative job roles and targeted recruitment drives based around the lifestyle on the Island is also in progress. Similar challenges in Highland Health and Social Care Partnership are being addressed with a Small Isles model which is being explored as a possible option in ABHSCP. Rotations from the Islands through Lorn and Isles RGH is being considered to maintain skills for island practitioners. Accommodation Although noted above as a significant risk within the recruitment section, the extent of the accommodation risk within the ABHSCP cannot be overstated and presents itself in a number of different ways Lack of affordable housing for sale for incoming employees resulting in failed offers of employment Lack of long term lets for incoming employees resulting in failed offers of employment Lack of short/medium term lets for those who are on placement within ABHSCP to enable them to undertake the placement, with placements then being held in other HSCPs/Boards. The issue is more acutely felt in remote and especially Island areas where there is a more dispersed population and housing. Urgent action is being taken at a local multi-agency level and within Argyll and Bute Council as this is critical to the wider economic growth of the region. In addition, local initiatives, such as work to secure short term lets through Housing Associations to support incoming employees, is also being piloted within Oban and explored as on the Island of Coll.
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27 There is, however, a risk of those short term lets extending due to the shortage of long term lets and the competition within the house buying market. Action is, however, required at Scottish Government level to support remote and island boards and HSCPs with this issue, where it is most acutely felt. The development and implementation of the new National Centre for Remote and Rural Health and Social care is a very welcome development but needs to be supported by a parallel development of the underlying infrastructure to support inward migration to remote, very remote and Island areas. Flexibility in retirement Despite the age of our workforce and the risks to experience, skill and knowledge retention that this poses, the ABHSCP does not have significant flexibility in providing options for those who wish to retire but continue working within the partnership. There are number of challenges around this: Financial constraints Backfill recruitment to part-time posts Lack of suitable job roles for those wanting to retire flexibly Operational requirements and culture of replacing like with like Employers across the partnership have or are working towards more flexible retirement options. NHS Highland has recently introduced a flexible retire and return policy which will enable managers to support employees wishing to continue in alternative roles post-retirement. Argyll and Bute Council are reviewing the eligible age for flexible retirement. COVID impact and aftermath The cumulative impact of COVID on the workforce cannot be underestimated and we continue to live with and manage the virus on a day to day basis through employee sickness absence and self isolation due to contracting the virus. The pandemic has been a traumatic experience for many of our frontline staff who have faced the death of clients and patients, working with additional PPE requirements and extended shifts for a long period of time,
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28 shortages across teams on a regular basis leading to additional hours and overtime, dealing and continuing to face backlogs of cases contracting the virus themselves and dealing with the physical and mental aspects of that These issues are on top of existing vacancy and recruitment challenges. Support mechanisms through teams and the more formal EAPs are in place to support employees with these issues but they take their toll on health and wellbeing over the protracted time of the pandemic, with staff feeling exhausted. This has and will continue to have an impact on the retention of employees as we progress over the coming few years. We continue to see more complex presentations in patients and service users as a result of not attending at the initial onset of symptoms. This increases the levels of patient acuity in hospitals and the time taken to care for those patients and further impact on employees. We continue to see increases in mental health referrals as a direct result of the pandemic and the effects of successive lockdowns on social isolation, health and the economy. The staffing challenges in this sector have been noted above. There will be a potential need to develop new services to support those most affected by COVID, for example, initially for Long Covid patients through our AHP team. Cost of Living crisis The impact of the cost of living crisis brings a number of potential risks, some of which may be unclear and others where the timescale of the impact of the risk may not be immediate. The biggest initial impacts are being seen in remote, very remote and Island areas where cost of fuel has a proportionally bigger impact and in roles where wages are lower. In a geography where we already face competition from the tourist sector where earnings can be higher than many social care roles the cost of living crisis will only increase the recruitment and retention challenges faced. Most significant impact on care at home sector, both in house and independent providers, where employees are having to spend greater amounts on fuel for travel than they are able to claim back due to the rapid rise of fuel prices. This will
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29 have an impact on retention within an already vulnerable sector and we have already had anecdotal accounts of employees moving to a role in a care home and others leaving the sector all together. Potential impact on health of population and increased requirement for health and social care but this is as yet undefined. Population demographic Risks relating to the demographics of the population have been noted above but are summarised again here. The population of Argyll and Bute is shrinking with an increasing proportion of the population over the age of 65. This creates a number of different challenges for the HSCP. Increased demand on health and social care services Reduction in the working age population Increased age of our own workforce Employee health and wellbeing Trends in sickness absence over the last 2 years are difficult to identify for a number of reasons Levels of COVID related absences impacts on overall numbers through different recording practices At points through the pandemic lockdowns reduced absence due to lower levels of contact in the population Remote working also reducing levels of interaction and opportunities for infections to spread We do know, however, from managers that staff are tired, burnt-out and exhausted particularly in areas where they have been directly in the front line of dealing with the pandemic, for example, social care. Both employers within the partnership have Employee Assistance Programmes that support staff in a number of areas. The Guardian Service is available for all employees working in Argyll and Bute – both from the Council and the NHS. The service is independent and confidential and is for staff to discuss matters relating to patient and service user care and
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30 safety, whistleblowing, bullying and harassment, and workplace grievances. The guardians are external to the HSCP and provide information and emotional support in a strictly confidential, non-judgemental manner. The ‘Speak Up’ Guardian Service can be accessed 24/7. As noted above, a further Listening and Learning survey will be undertaken in October 2022. Recruitment challenges Recruitment challenges across all professional groups, social care and other key workforce area were highlighted above. There are differences across localities and job families but the common issues are restated below. Specific issues for recruitment within the ABHSCP include Reputation and misconception of social care as a career Lack of affordable housing, higher proportion of second homes and competition with high earners re-locating to A&B for lifestyle The out of hours/on-call commitment which in smaller remote/island teams can be onerous Funding models for particular roles, particularly social work, fail to take account of the challenge of recruiting to part time, fixed term roles within small and remote teams Labour market competition, particularly with tourism sector. Interest over time in specialist roles when remote and Island areas need generalists with a broad range and depth of experience
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31 11.Strategic Workforce Action Plan In order to mitigate against the challenges noted throughout this workforce plan and the strategic workforce risks above, the following strategic actions will be taken forward as part of a programme of work with oversight through the Strategic Workforce Planning group. These are grouped here by the proposed working groups that will undertake the work. Topic Action Outcome Measuring Success or Target Timeline Developing Fundamentals through partnership Develop a regular huddle in partnership with Skills Development Scotland, Developing the Young Workforce, Further and Higher education providers, council education service and workforce planners/Talent/Workforce Development representatives from ABC and NHSH. Develop the infrastructure required to deliver the actions from the workforce plan specifically setting Develop shared solutions that meet local workforce needs by providing employment opportunities and career development for young people in the local community. Professional and operational representation influencing the % increase in under 25 age profile Draft Terms of Reference and Membership agreed by December 2023 Draft Terms of Reference and Membership •Developing Fundamentals through partnership •Attracting the Future Workforce •Developing the Future Workforce Developing the current workforce to meet future needs Alternative workforce roles and models Wellbeing and culture Accomodation
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32 Topic Action Outcome Measuring Success or Target Timeline up the Strategic Workforce Planning Group as part of the Transformation Programme Implement the partnership approach to workforce planning, sharing best practice across employers using a workforce planning cycle and risk assessment to target additional support for managers. Develop the infrastructure required to support work experience and placements across all roles within the partnership strategic direction responding to service need. Agree priority areas to work collaboratively to agree an integrated service plan setting out workforce, performance and finance. Agree a single, consistent approach, plan and supporting materials for engagement with schools and offering volunteering and work placement opportunities across NHS Highland Increased level of delivery against the agreed WFP actions Increased level of manager engagement in WFP planning training / % of completed integrated service plans % increase in requested for workexperience placements agreed by December 2023 Agreed number of integrated service plans in place - 31 July 2023 Review in 12 months Attracting the Future Workforce Baseline current activity against the Investors in Young People Framework and use the framework to drive activity based on best practice on attraction and employment of young people Working alongside DYW colleagues develop a coordinated approach to raising awareness of the wide range of health and social care careers through engagement sessions in schools for both pupils and guidance teachers Define strategy and actions to support in the recruitment and retention of young people. Implement these actions to progress to Investors in Young People Accreditation. Support young people to stay in the area by developing innovative pathways across a range of roles % increase in under 25 age profile Achieve Investors in Young People Accreditation July 2023 Review in 12 months
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33 Topic Action Outcome Measuring Success or Target Timeline Commission work to understand what could attract workers into A&B HSCP from outside the area and use it to refine attraction work across the partners, including commissioned services. Build on the #abplace2b brand to develop a partnership approach for recruitment campaigns for all roles, including commissioned services and continue to build on the partnership approach to social media recruitment campaigns for adult social care Maximise the benefits of the international recruitment agenda within NHS Scotland to fill key workforce areas that support education in local area. Develop and promote career pathways across all job roles within the HSCP and the varied entry routes to those pathways. Support managers to design job roles to support operational need and support career development. Action plans to overcome the barriers and challenges in attracting workers to the A&B HSCP Evaluate current international recruitment and then build expand for a small number of key hard to fill posts. % increase in under 25 age profile Pathways developed and visible internally and externally. Increased applications and appointments from our targeted recruitment and social media posts Increased applications and appointments from our targeted recruitment 31 March 2023 Developing the Future Workforce Develop peer support and mentor networks across the partnership to ensure there is adequate infrastructure for apprentices coming into the HSCP Define strategy and actions to support in the recruitment and retention of young people. % increase in apprenticeships Launch Apprenticeship
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34 Topic Action Outcome Measuring Success or Target Timeline Implement the actions from the Young Persons Guarantee and use the YPG framework to drive actions planning for the future. Maximise use of foundation, modern and graduate apprenticeship frameworks as entry pathways for young people Consider using multi-skilled generic care assistant roles as an alternative pathway approach to supporting young people into professional roles Develop approaches to graduate sponsorship and identify key roles to pilot the approach Develop an approach to the use of CESR posts to develop the future consultant workforce Implement actions to progress to Investors in Young People Accreditation. Implement a single, consistent approach to apprenticeships across NHS Highland, to ensure we are maximizing use of these roles, have consistent roles and responsibilities to support them Working with local and national professional leads, managers, education and training providers and develop a range of roles and career pathways and access points for professional roles and grow your own. Agreement of our strategy for apprenticeships Increase no. of training opportunities offered and delivered Develop a plan for engagement and activity for access to training and employment, working with public health and community and third sector partners Strategy in line with academic calendar 2023 Review 31 March 2023 Developing the current workforce to meet future needs Review the current Growing our Own scheme and implement changes to create opportunities Work across the partnership to develop leaders of the future in health, social work and social care enabling a broad understanding of the managing the system Create additional opportunities from school leaver exploring the opportunity to develop a pathway to support people to access manager posts % reduction in turnover of under 30s entering into the NHS Toolkit created, piloted and evaluated. Ongoing with review at July 2023
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35 Topic Action Outcome Measuring Success or Target Timeline Develop a succession planning approach for key roles in the partnership that gives equality of opportunity to all Ensure there is a sufficiently resourced education infrastructure to enable professional development across all job roles Complete assessment of readiness across the partnership for the Health and Care (Staffing) Act implementation in April 2024. Extend the use of the OU courses for nursing and social work for those with a desire to progress their careers Develop and embed succession planning toolkit. Ensure education numbers are documented in workforce plans. Feed into the NHS Highland wide self-assessment reporting template Number of high risk posts will documented succession plan and actions. Template completed for all relevant job families Alternative workforce roles and models Implement and maximise use of Retire and Return policy Continue to develop route to grow your own: assistant practitioner roles to support the registered workforce, generic multi-skilled community care roles a non-registrant career pathway, expand the use of advanced practice across all professional roles Assess and consider the use of Medical Associate roles Ensure a collaborative approach with potential retirees and managers to ensure Services can continue to provide with the correct skills Work to develop flexible, appropriate roles for those working into retirement Ongoing with review at July 2023
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36 Topic Action Outcome Measuring Success or Target Timeline Wellbeing and culture Progress actions agreed through the Argyll and Bute Culture and Wellbeing group Analyse i-matter survey results and agree any further actions required Undertake a further Listening and Learning survey in October 2022 covering the whole of the partnership Analyse progress from previous culture survey and refine approach and develop additional actions as required. Compare with survey results from previous years Compare with survey results from previous years All actions progressed % change in response rates, Employee Engagement Index Score and team action plans. % change in response rates. Actions from previous year completed Ongoing with review at July 2023 Accomodation Review own accommodation use and develop a strategic approach to its use to improve successful recruitments and support placements. Open an active dialogue with Scottish Government through the workforce plan as one of the biggest barriers to recruitment in Argyll and Bute Establish a multi-agency approach to tackling the affordable housing situation across the geography tailoring solutions to the particular locality as required. For example Working in partnership with Strategic approach established to support new recruits and placements. Collaborative approach established to ensure partnership working to provide the right services for our workforce Ensure a joined-up approach across the health and social care system to address underlying issue Reduction in the loss of student placements and onboarding due to accommodation issues. Working collaboratively with partner organisations secure short/medium and long term lets for HSCP employees Ongoing with review at July 2023
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37 Topic Action Outcome Measuring Success or Target Timeline Shelter Continue to explore options in each locality to work with housing associations Develop a project proposal for implementation next year with a view to bringing empty homes in A&B into use and prioritise their use for health and social care staff
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38 Appendix 1: Key Detail by Profession (NHS Argyll & Bute Workforce) PHARMACY SERVICES Workforce Summary Drivers Risks Headcount 39, WTE 34.3 94.9 % Permanent, 5.1% Fixed Term 2 fixed term contracts 71.8% Whole Time, 28.2% Part Time 42.2% over 50 years old 7.7% over 60 8.8% under 30 These are aimed at transforming the role of Pharmacy across all areas of practice Achieving Excellence in Pharmaceutical Care: Focusing on achieving excellence in improvement and integration of the provision of NHS pharmaceutical care, supporting the contribution of pharmacist and pharmacist technicians, enhancing roles and working together with other health and social care practitioners, to improve the health of the population Regional project for Implementation of HEPMA and Wellsky (Pharmacy Stock Control systems) Cancer Service Developments Community Pharmacy contract changes by the Scottish Government o Additional services Pharmacy First; Pharmacy First Plus o Additional PGD (Patient Group Directives) o Flu Vaccination Programme and Travel Vaccination Programme Redesign of Mental Health Services Primary Care Modernisation/Pharmacotherapy o Care at home and Care Home service developments o Drug related death and chronic pain service developments Pharmacy Education and Training developments - Undergraduate and Post Graduate Pharmacy Technician Education and Training Developments National Pre-Registration Pharmacy Technician Programme (PTPT) In comparison to medicine and nursing, there is little national planning done on Pharmacy workforce projections Retirements this year, with multiple further potential retirements within the next 5 years Additional Designated Prescribing Practitioner (ADPP’s) required to provide sufficient mentorship to the IP’s in training Short supply of ADPP’s in Highland leading to patchy Pharmacy First Plus service with a lack on continuity of access to the service Increased Acute pharmacy workforce risk due to increase in activity and introduction of new services (Covid, Vaccinations) Managed service Foundation Pharmacists workforce is inadequate to fill the current vacancies and will not meet the requirement to fill any new roles New opportunities for pharmacists living in Highland to work remotely across the UK (e.g. employment within the pharmaceutical industry) Future changes to regulation of pharmacists and pharmacy technicians by General Pharmaceutical Council Severe lack of Pharmacists (including locums) is resulting in unscheduled closures of community pharmacies. Patients are then severely affected as they are unable to access a pharmaceutical service from their pharmacy of choice on that day. Challenges Overall NHS Highland Pharmacy Services face an increased demand due to the development and redesign of services compounded with an increase in the number and complexity of medicines. The delivery of a Pharmacotherapy Service based on expansion of Pharmacists and Pharmacy Technicians working in Primary Care Delivering a seven day service in Acute hospitals with a funded five day service Maintaining cancer pharmacy services against increasing demand Recruitment, development and retention of pharmacists and pharmacy technicians in technical services e.g QA and Cytotoxic Chemotherapy production
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39 Recruitment to remote and rural locations is challenging and increasingly impacted by rising house prices and lack of supply of rental properties Community pharmacy contractors are not NHSH employed resulting in difficulty with co-ordinated action across managed and contracted pharmacy services Lack of ability to support staff training and development Increased demand on time for Education and Training of student pharmacists against the requirement to deliver clinical services Increasing length of experiential learning placements for undergraduate pharmacy students Intake of Pharmacists to primary care requiring significant training for primary care work Health and Care (Staffing) (Scotland) Act 2019 and the validity and reliability of need to be developed National tactical plan for pharmacy across the sectors is a barrier to delivery Nationwide increased demand for pharmacists and pharmacy technicians due to the development of roles in the managed service and other areas Lack of national, dedicated and resourced recruitment pipeline for pharmacy support workers with recruitment and training being unstructured, ad-hoc and on the job Pharmacist Independent Prescribers required to provide an enhanced service to patients to further reduce the workload burden on GP’s Lack of space in GP practices for Clinical Pharmacists to delivery face to face services MEDICAL AND MEDICAL SUPPORT SERVICES Workforce Summary Drivers Risks / Challenges Headcount 41, WTE 23.0 85.4% Permanent, 14.6% Fixed Term 6 fixed term contracts 39.0 % Whole Time, 61.0% Part Time 71.2% over 50 years old 17.8% over 60 0% under 30 46.3% Female, 53.7% Male General Medical Services Contract Clinical Prioritisation of Planned Care Redesign of Urgent Care Extended role for PH consultants Cancer care Regional solutions to service provision, Radiology, Psychiatry Job Planning GP Contract implementation Primary Care Improvement Programme Vaccination Transformation Programme Remobilisation of GP Practice activity following COVID Physician roles expansion to be explored explore the use of Clinical Development Fellowships to support the wider medical workforce and train the future medical workforce Difficulty recruiting Funding insufficient to deliver the aims of the primary care contract Inequitable service provision due to staff vacancies and inability to recruit. Changes to JD working hours will impact on rotas and service provision Junior doctor shortages/ rotation for junior doctors Locum costs / consistent service workforce impact of recent changes to pension schemes out of hours cover - GP no longer obligated to deliver out of hours services / NHS to cover provision Fri 5pm-Mon8am or weekday evenings 6pm-8am Fragility of staffing in GP practices/sustainability in particular out of hours services Lack of information on Primary care workforce Anecdotal age profile of GP workforce Challenges recruiting GPs with the requisite depth and breadth of experience to rural practices Challenges recruiting to all roles in the Primary Care Improvement programme, especially in remote locations where roles are part time.
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40 Significant impact of lack of accommodation on recruitment to roles Funding levels under PCIF, along with practice size and remoteness, impact on ability to development of an HSCP staffing model for Community treatment and Care services ALLIED HEALTH PROFESSIONALS Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount 172, WTE 139.5 94.3 % Permanent, 5.7 % Fixed Term 8 fixed term contracts 47.1 % Whole Time, 52.9% Part Time 34.3% over 50 years old 8.5% over 60 11.1% under 30 88.4% Female, 11.6% Male Need to develop portfolios/pathways to attract GPs , ANPs , and advanced AHPs and nurses in to Primary Care Diversification of workforce, increasing the pipeline Health and Care Staffing Act Implementation PMO Roster efficiencies / implementation of eRostering Unscheduled Care Enhancing Community Services Mental Health Strategy Outpatient redesign (all patient facilities for community hospitals, acute, inpatient services) Once for Scotland Rehabilitation strategy SG AHP workforce review Primary Care modernisation programme Clinical risks associated with non-compliance with professional registration ongoing training commitments - impact is on quality of care. AHP Professions have fragile staffing levels In the community specifically Dietetics, OT, Physio, Podiatry, Speech and Language Therapy Podiatry (only 30 students graduating this year normally 100 and 27 employed by GGC already) Increasing demand for AHP services and no commensurate workforce increase Nationally. Lack of strategic approach to education and development opportunities and pathways Lack of protected time for training Lack of standardised approach to learning needs analysis and coherent priorities for development support to deliver and transform service No local Higher Education providers offer AHP qualifications No HEIs currently offer distance learning options to reach registration Podiatry - 170 vacancies across NHS Scotland Boards and not counting private practice. Skills level not as previous years due to covid limitations during education Workforce not established to provide backfill for planned leave and absences. Lack of agencies staff as expensive alternative workforce Poor utilisation of the careers framework to support career long learning and development and transitions between roles Lack of skills and capacity within the workforce in research. QI and education
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41 NURSING Workforce Summary Drivers Risks/Challenges Headcount 622, WTE 520.5 95.7% Permanent, 4.3% Fixed Term 27 fixed term contracts 52.9% Whole Time, 47.1% Part Time 49.7% over 50 years old 11.9% over 60 10.1% under 30 90.7% Female, 9.3% Male Palliative & end of life care provision Vaccination Transformation programme Excellence in Care Transforming Nursing Roles PMO Roster efficiencies / implementation of eRostering International recruitment Long term gaps in band 5 provision Unsufficiant pre-registration nursing places Demographic analysis of workforce shows high percentage of nursing staff can retire in next 2 years if they choose to do so Ongoing reliance on locum and agency staff Reassignment of staff Demand uncertainty given the ongoing risks of the pandemic including interdependencies Nursing/ District Nursing Workforce availability Management of and impacts of fixed term posts (COVID funded) High levels of vacancies particularly in smaller rural teams Lack of affordable housing in some areas e.g. Skye and Lochaber Challenges in recruitment and retention of NMAHP advanced practice posts Inability to provide consistent skills mix in rosters across the week MIDWIFERY Workforce Summary Drivers Risks/Challenges Headcount 44, WTE 36.5 93.3% Permanent, 6.7% Fixed Term 3 fixed term contracts 32.7 % Whole Time, 67.3% Part Time 52.7% over 50 years old 5.1% over 60 13.7% under 30 100% Female, 0% Male PMO Roster efficiencies / implementation of eRostering Best Start - the Continuity of Carer model Proposed pathway between services in Dr Gray’s Hospital and Raigmore Hospital Redesign of Raigmore Hospital Maternity Unit/Community Hubs Increase in demand for home births and out of hours midwifery service provision NHS Highland currently has a registered midwife vacancy rate of 22% with vacancy rate in North Highland area being the higher than A&B. The main consultant obstetric unit has a vacancy rate of 27% with rate being as high as 40% in some of the smaller remote and rural Community Midwifery Unit teams. This poses a risk for sustainability of out of hours services and provision of local birth service in the CMUs and community areas Supply model of newly qualified midwives not meeting demand. National shortage of midwives, so very competitive market across Scotland Ratios of experienced midwives to newly qualified midwives (Raigmore) Midwives being attracted into higher banded posts such as Health Visiting and Family Nurse Partnership
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42 Workforce availability including bank and agency High levels of vacancies particularly in smaller rural teams Lack of affordable housing in some areas e.g. Skye and Lochaber HEALTHCARE SCIENCE Workforce Summary Drivers Risks/Challenges Headcount 28, WTE 24.5 92.9 % Permanent, 7.1% Fixed Term 2 fixed term contracts 75.0% Whole Time, 25.0% Part Time 34.3% over 50 years old 8.5% over 60 10.7% under 30 67.9% Female, 32.1% Male Equipment changes and additions Standardisation of working practices across the network Increased demand - automation, rural service, home monitoring devices for patients Online (NearMe) clinics Diverse workforce covering many disciplines National/international shortage of some professions Capacity/protected time to train staff PSYCHOLOGY Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount 7, WTE 6 100% Permanent, 0% Fixed Term 0 fixed term contracts 42.9% Whole Time, 57.1% Part Time 70% over 50 years old 26.7% over 60 0% under 30 85.7% Female, 14.3% Male Psychological Therapies Improvement plan – 3 year plan Recovery and Renewal fund increase capacity in primary care Integration psychological services Increase capacity in services to address lower tier PT Meeting the PT Waiting Times Standard Clearing waiting lists Lack of available Psychology workforce Data accuracy issues around waiting times and services Systems and infrastructure supporting patient pathways need development Data inaccuracies contribute to difficulties in waiting list management for the right service Inability to recruit to posts impacts on service provision Patients on wrong pathway risk delays in care Fixed term funding for some services DENTISTRY SERVICES Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount 48, WTE 36.9 Remobilisation of dental services Anticipation of Scottish Government changes to GDP contract Recruitment challenges compounded by early retirements
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43 95.9% Permanent, 4.1% Fixed Term 2 fixed term contracts 45.8% Whole Time, 54.2% Part Time 41.3% over 50 years old 5.4% over 60 6.3% under 30 Oral health improvement Equitable provision of services post remobilisation Opportunities to reintroduce trainee Dental Nursing posts to the PDS establishment. Insufficient number of Dentists to meet the demand for NHS services due to delayed graduation of current final year students to 2022 Funding for General Dental Practitioners has not yet returned to the pre-covid arrangements Timescale required to increase skill mix through mobilising greater numbers of Hygienist/Therapists Difficulty in providing accurate workforce data on GDP contractors to understand independent provision Lack of provision of routine care Accessing and funding additional training to upskill the workforce Social Work and Social Care Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount475, WTE 356.44 38% Whole Time, 62% Part Time 61% over 50 years old 21% over 60 4% under 30 91% Female, 9% Male Social Work protective statutory duties increasing Community led hubs Unscheduled and scheduled care Increasing complexity of care in community Recovery of Services coming out of COVID pandemic Ongoing management of COVID in both services and the workforce Continued focus on infection prevention and control Development of mobile response team within Care at Home Establishment of nursing leadership roles to provide oversight and support for Care Homes Maximising and continuing to develop partnership approaches with independent social care sector in, for example, attraction and recruitment Impact of unidentified and unmet health care needs on the demand for service Consideration of NCS and implications Mental Health redesign Social Work Management structure review Retirals in anticipation of NCS and aftermath of COVID Adult Social Work identity lost in Health and Social Care landscape Difficulty in recruiting for a number of reasons, including national shortages of social workers. Short term funding and allocation model compounds national shortages for remote and island based social work teams. Lack of recognition both in training and recruitment of remote and island practice as a specialism in its own right No distant islands/remote teamchers allowance equivalent for social work Training access for remote and island teams, where smaller generalist teams need a broader range of training with impact on service provision Current approach to grow your own needs considered creating trainee SW posts to retain those that have completed their training. Registration requirements of social care workforce • Longstanding recruitment challenges in independent sector • Ongoing management of services with COVID absences • Recruitment to all social care roles, including social care in the independent sector
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44 • Reduction in the availability of care home beds • increases in demand • High turnover within Care Homes. • Waiting list for adult social care qualifications (HNC/SVQs) for SSSC • ADMINISTRATION Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount 284, WTE 222.4 94% Permanent, 6% Fixed Term 18 fixed term contracts 44.7% Whole Time, 55.3% Part Time 49.5% over 50 years old 15.9% over 60 6.7% under 30 89.1% Female, 10.9% Male Finance new approach to band 3 recruitment - not insisting on qualification but offering the opportunity to train on the job - more generalist role can work across 'silos' eHealth potential restructuring, are currently in an ‘agency spiral’ as can't recruit skilled staff (wages), exploring automation including chatbots eHealth, future switch from server based to Cloud based infrastructure will impact on roles and training requirements Procurement adopting national structure, band 4 will be starting point and will lose 2s and 3s, becoming more strategic than operational People & Change - people partners, changes to structure of people services, changes to recruitment including international recruitment post Public Health - focus on anchor organisation role, refugees SUPPORT SERVICES Workforce Summary Drivers Summary Risks/ Challenges Summary Headcount 200, WTE 147.1 99.5% Permanent, 0.5% Fixed Term 1 fixed term contract 37% Whole Time, 63% Part Time 59.9% over 50 years old 26.9% over 60 8.9% under 30 63.5% Female, 36.5% Male New roles in Estates - multi-trade skilled workers and a new C&G qualification to train them Employability and Refugee agenda for entry level roles. Ageing workforce Competition from private sector for skilled workforce
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46 Appendix 2: Workforce Drivers, Challenges, Risks by Service Area REMOBILISATION Drivers Risks/Challenges Actions NHS Scotland Recovery Plan Growing backlog of patients waiting much longer Requirement to develop the role of Public Health services Ongoing need for enhanced infection prevention and control measures Impact of unidentified and unmet health care needs on the demand for service Harness opportunities to embed and enhance new ways of working, e.g. virtual consultations using Near Me Uncertainty about how the pandemic will develop and the potential impact on future surges Ongoing sickness absences both non-COVID and those caused by COVID-19 variants continuing within the community Burnout of workforce due to dealing with vacancies and absences within small teams Unable to fill vacancies, particularly within social care Supporting staff to take time and are supported to rest and take annual leave Sustainability of workforce post COVID with retirals, recruitment challenges and skill mix problems Develop a centralized booking service to ensure patient pathways are appropriate and access is improved for patients Continue to develop, embed and normalize use of virtual consultation technology Further develop Near Me infrastructure and work with NHS GG&C to support pressure specialties CHILDRENS SERVICES – Resources Drivers Risks/Challenges Actions Continue to realign the service to support the aims of The Promise. New national framework for workforce development once published to effectively support employees. This will require a change in culture and a change in the way that managers lead their teams. Become a trauma informed service training Ongoing roll out of The Promise will continue to have an impact the direction and objectives of the team The national refugee situation will impact the team over the next 1-5 years. The strategic focus of the service will likely see an increase in investment in certain areas of the team such as fostering and adoption Attracting suitable applicants to management roles, particularly within the Oban area. Age profile of the team could pose future risk should a number of people look to retire at the same time. High reliance on casual staff and are actively looking at ways to reduce this however positives re use of use of casual posts prior to applying for a permanent post with benefits for employee and employers in terms of retention Residential teams 12 hour shift patterns is too long for both the children and the team. Reducing this could also help the impact that the role has on individuals Ensure training plan remains in place, relevant and on track, and that training is accessible Ensure the requirements of the first phase of The Promise are delivered and embedded into the culture of the team and that managers have the tools to lead the teams in this way. Action on the reduction of use of casual staff, whilst retaining some of the benefits of this as a pathway to career.
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47 Review of number of children’s houses and potential upskilling requirement should part of the workforce required to be redeployed. Upskilling workforce to reduce the number of children being placed with external care providers. CHILDRENS SERVICES – Maternity Services Drivers Risks/Challenges Actions Ensure that the service is able to meet the safe staffing legislation (2019) taking into account the current and future workforce and workload, the context where the maternity service practices and the national drivers impacting on care. Recognition that the preventative role of universal services is the single greatest return of investment, impacting on the future physical and mental health of our population. The midwifery led service, is progressing well in meeting the maternity policy direction for care to be person centred through a continuity of care model, provide care close to home bringing services around the woman in their home or in local hubs (CMU) using Near me and remote monitoring to enhance care, and that strives to keep mothers and babies together. While services across Argyll have often developed iteratively in response to the needs of women and families, as an early adopter for the Best Start (SG 2017) the draft model for care has been developed utilising a structured approach. Once implemented in full it will support the dispersed service model to be resilient, sustainable, support career development and promote safety by supporting flexible working. Agreeing and embedding model for Maternity & Newborn care. The services across 5 localities were developed iteratively. Agreed parameters and a sustainable model for services is currently being coproduced with midwives across A&B initially before taking to wider teams with a view to implementation over the next 3 years. Rostering all midwives to attend GGC for 75 hours in 18 months. All midwives are required to be skilled across all areas of midwifery practice; in addition, there is also Mandated Core mandatory training for midwives. Midwives in remote and rural areas of Highland and GGC are required to meet addition 75 hours clinical exposure this is not currently achieved. This will be focused around the skills required to maintain services in Argyll and Bute as well as to provide continuity that is central to Maternity Policy. Consolidating and developing skills to support future workforce. New midwifery proficiencies (NMC 2019) require further skills to be developed across HSCP. This requires substantive practice development hours for Midwifery in Argyll and Bute which have provisionally been agreed with North Highland. The consultant midwife role supports the clinical skills and evidence based practice. Workforce demographics (10 midwives can potentially retire in the next three years in the west of Argyll and All midwives meet the guidance for clinical exposure (75 hours 12-18 months) in a way that supports them in their current and future roles. Beyond orientation future outcomes to be SMART and agreed with manager during PDP. To systematically plan and monitor the implementation of the final model for maternity care utilising improvement methodology, that supports a dispersed model for clinical development within each portfolio area: Public health (GIRFEC, inequalities, Perinatal mental health, bereavement care,) Education and training, Infant feeding, Digital (Badgernet, Near Me remote monitoring) HAI & infection control. To develop role for consultant midwife using backfill to create during the next 2 years of HOM secondment underpinned by robust establishment setting. To meet continuity of carer for all women as per national guidance in a way that meets the needs of the workforce and the women and families. Increase resource around practice education/practice development in Argyll and Bute Ensure all audit around examination of the new-born is robust within a sustainable model
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48 Provision of Maternity Services to 23 Inhabited Islands with 3 permanent on-island resident midwives. Bute). Maintain the current level of successful recruitment where students and new midwives are supported to work and develop skills supported by experienced midwives who feel valued and supported. Move to retrospective rostering Maternity policy drivers requiring greater flexibility to provide person centred care through a continuity model with care being provided as close to home as possible. The current model is provided as on call over and above working day. There is a move to try to implement this within substantive hours. This is a challenge for all boards and a SLWG is being developed nationally with partnership to define models. Greater expectations of service: implementation of perinatal mental health pathways, bereavement care pathways, postnatal contraception over and above maternity and neonatal reform. Develop the hub on Islay as part of the Kintyre and Islay midwifery team to ensure a positive working environment for the team with close links and support from their team in Kintyre. Develop equity of scanning services across Argyll and Bute with radiography lead. COMMUNITY JUSTICE Drivers Risks/Challenges Actions Action to reduce the backlog of cases following the pandemic Initiatives driven by temporary ring-fenced funding, e.g., Bail, diversion, Covid recovery Requirement in small remote teams for generalist staff, who need increasing levels of specialist training Additional training required for Risk management (LSCMI) and court reports Scottish Government targeted/ring-fenced funding models do not take into consideration rural service delivery and make it difficult to deliver what is expected. Lack of specialist teams like larger urban areas means generic posts are required to cover all parts of the service adding to the challenge of recruiting to temporary posts. Attendance at multiple specialist Review recruitment process to eradicate any unnecessary delays, particularly where funding for the post is based on short term funding from Scottish Government. Consider alternative approach to short term contracts by considering permanent contracts with initial external funding and then redeployment to areas of need to reduce recruitment challenges, improve continuity and greater job security
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49 training courses increases service delivery difficulties substantially Short term funding for posts, combined with delays in recruitment and limited training dates available mean it is often 3-4 months into the term of the funding before delivery can start. Intervention and risk management training is required across the team but there are barriers to accessing the nationally accredited training programme both in terms of the practical accessibility and technology, and through the delivery method with impact on small teams in remote areas and equity of service across Scotland. There are often difficulties recruiting to roles based in more remote westerly areas of the geography Temporary professional social work workforce is not practicable in remote and island areas. PUBLIC HEALTH Drivers Risks/Challenges Actions The next 12 months will be a period of stabilisation and ongoing remobilisation as we emerge from COVID. We require to be able to step up / step down services in the event of further COVID pandemic pressures. We anticipate an increase in demand on all teams and the need to meet the requirements of the following: Remobilisation of core activities / return to pre COVID service levels – all teams (and related services) Local public health priorities emerging from COVID including social mitigations, poverty work, DPH annual report recommendations Demand uncertainty given the ongoing risks of the pandemic including interdependencies (e.g. step down and step up) Period of uncertainty given remobilisation of services and new developments locally and nationally (see strategic drivers above) Impact of funding / resource constraints (e.g. that current resources will not be retained or delayed and resourcing impacts in other parts of the system impacting on recruitment e.g. delays to evaluation of new posts) Management of and impacts of fixed term posts (COVID funded) – by Sept 2022 (or earlier) Management of fixed term posts in Health Improvement posts (Health Improvement bundle or wider funded) Benchmarking by peer review our workforce and associated plans with other Boards. Map staff skills to assist with skills mix planning, agile working. Develop our succession planning modelling and ensure plans are in place for potential retirement, vacancies, and support career development. Develop scenario planning to review unforeseen circumstances and map pathways of support. Actively support and manage career progression (assessment and planning) – for individuals and the system e.g. to reduce system bottlenecks to career development (e.g. teams with flat management / progression structures), actively support staff in their career
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50 Local strategy: review will be required as a result of the development of the NHS Board strategy / public health strategy; remobilisation plan / AOP 2022/23; Community Planning Partnership strategic intentions National and regional developments (PHS, NoS, ‘Once for Scotland’) and e.g., PHS providing intelligence support to the team and community planning. This is likely to be a considerable workforce we could make use of and align to our workforce planning (PHACTs, LFIT, LIST) National strategies (new and remobilisation) National workforce planning strategy: (influencing through our operational activities but specifically address) Revisiting the specialist public health workforce arrangements taking into account learning from COVID-19, to support the renewal of the public health system and progressing the implementation of the National Public Health workforce planning plan. Developing an effective workforce planning system which enables the public health workforce to predict future capacity, and capability requirements along with identifying gaps and pressure points. Review Antimicrobial Stewardship, Health Protection and Infection Prevention and Control Workforce with a draft strategy being issued for consultation early February 2022, and the final strategy being published at the end of March 2022 (understood to be on hold). Supporting the development of a further programme of work in relation to Public Health Leadership and Succession Planning in Scotland. Recruitment to senior positions (principally CPH / Public Health Specialist levels) Staff health and wellbeing and specifically recovery from COVID (short and medium term) Resilience of functions within all teams but specifically: Faculty of Public Health Educational Trainer(s) and Supervisor(s); support to Partnership arrangements (Violence against Women, Green Health Coord, Alcohol and Drug Partnerships) Risk of staff moving on or temporary cover requirements (maternity leave, retirement, job change, career development or gaps due to ill health / COVID impacts) Funding and funding models e.g. short term funding (HPT/HIT) for staffing and programmes development / growing our own (recognising these needs impact across teams and across different timeframes). Work with other teams in NHS to ensure efficient and effective use of skills e.g. support for commissioning and contracting (including finance and monitoring). Capture the resources gap elsewhere in the system over which we have less control e.g. through Lead Agency model – which equates to unmet need e.g. in supporting children’s integrated services in Highland area due to reduction in Health Improvement staff in the Highland Council. HPT - Plan to evaluate the experience of the expansion of clinical fellows in health protection. Increase the profile of health protection as a career choice for nurses. Support those colleagues in training to explore public health as a career / speciality e.g., ScotGem and medical students. Develop a revised / cross Directorate Learning and Development Plan – to improve education and career pathways ensuring provision of relevant skills and training (this will include ensuring all key staff are trained in the workforce planning 6 steps and tools and ensuring workforce planning is embedded in our every-day work). Maximise access to and support for staff wishing to apply for the UKPHR specialist register (practitioner and specialist) and ensure that these developments align with our grow your own opportunities within NHSH at all levels i.e., career developments at practitioner and consultant levels. Advocate for an expansion of the Specialist Training programme through an increase in National Training Numbers (NTNs) (all specialities). Maintain and focus on staff health and wellbeing – particularly recovery from the impact of COVID
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51 Establishing a Public Health Workforce Development Programme to build workforce quality, capacity and capability to ensure high standards of public health practice, maintained through a culture of learning, qualifications, registration, and regulation for the public health workforce. Establish a programme of work to review and support public health workforce recruitment which addresses some of the current challenges. Public Health – Population and Morbidities projections (this will be updated on behalf of the Board and will influence public health planning) Concerted moves and plans towards career development and registration and regulation for the public health workforce ADULT CARE SERVICES Drivers Risks/Challenges Actions Recovery of Services coming out of COVID pandemic Ongoing management of COVID in both services and the workforce Continued focus on infection prevention and control Development of mobile response team within Care at Home Establishment of nursing leadership roles to provide oversight and support for Care Homes Long Covid services development Maximising and continuing to develop partnership approaches with independent social care sector in, for example, attraction and recruitment Transformation of Services programme boards International recruitment Ongoing management of services with COVID and general absences Recruitment to all social care roles, including social care in the independent sector Sustainability of islands services on a number of Islands, including Coll and Tiree Skills maintenance and potential isolation of Island based employees Lack of accommodation across the area is a significant barrier to recruitment especially but not limited to Islands Age profile of Island based workforce Post pandemic fatigue and workforce wellbeing Sustainable medical staffing at Lorn and Isles Hospital Recruitment to professional roles across the area, but in particular adult social work, physiotherapy and Occupational Therapy Remove barriers which are preventing people from accessing jobs within the service. For example, current JDPS’s (job descriptions) are not user friendly and we are looking to review and simplify them by December 2022 Promote the adult social care as a career to try and attract a new potential workforce and showcase the opportunities for development. – by March 2023 Review the current Growing our Own scheme and implement changes to create opportunities from school leaver to qualified officer including exploring the opportunity to develop a pathway to support people to access integrated manager posts.
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52 Out of hours social work provision and onerous on-call requirements at senior level Significantly onerous on-call requirements in many professions, including but not limited to radiography, mental health Pressures on care at home provision due to vacancies, absence and ongoing covid absences. Nursing shortages in care homes Risk of just moving employees between employers and not growing the overall sector workforce, particularly in social care, but this is also a risk in other services and professions where private sector provision exists. Staff isolation on the Islands Fuel costs impacting on ability to carry on working within care at home has a differential impact in remote service locations where distance between client visits is greater Failed employments in independent social care sector and wasted costs of training/induction Difficulties recruiting to more specialist roles at Lorn and Isles, for example cardiac physiology, specialist radiography. Inability to recruit generalist Consultant physicians and surgeons and gaps in middle grade medical positions Unable to get full allocation of junior doctors leaving gaps across the rota and requirement to backfill with locums Increasing number of overseas graduates applying for roles who need more supervision in a large teaching hospital before being ready to deploy in an RGH with the range of activity seen in Lorn and Isles and with a developed education infrastructure to support No nurse manager at Lorn and Isles Unable to provide breadth of training exposure to medical trainees at all levels resulting in little conversion rate to Consultant level
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53 MENTAL HEALTH SERVICES Drivers Risks/Challenges Actions Mental Health Strategy 2017-2027 Health and Care Staffing Act Stability of inpatient services Reducing Psychological Therapies waiting times Reduce levels of unmet need Urgent and emergency care pathway and impact on acute inpatient ward. Recruitment to Consultants and Junior doctors remains challenging Shortage of Mental Health Officers, with recruitment, retention and age profile issues for this role with no recognition of the enhanced status of the role. Specialist gaps in psychological therapies services given recruiting to each of these as standalone services would be unrealistic. No third sector mental health providers within the area No home treatment services which could reduce admissions Recruitment to community and addiction teams tends to be from other teams into more specialist roles which has been more challenging recently. Develop a specific mental health grow your own campaign supporting candidates from outwith the HSCP. Develop/Implement a Mental health advanced nurse practitioner model, recruiting 4.9WTE MH ANPs to mitigate junior doctor gaps and vacancies within inpatient services. Develop Band 4 mental health assistant practitioner to lead health care assistants. Review skill mix for urgent and emergency care team aim of increasing the sustainability of the team through use of assistant practitioner roles Build a structure within the community teams that provides opportunity for learning and development and promotion, such as grow your own from health care support workers through to advanced practice. Development of advance nurse practitioner roles within specialist services Consider the role of MHO within the HSCP as a senior practitioner in line with other HSCPs across Scotland to develop the career pathway and improve recruitment and retention to this key role. PRIMARY CARE (GENERAL PRACTICE) Drivers Risks/Challenges Actions GP Contract implementation Primary Care Improvement Programme Vaccination Transformation Programme Remobilisation of GP Practice activity following COVID Sustainability of Island GP practices and in particular out of hours services Lack of information on Primary care workforce Anecdotal age profile of GP workforce Complete recruitment and establishment of vaccination teams Recruit to primary care nursing posts for community treatment and care Review of sustainable services on the Island of Coll. Establish sustainable GP out of hours service for Jura
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54 Challenges recruiting GPs with the requisite depth and breadth of experience to very remote and island practices Challenges recruiting to all roles in the Primary Care Improvement programme, especially in remote locations where roles are part time. Significant impact of lack of accommodation on recruitment to roles Remote and island related challenges of accessing training for, for example, pharmacotherapy. Funding levels under PCIF, along with practice size and remoteness, impact on ability to development of an HSCP staffing model for Community treatment and Care services