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Introduction

9.1 NHS staff, at every level, are the key to reform. Extra staff will bring big benefits. But expanding the size of the workforce will not on its own be sufficient to deliver the major improvements in patient services the country needs. Radical changes are needed in the way staff work to reduce waiting times and deliver modern, patient-centred services. This is not a question of staff working harder. It is about working smarter to make maximum use of the talents of all the NHS workforce. The changes described in this chapter will offer better services for patients and more opportunities for staff.

Breaking down barriers between staff

9.2 Throughout the NHS the old hierarchical ways of working are giving way to more flexible team working between different clinical professionals. Midwives, for example, are leading more responsive childbirth services in many parts of the country. In many accident and emergency departments nurses are treating patients with minor injuries and ailments, freeing up doctors' time and so delivering shorter waits for treatment. In some community clinics teams made up of occupational therapists, district nurses, physiotherapists and social care staff, working flexibly together across traditional boundaries have halved the length of stay for orthopaedic patients and enabled more frail people to stay at home. 9.3 For every example of good practice there are too many examples where change has yet to take place. Best practice can no longer be an option. Managers and clinicians across the NHS must make change happen.

9.4 By 2004 the majority of NHS staff will be working under agreed protocols identifying how common conditions should be handled and which staff can best handle them. The new NHS Modernisation Agency will lead a major drive to ensure that protocol based care takes hold throughout the NHS. It will work with the National Institute for Clinical Excellence, patients, clinicians and managers to develop clear protocols that make the best use of all the talents of NHS staff and which are flexible enough to take account of patients' individual needs.

9.5 The new approach will shatter the old demarcations which have held back staff and slowed down care. NHS employers will be required to empower appropriately qualified nurses, midwives and therapists to undertake a wider range of clinical tasks including the right to make and receive referrals, admit and discharge patients, order investigations and diagnostic tests, run clinics and prescribe drugs, as described below.

. 9.6 As part of this approach by 2001, around 23,000 nurses will have the right to prescribe a limited range of medicines. We will then extend both the range of medicines which can be prescribed and the numbers of nurses who can do so. The introduction this year of 'Patient Group Directions', which enable nurses and other professionals to supply medicines to patients according to protocols authorised by a doctor and a pharmacist, will mean that by 2004 a majority of nurses should be able to prescribe.

9.7 Midwives too will develop their role in public health and family well-being. They will work with local doctors and nurses in developing maternity and child health services and Sure Start projects.

9.8 Pharmacists will be able to take on a new role as they shift away from being paid mainly for the dispensing of individual prescriptions towards rewarding overall service. Proposals will be invited for Personal Medical Services-type schemes, that pilot alternative contracts for community pharmacy services. They will cover areas such as medicines management and repeat prescribing.

9.9 Other key groups of staff including therapists, scientists and health visitors will develop their professional roles. Local clinical teams will need to review the care being delivered, how and by whom.

9.10 The Commission for Health Improvement will monitor performance in each NHS organisation to ensure that the new powers are genuinely available to clinical staff who are competent and confident enough to take them on.

Training and development for staff

9.11 To help people to take on these new roles there will be an extra £140 million by 2003/04 to support a major programme of training and development for all staff.

9.12 For professional staff there will be investment to support their continuing development. All members of staff should receive support from their employers to fulfil the requirements of clinical governance and revalidation. We will enter immediate discussions with the professions and NHS employers about how to ensure this commitment is guaranteed. We will review existing requirements for re-registration in nursing. Better use will be made of the investment in continuing professional development with greater emphasis on accredited workplace based systems of learning.

9.13 The NHS has neglected for too long the need to invest in the skills and potential of staff who do not have a professional qualification. That will now change. Over the next three years we will guarantee all such staff access either to an Individual Learning Account of £150 a year or dedicated training to NVQ level two and three. This investment will help the NHS make better use of the potential of healthcare assistants, operating department practitioners, pharmacy technicians and others. New national occupational standards will be developed for this group of workers. These staff will play a key part in raising standards in the fundamentals of patient care. Proposals will be published for the effective regulation of health support workers.

9.14 Staff will also be given the necessary training to take on new roles altogether. We propose to create assistant practitioners in radiography, appropriately trained and qualified, to take mammograms under the supervision of a radiographer. This will release radiographers to extend their role into some of the tasks traditionally undertaken by radiologists, thereby significantly increasing capacity for our breast-screening programme. (see paragraph 14.5)

9.15 This principle can be extended to other areas of care, building on Royal College proposals for a physician's assistant. We will identify the scope for similar action, particularly in some specialties where waiting times are longest and workforce shortages greatest. A timetable for action will be published later this year.

Modernising education and training

9.16 Radical reform is required in NHS education and training to reshape care around the patient.

9.17 The new model of nurse education and training, described in our nursing, midwifery and health visiting strategy, Making a Difference, with its emphasis on improving access, developing practical skills earlier in training and with stepping off points at the end of the first year will be rolled out nationwide. By autumn 2001, 85% of all nurse training organisations will be operating the new arrangements. By autumn 2002 it will be standard across the whole of England. Similar principles will be applied to education and training for the other health professions and health scientists.

9.18 There will be reforms to the health curricula to give everyone working in the NHS the skills and knowledge to respond effectively to the individual needs of patients. There will be new joint training across professions in communication skills and in NHS principles and organisation. They will form part of a new core curriculum for all education programmes for NHS staff. By 2002, it will be a pre-condition of qualification to deliver patient care in the NHS that an individual has demonstrated competence in communication with patients. A new common foundation programme will be put in place to enable students and staff to switch careers and training paths more easily. Nurses, midwives or therapists who want to become doctors, for example, will no longer have to start their training from scratch. We will be looking for innovation of this kind in allocating the next tranche of medical school places.

9.19 The NHS is also committed to building a diverse workforce and using its leverage as an employer to make a difference to the life opportunities and health of its local community. Education programmes must open up opportunities in healthcare to the whole of the local community.

Leadership

9.20 Delivering the Plan's radical change programme will require first class leaders at all levels of the NHS.

9.21 Action needs to start in hospitals. The public consultation provoked a strong call for a 'modern matron' figure - a strong clinical leader with clear authority at ward level - and we will do it. The ward sister or charge nurse will be given authority to resolve clinical issues, such as discharge delays and environmental problems such as poor cleanliness. By April 2002 every hospital will have senior sisters and charge nurses who are easily identifiable to patients and who will be accountable for a group of wards. They will be in control of the necessary resources to sort out the fundamentals of care, backed up by appropriate administrative support. In this way patients' demand for a 'modern matron' will be met.

9.22 There will be other new clinical leaders. By 2004 there will be around 1,000 nurse consultants employed in the NHS. By then a first generation of therapist consultant will have started work. They will work with senior hospital doctors, nurses and midwives in drawing up local clinical and referral protocols alongside primary care colleagues.

9.23 We need clinical and managerial leaders throughout the health service. The best NHS leaders are outstanding. There are simply too few of them. NHS organisations should be led by the brightest and the best of public sector management. Leadership development in the NHS has always been ad hoc and incoherent with too few clinicians in leadership roles and too little opportunity for board members to develop leadership skills. That will now change.

9.24 Service modernisation relies on staff - especially those in clinical posts - having the time and space to redesign and re-organise their services. That is what staff throughout the NHS want to do. Relentless daily service pressures often make that difficult. We will introduce 'service modernisation sessions' throughout the NHS where local managers and clinicians can apply the lessons that have been learned elsewhere in the NHS to redesign local services. They will be helped by the NHS Modernisation Agency.

9.25 We will provide management support and training for clinical and medical directors to better equip them for their leadership tasks. Local trusts will be expected to open these posts to competition.

9.26 To deliver a step change in the calibre of NHS leadership, the Government will establish a new Leadership Centre for Health. Operating through the NHS Modernisation Agency the Leadership Centre will be in place by 2001. The Centre will promote leadership development closely tied to the Modernisation Agency's work to deliver improved patient services. It will benefit all staff by widening access to work based development programmes, delivered online as well as face to face. It will provide tailored support for clinicians and managers with leadership potential at different stages in their careers and for those already in leadership roles. Its target group will include people who run service departments, clinical services and community based networks who want to stay in the front line as well as those who seek to progress into executive roles. Chair and non-executive development will form part of its remit. It will be open to social care organisations.

Conclusion

9.27 Developing the skills and potential of NHS staff is a fundamental part of this Plan. The Government is committed to giving them the support they need in order to make the most of their contribution to patient-centred care. By liberating the potential of staff the NHS can shape its services around the needs of patients.