Welcome to this session of the Health and Social Care Committee. This is the first of two sessions that the Committee has decided to do on the issue of neighbourhood health and, in particular, looking through the lens of the workforce. It is in response to the 10-year health plan, which has a stated aim of bringing care into local communities, convening professionals into patient-centred teams and ending fragmentation. We want to understand better what impacts that will have on the professions and the skills mix, and what we need to do to help deliver that. We have two panels with us today. I will start by simply asking you to introduce yourselves and what you do.

I am Steph Lawrence. I am the chief executive of the Queen’s Institute of Community Nursing. I am a district nurse by background.

I am Kamila Hawthorne. I am a GP in south Wales and chair of the Royal College of GPs.

My name is Amandeep Doll. I am the director for England at the Royal Pharmaceutical Society, and I also still work as a clinical pharmacist in my local trust.

I am going to start with what I hope is a simple question. What is a neighbourhood health service?

At the moment, we do not have any real detail about what the neighbourhood health model looks like and what the proposed single and multi-provider contracts are. Through the work that is happening with the 43 neighbourhood health teams and working with our pharmacy partners in those, we know there are areas where community pharmacy is quite embedded in those neighbourhood health teams, looking at how they are delivering care closer to home, but it is inconsistent. We are waiting to hear how the pilots are going and what recommendations will be coming out from those pilot sites. From talking to NHS England colleagues, we know there is also a model neighbourhood, which is coming out in the next few weeks. Again, we are awaiting that further detail. We also welcome the £300 million budget that was announced yesterday. We would hope to see that, from a pharmacy perspective, when we are thinking about the formation of the neighbourhood health teams, they are collaborative from the outset. We need community pharmacy, alongside other healthcare providers, social care and voluntary sector people, to be part of those initial discussions. We are hearing that it is a little bit of a mixed approach at the minute. We need to make sure that pharmacists are part of the clinical pathway right from the beginning. In order to support that, we need to have informed population health data to help establish what the local population needs are, as well as really comprehensive workforce data to identify where those gaps are to support that appropriate workforce planning. When you bring both of those datasets together, we have a much more comprehensive dataset. Talking to one of our community pharmacy chains, it is looking at that patient pathway. For example on asthma, it is thinking about how they make that patient experience better. Could you invite the patient in, where you have an asthma clinical service with a prescribing pharmacist? You do an asthma check and look at the inhaler technique and adherence. You could offer them the flu vaccine at the same time, and any lifestyle advice. Rather than them moving to different parts of the system for each of those bits, they can have that more holistic care delivered to them in one place. The one thing we would also like to see is that, from a patient perspective, the system is easy to navigate. The healthcare system is quite complicated at the point of entry. We would hope that the neighbourhood health team would make it very simple and easy to be signposted between different areas.

Kamila, what do you understand neighbourhood health to mean?

We absolutely welcome the plans and the shift from secondary care into community, and in fact the other shifts too—the analogue to digital and the sickness to prevention shifts. It is high time, I would say. Neighbourhood services are going to differ depending on where in the country you are. It is going to depend on local systems to understand what their communities need, working with those communities alongside patients to understand those needs and deliver accordingly. There are definitely some bright spots already across England. I would cite York as one place, Cornwall as another and Tower Hamlets in the east end of London as another. They are all doing it differently, but they are achieving a huge amount. The interesting thing is that they have been doing it for years, and in spite of, rather than because of, these changes. It is going to be really interesting to see whether they can then accelerate what they are doing, and if these changes are actually going to help them achieve that. The way that I have tried to portray it in my mind, because we are all struggling to understand what neighbourhood services means, is by likening it to a four-tier wedding cake. The bottom tier, which is the biggest one, is universal access, which still centres around GP practices and registered patient lists, where you can go and see your GP and the associated team: the community pharmacists, the optometrists, the dentists, et cetera, with the primary healthcare team all around. That involves the district nurses, midwives and health visitors, just as we have always had. We think that about 60% to 70% of the public would use that universal access tier of the wedding cake. The next tier up is this new tier of neighbourhood services, probably needed by maybe 20% to 30% of the population, so people who are frail, are complex, have multiple morbidities or are in special inclusion groups that are hard to reach. We call them “hard to reach”, but they find us hard to reach. Those groups of people will probably need specialised services, perhaps led by GPs with extended roles or other healthcare professionals, working together to provide care plans for these more complex patients, keeping people out of hospital and at home. Frailty is an obvious one, but others are chronic disease management, women’s health hubs and mental health. As people will know, these things are already happening to some extent, but not to the full extent that the health plan is envisaging, because there is then the horizontal integration into local authority, social care, voluntary sector, social prescribing, et cetera. This is what is going to add the magic, if you like, of the 10-year health plan. Above that, the next tier up is a smaller tier, and that would then become secondary care. I would like to see most outpatient clinics taking place in the community and not in hospital settings. Beyond that will be the tertiary centres. That is my wedding cake, to answer your question. In order to do that, I do not think it can be achieved without some shift of resources. I have read the 10-year healthcare plan very carefully. It is actually, I think, on page 135 where it is mentioned, but only once, that resources will move. One of our worries is that it looks as if resources will only move—because the envelope remains the same—if we can reduce admissions. It is a kind of chicken-and-egg problem. If we can reduce admissions and outpatient attendances and save money, that money could be used to fund these neighbourhood services that I have been talking about. My worry is how that actually happens. These new projects that have been set up are being specially funded, but it does not look as if there is any more funding beyond that. That is a distinct worry for me. We have been worried for a long time about a shortage of GPs. Stephen Kinnock keeps saying to me that GPs will be the conductor of the orchestra in this new world. Obviously you need the orchestra, but you need enough conductors as well. We are many thousands of GPs short at the moment. We are hoping to see some numbers in the 10-year workforce plan. We are being told that there will not be many numbers, and that is a worry to us. Maybe there will be for general practice, because it appears that we are special, which is very nice, but we were special the last time there was a workforce plan, until we realised, after it was published and the NAO came knocking on the door, that in fact GP numbers would only increase by 4%, whereas hospital doctors increased by 49%. We felt, “What was the point of all that?” This time it has to be different. We would like to see the modelling. We would like it to be transparent. We would like some numbers.

That is very helpful.

I would agree with some of what my colleagues have said. For me, neighbourhood working exists across the country now. It is certainly not something new to me. It is something I have worked in for a number of years as a nurse, and led as a nurse as well. Nursing is central to it, and there are a number of elements of community nursing that we need to think about within that neighbourhood. The neighbourhood has to look at the population needs and then, based on those population needs, what is needed within the workforce. I am here to represent nursing, but it is important that we are a multidisciplinary team, and that we work across a multidisciplinary team in a neighbourhood setting. With respect to nursing, we need things such as district nurses, but we must not forget children in our neighbourhood. It cannot all be about frail elderly people. It has to be about children and prevention. Things such as health visitors and school nurses are going to be highly critical within that. We also need to think about adult social care nursing. Nurses in our care homes are going to be instrumental in making sure that we can make these neighbourhoods work and look after some of our most frail and vulnerable elderly people in society. The numbers are going to be really important, and we are going to need the capacity to ensure that we can deliver that. We know that we currently do not have the capacity in the community. We know that care gets left undone, which is of concern to us. We also think that we do not need to develop shiny new services. If we build on the fundamentals of what we have around things such as district nursing, community nursing services and others, we can build on what we need. I do not think that neighbourhoods are made of people who you just transfer out of a hospital, in terms of the workforce, because it is a skill to work in the community. It is very different. We need to train nurses not just to work in hospitals, as we do currently. We need to think about the community aspect of what it means to nurse people in the community and in their own homes. We think that is really important. It is also important that we look at the skills of those people and train enough of them to deliver what is needed within those neighbourhoods. As I said, the prevention side of things is really critical. With health visitors and school nurses—in particular school nurses—we have seen the numbers drop over recent years to really critical levels now. It is the same for district nursing. The recent Nuffield Trust report cites a 43% reduction in district nursing between 2009 and 2024. That is of critical concern. If we are really to see more neighbourhood working and more care delivered in the community, we cannot do that without the skills of those people. We need to think about the workforce and what we need for the neighbourhood, and then build around that. We also need to think about equity and where we are with it to make sure that we are delivering equitable services across those neighbourhoods.

That was a very clear underlying picture for lots more detail to come from colleagues.

Good morning. If we start with the current supply and demand, are there any areas, either geographical or within your specialism, that are particularly acute, where demand is not being met by supply?

The data is quite poor. We have asked NHS England again and again for more data, and it does not seem to have it. From the surveys that we have done, it is coastal and rural areas, but there are also shortages in the north-west of England for GPs, as well as in the Coventry area and parts of London. They seem to be particularly affected at the moment.

Interestingly, my constituency is not rural, in London or in the north-west, but we have one of the worst shortages of GPs in the country. We are under-doctored in Thurrock. We are quite often hovering near the bottom. I think we were the worst a few years ago. Is there something around targeting where GPs are needed, or is it more about allowing local commissioning to identify that need? Would it be more useful for you, for example, to have that information on a national basis?

It would be really useful to have a heat map so that you could see. Last summer, when Wes Streeting managed to get—I cannot remember how much—£86 million, I think, for 1,000 more GPs to be employed through the PCNs, we went to see him and said, “It is amazing that you have got this money. We cannot believe you have got it. Thank you. Now you need to make these jobs so good that everybody wants one”. One suggestion we had was that, if we knew where the hot spots were where GPs were particularly needed, you would actually concentrate those roles in those areas, because you want to level up. You would give them some support. You would put them in practices where they would stay in the one practice rather than within a PCN in, say, five practices where you act as an internal locum. As a newly qualified GP, that is not good training and does not persuade you to stay. There could be some mentorship and opportunity to develop yourself professionally. He listened to all of that and said, “Yes, that all sounds good”, and we went off thinking, “Job done”, but unfortunately nothing happened. They just put one GP in every PCN in the country, right across, being equitable. Sometimes, you have to start with levelling up before you start being equitable, and we were really disappointed.

That is really interesting. Do you think targeted intervention would be more effective?

Yes, that is what we were asking for last year, but I was told, “No, it is not our job to do that. It is up to the ICBs to decide”.

ICBs have not necessarily been given the resource they need that meets that local population.

Nor do they have the data. When you said “resource” I was thinking money, but that includes the data. You need the data to be able to say, “Yes, Thurrock really needs more GPs than somewhere else”.

Would you look at historical data as well? I do not want to harp on about my patch, but it is close to my heart. We are historically under-GPed. We have very unique geographical challenges, being so close to London. You can earn roughly £7,000 to £10,000 more a year if you just walk 10 feet up the road. Would historical data looking at where GP gaps are be useful as well?

It will be useful to some extent. It is just that things change. We have the same problem in the Welsh valleys, where I work as a GP. The further up the valleys you go, the more difficult it is, because you cannot commute from Cardiff, which is where everybody wants to live. You need to find ways to encourage people to go and work in these places that are, historically or even currently, under-GPed. Usually, once you get stuck into a community, you start to enjoy it and want to stay.

It is interesting. It reflects exactly what our very junior GPs have said to me, especially ones who are very new to the profession. They want to be working out of one practice. They do not want to be a locum.

It is soulless, because you do not get to offer continuity of care. Part of the joy of general practice is knowing your patients, and your patients knowing you. That is why you do it.

You get people in supermarkets saying, “Can you have a look at my leg?” and so on.

Actually, they do not. They come up to me and say, “Hey, Dr Hawthorne, I have just passed my driving test”. That is what they do.

That is lovely. Are there similar geographical gaps in nursing and pharmacy, and do you have the data that you need to be able to plot that?

Looking at NHS England workforce data for pharmacy, it would indicate that there is an adequate number of pharmacists. However, there is geographical variation. When talking to employers and organisations, there are gaps—it is very similar—in coastal and rural areas and perhaps where there are not the university towns, so down in the south-west, where there are one and a half pharmacy schools compared with, say, the midlands, where there are at least six to eight pharmacy schools. There is variation geographically. We do not have comprehensive workforce data. Pharmacists work mainly in three different areas, so in hospital, GP practices—PCNs—and community pharmacy, but we do not have a full picture of where everyone is. Pharmacists can now prescribe, so we are also upskilling pharmacists to become prescribers. We do not have information about where the prescribers are working exactly, so again there is a skill mix review gap here. We do not know where we can deploy pharmacists. We know that a third of pharmacists are currently prescribers, and that less than 10% of them are working in community pharmacy. If we want to have that shift from hospital into community pharmacy and community, we need to make sure that skill mix is there to help deliver these services. We would need a more comprehensive dataset to do that. We would also need to make it appealing to do the work. We need to make sure that there are actually prescribing services on offer in community pharmacy that are nationally commissioned for people to utilise their skills. Some of the concern is whether you would be using your prescribing skills that you have built and developed in those areas. If you are not, you are going to move somewhere else where you can. In pharmacy, we have pharmacists and pharmacy technicians. We cannot do our job without pharmacy technicians picking up some of that stuff while pharmacists go and do more clinical work. We also need to be looking at the pharmacy technician workforce, seeing where its gaps are and how it can support us. For example, in a community pharmacy, we need them to help with the dispensing and the labelling of prescriptions, so the pharmacist can go off and have a consultation with the patient.

I assume that the situation is fairly similar for community nursing in terms of data. A bit more widely, do you find that, if you look at regional disparities, those gaps tend to exist across the board, but in very specific communities, so if you are under-GPed you will be under-prescribing-pharmacisted and under-community-nursed?

Yes, I think so. What I would say about community nursing is that there are geographical differences. Rurality is a big issue for district nurses because of the travelling and the mileage payments, so that is a specific issue for district nurses and community nurses. There is also a disparity for community nurses in progression in community. It is not paid at the same level as hospital nurses. If you took a district nurse as an example, they tend to be a band 6, whereas in a hospital, a ward manager will be a band 7. A district nurse could be managing a caseload of hundreds of patients, as opposed to a ward of 30 to 40 patients. They are prescribers. District nurses are now prescribers. They are advanced practitioners, and they do not just manage the patient caseload. They manage their teams as well. There is a lot specifically around progression for community nursing, and particularly for that district nursing, that causes specific issues. Yes, I think that, where you have lack of other professions, that tends to follow. If you do not have as many GPs as you need, you probably do not have as many district nurses either.

Looking forward to the change in the workforce strategy, the previous long-term workforce plan showed the NHS broadly meeting workforce demand by 2036-37. Do you think that is an accurate forecast? Have there been significant changes in demand since that workforce plan was made that perhaps the new one should reflect?

I am sorry to labour on GPs all the time. When that first workforce plan was written, it was apparently based on figures from 2015-16, when we were already being told that we needed 5,000 more GPs. We were already starting in a deficit, if you like. To then discover that the modelling of that first workforce plan increased the number of GPs by only 4% becomes a real disappointment. You stop believing in these plans that are given to you with, “You are special. You are going to be mentioned specially in the workforce plan”. There are real worries about this next workforce plan coming through. We have done some calculations, and they are very rough, based on the population of England and roughly the number of patients per full-time-equivalent GP that I had when I first qualified in 1988. I know that is a long time ago. In those days it was 1,600 to 1,800 patients per GP. Now it is closer to 2,300. The workload has gone up really considerably just from numbers alone, as well as an ageing, frailer and more morbid population. It gives you an idea of what is happening. When I first came in as chair three years ago, we were about 1,000 GPs short of where we should be. We are just about level pegging now, but I reckon that we probably need between another 6,000 to 8,000 full-time-equivalent GPs. The number of GP trainees has gone up quite rapidly over the last few years.

We are going to come to training places separately.

Okay, I will come back to that.

I have already said that the 43% reduction is alongside a 24% increase in need for district nursing and a predicted increase of 34% more capacity needed by 2040. We definitely need to train more district nurses, but we know that the number of district nurses in training is falling. That is in part due to the level 7 apprenticeship funding being cut. Yes, we are short of district nurses, but not just district nurses. It is all community nurses, including health visitors, school nurses, community children’s nurses and mental health and learning disability community nurses as well. It is going to be really important to make sure we get that parity across physical and mental health

From a pharmacist perspective, there is an increased demand for the pharmacist skills. Looking at the 10-year plan, pharmacists are going to help with everything, so we need to make sure that the pharmacists are clinically skilled, have been developed and have the time and space to do that clinical training as well. I want to take the opportunity to go back to that workforce data piece. As we are sitting here, there has not been that collective consideration, across the system, of how pharmacists, GPs and nursing work together and what the gap as a whole pathway is, and then looking at the patient pathway, and identifying where each professional can contribute, and therefore work together. We have been looking at it in silos. Perhaps a comprehensive picture across the system might be helpful.

We had the workforce plan a few years ago. How confident are you that the current pipeline of training places in each of your professions is sufficient to meet future need? Could you give me a brief answer? I want to make sure that we stay on time

In nursing generally, we have seen the number of nurses coming into pre-registration training falling over the last five to 10 years, and again we have had a drop this year. I am not sure there is the pipeline coming into nursing to start with, but attracting people to come and work in the community is another challenge on top of that. Because of the reasons I have already stated around not always being remunerated on the same level as a hospital nurse, that is a real challenge. There is also the fact that the majority of pre-registration training is spent in a hospital. We train nurses to work in hospitals. We do not train them to work in the community. No, the pipeline is not there. We need to work on that for pre-registration, but also the pipeline into community is a secondary issue.

The number of GP trainees has definitely been rising over the last few years, in line with the long-term workforce plan, but it is behind its projection. There should be about 4,500 coming through this year, rising eventually to 6,000 a year, but we think it is closer to 3,500 this year, so they are short. Part of the problem is that there are not enough training practices and premises for training more GPs. They are just not suitable, and there is not enough room. We raised that problem with the plan when it was first published and were told, “No, that belongs in somebody else’s budget”, so end of question, really. We are worried about that. The other thing I want to point out is that we are not just talking about recruiting GPs. We need to talk about retaining them.

We will come on to that in a moment. One of my colleagues will cover that.

With the pharmacist pipeline, the NHS long-term plan previously recognised the need to boost pharmacist recruitment and training. Seven new schools of pharmacy have opened in the last year, so we have a good, healthy pipeline coming through. However, there is a risk and a concern about the number of foundation training places available. Once the pharmacists graduate, they need to do a year in training. There is a risk that there are not enough funded places for them to be trained and then qualify and work as pharmacists in the practice areas that we need them to. Again, there is a risk that parts of the system are not ready for the number that we have coming out from the university. It is also the number of clinical supervisors to help with supervising them in practice.

What can we learn from your experience so far? Given the fact that the workforce plan looks forward to 2036-37 and we are looking at, across the board, 70%, 80% or 90% increases in each of those professions, depending on which one we are talking about, a lot more work needs to be done. If there was one thing, because of time, for each of you, from that experience so far, what do you think, above all, needs to be done by policymakers?

There needs to be a holistic view of this. As you were saying, across the professions, what is needed? Also, what training capacity is therefore needed? Pharmacists are going to need training in general practice. District nurses will need training in general practice. Who is going to train them in those practices, and where is the space to train them? Instead of just saying to us, “Sorry, it is not in the budget of the workforce plan; therefore, we cannot answer your question”, there need to be some answers.

Steph, I wonder whether I could focus on community nursing for a second. It may just be for my edification; I am not sure. There is the interchangeability of the expressions “district nurse” and “community nurse”. Even in my own patch in west Cornwall, it seems to be interchangeable. You talked a moment ago about district nurses being on band 6 and being prescribers and managers, et cetera. Does that mean that a community nurse is significantly different and is not a prescriber and is on band 5? Is that correct? Can you clarify for my understanding?

“Community nurse” is a generic term for a registered general nurse, basically. A district nurse has gone on and done a specialist practice qualification. They have gone on and done another year to two years of training, dependent on the route they have taken. Within that, they will undertake elements of advanced practice and learn to prescribe and learn about caseload management. There is a significant difference between a district nurse and a community nurse, yes.

Steph, I wonder whether you could say something about practice nurses.

It works in exactly the same way for general practice nurses. A general practice nurse has a specialist practice qualification in the same way as a district nurse. They have also undergone a similar programme, but more around general practice nursing and what it is to work in general practice, as opposed to a practice nurse or a staff nurse working in a primary care setting.

Generally, all of them—that is community nurses and practice nurses—are on band 5?

They are on bands 5 to 6, but district nurses specifically, across the country, are generally on band 6 and in some areas have moved to band 7.

In relation to the training, Nuffield has identified what it describes as a leaky pipeline. An astonishing number do not complete the course, which seems extremely worrying. Why is this, and what can we do to address it?

It is in part because of the lack of community nurses and district nurses to support them while they are out on training. There is no backfill, so there is nobody to undertake the work. Releasing people to do the training is a real issue.

I do not want to stray into the area of retention, but, when people are looking at the job, they need to understand what is involved. What is an appropriate ratio of registered nurses to patients in the community? No doubt it varies for children, the acutely ill and so on.

Yes, absolutely, it will vary. We did some work at the Queen’s Institute of Community Nursing a couple of years ago around benchmarking what acceptable caseload sizes should look like and how many visits a day a nurse should undertake. In reality, it should be somewhere between about 10 and 14 visits a day, obviously dependent on the complexity of the patient. We are actually seeing nurses being asked to undertake 20-plus visits a day and then burning out and saying, “It would be easier to go back into a hospital and work on a ward, because it is more planned and you know what is happening”.

Is that one of the reasons why people are not being attracted into the profession? Is that generally understood, and therefore registered nurses are looking to stay in hospitals or find other settings?

You get both ends of the spectrum. Those who know and understand it know that the work is really difficult, complex and challenging because of that caseload size, but we also still hear, “It is really easy in the community. You will de-skill if you go and work in the community. It is not acute care”. It absolutely is acute care across all aspects of community, whether that is primary care or in somebody’s own home. It is complex care that we are delivering, so there are both ends of that spectrum. Some people do not come in because they think that the work is easy and not what they want to do. Others do not come because they know that it is really hard, complex work and they will burn out.

One attraction is that presumably there is not very often a night shift, whereas a hospital nurse would be doing a night shift.

I would disagree there. Most of these community nursing services, certainly the adult community nursing services, are 24/7, so there will be a night shift. There are probably not as many night shifts as there are in hospitals, so that is more something that people will look to. Certainly in primary care nursing there is not a night shift, so people will look at that and think, “That is something that I want because I do not have to work a night shift”.

Finally—Kamila answered the question for all of you—what one thing with regard to nursing, particularly community nursing, do you think that we or the Government could do to improve recruitment and training?

It would be to ensure we understand what we mean by community nursing and what happens in community nursing.

Professor Hawthorne and Ms Doll, you have both touched on some of my questions. You have presented what was, I would say, a stark picture in terms of the infrastructure for GP places in your case, Professor Hawthorne, and placements and supervisors in your case, Ms Doll. You outlined the problem. What is the solution, and how long would it take if you had the money to do it?

From a pharmacy perspective, we would like to ensure that we have protected learning time for people working in practice to be able to go and do the training and development. We would also need to make sure that it is part of the job plan of the clinical supervisors so that they have the time and space to deliver that training, and train up to become a supervisor. People might underestimate what is required to be a clinical supervisor and the time that it takes to do that. Having the time would be really helpful, and having that funded. That could be embedded across any potential services or even in a clinical pathway service. If it is a new pathway, you need to upskill in that area and have that funding baked in. The other thing is looking at the cuts within the NHS and the ICBs at the moment that will impact the staff available to do the training. The way that pharmacist training is delivered, training teams are part of NHS England. Cutting those numbers means there is less available to help people in the workplace. We need to be thinking about the inadvertent impacts when we are talking about cuts to one part of the system and the impact that that has on another. There is also an opportunity for multidisciplinary supervision here. That will help each part of the system understand what we bring to the patient pathway and how we can help support each other in that clinical supervision. It is time and money, if we could have what we wanted.

I would agree about the time and the holistic approach. It is also the infrastructure for training premises, essentially, because we are very tight.

Can I press you on that? If money were no object and the Government were to give you the money, how quickly do you think you could attain the premises that you need across the country to do this?

Usually, people already have premises that they would then extend or improve on. I think it could be done in a year or two. In our manifesto, we have asked for £2 billion. That was our back-of-the-envelope calculation, based on surveys of GPs who said that they needed additional funding to make their premises fit for purpose. 20% of premises were built before the NHS even started, so they are very out of date. The other thing to bear in mind is that there is no shortage of people who want to become GPs, so there is a lot of competition for entering training programmes. Just about half of our trainees are, in fact, international medical graduates. We really value and need them. We need to think about how we grow our own graduates to come into general practice. There is a lot of dissing of general practice in medical school training, with people saying things such as, “You are much too clever to be a GP. Why do you want to do that?” and that kind of thing. We need to be thinking about how we get a parity of esteem for our own graduates. We have to better look after the international medical graduates that we have. There seems to be a turnaround happening that the GMC has been talking about, of people returning home or going elsewhere. Canada, Australia and New Zealand have really aggressive recruitment policies.

We are going to come back to overseas.

Will you come back to tier-2 visas?

Yes, we are going to come back.

That neatly leads on to the question I was going to ask about that. Given, as you have rightly stated, our high reliance on international workforce, not just for GPs but across the professions, do you think the Government’s desire to reduce our reliance on overseas staff is workable? If it is workable, how do we do the things that you were talking about to get more homegrown staff into not just general practice but across the professions?

It is workable in medicine. We need to increase medical student numbers, and that was in the first workforce plan. There are resident doctors now who are finding it difficult to get on to training places. This is particularly in secondary care training, rather than in primary care training.

Is that because they are being squeezed out by international applicants?

In some respects they are having to compete with international medical graduates. There are just not enough training places for the people we need to train and bring through, so that needs to be looked at much more carefully. We need to be valuing the international medical graduates that we have much more than we currently do. Making people feel that they still have to apply for visas once they have finished their training is wrong. We should be welcoming. We have paid for their training. We should be welcoming them in and putting them to work.

I would agree. In nursing it is probably slightly different. To stop overseas recruitment for nursing is probably a big issue for us. We need it. It is a particular issue to bring overseas nurses into community settings because community is very different across the world. Not many places have community like we do here in the UK. That is a particular challenge. Driving poses a particular challenge for international nurses coming in because often, if they can drive, they are on an international driving licence, which is valid for only a year, and then they have to go through the whole process of learning to drive. That is a particular challenge in community nursing. I would agree with what Kamila said. The valuing and respect we need to show to our overseas colleagues is really important, and I do not see that universally across settings. We need to think very seriously about that.

Within pharmacy, 90% of the pharmacists on the GPhC register qualified in the UK, so we do not have that same reliance on an overseas workforce. Approximately 11% of pharmacists on the register have qualified overseas. In a unique way, we are quite a homegrown profession. We have the new schools of pharmacy opening as well, so we have that locally grown pipeline.

This is a final question from me. Earlier on, Professor Hawthorne described, I think, the Social Care Minister describing GPs as being the conductors of this new orchestra. Is that the model that you, Ms Doll and Ms Lawrence, respect and think is the right way of going forward?

Who that conductor is depends on the population and what the needs are. We need to work as multidisciplinary teams and look at, within that, who the conductor is and who the orchestra are. I am not keen on that analogy. We all have an equal part within that team, and it is important that we wrap the services that are required around the people who need them.

If I put words into your mouth, in some cases it may not be a GP-led service; it could be a district nurse-led service, a pharmacy-led service or something like that.

Absolutely, yes.

Ms Doll, do you agree?

I agree in that sense. It depends on the patients who we are seeing in the population. Every healthcare professional brings their own unique skills and will be able to support patients in a particular way. We are all equal, so it depends on the patient. There is value in our working together to recognise where we can contribute our skills and having those conversations. Pharmacists are really good at medicines optimisation. That is where we can support, so you can have pharmacist-led clinics. If you have a more complex patient, that is where you need to signpost them and refer them to the GP, for example. We need support with the administration of the medicines, and that is where we can speak to the district nurse. It is also about recognising where we will fit together.

Do you want to come back on that, Professor Hawthorne?

Are you trying to provoke a fight here?

That would be very unlike me.

Because of the historical way that primary care has been set up in this country, general practices are the natural hub for community and neighbourhood services. Because they are run by GPs, that is really where I think Stephen Kinnock was coming from. It is either that or he was trying to placate me, but you will have to ask him.

Maybe we will.

To follow on from that, Professor Hawthorne, are GPs clear on what their role will be in neighbourhoods?

Some are and many are not. Some are waiting to see how things develop. There is a lot of confusion. There is confusion in ICBs and in the structures below them, but there are some places that are absolutely buzzing and moving forward at a great pace. Cornwall is one. As I said, York and Tower Hamlets are others. None the less, many GPs are not really sure what they are supposed to be doing. In my fortnightly blogs to members—because we have 55,000 GP and GP trainee members—I have been trying to put out tips: “If you do not know what you should be doing, this is the person who you should be contacting in your PCN in order to get involved and get stuck in quick”. There are many people who are looking at these changes who want to be within those changes. Some people will lose out. If you snooze, you lose.

On the one hand, you have Stephen Kinnock describing GPs as the conductor of an orchestra. On the other hand, you have Wes Streeting likening going to the GP as going to the hairdressers. Do you think the Secretary of State respects and understands the role that GPs can play in this?

I think he does. Whenever I speak to him, I definitely get the feeling that he understands. I do not know why he said it the way he did, and certainly it caused a certain amount of indignation. This is about patient access, is it not? As most of you know from your surgeries, when you are seeing constituents talking about the NHS, we know that the primary concern is access to general practice. I think it was in that context that he was saying that the times are a-changing and we are in the 21st century. You can order a pizza at 3 o’clock in the morning. Why can you not get your sinuses dealt with at 3 o’clock in the morning as well?

He also talked about one in three GP partners receiving more money than the Prime Minister. I can understand why Wes Streeting has been looking at the Prime Minister’s salary recently, but does that wider narrative really help build trust between the person at the top and the people who will be asked to deliver a lot of this healthcare?

It really does not. There is a great disparity in what GPs take home. Of course, as independent contractors, they are running businesses. At the end of the day, you take home your profit share of your business. If you are running a profitable business, you will take home more than if you are not. We know that many GPs, particularly those working in deprived areas, take well below the average. I have worked in deprived areas for many years and seen GPs come and go because they just are not taking home enough. That is a real shame.

I will share my concern and then invite comments from others on the panel. The Health Secretary said that there is no reason that GPs cannot lead neighbourhoods. That is just a permissive comment rather than a mandatory comment. My concern is that there may be very uneven provision across the country. On the one hand, you could frame it as being very responsive to the particular needs of different areas. On the other hand, you could end up with a real postcode lottery and very uneven-looking services depending on where you live. I do not know whether there is any comment to be made on that across the panel.

I am certainly very concerned about it, yes. It is too early to see things going down the drain. We are currently being told by NHS England of all the bright spots, but we are well aware that there are a lot of practices, and no doubt other services, that are just wondering what the hell is going on.

I would suggest that the leadership depends on what is needed in that area, and therefore who should lead it. It should be people leading these things who understand the community, as I have already said. I do not think this is about hospitals leading neighbourhood health. It is about people working in the community, whether that is primary care, community nursing or others working in the community setting, including our social care colleagues and those from the VCFSE as well. That is going to be really important.

That really worries us about these IHOs that are being set up and hospital acute care trusts and other trusts, which are already well set up to run things, moving in before the community services themselves are ready to take this on. It takes some months, if not years, to get yourself into a position where you can run things well. We are worried about hospital trusts that always work at a deficit taking on the running of GP practices, for example, that never work at a deficit. Because we are small businesses, you have to make the accounts stack up at the end of every financial year, so you are never in deficit.

What lessons can we learn from the additional roles reimbursement scheme about how to incentivise and finance multidisciplinary teams?

From a GP point of view, there is no doubt that, when that scheme was set up, it was needed. We were desperately short of staff in primary care. Now, it has some perverse incentives as well in that, for a long time, we were not able to determine whether we could employ more GPs or more nurses through that scheme. Now you can, but that has only been in the last year or so. That has been a learning point. I personally think that, for practices, it needs to be through core funding now. The scheme needs to be disbanded and that money moved into core funding, so that practices and their neighbourhood teams can decide who and what they need to employ, depending on what their community needs.

I would add that it is hugely important. At the time I was working in a community service and we actually saw duplication. Suddenly primary care could employ people such as occupational therapists or paramedics. What we saw then was duplicating what was already happening in community services. We cannot afford to duplicate, so looking at it across the sector is really important.

It seems to me that retaining that sense of autonomy is going to be really important here. To what extent have practice managers been consulted?

We have recently conducted a survey of 500-plus practice managers. It was our first ever. They definitely see a shortage of GPs as being one of the big problems in terms of patient access, but their practices lack the funding to be able to employ them.

From a pharmacy perspective, the ARRS roles have been really positive. I know from the feedback we have had that GPs have really valued the pharmacists taking on those ARRS roles. The only thing that we would like to see more of is that support with the clinical supervision and being given tasks that are appropriate to their competencies also. Many had felt that the GPs had underappreciated their abilities, but that comes back down to that learning and understanding what each role does. From a pharmacy perspective, ARRS roles have been really positive, but some lessons have been learnt about how we could value each other’s skillset.

Starting to work side by side has made a huge difference in my practice. I agree.

The 10-year plan sets out a vision to continue to shift the role of community pharmacists towards more clinically focused roles. What support and training do you think is needed to support this shift?

We need to upskill the current practising pharmacists to become prescribers. From summer 2026, everyone is going to qualify as a prescriber, but there is a legacy or existing workforce where not everyone is a pharmacist prescriber. We need to upskill community pharmacists to help deliver some of that specialist clinical care. There is also a need to look at their specialist area and give them support to develop in that clinical area. I think I have already referenced that NHS England has an IP pathfinder site. It has looked at particular conditions where it has identified that you need to upskill pharmacists to deliver that care. The additional thing we need to be thinking about is our hospital colleagues. There are lots of highly specialist pharmacists trained in hospital. We have consultant pharmacists who could help with some of the upskilling across the boundary and help support, mentor and develop them. There is also something about encouraging pharmacists to work across boundaries. Could you be a hospital pharmacist? In Northumbria, there is a really good example of pharmacists working in hospital and going out to visit patients in care homes, GP practices and even their own homes when they cannot come into hospital, looking at their medicines and providing that holistic care. It is thinking about how we can learn from each other and other parts of the system.

Finally, Professor Hawthorne, to the extent that GPs will play a central leadership role—I think that is a little unclear at the moment—or are intended to and will, what do the neighbourhood provider contracts need to contain to support you in filling that role?

There desperately needs to be additional resource, because there is going to need to be more staff and more time at all levels of healthcare professional teams. From a GP perspective, we are seeing the upskilling of GPs into GPs with extended roles. As a college, we are now providing accreditation for those extended roles, be they in frailty, women’s health, prison health, et cetera. All those will be neighbourhood teams that need to be upskilled to be working in that second tier of the wedding cake that I was talking about. That is the new tier, if you like. There will need to be provision for premises so that we have co-location. You work much better as a team if you have those corridor conversations with people. We need training as well, especially leadership and digital training. Digital is going to be absolutely vital. The other two shifts will not happen unless we can properly share patient records.

On training, the King’s Fund has also identified potential for training in mindset in multidisciplinary working. Would you all agree that is something that is desperately needed? I will take the nodding as read.

It is desperately needed but difficult to do.

Quite, yes. Do you have any tips on what should be in the plan to make sure it happens?

It needs to start right from university and the first primary qualifications, where you are actually training people together from the get-go. Otherwise they are already coming out into their silos and it is difficult to bring them together again.

It needs to be right from the top.

Retention is vital. It is crazy that people are leaving in their mid-50s because they have had enough and feel that they cannot carry on and do another day. We know that at least a third of GPs say that they will not be in practice in the next five years. Yes, some of them will be retiring, but a lot of them are leaving early or going off to do something else. We cannot afford that to happen at a time when we need more GPs. There is no doubt that there have been retention schemes, particularly for new GPs, but GPs are leaving at all stages of their career. There are new ones coming out who will go abroad or are finding other things to do.

The online access is a contractual thing that was done between the BMA and NHSE in April of this year. We have not really been involved with it because we do not deal with contractual issues. We are hearing that, while many practices are coping with this, there are also quite a number of practices that are really struggling because the demand coming through online is so great that they cannot deal with that together with their telephone demands and appointments. They are having to divert GPs to deal with the online demand, who then cannot offer face-to-face appointments. It is a capacity issue. It is not that people do not want to do it; it is a capacity issue.

It is a bit of both, but also there are some practices that are just not able to cope with the quantity of additional demand. Some practices are telling us that there is an extra 20% to 30% demand in a day and they just do not have the capacity to deal with it.

We need more GPs. If you have more workforce in your practice, everybody can take a breath. You can have a lunch break, or even a coffee break. You can go to the toilet and all those things. I would like to see that.

The best way is to recruit more and retain more. GPs will live on hope—it is amazing—if you can give them some hope, which they do not have at the moment.

Unfortunately, there is not an easy answer to this. You need to give people hope that things are going to get better soon and that there is more money in the system to enable them to employ more GPs. There are GPs there who want to do more work, so it is not as if they do not exist. They exist, but we need to be able to employ them. That would make a huge difference and be a starter.

Money.

It is their core funding.

They definitely do. Don’t we all?

I think so. Don’t we all need hope? There was a degree of hope when the 10-year health plan came out, but it is starting to dissipate because we are not seeing enough change. We are not seeing enough happening and there is not enough clarity on where we are going.

Yes, being more flexible as to how we employ people. For mid-career GPs, we have a feminised workforce now. They are people who need to take their kids to school and pick their children up from school, and they may have caring responsibilities for elderly relatives. There is all of that, so we need to be more flexible. For people coming to the end of their career, giving them an opportunity to slow down a bit and not have to do quite as much as a mid‑career GP would perhaps keep them going for a few more years. I am finding that, among colleagues of my age, most of whom have now left the profession, they hang around the edges. They do locums. They go up to the highlands of Scotland to see patients up there. They do not necessarily want to leave medicine.

That is already happening to some degree. For eye care or musculoskeletal care, there is a lot more direct access. Quite a lot of our time is spent trying to handle the backlog of the waiting list problems that we have, because people keep coming back. They have heard nothing. It has been a couple of months. They think they have been lost in the system, so they come back to find out what is going on. They come back to the GP because that is their only point of contact. I spend a lot of time expediting—ringing clinics to find out where somebody is in the waiting list, then ringing the patient to explain why they will not be seen for a few more months—and safety netting so that, if things are getting worse, you can get people seen quickly.

I would like to see more career progression. Nursing has more band 5s than any other health profession. That is the entrance level. Flexible working is really important and then CPD, so continuing professional development. Nurses do not have protected learning time like other professions do. Excuse me while I take some water.

Needless to say, pharmacy is also under pressure, with risk of burnout with inadequate staffing levels, long working hours and issues around work-life balance. We would like to see that the job itself has the adequate staffing levels required. There are changes to supervision legislation that could potentially enable us to better use a skill mix within a community pharmacy.

Currently, as a community pharmacist, you have to be in the building for pharmacist medicines to be supplied. You could be removed for about an hour, go and do some development and learning and the pharmacy technician could be trained up to then hand out the prescription. Using skill mix better would help us.

It would cost more because it would mean putting funding into pharmacy technician skills, ensuring that there is a good skill mix and perhaps having more than one pharmacist within the community pharmacy as well. One could go away and do clinics in a consultation room, and the other could respond to queries with patients coming in.

Making the job interesting is one thing, so making sure we are utilising their skills. If all these pharmacists are going to become prescribers, unfortunately we need to look at money, because we need to commission prescribing services nationally, whether they are national or local. We need to make sure that pharmacists are being utilised and therefore have better job satisfaction and want to stay in the profession.

It is not boring.

There is lots to do and not enough time to do it. There is a concern with shifting hospital into community. How do we make sure it is incentivised and funded adequately?

There are chief pharmacists and medicines optimisation teams embedded within ICBs. However, there is a real risk with the 50% cuts to ICBs that medicines optimisation is considered an administrative role and we lose that skillset within the ICBs. We need to ensure it is prioritised. Medicine is the biggest intervention in patient care and one of the biggest spends. If we lose that expertise, it is not going to be strategically managed, so there is a concern.

Continuing professional development is really important, and protected learning time for nursing. As I said, it is the only health profession, I think, that does not have that. That is really important going forward. Flexible working and allowing nurses to work flexibly is really critical. Not all areas do that and embrace that.

No, it is not. Most organisations will have a flexible working policy, but how flexible those are can be very variable. I would suggest that, if you are asking what we can do with no or very little money, that would be the one thing we can do. Flexible working across different professions, and particularly in community, is really critical.

It is a little bit of both, but particularly the hours worked. Some people may want to work school hours, which you can incorporate in community working. Some people may just want to work evenings and nights—we talked about that earlier—or weekends. As a very young nurse, I just worked weekends when my children were little. Allowing nurses, and other professions, to do that sort of thing is really critical.

You might not necessarily need to expand the workforce. Embracing part-time workers is really important, because part-time workers tend to be more flexible as well. You might be able to use them, not inappropriately but in a way where they can fill some of the gaps when you have gaps.

Funding is there. The funding is there for CPD and, as I understand it, that is going to continue. It is the ability to down tools and be able to undertake the CPD in the first place.

It is.

Thank you so much. That brings us to the end of panel one. Witnesses: Richard Evans, Karen Poole, Tanya Rumney and Karin Orman.

Could I start by asking you to introduce yourselves and the organisation you are from? We will then go directly to our first question.

Good morning, everybody. I am Karen Poole. I am an allied health professions rehabilitation consultant working for East Sussex Healthcare NHS Trust. I am also a clinical director for the rehabilitation intermediate care programme within NHS Sussex. I am here today as a rehabilitation consultant and as a member of the Chartered Society of Physiotherapy.

Hello, everyone. I am Richard Evans. I am the chief executive officer of the Society of Radiographers. I am also the chair of the Allied Health Professions Federation.

Hi. I am Tanya Rumney. I am a dietitian working in the NHS with 25 years’ experience. I lead a large service up in the north-west of England. I am also the workforce lead for the British Dietetic Association.

Hello. I am Karin Orman. I am an occupational therapist and director of practice and innovation at the Royal College of Occupational Therapists.

Thank you for coming along this morning. You are all allied health professionals and represent allied health professionals. I would like to ask you about how we can better improve visibility in the workforce planning for allied health professionals. Could you tell us very briefly what you think? Is anything currently good? What is missing, and what would you like to see?

In terms of the workforce plan, having leadership visibility is really critical. In order for us to help the Government to achieve the ambitions of the shift into neighbourhood health and the community, we need to have those voices at those levels, being able to inform and bring along those skills and perspectives so that we understand how we are going to do this.

For clarity, Karen, which levels specifically are we talking about?

It is thinking about within provider organisations, so within health trusts and local authorities, but also thinking about system leadership and in terms of some of those regional and national representations. It is about ensuring that we have that visibility of AHP leadership there, which can advocate and describe the opportunities around how we start to deliver care within the community. An example might be my role. Within my provider organisation, I am part of that integrated leadership team. I am able, from a clinical perspective, to describe to my colleagues how we start to make those shifts into the community. It is also within my system role. I work within NHS Sussex, which is the ICB in Sussex, helping to inform their clinical commissioning plans, ensuring that we can move and shift that care.

It is clear that allied health professionals are not currently represented in leadership roles as you would want them to be. In terms of workforce planning, if we move along to Richard, do we need to recruit more allied health professionals in any particular area? When we are workforce planning, what is missing there?

There are 14 different professions. The fact that there are four of us here representing that scope indicates the importance of people who can understand the scope of what is done by allied health professionals. In terms of recruitment and flow into the professions, that will be quite variable, but health demand is not static. It is moving on.

If I am looking at the workforce plan and I have a section on allied health professionals, where are we currently in terms of allied health professional recruitment and retention, and where do we need to get to? I appreciate that there are 14 different professions here, so you might not have the same answer for every profession, but I am looking for a general understanding of the shortfall or, “We are all fine. Do not worry”.

There is a considerable shortfall. I doubt there is a profession that would say there is not a shortfall.

Can you specify the percentage shortfall for any particular profession?

In radiography there is probably about a 13% shortfall across the country. That is a combination of recruitment, retention and the ability to open up vacancies fast enough.

Tanya, is there a shortfall in dietetics?

It is very similar to what Richard is describing. It is about 10% in dietetics. You will see that there are differences across England. Some areas might be working with a 50% or 60% reduction in their workforce. Some areas will be very well staffed. We need to be able to target that recruitment and retention a little better to keep that level.

That makes sense. Some parts of the country are doing well, and some parts not so much. Karin, what is the situation for occupational therapists?

It is very similar. We are seeing a shortfall in areas such as London and the south-east, as well as coastal and rural communities. It is also the make-up. We see that certain areas can recruit band 5s but are really struggling to retain band 6s and 7s. It is a very mixed picture.

I am sure we will look further at allied health professionals and recruitment and retention. Going back to leadership, the current structure of leadership in the national health service is fairly hierarchical. I wonder whether you have any thoughts about allied health professionals and whether we should change the structure of leadership in the NHS to make it easier for allied health professionals, for example, to be on executive boards or to be represented in whatever the newly formed NHS England is going to look like.

I would agree that it is critical to rethink that structure. We know that we are losing some of those chief AHP officers across provider organisations and within our system.

Why are we losing them?

It is because of recruitment freezes and changes in terms of, particularly, the restructuring of the ICBs. We are losing those posts. Also, for many of the allied health professions, there are no chief AHP officers on boards. We are often reporting into our director of nursing colleagues, so we are one step away from the board in terms of having that opportunity to influence and advocate for change.

According to the papers we have, 50% of ICBs—integrated care boards, so regional health people—employed a chief allied health professional prior to the ask to cut ICB running costs by 50%. Do you have any sense now of how many of those 50% are currently still there? Do you have any figures on that?

I cannot give you an exact figure, but I know we have lost ours in Sussex.

Is there any other information on that?

We do not have a clear picture at this moment because they are still undergoing that process.

This is a final question from me on the workforce planning. You have outlined a shortfall of between 10% and 15% across various allied health professions. If you were putting in that additional 10% to 15%, are there perhaps two or three particular endeavours that would make a difference to retention and recruitment?

One would be good.

Yes, one. We are running behind. Karen, is there one thing that would increase recruitment and retention? Are we short of training places? Are we losing people to other professions? What is going on?

We do not have a supply problem. It is probably around career progression, so reflecting some of the comments earlier.

Clinical placement capacity is very limited. Looking at different models for progression from a support workforce to degree level would be a key one.

That is interesting.

I would agree. It is about career progression. We know that dietitians might struggle to get their first role within the NHS. That means you then get vacancies across all the bands. It is about both ends of it. You have your entry-level roles, which are really important to get people into the workforce and support them to stay in the workforce, but then you need to have those advanced practice opportunities as well, so that your workforce is developing and delivering the care they want to deliver.

Again, the supply is healthy. It is looking at retention and career development. Twenty-one per cent of occupational therapists leave the NHS within the first two years. They are not leaving the profession, but they are leaving the main employer.

I probably need to pick up on that, where people are moving and leaving the employers, because I am going to talk a bit about left shift and shift to the community. As things stand, how is the AHP workforce currently split between community and acute settings?

We are moving more to community. It would not be very long ago when my own profession—radiography—would say that there has always been some community work, but it is pretty limited. With the growth of community diagnostic centres, that has changed substantially. Radiographers are seeing opportunities in communities much more than previously. Although the model for community diagnostic centres initially stretched the workforce even further, because the workforce supply to open these was not adequate, it is providing a great model for radiographers to see a blended career, which might be centred in the community and open to other opportunities. I will let colleagues talk about other professions, but one other aspect of diagnostics, which we have not touched on so far, is about screening. Screening units provide a unique experience in terms of access to hard‑to‑reach populations. I have not found anyone who has really explained why people will show up to a screening appointment but not go to their GP or to a hospital clinic, but they do. The best practice is to see that growth around holistic care delivered in a screening service. That is part of what diagnostic radiographers do, but other professions are increasingly getting involved in screening.

It strikes me that, like with a lot of things with the NHS, you are suggesting that the change has started because buildings and centres have been built, not just because they have tried to redirect clinical and AHP resources to the community. Is that the case? Is this something that we could do without needing to open a diagnostic centre but by just shifting the roles, or is the diagnostic centre the thing that makes it possible?

In the case of radiography, it definitely drove that change. You need a piece of kit, even if it is a relatively inexpensive ultrasound machine, to be available to deliver the diagnosis.

I am probably thinking more for Karin and OTs. Have the roles gone more into the community with community diagnostic centres? Were they always a bit more in the community?

No, not specifically around diagnostic centres. We have seen growth in occupational therapists working within primary care services, but we are starting to see a shift. When we talk about neighbourhood delivery, a lot of the conversation is around GPs and diagnostic centres. It is very medically based. We can start to deliver services within schools, jobcentres and leisure centres. We can use our community assets and make sure it is not just the right level of support at the right time, but it is in the right place as well. We have examples of occupational therapists doing coaching in mainstream schools. We can make sure the environment is more supportive of young people and children who are neurodivergent. We are seeing a reduction in pressure on waiting lists for CAMHS and paediatric services. We have to move from referring and assessing individuals. Professor Hawthorne talked about targeted services. We need to think about commissioning AHPs to go in, share their expertise and do that coaching and support, so that teachers, learning support assistants and staff in leisure centres are able to do some of that prevention. They have that guidance and they know how to refer up when there is greater complexity of need.

If you will excuse me, who is doing the commissioning here, then? Is that done through a CCG or an ICB?

It is through the ICBs, yes.

I am just going to build on that. The thing that you said about schools was quite interesting to me. One of the elephants in the room about how our services do not work is that they do not always go to where the patients are. The education setting is a prime example. It is a shame that there is not someone from speech and language therapy here. When I talk to parents, a lot of the time that is the thing that is not getting commissioned in school. Is there a way that we can work with our commissioning to make us not only work better in community settings and various community bodies but, going even further, to work with, as Karin said, leisure centres, schools and other community assets? Is there a way that we can make the community shift work better and not always be attached to a health centre?

We have to widen our conversation around integration. We are not just thinking about integrating hospital services with primary care and community services. We have to involve local authorities. We have occupational therapists based in local authorities, for instance. We also have to include education. We also have the charities and their assets. They need to be involved in those conversations around what they are able to offer and what they can do.

There is another argument for having AHPs involved in the commissioning process. It is brilliant that you have brought up speech and language therapy, but for a lot of people it is not self-evident that it is important that SLTs are available in education, in the community and in local government in some cases, as well as in secondary care. Some understanding in the commissioning function from lead AHPs will be vital to make sure that happens.

I wonder whether I could share an example from Sussex about how clinical commissioning is happening. I have a clinical director role within the Sussex ICB. Part of that role is to help inform the clinical commissioning direction. As colleagues have said, this is about bringing together all of those partners. We have been doing a huge piece of work in terms of major service redesign for rehabilitation, intermediate care and urgent and emergency care in Sussex. Fundamentally, that has brought together all those workforce partners, from both the local authority and our voluntary and community sectors, to start to re-describe the models of rehabilitation and intermediate care delivery from that perspective and that lens. One of your original questions was, “Do we have the right amount of workforce in acute versus in the community?” This is about working across the pathway. It is not an either/or. It is about understanding what that population needs and how we can shift care into the community.

Just very quickly, Karen, you are involved in the commissioning of a really good model. We have a hugely diverse group of medical professionals here, and there are another 10 or so professions under the umbrella of AHPs that are not represented. How much do you know each other’s work? When it comes to getting the right voices of AHPs, Richard, could you see the need for a speech and language therapist? Karen, could you see the need for a radiographer? Do you have that knowledge? Is one AHP able to be a voice for all?

It is about networks. We talked earlier about some of those networks. It is about how we create those connections. First, there is something about the visibility of the leadership and the responsibility and accountability of that leadership to ensure that they are creating the right forums and conditions so we can share and understand all those roles. That is really critical for us. This comes back to one of the earlier questions, which was around those really accountable chief AHP roles within systems, ICBs and providers.

You said “chief AHP roles within systems”. Can you just break that down a bit?

Yes. That might be a chief allied health professions officer who sits either at a regional level, within NHS England at a regional level, or within ICBs, which is at that more micro-system level. They can advocate and be the narrator, if you like, of the opportunity that allied health professions will bring in terms of that left shift.

AHPs understand what each of our professions do, but it is about that wider understanding so that everybody knows what we can bring to the table and where we are able to best influence health. That is public as well as Government and NHS. We need to look at how we better use language. We need to use inclusive language around AHPs. We should not just be talking about doctors and nurses within the system. It is about all of the professions. We all bring something unique to the table.

Thank you all very much. It is so interesting that I have gone hugely over time.

I want to turn to changes in demand over the last two years since the previous workforce plan was published. How will the proposed shift to community impact the workforce demand for allied health professionals?

The shift to community, as we have already touched on, will be different across the diversity of the professions. The overall demand for healthcare is not showing any signs of slowing. We need to see more on the prevention side. We need to be involved in early diagnosis in the diagnostic sense and early treatment elsewhere. I cannot see that the move to community reduces workforce demand. It will be maintained. There is an exercise involved in making community work for those who have a choice between an acute centre profession and moving to community. We need to let the professionals see the value of that, both for themselves in terms of their own work and their work‑life balance but also in the value that they can bring. By working across professions in multidisciplinary teams and communities, AHPs could see an increased sense of value and self-worth. With the right management, especially in professions like my own, which would not have seen that as being a very sexy choice, the AHPs will see that community and neighbourhood working is where the real work is happening these days and the difference that can be made by colleagues in teams working together.

Workforce demand comes back to our understanding the needs of our population. We are at a perfect juncture at the moment as we start to shift from perhaps an acute-centric model towards a more community-based model. In terms of that workforce demand, previously we probably have not been able to do that proactive and preventive piece. The more we build into neighbourhoods and the more we start to understand the unique needs of that population, the more it will change the workforce that we need and our understanding of what that workforce looks like. That will be about, yes, having more AHPs to support in that space, where we have not been able to offer proactive care. It is not just about AHPs; it is about working with broader voluntary and community sector partners and understanding what we are not currently delivering within the acute setting. It is easy for us to think about shifting care, workforce and resource from acute to community, but it is not like that. We have long hospital stays. I see that every day clinically. That is because we are not delivering the right amount of rehabilitation across this broad spectrum to help people get out of hospital quickly. There are two things that we have to do. We need to make sure we have the right investment into our acute therapy staffing, but we also have to make sure that we are beginning to think more broadly around our workforce models to do that real preventive piece that Kamila talked about in terms of the layered triangle, which is the bit that is missing. That universal offer is the bit that we are missing out on.

I would agree. There is going to be pressure as we make this transition, but where services are thinking about what a universal offer is and doing the targeting, we are seeing a reduction in pressure on the workforce, greater staff satisfaction and retention within teams. As we make the transition, there will be an initial period where the demand will be high and they will be under pressure, but inevitably that will take the pressure off the workforce.

There is also something about making sure that, when you are developing these pathways, you really do include the experts in those areas. If we take dietetics as an example, we have some challenging conditions around diabetes and weight management, but sometimes pathways are developed without dietitians, who are the experts in those areas, being involved in implementation and development. That potentially means that dietitians are getting involved a lot later in the patient’s diagnosis, when they are already quite medicalised. They may already be on an awful lot of medications; they may have had a lot of diagnostic tests. By being able to frontload the workforce into some of those pathways, you are optimising diet and lifestyle, which are cost‑effective interventions compared with medications and investigations.

Vacancy rates for allied health professional posts in community settings are higher than those in acute trusts. Why might that be? Where is the challenge there, if we want to bring more people into community roles rather than acute trust roles?

It is the lack of mixed models. In community teams, you tend to be looking at band 6 posts or advanced level practice. You will see one AHP in a community team. You do not have the infrastructure. You do not have a mixed model. You are not bringing in newly registered occupational therapists and creating those career pathways. Where that has been established in community rehabilitation services and community mental health team services, we see people going in at band 5 and having a whole career within the community setting. It is limited. If you work in a hospital, you have more opportunities for career progression, more wraparound support from a team and more opportunities for good-quality supervision.

Is that not therefore going to be an ongoing challenge, if we are looking to increase the posts in community settings? You have just described why people might prefer an acute setting in terms of their own career progression, daily experience or fulfilment from their work. Is not that going to be an ongoing problem?

I do not think so. We have examples. If you look at mental health services, they have been chronically underfunded, but they still run. They are primarily based in communities. You have existing career structures; you have supervision; you have opportunities to stay professionally up to date and develop. It is possible. We need to take those examples and think, “What can we learn from those? How can we extrapolate?” We tend to have pilot-itis. We have lots of great pilots going on.

We will come on to that as an entire theme very soon. Do not worry. We are on it.

Logistically, it costs you more money to work in a community setting. You might need access to a car; you might need to pay for petrol and parking. There are some logistical reasons why people choose to work in an acute setting as well.

It does not sound like that is necessarily going to change, in and of itself. One thing that does sound like it could make a difference is money, having more funding in that space.

It is about how we think about roles across organisations and thinking about how we can pool some of those resources. The organisation that I work for is what we call an integrated provider. They provide the acute care; they provide the care within rehabilitation hospitals; and they provide care within the community. You could do that with a networked or allianced approach. We need to think about how we share our workforce, how we share our training and how we share things that enable people to be retained. That could be things such as preceptorship programmes and practice development roles, which are there to support early-career graduates who are coming in. How do we help them to stay in those roles? If they are coming into the community, that may feel different from what they were expecting, if they were going into an acute hospital. The other bit is really thinking about, as Karin said, that mixed model. We need to think about those clinical leadership roles. As a clinician, you want to go where you have really good support, where you have senior clinicians who you can turn to and lean on. In the community space, we have been fairly under-resourced for a fairly long period of time, which means we have not been able to think about that broader model. It is about putting in some of those advanced practice roles and seeing career progression as well as seeing some of those diverse support worker roles, which also have career progression between bands 3 and 5.

It is a much more complex space though, is it not? It is more complex even in terms of things such as employment. In an acute setting, you are talking about the same employer, for example. When you are learning from a senior professional, they are employed by the same person. It is much more complicated within the community space, where you have a multitude of organisations, even from an employment perspective, which cannot be ignored.

That is how we will come together as integrated neighbourhoods. That is about how we start to develop the architecture and infrastructure to help us work in a more collaborative way. Collaboration has to be the key going forward.

I want to turn to early career. We have touched on career development. In terms of training and early career development, what are some of the issues that AHPs or prospective AHPs are facing?

One of the challenges is that you are expected to specialise at quite an early stage, which does not really reflect population needs. A newly registered occupational therapist can go and work in mental health, in local authorities or in general physical health. However, you tend to specialise very early on.

Why is that?

It is due to the way the systems are set up. We are now starting to see a resurgence of newly registered occupational therapists being offered rotations. Some of those rotations are not just within the NHS; they are across local authorities as well. You might do six to nine months in a hospital, six to nine months in the community and six to nine months in mental health services. We need specialists who have deep expertise in a particular area, such as stroke or cancer, but we also need to create career pathways where your specialism is understanding population health. Those people will retain a broad range of skills, but, as their career develops, they will not just think about the individual in front of them; they will think about their wider team, the service, the population that they serve and then, as they progress, more broadly about the wider population health need. It is about understanding and supporting that professional authority to grow.

As well as specialising within the strand of the AHP profession, is there potential for a more general route into AHPs? Doctors and nurses tend not to specialise early on. You become a more general medical professional and then you specialise as you rotate around different services. Is there a sense that having to pick your AHP profession early doors might be a barrier to people who are not quite sure whether they want to be an OT or a physio?

It is about understanding that the AHP professions are separate professions, as medicine and nursing are. We are not subsections of the same overarching profession. We are professions that are under the allied health professions leadership. A physiotherapist is different from a radiographer, which in turn is different from an occupational therapist.

Are the boundaries blurred? I am not disrespecting the professions. Equally, while a community nurse is very different from a nurse in secondary care or primary care, there can be some movement between those professions.

We have some shared skills. Certainly, I have experience of community therapy teams. Within a community therapy team, there will be some core skills that we share across our nursing, our GP within the service, our occupational therapists and our speech therapists, so that we can target patients in a core way to begin with, and then understand, through that trusted assessment, what the needs are and therefore whether we need an occupational therapy specialist or a physiotherapist to support that patient. There will be a degree of core skills, but it will not just be across the allied health professions. It will be much broader. It will be across all our health and care professions, so we do that trusted assessment and reduce the patient needing to tell their story more than once.

There are great examples of blurred boundaries between professions that could be developed further. By definition, all the definitions that we are talking about are statutorily regulated professions. They are responsible for their own scope of practice. You can train in an area that is at the boundary of your practice, and it might be occupied by other professionals a lot of the time.

In terms of routes into those qualified designated professions, we hear that recruitment is a challenge. If it is not a challenge, that is great, but we hear it is a challenge. In terms of entering one of those registered professions, we have received a bit of evidence around apprenticeship routes and degree apprenticeship routes. You might have thoughts about those. From my perspective, the young people who I meet do not come to me and say that they definitely want to be a physiotherapist or one of the AHPs. Is there a way of exploring what they might want to do that could be built upon to develop the future workforce?

Some universities do a lot of shared training in the early stages of degree courses. The curricula are very crowded, so it is difficult to make a lot of time for that. In my personal opinion, more work could be done at an earlier stage in people’s careers to understand options and potentially to switch, if they see something that they feel more akin to in another profession, rather than wait, train and then leave and start training again. There would need to be work and resources put in to do that. You mentioned apprenticeships. The apprenticeship route is a terrific opportunity, particularly in coastal and rural areas where the workforce is probably not that mobile. As we have already discussed, it is quite difficult to get people to see those locations as great options, when there is increased travel and inconvenience in getting from where they are to train in those locations. If you are growing your own workforce, not only can you have career progression from a receptionist through to a consultant radiographer practitioner, for example, but that person is likely to have roots in the community and stay there. That kind of model is worth a bit of pump-priming because some of these communities are in desperate need of community development and economic development, not just healthcare. It helps if the people who are delivering the healthcare are local.

How many of the 14 AHP strands are open to people with apprenticeships or have apprenticeship routes into them?

All of us have apprenticeship routes. Arts, music and drama therapists are second degree-level programmes, but they have been developing master’s levels apprenticeships in those professions as well.

If I can go back to your original point about whether there is some commonality, that goes back to the point about the fact that AHPs as a whole are not well understood. People might go into a programme thinking, “An OT or a dietitian does this”, but, because there is not that level of understanding, it may be very different to what they expected. Again, most people know what a doctor, a nurse or a physio does, but we need to have a wider understanding of the other AHPs so we are getting the right people into those roles.

Most people will not train. Being a GP is very different from being a doctor in secondary care or being a doctor in another part of the care system in the community. I am just pointing out that there is a level of fluidity in those professions. It sounds to me that in the current training system you have to decide quite early doors which brand of AHP you want to be.

You do. When you do that training, you are quite generalist. As Karin said, one of the problems is that, in order to progress within whichever sector you are working in, you need to specialise quite early on. We need to celebrate and keep those generalist skills within our professions. That is how you are going to enable people to work in the community setting.

To a certain extent, you have covered some of the areas that I was going to ask about with regard to career progression. In your particular specialties, what could be done to improve career progression within the community setting? You have indicated that if your particular roles remain in the hospital setting, the chance of career progression is somewhat greater. I just wondered what else could be done, if we are to make this shift, to make the role more attractive in the community for those wanting that career progression.

It is about starting with undergraduate training. As we start to move our care more into the community, we need to ensure that our undergraduate programmes are really developed with that community skillset in mind. We need to be readying our workforce. As they come out of university into our early graduate and early-career programmes, they already need to be thinking about what it is like to work within the community. The other thing in terms of the early careers opportunity is, as I said earlier, about making sure we have preceptorship. We need to ensure that we have a structure around how we support people as they move from university into the NHS or the local authority. It is a very different world to be in. The other thing is that apprenticeships should not just be for graduates. We need to be thinking about apprenticeships in a broader way. If I take my role, for example, it has taken quite a while to become a rehabilitation consultant. There is no pipeline for me. There is no pipeline coming behind me. How are we creating the support network or support structure to help people move into those very senior roles? It is those senior roles that we have just described in terms of that visibility. It is all the way through in terms of that career opportunity.

You need to look right the way back to the recruitment process.

You need to look back. Yes, absolutely.

It is the other end of the spectrum as well. If we want to incentivise people to move into the community, we need to have advanced practice pathways that are open to all professions for AHPs to move into. At the moment, our advanced practice pathways are quite medical model-focused. It might be looking at medical replacements. That is not always the case, but certainly in the community setting, we need to think more broadly and not have roles that are ringfenced to certain professions. For example, not all professions can prescribe. When you advertise roles that require an independent prescriber, you are by default ringfencing it to certain professions. Our AHP colleagues have lots of things to offer in those pathways, whether or not they can prescribe. Levelling that playing field and ensuring that independent prescribing is available to all AHP professions would help that situation.

If they are prescribing, surely that would be part of the career progression. They would go up another band, would they not? Have I misunderstood?

Not necessarily, no. We need to make sure that people have the roles to go into as well. Within dietetics, we have hundreds of prescribers within our profession, but we are currently restricted to supplementary prescribing. We do not have independent prescribing rights. That restricts us to a certain extent. If a role were advertised as an independent prescriber, we would not be able to apply for it, even if it might be a condition or an area that we have expertise in, such as weight management or diabetes, et cetera. We really need to level that playing field and have independent prescribing rights across the AHP professions.

Can I turn the question the other way around? If we are seeking to shift to the community, how would having more higher‑level posts within the community, at bands 6 or 7, help to enhance the shift from hospital to community?

It is all about your structures and your support. For instance, in England, we have occupational therapists who work in primary care, but they tend to be in first contact practitioner roles, which are advanced practice roles. It is similar with physiotherapists. In Wales and Scotland, they have created those senior roles at band 7, but then they have also brought in band 5s and 6s. You have a mixed model. You can then see a career. You are not just going to come into community services. The risk of people coming in at just one level and remaining fixed is that after a couple of years they will leave primary care because there is nowhere for their career to go and you lose that expertise. We should not just be thinking about putting in an AHP at band 7 or 8 within a service from the word go. We need to take that first step to argue and establish the role, but then you need think, “What can we do to bring in band 5s and 6s?” It works within hospitals. It should work within community services, especially now that we have the technology to enable people to have supervision, attend multidisciplinary meetings, get mentorship and do shared learning online. They no longer have to travel to meetings, or to see supervisors. We have that technology already. We have to use that to enable us to have a more mixed career pathway and make community services much more attractive to the professions.

Richard, your profession involves having quite expensive equipment out in the community. I come from a particularly remote rural area. Assuming that people are going to be scanned and diagnosed out in the community—we are rolling those things out—we are going to have radiographers with MRI and CT scanning capacity in communities with all the support infrastructure. How can you run those services without the senior roles being based in hospital and having a peripatetic network to support the community outreach?

Technology is a great aid in that sense. Incidentally, I agree with Karin. There is no reason why the model always has to be what has worked historically, with community as a poor relative. We should be able to see full career progression and leadership in community services. That might be quite blended across AHPs with some shared roles, but we need to start thinking differently about that. You asked about how high-value diagnostic equipment can be managed. All of this work around community diagnostic centres is showing what can be done. There is great capacity, as most people are aware, to have mobile scanning units and screening units, including some quite high-end equipment, that are fully mobile and can be taken into communities on a regular basis. Managing that could be done out of a central large NHS trust with the radiology manager strategising for the community care. That works in certain areas. It also works where an independent sector provider, typically, has won the contract to run the community diagnostic centre, and that is managed through that independent company. In the middle, there are standalone NHS-run centres where the management is linked into technical specialists via teleradiology, for example, if they want advice and support on any particular instance. It can be done.

I am aware of time. Are you saying that even an MRI can sit in a wagon and be taken into the community?

Yes.

That is very helpful. In terms of understanding what this means, you are saying that in fact the acute trusts themselves, rather than having resources taken from them into community trusts, could be the facilitators and drivers of the process whereby there is that shift to the community. They could deliver those services into the community through your profession.

They could in the diagnostic imaging and, to some extent, radiotherapy professions. I am sure there could be examples in other professions. What we are seeing in radiography is quite new in comparison with other allied health professions, where the community has always been a choice. That takes me back to my earlier comment.

To round us off, we are going to talk about retention, which has come up at various points in your answers. I am going to ask you a series of quite difficult questions. I am going to ask you to choose one thing in your profession that is creating an atmosphere that is leading to poorer retention than you would wish.

Occupational therapists have quite flexible skills. They are often used to plug the gaps in services. They are not putting occupations at the forefront of their practice. They are discharge co-ordinators and mental health practitioners. They can step into those roles, but it is not occupational therapy. Therefore, people become disillusioned and disheartened. That is a risk.

We need to understand the vacancies and take steps to be able to address those. The reality is that you are not ever just doing one person’s job. In really small professions such as dietitians—there are only 6,000 across the entire NHS—that puts real pressure on the system. It means you are not able to do as much of the work in the location that you would want to do it. We need to understand those vacancies and take steps to address the issue.

Flexibility would be my one. You need to be able to feel like you have a life alongside the work you have to do. There is a lot of pressure. Feeling in control of your work and where your career is going to take you requires employment flexibility. That would be my one.

We are not being competitive with our opportunities to upskill our workforce. That leads to some issues with retention. Also, there is a glass ceiling with allied health professions in terms of where we can go. We need to break through that glass ceiling. That will make all the allied health professions much more attractive. That goes back to the earlier comments with how we attract people into these professions and how we keep that pipeline.

There are a couple of themes there. One is around doing the work that you love and that you are trained for, and the other is around career progression. If we agree that those are the broad themes that have just come out, what would be your top solutions to solving those two issues?

In terms of doing what we love, it is about making sure that we have the right workforce around us, so that we do not end up doing other people’s roles or parts of their jobs. We need to make sure we have the right support infrastructure around us so that we can release that time to do clinical delivery. In terms of the glass ceiling and career progression, it is about making sure that the roles that are advertised within systems and organisations are open—Tanya mentioned it earlier—to the allied health professions and we have those credible skills to help deliver those roles.

I would pick on CPD. We need protected CPD time and resource so that people are able to raise their heads, be curious and say, “I will find out how that works and see whether I can integrate that”.

We need to ensure there are enough entry-level roles for people to go into the NHS. Lots of the AHP professions have opportunities outside the NHS. We need to make sure that we are capturing them at the point of graduation.

I would agree with the other comments. I would take forward something else, though. AHPs come out as autonomous professionals. Newly registered occupational therapists and other AHPs have the skills to do service improvement projects or audits. They can build up evidence. They do not get freed up to do that. Often within the system it is not until you become a band 6 or 7 that you are given some capacity to carry out those projects. They have the skills coming out, and we need to nurture that. It is not just CPD; it is doing that sort of service improvement and capturing what is working well so that we can learn, extrapolate and then roll out further.

Thank you very much, all four of you, for your time today. We have to be prompt, sadly, in leaving. We are about to lose quorum as well, as people rush to the Chamber. Thank you so much for helping us understand better the range of skills that is available in your professions and beyond. Thank you, everybody. Thank you to the first panel, too.