Diminishing the impact of skills shortages (3)

Skills substitution  

However many new doctors and nurses are promised in return for the extra resources that the NHS receives from the British people, my prediction is that we won’t get them.

My hope is that, as I suggested in yesterday’s post, that the NHS will reach out to a wider domestic pool of talent to provide our future skilled clinicians. However I am pretty sure that, in the next few years, the terms of international trade for the migration of clinical staff is very likely to turn against us. The increase in demand for health care staff will be international and the amount of resources going into new health services across the world will provide some enticing 10 and 15 year contracts for English qualified staff. We will lose more than we ever have before.

We know already that there will be a severe global shortage of skilled clinical staff, and across the world this will be mainly solved through skill substitution. This is a simple process that works across all services and industries. Whatever level of skills you possess, it is almost certain that you will be performing some activities that could readily be carried out by people will fewer skills than yours. So that part of your work can be carried out by someone with fewer skills. And in the 21st century we have the additional possibility of some of everybody’s work being carried out by new technology and artificial intelligence.

Given the shortage of clinical staff, more than any other factor, it is skill substitution by people and machines that will ensure the NHS continues to thrive.

Some of the things that qualified doctors do can be done by qualified nurses and some can be done using artificial intelligence; some of the things that qualified nurses do can be carried out by nurse associates and some by using artificial intelligence; some of the tasks that nurse associates perform can be done by NHS apprentices and some by artificial intelligence, and some of the things that all of these staff do can be done by patients and artificial intelligence.

If the NHS goes about this skill substitution with pace it will thrive. If it moves slowly and grudgingly – with resistance from all existing categories of skilled staff to substitution or artificial intelligence – then it will not and may, if it resists for the next decade, fail as an organisation.

Let me give you an example of how skill substitution works – nurse prescribing.

I remember the struggle to deliver the legislation and training to create this in the very early ‘noughties’. Whilst doctors were very much overworked – and are even more so now – part of the work they could safely give up was to have nurses carry out prescribing. The latest figures I can find show that in 2014 one in every three primary care practice settings, and one in every four hospital settings, use nurse prescribing. That’s certainly progress but it’s not rapid and it’s still not the median experience for NHS settings to have nurses prescribing – more than a decade after its introduction.

The point is that in terms of the changes that will be necessary for the next few years this is not fast enough.

The paradox here is that our skilled staff are worked off their feet and feeling intense pressure on their time and lives. They are desperate to find some way of easing this pressure and skill substitution is an obvious way of achieving it. But some skilled staff members – at every level – are anxious about substitution. What if all our skills can be substituted? Will that make us redundant?

Overworked, skilled people resisting skill substitution to lessen their work load.

And yet our problem for the next few decades at least will be an ever increase in demand from the sick. For the foreseeable future there will be enough sick people to go round for all of the skilled clinical staff we have. Providing they can care for people across a broad spectrum of health care I cannot see any skilled care worker being made redundant in my lifetime.

But skilled staff seem afraid that we will, seemingly in a trice, move from a long-term chronic skilled shortage to a glut of skilled staff and their jobs will be in peril.

It is a paradox that we have to unravel with some alacrity.

One final point – in the hierarchy of skill substitutions I set out above I ended with the point that patients and their carers are going to up their skills to take over some of the tasks at the moment carried out by skilled staff. Any of us who have, or have had, a prolonged illness come across a wide range of activities where we want to do a bit more for ourselves. This is especially true with long-term conditions (the clue is in the name – if you have a condition for a long time you get to know a lot about it).

If the NHS helps us to self-manage our conditions better, it could prove to be the most transformative substitution to alleviate skill shortages in health services.

We know with some certainty that there will be a substantial worldwide increase in demand for health care. If that extra demand is met with the same configuration of skilled staff as previous demands, then we will run out of staff very quickly. The skill substitution outlined above is necessary and it needs to be carried out smoothly. The health services of nations that do this, will do well.

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