Understanding workforce - full abstract

Conceptualising skill mix: theory vs practice

Imelda McDermott, Sharon Spooner, Mhorag Goff, Kath Checkland, Anne McBride, Damian Hodgson, Matt Sutton, Jon Gibson, Mark Hann
University of Manchester

Background: Skill mix is heralded as a policy ‘solution’ to a workforce ‘problem’. However,  variation and ambiguity mean that the term ‘skill mix’ is used in different ways;  to describe a mix of different roles working in an organisation, the mix of staff in a given role, the combination of skill sets, or the combination of activities that comprise each role (Buchan, Ball and O’May, 2000). Attempts have been made to provide a general framework by focusing on changing roles and changing relations between healthcare services (Sibbald, Shen and McBride, 2004), embracing micro, meso and macro factors affecting scope of practice for health professionals (Bourgeault and Merritt, 2015) and developing a conceptual model of skill mix (Cunningham et al., 2019).
Skill mix is difficult to conceptualise in part because it cannot be considered in isolation from the broader organisational and healthcare system contexts in which people work (Dubois and Singh, 2009), and other concurrent policy initiatives and organisational developments (Buchan, Ball and O’May, 2000).

In this presentation, we explore the conceptualisation of skill mix in the context of its implementation in the UK NHS. We consider the introduction in primary care of new practitioner roles, such as clinical pharmacist, paramedic, physician associate, physiotherapist and social prescriber; with a new GP contract introduced to enable the implementation of these new roles (NHS England and British Medical Association, 2019). We explore how skill mix is conceptualised in policy documents in relation to how practice staff understand it and what was observed in practice.

Methods: We observed clinical consultations (19 hours) and interviewed practice staff (29 interviews) in 6 GP practices. We also conducted patient surveys and focus groups with Patient Participation Group members and/or patients.
Results: Early analysis of our data shows that role titles and qualifications are an inadequate proxy for practitioners’ skills. In addition, building a diverse team of practitioners does not necessarily enable skills to be deployed effectively to counter specific deficiencies in the primary care workforce. The personal attributes and ‘personalities’ of practitioners are seen as important in enabling the less visible care coordination, communication and teamwork, in addition to background and specialism. Skills in terms of deployable clinical expertise and ‘soft’ skills are a reflection of an individual’s past clinical and non-clinical experiences and interests. Practices need to develop an understanding of the skills that their existing practitioners have and what they require when recruiting staff.

Implications: Developing an understanding of the concept of skill mix in contemporary general practice can assist policymakers, practices and other stakeholders with ensuring that the potential of skill mix is maximised.


Bourgeault, I. L. & Merritt, K. (2015). Deploying and Managing Health Human Resources. In International Handbook of Healthcare Policy and Governance. Palgrave Macmillan UK, pp. 308–324.
Buchan, J., Ball, J. & O’May, F. (2000). Determining skill mix in the health workforce: guidelines for managers and health professionals Skill mix in the health workforce.
Cunningham, J., O’Toole, T., White, M., & Wells, J.S.G. (2019). Conceptualising skill mix in nursing and health care: an analysis. Journal of Nursing Management, 27(2), pp. 256–263.
Dubois, C. A. & Singh, D. (2009). From staff-mix to skill-mix and beyond: towards a systemic approach to health workforce management’, Human Resources for Health, 7(87).
NHS England & British Medical Association (2019). Investment and evolution: a five-year framework for GP contract reform to implement NHS Long Term Plan.
Sibbald, B., Shen, J. & McBride, A. (2004). Changing the skill-mix of the health care workforce. Journal of Health Services Research & Policy, 9(1_suppl), pp. 28–38.

Beneath the numbers: Qualitative stakeholder perspectives on general practice workforce data reporting

Pauline Nelson, Fay Bradley, Abigail Tazzyman, Jane Ferguson, James Higgerson, Jonathan Gibson, Damian Hodgson
University of Manchester

Background: Against a backdrop of demand exceeding capacity and declining GP numbers, the general practice workforce in England is undergoing rapid change with efforts to introduce a greater level of ‘skill-mix’. However, as recognised by the NHS Long Term Plan, the current ‘disjointed’ approach to NHS workforce planning needs improvement at both local and national level to enable better ‘day-to-day and strategic workforce decision-making’1. Historically, workforce planning in primary care has been challenging and workforce modelling in the NHS has been hampered by poor data quality. NHS Digital holds the largest general practice workforce dataset, collected quarterly via the National Workforce Reporting System (NWRS), although the validity of this dataset has previously been hindered by non-completion and missing data. Despite the widely acknowledged problems with workforce planning in general practice little is known about stakeholder views on the collection and sharing of primary care workforce data.

Method: Qualitative study involving in-depth semi-structured interviews and focus groups to explore national, regional and local stakeholder views on workforce data collection/sharing. Participants were sampled purposively according to professional role from: 1) national and regional GP and primary care policy leads; 2) regional CCG and GP provider leads across Greater Manchester (GM); and 3) CCG leads, Primary Care Network (PCN) Clinical Directors and practice managers from one GM area. Data were coded in NVivo 12 software and analysed using Template Analysis. Ethical approval was obtained from a University of Manchester ethics committee.

Results: Fifty-six participants took part in 32 interviews and four focus groups. Three key themes were identified:

  1. Resistance to data sharing: Workforce data sharing was considered politically challenging with concerns around access to as well as ownership and use of commercially sensitive information. Stakeholders reported being unclear about how their data might be used; leading to a ‘degree of suspicion’ that it could be used for performance management or standardisation. Reluctance to share data was said to hinder workforce planning at both practice and neighbourhood/regional level.
  2. Going through the motions: Practice staff reported overwhelmingly negative views of completing workforce data returns. The NRWS was described as ‘laborious’ and ‘clunky’; other tools used locally were felt to be over-complicated and not user-friendly. Generally, existing tools were considered inflexible, unable to capture the nuances of an individual practice’s workforce. This, coupled with concerns that data-sharing was a one-way process with no feedback provided, led to a reportedly tokenistic approach to workforce returns by practices and raised questions about the quality of data provided.
  3. Overcoming the stalemate: There was recognition that general practice workforce data capture and planning was at an impasse. A lack of data meant that practice needs could not be easily assessed and that innovations were often designed/implemented ‘blindly’. While data were needed for strategic workforce planning, a lack of action created a vicious cycle. Although a variety of efforts and approaches to obtain data were reported, collective working based on trust relationships between stakeholders was cited as the only tangible way to overcome the stalemate.

Implications: The study highlights that resistance by stakeholders to primary care workforce data collection and sharing has been exacerbated by a lack of clear purpose for data collection, limited feedback to providers and technological issues. The political context of general practices seeking to uphold their independent contractor status in the health care system adds further complexity. PCNs may help to influence a cultural shift in data sharing by providing a greater sense of ownership and leadership at network level, enabling practices to engage in workforce planning to match local populations across a network area.

NHS England. The NHS LongTerm Plan. https://www.england.nhs.uk/long-term-plan/2019.

The influence of the informal organization on employee voice in inpatient care

Frances Wu (1), Graham Martin (2), Emma-Louise Aveling (3), David Bates (4), Anne Campbell (5), Christian Dankers (6), Imogen Mitchell (7), Peter Pronovost (8), Mary Dixon-Woods (2)
(1 )THIS Institute, (2) University of Cambridge, (3) Harvard TH Chan School of Public Health, (4) Partners Healthcare, (5) Imperial College London, (6) Brigham and Women's Hospital, (7) ACT Health, (8) University Hospitals

Background: Recent attention to speaking up of healthcare workers and its link to patient safety has highlighted the importance of employee voice. Yet problems of silence remain pervasive within healthcare organisations. While formal organisational elements such as roles, rules, and procedures are key drivers of employees’ behavior, informal day-to-day work practices and interactions outside of formal work roles form informal influences that guide emergent patterns of behaviour and social norms. The purpose of this paper is to understand the informal organisation and its interaction with the formal organisation in influencing employees’ perspective and willingness to exercise voice.

Methods: Across three academic medical centres, 165 semi-structured interviews were conducted over the telephone with participants. Both leaders and managers at the “blunt end” of care as well as frontline staff at the “sharp end” of care were invited to participate. Those at the sharp end included physicians, nurses, technical/administrative staff, building and housekeeping staff. Initial site selection was pragmatic; the second and third sites were purposefully selected to test the generalisability of constructs. Qualitative analysis was based on the constant comparison method and used to identify the various informal organisational elements that either supported or worked against formal structures which encouraged or inhibited voice.

Results: In all three sites, aspects of the formal organisation both encouraged and inhibited voice. Aspects of the informal organisation both supported and worked against the formal organisation: sometimes it supported the formal organisation in encouraging voice; sometimes it supported the formal organisation in discouraging voice; and sometimes it worked against the formal organisation to encourage or discourage voice. Positive relationships with managers and team members outside of formal roles could encourage voice, but the informal organisation could also reinforce hierarchical relationships in a way that deterred individuals in lower-status roles from speaking. Moreover, the informal organisation could reinforce the formal organisation’s tendency to suppress voice by framing speaking as disruptive and propagating social norms against “ratting” or “dobbing on their peers”. However, strategies such as leveraging informal networks and forming coalitions to advance concerns (even in the face of resistance from the formal organisation) helped to offset such influences.

Implications: We use an organizational theory lens to describe the informal and formal organisations and their interaction to either encourage or inhibit employee voice. Formal organisational structures are necessary yet not sufficient to ensure voice. Given that informal organisations could moderate, and potentially inhibit the use of formal approaches, organisations should seek to understand them and their interactions with the formal organisation. Thus, optimizing safety culture to promote a ‘speak up-supportive’ environment up is likely not a matter of either formal or informal organisation, but of the unique, context-specific interactions between the two. Practically, skills training in having difficult conversations can help managers address legitimate safety concerns and reinforce the value of speaking up while giving staff a tool for informally raising concerns with colleagues. Finally, actions by and words from leaders that invite and appreciate others' contributions has been shown to positively influence speaking, especially in hierarchical environments such as inpatient care settings.

Determinants of Primary Care workforce variation in England.

Jon Gibson, Sharon Spooner, Matt Sutton
University of Manchester

Background: An increase in the number and types of practitioners providing health care in general practice is seen as an integral part of health policy aimed at strengthening this front-line service during a period when the number of GPs has been dropping. While some of the expansion is achieved by employment of practitioners from disciplines that are long-established in general practice teams, GP practices are increasingly employing practitioners in less prevalent or ‘new’ roles to meet demand for health care; advanced nurses, clinical pharmacists, physiotherapists, physician associates, and paramedics. 

Methods: This study examines what GP practice characteristics are associated with current levels of employment of these roles. Using publically available data from NHS Digital we look at the full time equivalent (FTE) of practitioner groups in the workforce of each practice during the period 2015-2019. We model FTE of specific workforce groups (e.g. advanced nurses) as a function of deprivation, practice rurality, patient demographics (total list size and percentage of patients over 65 years old) and FTEs from other staff groups.

Results: Analysis is ongoing, however there are indications that the employment of ‘new’ roles is associated with larger practice list sizes, in practices with a higher proportion of patients living in deprived areas and practices where a greater proportion of patients are aged over 65. The FTE for Advanced Nurses is negatively associated with GP FTE.

Implications: A negative correlation between Advanced Nurse FTE and GP FTE is potentially suggestive of substitution between these roles, whether by choice or of necessity when practices are unable to recruit GPs but can recruit staff to undertake work that would otherwise have been done by GPs. Further work is needed to confirm these findings and to explore the reasons behind practice employment decisions.

Nursing establishments and flexible staffing on hospital wards: the cost and consequences of different strategies

Peter Griffiths (1), Jeremy Jones (1), Christina Saville (1), Thomas Monks (2), Jane Ball (1), Natalie Pattison (3)
(1) University of Southampton, (2) University of Exeter, (3) University of of Hertfordshire

Background:  The Safer Nursing Care Tool has been adopted throughout the NHS in England as well as some other countries to guide decisions about nurse staffing requirements on hospital wards, in particular the number of nurses to employ (establishment). The tool is designed to match the staffing establishment to average patient need on a ward, recognising that not all patients have the same requirement for care. Increasingly, its core acuity dependency measure is being used to estimate daily demand and match staffing to that demand, opening up the possibility that it can be used to guide more efficient flexible staffing policies.

However, there is a lack of evidence about how effective and cost-effective nurse staffing tools are at providing levels of staff needed for safe and quality patient care. As part of a larger study exploring the use of the Safer Nursing Care Tool, we explored the cost-effectiveness of different approaches to setting baseline staffing establishments and using flexible staffing to meet varying patient needs. Specifically we compared low baseline establishments (with high use of flexible staffing to meet peaks in demand) with a baseline establishment set to meet average demand (the standard approach) and a high baseline establishment set to march peaks in demand (90th centile).

Methods: We used data from an observational study of staffing and patient acuity / dependency over one year on medical/surgical wards in four NHS hospital Trusts (26,362 wardsXdays of observations). Using these data to provide parameters, including probability distributions for varying demand for nursing care from patients, we developed a computer simulation to model the effects of different establishments and approaches internal staff redeployment and use of temporary staff. The model was used to identify the daily staffing costs and the occurrence of critical (>15%) understaffing. We used economic modelling to estimate the cost per life saved for high and flexible (low) establishments compared to the standard. We compared effects and costs of a ‘high’ establishment (set to meet demand on 90% of days), the ‘standard’ (mean-based) establishment and a ‘flexible (low)’ establishment (80% of the mean) providing a core staff group that would be sufficient on days of low demand, with flexible staff redeployed/hired to meet fluctuations in demand. The effects of low staffing, in terms of mortality risk and length of stay, were estimated using parameters from a recent longitudinal observational study in one of the participating hospitals.

Results: In simulation experiments, ‘flexible (low)’ establishments led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. ‘High’ establishments were associated with reductions in understaffing and improved outcomes but higher costs. Cost savings from higher establishments were small when high temporary staff availability is assumed. Under most assumptions the cost per life saved from moving from a lower to a higher baseline establishment was below £30,000. If unlimited availability of temporary staff is assumed, the harm associated with low establishments is minimised but net cost per life saved for standard vs low establishment was £946 and for high vs standard £5524

Implications: Apparent cost savings from a policy of flexible staffing with a low establishment are largely achieved by below adequate staffing. Cost savings are eroded under the conditions of high temporary staff availability required to make such policies function safely. Higher establishments appear to be cost-effective. In the face of nursing shortages, these findings serve to illustrate the possible consequences of short staffing and to illustrate that higher establishments remain a desirable goal even if staff redeployment and use of temporary staff can be used to fill gaps in rosters.

A theoretically-informed qualitative study of the determinants of staff wellbeing in the ambulance service workforce and the links to care quality and safety

Jonathan Benn (1), Gillian Janes (2), Caitlin Wilson (1), Freya Thompson (1), Binish Khatoon (2), Rebecca Lawton (1)
(1) University of Leeds, (2) Bradford Institute for Health Research

Background: Research suggests that ambulance service staff experience challenging job demands with high incidence of posttraumatic symptoms, burnout and general psychopathology (Alexander, 2001; Soh, 2016; Petrie, 2018). Research and theory in the area of work psychology offers potential insights into the job-related determinants of wellbeing and how psychological processes may mediate the effects of work design on staff and performance outcomes. Relatively little research, however, has explored the mechanisms by which modern prehospital role characteristics impact upon ambulance service staff wellbeing, engagement and the quality and safety of patient care.

Method: The aim of this study was to investigate the work-related determinants of wellbeing amongst ambulance service staff and understand the mechanisms of impact upon staff and care quality outcomes. A secondary aim was to identify potential opportunities for development of workforce interventions for this group. A semi-structured interview study with theoretically-informed analysis was undertaken to capture the perceptions and experiences of ambulance service staff. Participants comprised 25 professionals in a range of prehospital mobile clinical roles. An iterative, thematic analysis was undertaken by a multidisciplinary research team using the Job Demands-Resources (JDR) model by Bakker et al. (2017) as a framework to interpret the data and identify mechanisms and processes.

Results: A range of job characteristics were found to be important for staff and care outcomes, including: time pressure, emotional demands, shift-working, role ambiguity, role conflict, decision-complexity and lack of task feedback. The limited opportunities for outcome feedback and debriefing in modern paramedic roles was a prominent theme in the interview data and was thought to impair professional development, learning from practice and gaining closure following stressful work experiences. The JDR model provided a useful framework for understanding how work characteristics influenced motivational/impairment processes and ultimately staff and care quality outcomes. The model was limited, however, in accounting for the dynamic effects of a changing service context on professional identities, professional frustrations, opportunities for teamwork and feedback-seeking behaviour. 

Implications: Further attention is needed to understand the impact of changing service organisation, public expectations and professional roles in the prehospital setting on staff wellbeing and quality and safety of patient care. Potential areas for development and intervention in this area include: enhancing feedback for mobile clinicians, improved rostering and deployment models and enhanced teamworking in order to increase opportunities for peer-support, interprofessional engagement and collaborative quality improvement work. Enhancing feedback for staff in mobile prehospital roles should be a priority for future workforce interventions and may improve both staff wellbeing and patient safety.

Small Steps to Big Changes: Transforming Practice with Supported Self-Management Training in Stroke Services- The “People1st” project 

Nicola Hancock, Julie Houghton
University of East Anglia

Background: Organised, multi-disciplinary delivery of rehabilitation is crucial to outcomes for people with stroke. However, service organisation and the delivery of rehabilitation are typically focused in the first months of stroke and often fail to meet patients’ long-term and evolving needs (RCP, 2016). Models encouraging dependency on professional expertise may contribute to unmet support needs post-stroke. Supported Self-Management (SSM) programmes, underpinned by self-efficacy principles, offer approaches that move away from such models and are linked to positive rehabilitation outcomes. Embedding and sustaining SSM approaches in rehabilitation practice has potential to encourage stroke survivors’ independence and improve quality of life. Hence, national guidelines indicate that stroke service staff should be supported in developing SSM knowledge and skills (RCP, 2016).  However, evidence related to how SSM training results in transformational change in practice is limited. Such evidence is crucial to the implementation and sustainability of SSM programmes for potential patient benefit. 

This large-scale quality improvement project evaluates an evidence-based SSM training programme (“Bridges Self-Management") for staff in stroke and neurological services in six Sustainability and Transformation Partnerships (STPs) in eastern England. 
Objective: To determine if the Bridges SSM model could be successfully embedded and sustained in neurorehabilitation practice. We focus here on two key aspects of the evaluation- changes to individual and team practice as a result of the training and perceived benefits of using the approach.

Methods: Design & setting: Mixed-methods evaluation of the “Bridges” Supported Self-Management (SSM) programme for stroke and neurological service teams in six STPs in eastern England. 
Data collection methods & analysis: Data were collected via pre- and post-training hard-copy questionnaires at both introductory and follow-up ‘Bridges’ training workshops; embedded observations of workshops; semi-structured telephone interviews.
Analysis was guided by Kirkpatrick’s Four Levels of Evaluation and by Normalisation Process Theory (NPT). Quantitative data were analysed using descriptive statistics.  Observation field notes and interview data interrogated using thematic analysis. 

Results (to date): Twenty-four NHS trusts and 650 staff across acute, early supported discharge and community services engaged with the ‘Bridges’ programme between September 2018 and May 2020.  
The response rate to evaluation questionnaires was 80+%.  The evaluation team conducted over 100 hours of training observations and 25 practitioner interviews.
Practitioners identified the importance of the time offered by the training to reflect on practice and to discuss collaboratively ideas to enhance the delivery of SSM in their specific context.  There was a demonstrable growth in confidence and performance of SSM tasks. Staff identified small changes that could be incorporated into everyday practice to the benefit of the team and the patients, including:

  • Modifications to individual and team language and questioning style with patients according to the Bridges approach- supporting the development of more meaningful therapy, enhancing patient participation through the pursuit of goals relevant to their needs.
  • Changes to paperwork and patient-facing materials to enhance a collaborative SSM approach across the rehabilitation teams, patients and carers.  Plans to audit and evaluate new resources were identified.
  • Changes to new staff orientations to ensure consistency of an SSM approach is maintained.

Organisational context presented a key challenge- staffing and time pressures were perceived as barriers to implementation.

Implications: The People1st project is the largest evaluation of an SSM approach in current rehabilitation practice.
Bridges training afforded teams the valuable opportunity to reflect on their practice and to plan ‘small steps’ for service improvement, encouraging a range of changes to practice. Such beneficial steps were perceived to offer potential to enhance patient experience and outcomes, as well as efficiencies and satisfaction of staff.  Plans by local teams to sustain and evaluate the approach are underway.