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South Wales Programme

Workforce Technical Document

Purpose: The papers contained within this document were prepared in order to assist the workforce modelling and simulation

Status: Approved

Approved By: Planning Leads and Clinical Reference Groups

Author: Julie Cassley

Date: 15 May 2013

CONTENTS PAGE

Introduction 3 - 4

High Level Modelling Papers

Emergency Medicine 5 - 12Maternity/Obstetrics 13 - 18Paediatric Workforce 19 - 26Neonatal Workforce 27- 34

Appendix 1Workforce Work-stream Terms of Reference 35

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Introduction

A Workforce Work-stream was established to provide professional workforce/human resource advice into the engagement and consultation phases of the South Wales Programme. Terms of Reference are included at Appendix 1. The objectives of the Work-stream included:

Produce baseline Workforce Information from all four Health Boards into composite report to feed into the Planning Work-stream modelling process

Compile Age Profile for each service

Gather data on Advanced Nurse Practitioner roles and other “extended” roles

Collate and provide relevant information on high level workforce key issues which impact on the areas of service delivery e.g., changes to medical education and training

Members of the Workforce Work-stream attended Planning and Finance Work-stream meetings and Clinical Reference Group (CRG) meetings in order that key issues were discussed as a whole and not in isolation.

Workforce Modelling Papers

A workforce summary paper has been produced for each of the four fragile services and validated through the CRG and clinical leads. The papers are contained within this document. The purpose of these papers is:

To capture the current workforce information and situation within the South Wales Programme for each service within scope

To highlight the workforce issues and aims as expressed through the Clinical Reference Group (CRG), Service Model and relevant standards; research and publications

Provide a high level analysis/comment of the workforce modelling undertaken to date of the scenarios and options which will be put forward for Public Consultation

The papers support the work prior to the Public Consultation phase of the Programme and are not a staff consultation document. It is accepted that following Public Consultation detailed workforce planning will be required to support implementation, across all staff groups, as the respective service models are further developed. In context, it should be noted that the general timescales for the delivery of the South Wales Programme are estimated to be long term over the next 3-5 years.

A broad range of publications have been referenced during this work e.g., Royal College of Obstetricians and Gynaecologists: The Future Work in

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Obstetrics and Gynaecology June 2009; Wales Neonatal Network, “Draft Capacity Review 2013”; Centre for Workforce Intelligence Paediatrics Medical Specialty Workforce Factsheet; Wales Deanery Factsheets; The College of Emergency Medicine (CEM) “The Way Ahead (September 2011”

A specific piece of work was undertaken to validate that the workforce modelling output from the Data Analysts could meet the European Working Time and New Deal Regulations. This work produced a sample of approximately 40 rotas in order to feasibility test the data and the outcome was that, based on the modelling and assumptions being undertaken, the rotas would be compliant.

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Approved By: Clinical Reference Group: Emergency MedicineAuthor: Cathy BrooksDate: 15th April 2013

Workforce Modelling

Together for HealthSouth Wales Programme

Emergency Medicine

1.0 The stated vision for the Emergency Medicine Service is:

“To ensure patients have appropriate, timely access to reliable, safe, timely, high quality, sustainable emergency medical and emergency surgical services”

2.0 Current Baseline & Workforce Information

To date, the priority for the baseline workforce information has been to support the modelling and simulation for medical grades. The rationale being that this is where the most pressing workforce issues are. A nursing workforce baseline is also in development. It is acknowledged that the changes will impact on a much wider workforce, spanning allied health professionals, health science, WAST, support workers and ancillary staff to support the service model. Further work will be done on these professional grouping in the next phase of the South Wales Programme.

2.1 Non Medical Workforce InformationA number of non medical roles support the function of existing Emergency Medicine service model:

Advanced Ambulance Practitioners - WAST

Over recent years WAST has developed 12 Advanced Ambulance Practitioners covering 3 of the 4 Health Boards. These are highly specialised and fully autonomous practitioners in the pre-hospital and primary care setting following the former National Leadership and Innovation Agency for Health Care (NLIAH) Framework for Advanced Nursing, Midwifery and Allied Health Professional Practice in Wales.

The role of the Advanced Practitioner is to undertake an initial triage, clinical assessment of the patient and formulate a diagnosis. The Advanced Practitioner develops a treatment plan based on diagnosis and related factors, this plan may include the administration of a broad range of therapies. Where

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necessary the Advanced Practitioner will refer patients to an appropriate alternative level of care other than Emergency Medicine.

The Advanced Practitioner also acts as a senior clinical lead providing supervision and mentorship to developing pre-hospital care professionals.

Emergency Nurse Practitioners (ENP)

It is recognised that ENP training is 1st degree level module, with consolidation in clinical practice of 12 – 18 months. The role of the ENP has been shown to improve patient experience, contribute to service modernisation and can provide treatment that is equal to that of doctors (references available). Each LHB’s MIU / ED will have ENP Clinical guidelines, a competency framework, with agreed training requirements to meet the governance agenda.

Delivering Emergency Care Services (WAG, 2008) highlighted the importance of developing skilled and competent nurse practitioners to meet both the modernisation and workforce planning agenda across Wales.

Major Nurse Practitioner (ANP)

Majors NPs have not been widely introduced in Wales but are firmly embedded in some Emergency Departments in England. Majors NP in emergency care are working at advanced nursing practice level. They are experienced nurses with extended roles who can autonomously manage the patient’s treatment from admission to referral or discharge across all streams.

Nurses who can see, diagnose, treat and discharge or refer patients across the full range of A&E presentations e.g. Chest Pain, COPD, Asthma, Abdominal Pain are dual trained to see Adults and Children.

Majors Nurse Practitioners could not replace ‘middle grade’ or senior doctors in the current emergency care environment in Wales but there is a potential for Majors NPs to improve patient outcomes in Emergency Departments and support medical decision making.

2.2 Age Profile Medical Workforce

The graphs below show the age dispersion of the current EM medical workforce are as follows:

Consultant workforce

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The average age of consultants in this speciality is 40-44 years of age, with a fairly equal distribution of age ranges around this. Approximately 19% (age>55years) of the consultant workforce should they chose retire in the next five years based on an average age of retirement of 60 years.

Non Consultant Grade/Other Medicine

The average age of non consultant grade (Speciality doctor, SAS etc) staff is 35-39. However, the age distribution in this group of staff is not equally distributed around the average, identifying this group of staff as a more aging staff group. Approximately 23% could retire in the next five years should they chose. The graphs also demonstrate increased feminisation of this workforce.

The graph below gives the age profile for all 5 organisations.

0%

5%

10%

15%

20%

25%

30%

23-25 26 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60+

All 5 Organisations - Consultants Emergency Medicine by age band

FEMALE Consultant MALE Consultant

0%

5%

10%

15%

20%

25%

23-25 26 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60+

All 5 Organisations - Non Consultant Career Grade / Other Emergency Medicine by age band

FEMALE Non Consultant Career Grade / Other

MALE Non Consultant Career Grade / Other

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

23-25 26 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60+

All 5 Organisations - Doctors in Training Emergency Medicine by age band

FEMALE DOCTORS IN TRAINING

MALE DOCTORS IN TRAINING

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The average age of this group of trainee staff is 26-29. It is anticipated that this group of staff would have a low age profile. However, the graphs illustrate the increasing feminisation of the workforce.

3.0 Key Workforce Issues

There are a number of challenges facing the EM medical workforce including:

Difficulties in recruitment across the range of grades of doctors in Emergency Medicine.

A high number of staff vacancies have resulted in an increased workload of existing staff which has been reflected in poor results in relation to workload and supervision, in the GMC Trainee Survey of 2011. However, it should also be noted that the survey also reported the overall quality of higher training being delivered in Wales is very good (ranked 5th highest in the UK).

Insufficient numbers for current rotas. Difficulty recruiting higher trainees has resulted in gaps in middle-grade rotas (of the 23 higher training posts there are currently 15 unfilled posts on the programme)

In August 2012, the numbers of Acute Care Common Stem Emergency Medicine posts (core training scheme which feeds higher specialist training) were increased. It is hoped that this increase will improve recruitment numbers to specialist training from August 2013.

As of 1st March 2013, the number of higher training specialty training posts filled across Wales was 8 of the 23 available on the rotation.

4.0 Key Workforce Objectives

The objectives of workforce modelling are based on the following:

Rotas will be meet European Working Time Regulation Training and clinical supervision will meet Deanery/General Medical

Council requirements Improved recruitment and retention of high calibre, appropriately skilled

clinicians Improved staff wellbeing, job satisfaction and enrichment More flexible clinical workforce through the increased development of

advanced practitioner/ clinical support roles For Emergency Medicine to be an attractive and sustainable choice

and the working pattern of consultants to provide a workforce life balance that is competitive with other acute specialities.

A workforce that must be fit for purpose, sustainable and affordable.

5.0 High Level Analysis/Overview of modelling scenarios

Assumptions

The new service models must significantly improve compliance against staffing guidelines and standards. There is recognition of the College of Emergency Medicine Standards, and the modelling will endeavour to work

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towards these. However, the standards reflect traditional workforce models and this will need further consideration in light of new service models.

Standards

The College of Emergency Medicine (CEM) in The Way Ahead (September 2011) has identified some of the key service and workforce requirements.

ED’s to have 24-hour cover by experienced EM senior medical staff cover (ST4 level or above).

The CEM recommends 16 hours “shop floor” cover a day for all ED’s. A minimum of 16 hours coverage by ED consultants but 24/7 presence

of experienced ED doctors (ST4 or above) A minimum of 10 ED consultants are required to provide 16/24 hrs

coverage. This number increases as the number of attendance rises from 50,000 (10) to >100,000 which equates to 16 ED consultants

The ED workforce must be multi disciplinary, integrating doctors, nurses, therapists and other specialties

ED size by attendance per annum

Rec min no wte ED cons to achieve 16/7 shop floor leadership

<50,000 1050,000 – 80,000 10

80,000 – 100,000 12>100,000 16

Deanery requirements of circa 1:11 for trainee staff to cover feminisation of workforce and quality of training.

GMC and Deanery Standards will be factored into workforce plans. FP1/2 trainees cannot be resident in the hospital at night without resident middle grade cover from within the specialty.

In order to secure training accreditation, trainees should be concentrated on major ED sites. Should resources allow there is opportunity for middle grades to rotate out to local sites on an in hours planned basis.

The junior rota may include advanced nurse practitioners - not a general feature of EM model as yet.

There should be a minimum of 2 trainees on each rota to ensure appropriate peer support.

Assume junior doctors rotas are EWTD compliant.

Assumptions for Medical Modelling

No allowance has been factored in for non medical staff substituting on rotas – this will be further tested.

At the time of modelling it was assumed that there would be no improvement in the recruitment of middle grade training grade doctors and to reflect this, modelling has been undertaken using forecast predictions of only 8 middle grade staff being available from the 23 available posts.

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Assume trainees work 48 hours per week and 38 weeks after study and annual leave 7% sickness and maternity rate for training grades and SAS doctors

For consultants, have assumed that in a 10 session contract 5 of these will be for shop floor work. Non training middle grade (CF's and SAS) have assumed a 40 hr week with 4 hrs for training, 44 wks per year after holidays and study.

Some professional staff groups maybe required to rotate between the major acute site and local hospitals to maintain and enhance skills or work across more than one site on a sessional basis.

Assumptions for Nursing Minor Injury Units (MIU)

Where LHB's have satellite Minor Injury Units (MIU), ENP's are often rotated to facilitate cover at both ED’s and MIU’s. This is recommended by the CEM.

ENP’s’ job planning needs to include 9 sessions + 25% uplift to maintain mandatory training, CPD, sickness, AL etc

ENP’s are able to treat both adults and children, with paediatric attendances < 1 year being referred to a senior clinician

Nursing staff will have been assessed as competent within the Health Boards’ policy and they will recognise and work within the limits of their competence. The Nursing & Midwifery Council highlight competency required within The Code: a nurse must have the knowledge and skills for lawful, safe and effective practice when working without direct supervision (NMC 2009)

6.0 Outcome of Rota/EWTD Compliance

All rotas designed are theoretical and therefore have not taken into consideration work life balance of middle grade and junior doctors. This would normally be a priority consideration as it is seen as an incentive when recruiting medical staff.

Due to time restrictions, it has only been possible to undertake theoretical modelling for one 4 site and one 5 site scenario for both senior and junior medical grades.

All rotas are compliant for both New Deal and EWTD hours and rest requirements. New Deal regulations apply to doctors in training and the Health Board equivalent grades not SAS doctors.

Bandings on some rotas could possibly be reduced as the coverage provided was in excess of requirement. This would only be possible to assess when actual design takes place to ensure that the work patterns meet all requirements for training, service and compliance.

7.0 Training and Development Need

The Emergency Nurse Practitioner

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The current training programme for an ENP is either 1st degree level module, with consolidation in clinical practice of 12 – 18 months (37.5 hrs as a trainee ENP)

Staff completing an ENP training programme are often referred to as ‘trainee ENP’s and are Agenda for Change Band 6

The allocation of a Registered nurse to work within the Minor injury setting is essential for succession planning. The entry criteria for ENP training is a minimum 2 years post RN Degree training

Examples of skills required by ENP at MIU’s Adult Basic Life Support Immediate Life Support, including the use of AED Paediatric Basic Life Support Paediatric Minor Injuries Management of anaphylaxis Child Protection Protection of Vulnerable Adults (POVA) Administration of medication, within Patient Group Directives or

Nurse PrescribingSource (CEM – Way Ahead 2011)

Majors Emergency Nurse Practitioner (ANP)

The current ENP workforce and / or senior ED nurses could expand their scope of practice to extend to Majors ED’s and compliment the medical workforce, whilst developing their Majors NP competences. The current challenge to this is the clinical supervision support required from the emergency medicine Consultants, and financial constraints to enable staff release, supernumerary time and course costs.

It is acknowledged that for staff required to work differently and across the network, there will be development needs relating to new technology, equipment and local processes/systems.

8.0 New Ways of Working

As stated above, one of the key workforce objectives of the South Wales Programme is that greater flexibility is required to underpin optimum service and safe, high quality and sustainable care.

Delivering Emergency Care Services (WAG, 2008) highlighted the importance of developing skilled and competent nurse practitioners to meet both the modernisation and workforce planning agenda across Wales. The development of these roles should be supported and effective workforce planning undertaken to ensure effective career development.

Improved Multi disciplinary team working with Medical, nursing, therapy and diagnostics.

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Requirement to look at senior speciality doctor who works at senior decision making level.

9.0 Risks

There are a number of risks associated with the workforce modelling and approach to date that should be noted:

Current modelling is based only on theoretical modelling and this causes concern if the unsociable patterns of the rotas are not able to be designed with further consideration for an improved work life balance. Failure to do so may result in further recruitment difficulties in EM.

The ability to attract and recruit appropriate calibre medical staff at consultant and SAS level in Emergency Medicine to meet standards

That there remains a minimum of 8 middle grade trainee doctors across the network.

Ability to train and recruit to appropriate numbers and calibre of Emergency Nurse Practitioners

Consideration of changes within national terms and conditions for Consultants and Junior Doctors which may impact over the coming 1-2 years. (Pay and Incentive Schemes). Unknown impact.

If staff are required to relocate, without sufficient detail of the exact circumstances at this stage, it is difficult to determine whether this could have a cost implication.

High dependence on non consultant posts providing service

The gender balance for trainee doctors already in training and graduates entering means that this group of staff are now predominantly female – requirement to meet family friendly and flexible working.

Changes to pension arrangements may result in medics of the age 55 and above having access to the pension regulations and it is possible that these doctors will access their pension and will leave or will return on fixed term flexible arrangements.

That doctors approach retirement age will seek to come off on call commitments.

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Status: Approved Approved By : Clinical Reference Group: MaternityAuthor: Sharon VickeryDate: 15th April 2013

Workforce Modelling


Maternity Services

1.0 The stated vision for the Maternity Service is:

“To ensure that women and babies requiring Maternity care have access to safe, high quality and sustainable services recognizing their clinical acuity and personal choice”

2.0 Current Baseline/Workforce Information

To date the priority for the baseline workforce information has been to support the modelling and simulation for medical grades. It has been essential to concentrate on this staff group as there are currently acute pressures with the supply of medical staff to this specialty. A midwifery workforce baseline is also in development and some further information is provided later in this paper. It is acknowledged that the changes will impact on a much wider workforce in the longer term, possibly spanning therapies, health science, support workers and ancillary grades.

A Workforce Summary is attached as Appendix 1. This contains details of the medical staff numbers by grade across the 4 Health Boards and includes any midwifery roles that contribute to medical rotas. Numbers of qualified and unqualified midwives are also included in the Appendix.

The graphs below represent the percentage of the total medical workforce in this specialty by age and gender split. It should be noted it has not been possible to separate Obstetric and Gynaecology medical staff and so the graphs indicate the staff in both these specialities.

Data source: ESR Data Warehouse. Staff in post as at 30/9/2012, ABMU, AB, C&V, CT, Powys

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It can be seen that for consultants and non career grade doctors that there is an aging workforce. Also the feminisation of this specialty will increase in the future, as evidenced in particular, by the gender breakdown of the Doctors in Training.


The Royal College of Obstetricians and Gynaecologists (RCOG) has recommended a small reduction in training numbers for the specialty. This will make it increasingly difficult to sustain the provision of all services on all hospital sites with out-of hours service provided by trainees alone. Therefore, networking of care across Health Board boundaries is vital.

There has been a huge feminisation of the workforce in this specialty which will mean that the service will need to be more flexible in accommodating doctors in training and in Consultant roles. This is likely to have a knock on effect in terms of the supply of medical

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numbers to run sustainable rotas. Feminisation has lengthened the average training programme from 7 to ten years in this specialty with a run through training programme.

Obstetrics and Gynaecology is proving an increasingly difficult specialty to recruit to junior doctor posts outwith the run through training scheme. This leads to multiple rounds of recruitment and many rotas currently run with gaps that either remain unfilled or have to be supplemented by locums/specialty trainees working more than 1 in 8 rotas.

Information from the GMC survey data and the work of the Wales Deanery Quality Unit has demonstrated that gaps on the rota adversely affect the training experience for trainees. This in turn makes it harder to attract and recruit to the training scheme as potential candidates communicate quickly via social networking.

The Deanery has recognised the need to reduce the on call requirement to a 1 in 11. The Temple report states that currently most rotas run on a 1 in 8. Whilst this is compliant with the EWTD if the rota has either gaps within it or doctors go sick etc it no longer remains compliant and this affects the quality of training for junior doctors.

Units which have fewer than 2500 births are not believed to be able to offer the range of training that is required to ensure that trainees receive the necessary experience to become skilled consultants in the future.

In the UK there is an over production of CCST holders. The RCOG recommend a reduction in training numbers to balance this. This may lead to a reduction in the number of training posts in Wales.

Medical training has changed significantly with the introduction of competency-based assessment and valuable training can be offered outside ‘normal working hours’ when consultants are available to support the trainees.

There is a need to address the future development needs of non career grade doctors. Without this, there is a risk of a lack of career progression and poor job satisfaction.


The objectives of workforce modelling are based on the following:

The workforce must be fit for purpose, sustainable and affordable. Improve the quality of care for patients and quality of training for

trainees in both acute and elective care. We owe it to the public and the future workforce in Wales to be prepared to face the challenges that reconfiguration will inevitably pose.

Consolidate rotas to meet the Temple recommendations Ensure doctors are trained to deliver the service of the future – trainees

need to work within a system of service delivery that will allow them to attain the competence required to deliver services and be trained appropriately to achieve this aim.

Rotas will be designed to meet New Deal and European Working Time Regulations (EWTD).

Training and clinical supervision will meet Deanery/General Medical Council requirements

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Improved recruitment and retention of high calibre, appropriately skilled clinicians.

Maximise consultant presence on the labour ward in line with RCOG standards.

Improved staff wellbeing, job satisfaction and enrichment More flexible clinical workforce through the increased development of

advanced practitioner/ clinical support roles,

5.0 Outcome of Rota/EWTD Compliance

It has been possible to produce theoretical rotas for this specialty. Based on the modelling these rotas are both New Deal and EWTD compliant. The banding supplement is 1A.


Assumptions

The workforce modelling is based on the following assumptions and standards:

That the Deanery will not recognise units with fewer than 2500 births for training purposes.

The RCOG sets standards for labour ward cover. The aim will be in the longer term to plan to meet these standards and the service model will develop on an iterative basis. For units with between 2501 and 5000 births the longer term aim will be to have 96 hours of consultant labour ward cover per week. The short to medium term target will be 60 hours.

For units with more than 5000 births the longer term aim will be to have 168 hours of consultant labour ward cover per week. The short to medium target will be 98 hours. If births exceed 8000 this will necessitate a second trainee rota.

Deanery requirements of no less than a 1:11 rota for trainee staff to cover. This can be achieved with a mix of doctors with the equivalent skill level of ST1 -3 and may include midwifery practitioners.

Middle grade cover on rotas of no less than a 1:11 in order to achieve Deanery standards. This can may be achieved with a mix of doctors with the equivalent skill level of ST 4 and above to ensure appropriate skill and experience for the responsibility of providing out of hours medical cover.

The need to review multiple levels of staffing at handovers to ensure this is arranged optimally.

Explore opportunities for recruiting additional consultants where needed, targeting the over production of CCST holders, on a flexible job planning basis.

The need to adjust existing job plans to accommodate the new service model.

Uplift of 24 % for training & education for Midwifery staff/sickness Midwifery workforce requirement be calculated by using Birth Rate Plus

Data. The strategic ratio will be used which will look at the requirements for midwives in terms of direct clinical care. This may lead to differing data than that presented at Appendix 1. Further

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modelling may be necessary to understand the nuances of the impact of this tool on midwifery numbers.

7.0 Training and Development Needs

The need to improve the quality of training and change the way that training is delivered to junior doctors has been explained fully in this document. There will, however be a need to:-

Upskill the Specialty Doctor workforce. In the new model, the competence and flexibility of this group of doctors will be key.

There will be a need to develop and extend roles. These are likely to include increased numbers of Midwifery practitioners and Maternity Care Assistants. The lead in time for developing these roles will be approximately six months as both roles are currently developed via competency programmes in house.


In the new models there will be opportunities to develop and extend the following roles:-

Midwifery Practitioners Consultant Midwives Maternity Care Assistants Nursery Nurses Appoint junior consultants with flexible job plans Develop and extend the roles of Specialty Doctors. Staff working across Health Board boundaries and within newly defined

clinical networks.

9.0 Risks

Inability to recruit junior and middle grade doctors leading to the need to source locums. This would have an impact on the cost and the quality of service delivery.

That Wales would continue to be seen as an unattractive place for junior doctor training. This would not alleviate the current recruitment difficulties.

A range of contractual risks:-

- That Speciality Doctors will not want to change their working patterns to include out of hours work.

- That staff will not be prepared to work flexibly across Health Board boundaries within clinical networks.

- That staff will not be prepared to move with the services where this is required.

- Contractual constraints associated with current arrangements i.e. Consultant, Speciality Doctor, and Junior Doctor Contracts.

- Unknown effects of impending UK wide negotiations around a new consultant and junior doctor contract.

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- The theoretical rotas whilst compliant with New Deal and EWTD do not currently include an appropriate work life balance which could exacerbate recruitment difficulties.

Retention issues and turnover BMA & Royal College views about new ways of working. Lead in time to train Advanced Practitioners in non medical grades. Appropriate career pathways and support networks for Advanced

Practitioners e.g. Midwives Practitioners and the effect of the glass ceiling

Costs of investing in the workforce within the current financial climate.

10.0 References

Full Report from the Royal College of Obstetricians and Gynaecologists: The Future Workforce in Obstetrics and Gynaecology June 2009

Temple Report

Wales Deanery Reconfiguration of Obstetrics and Gynaecology Training: The Current programme, The Challenges and Proposed Future Modelling.

GMC trainee survey

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Status: Approved Approved By : Marie Davies/Clinical Reference Group MembersAuthor: Angela LloydDate: 03rd May 2013

Workforce Modelling


Paediatric Services

1.0 The stated vision for the Paediatric Service is:

“ To ensure that children and young people requiring consultant-led paediatric hospital services have access to safe, high quality and sustainable care”


To date the priority for the baseline workforce information has been to support the modelling and simulation for medical grades. It has been essential to concentrate on this staff group as there are currently acute pressures with the supply of medical staff across all the services within scope. A nursing workforce baseline is also in development. It is acknowledged that the changes will impact on a much wider workforce, spanning therapies, health science, support workers and ancillary staff.

A workforce summary is attached as Appendix 1. This contains details of the medical staff numbers by grade across the 4 Health Boards (not including Powys who do not provide acute paediatric care) and also numbers of Advanced Nurse Practitioners who also contribute to the medical rotas. The summary details separately the staff employed within the acute hospital, general paediatric service within the Health Boards.

Staff working in neonatology are linked to paediatrics and are included in the workforce summary where they are currently providing joint cover for level 2 high dependency neonatal and general acute paediatrics services. It should be noted that some of the medical staff also work in community paediatrics so these staff work mixed rotas in association with general paediatric units. For clarity, these staff numbers are therefore not purely related to the acute paediatric service.

Age Profile:

The graphs below indicate the broad age range of staff within paediatric services within the South Wales Health Boards. It is not possible to separate out neonatology medical staff and so the graphs include all staff within paediatric services and neonatology. As the staff numbers are small in some areas the data has been extrapolated in broad ranges so that individuals are anonymous and data protection is maintained.

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As would be expected, 75% of the Consultant workforce is aged between 40 and 55, and 91% of the Doctors in Training are under 40. However it is worth noting that 53% of the Career Grade doctors are between age 50 and 60.

It can also be seen that the feminisation of the Paediatric medical workforce will increase in the future, as evidenced in particular, by the gender breakdown of the doctors in training.

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Clearly defined staff numbers needed for each rota have been defined by the standards set by the Royal College of Paediatrics & Child Health (RCPCH)

The assumption is of a 1:11 rota across 4-5 sites that is EWTD compliant The Deanery requirements are a minimum of 4 trainees on 1 rota However recruitment of medical staff to junior and middle grade positions

is difficult and the number of posts filled varies at different times. The assumption is that as the tier 2 (i.e. middle grade ST 4 and above)

training posts reduce over time, they will be backfilled by doctors undertaking a ‘hybrid’ role who will support the middle grate rota in order to deliver the service

GPVTS are also being used to compensate the gap in the junior rota to cover the service

There needs to be further development of Advanced Nurse Practitioners (ANPs) in order to supplement the rotas

In order to clarify the nature and degree of clinical interdependencies, a framework has been developed by the CRG based on a Department of Health report in collaboration with the relevant Royal Colleges on Commissioning Safe and Specialised Paediatric Services

Information given to the CRG by Helen Fardy, Reconfiguration Lead for Paediatrics, highlighted the following key challenges for specialist paediatrics:

- The number of less than full time (LTFT) trainees was increasing and was currently at its highest level: this led to a decrease in the numbers of Whole time equivalent doctors that were recruited and retained

- There is a lower than average exam pass rate in Wales compared to the rest of the UK Deaneries

- The programme produced only 4 or 5 CCTs per year although the capacity was for 16

- There were 38 general acute paediatric tier 2 posts for the whole of South Wales. If workforce planning predictions were correct there was a predicted need to decrease the number of posts to 26 by 2020

- The Welsh Deanery has also advised as part of their proposed Reconfiguration of the Paediatric Training programme, proposals to reduce the number of neonatal posts at each level from 2014; e.g. ST1-3 for the whole of Wales reducing from 22 in 2013 to 11 in 2020.

- The impacts of compliance with EWTD- The ‘Feminisation’ of paediatric workforce and consequential impact

of “less than full time” doctors as evidence exists that female doctors are more likely to work less than full time hours than their male counterparts

- Generation X and Generation Y doctors generally work fewer hours than previous generations; and perception changes to work-life balance expectation impacting on choices trainees make (Fraher, E.2010)

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- Aging Nursing Workforce, loss of senior expertise in the next few years


The main objectives of the workforce for Paediatric services are based on the following:

The workforce requirements to deliver the hospital services in the model are set out by the Royal College of Paediatrics and Child Health (RCPCH). The detailed staff requirements to meet the standards are included within the Service Model, however in summary this means:

4.1 Regional Acute Hospital Services General Paediatric Inpatient Services - Level 3

Consultant level service – Royal College guidance is:

7.7 consultants for 2,500 admissions9.3 consultants for 5,000 admissions10.9 consultants for over 5,000 admissions

The CRG confirmed that the critical requirement was to ensure sufficient consultant numbers to provide a consultant presence at each acute hospital site at times of peak activity 7 days a week.

Numbers would need to increase if the same consultant body provides community paediatric services or if they provide cover on the middle grade tier

Middle grade would require a 1:11 rota to be EWTD compliant Trainees should be concentrated on inpatient sites The rota can include a mix of training grade and speciality doctors ( or

consultants) but a minimum of 4 trainees on the rota is required to ensure adequate Peer support

Junior grade cover - again a minimum of 11 WTE with 4 trainees is required as per the middle grades.

The junior rota could include trainees, advanced nurse practitioners, experienced foundation doctors, GPVT trainees with the equivalent skill level of ST1-3

4.2 Local Hospital Paediatric Services (Non- inpatient) – Level 2

The workforce requirements for this level of care will be dependent on the type of service offered and hours of availability

Daily rapid access ‘hot’ clinics are provided to enable specialist paediatric opinion for patients referred by GPs in hours

Clinics available 7 days or Mon to Friday depending on workforce availability

4.3 Out of Hospital Care – Level 1

Primary care services Community paediatric services

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Health visiting School nursing

4.4 Key Workforce Assumptions:

The workforce will be deployable across the units as required Rotas will be designed to meet European Working Time Regulations and

will comprise 1:11 for trainee staff to cover quality of training At least one medical handover in every 24 hours is led by a paediatric

consultant ( or equivalent) Every child or young person who attends a paediatric department with an

acute medical problem is seen by a paediatrician on the middle grade or consultant rota within 4 hours of arrival

Children’s social care , police and health teams have access to a paediatrician of level 3 safeguarding competencies available to provide immediate advice

The workforce must be fit for purpose, sustainable and affordable i.e:- Will enable recruitment and retention of high calibre, appropriately

skilled clinicians- Training and clinical supervision will meet the Deanery/General

Medical Council requirements - Improved staff wellbeing, job satisfaction and enrichment- More flexible clinical workforce through the increased development of

advanced practitioner/ clinical support roles


The scenarios used for modelling have been based on service standards and forecast activity in order to identify the workforce capacity on each site and have been approved by the CRG

The outcome of the scenario modelling has evidenced:

There is a shrinking middle grade rota The future model is likely to depend on consultants being present in the

hospital for a greater number of hours per week The assumption in order to meet the RCPCH standards is that consultants

would work across 7 days of the week Senior staff would need to operate on a network basis in order to provide

the appropriate level of cover There is a need to include in the workforce plans going forward the

appropriate level of cover for Level 2 Neonates Services at 1 or 2 sites as no separate senior neonatal rota, i.e. no level 3 ITC

6.0 Outcome of EWTD Compliance

It has been possible to produce a sample of theoretical rotas for this specialty. Based on the modelling undertaken these rotas are both New Deal and EWTD compliant.


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The need to improve the quality of training and clinical supervision is critical to ensure that trainees in appropriate numbers and calibre can be attracted to train and work in Wales.

Training and clinical supervision will meet Deanery/General Medical Council requirements, e.g. all hospitals providing training for medical trainees will need to receive 4,400 acute paediatric presentations a year to ensure doctors in training receive appropriate experience in managing acute paediatric patients, i.e. each trainee sees around 400 acute presentations per annum

Nurses

There are currently only four Advanced Nurse Practitioners (ANPs) employed by the Health Boards in Paediatrics in order to cover the medical rotas. They have been in post since 2006 and cover the rota seven nights a week. They completed a three year Masters Degree Course in Clinical Practice at the University of Glamorgan and also an Independent Prescribing Course.

Years one and two of the course cover :Clinical Conditions in PracticeClinical Skills for ParactionersTherapeutics and Diagnostics

Year three covers:Independent Prescribing(There is a dedicated route for paediatric practioners)


As stated above, one of the key workforce objectives of the South Wales Programme is that the workforce will be deployable across the units as required. This greater flexibility is required to underpin optimum service and safe, high quality and sustainable care.

The development of more Advanced Nurse Practitioners ANPs is key to increase flexibility of the paediatric workforce. Advanced nursing has been strategically advocated as a cost effective redesign tool/resource that can overcome workforce shortages and problems facing the NHS ( DH 2007).

However numbers of qualified ANPs are currently small. More research needs to be completed on the numbers of nurses who are currently undergoing training and on numbers of nurses who would be interested in undergoing the Msc in Advanced Clinical Practice at the University of Glamorgan.

Initial research has suggested that the number of qualified ANPs is small and that there are few registered nurses who are interested in training to become ANPs because they would prefer to remain working holistically. More work will be needed to encourage numbers to train to become ANPs if this is to be a realistic solution.

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9.0 Workforce Risks

Inability to recruit junior doctors leading to the need to source locums. This would have an impact on the cost and the quality of service delivery.

Reducing training posts combined with the inability to appoint sufficient permanent or temporary middle-grade level speciality doctors may result in existing paediatric rotas becoming unsustainable before the South Wales Programme consultation on reconfiguration of acute, inpatient paediatric services is completed

Wales continues to be seen as an unattractive place for junior doctor training. This would not alleviate the current recruitment difficulties.

Long term attractiveness of consultants being resident evenings and weekends posts to provide tier 2 cover to compensate for reducing numbers of middle grades , i.e. the need to build career progression.

Given the age profile, the likelihood of existing SAS doctors wishing to reduce their out of hours commitments in covering the rota

A range of contractual risks:-- That staff will not be prepared to work flexibly across Health Board

boundaries within clinical networks.- That staff will not be prepared to move with the services where this is

required.- Contractual constraints associated with current arrangements i.e.

Consultant, SAS, and Junior Doctor Contracts.- Unknown effects of impending UK wide negotiations around a new

consultant and junior doctor contract. Retention issues and turnover BMA & Royal College view on new ways of working and the development

of ‘hybrid’ medical roles. Lead in time to train Advanced Practitioners in non medical grades. Appropriate career pathways and support networks for Advanced

Practitioners Cost of investing in the workforce within current financial climate

References:

Centre for Workforce Intelligence Paediatrics Medical Specialty Workforce Factsheet

Workforce Summary NHS Wales 2011, Rhydian Owen

Facing the Future: A Review of Paediatric Services RCPCH2011

“Cutting Time? How Hours Spent in Clinical Care vary for General Surgeons

in different generations” (Fraher, E. 2010)

Commissioning Safe and Sustainable Specialised Paediatric Services: A

Framework of Critical Inter-Dependencies, DOH.

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5.4.2013, Produced by the Workforce Work-stream in Association with Planning Leads

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Status: Approved Approved By : Lead Planner Sian Harrop-Griffiths and Karen

Stapleton Author: Julie CassleyDate: 15 May 2013

Workforce Modelling


Neonatology

1.0 The stated vision for the Neonatology Service is:

“To ensure that babies requiring Neonatal services have access to safe, high quality and sustainable care”


To date the priority for the baseline workforce information has been to support the modelling and simulation for medical grades. It has been essential to concentrate on this staff group as there are currently acute pressures with the supply of medical staff across all the specialist services within scope. A nursing workforce baseline is also in development. It is acknowledged that the changes will impact on a much wider workforce, possibly spanning therapies, health science, support workers and ancillary staff.

A Workforce Summary is attached as Appendix 1. This contains details of the medical staff numbers by grade across the 4 Health Boards (not including Powys who do not provide neonatal care) and also numbers of Advanced Neonatal Nurse Practitioners who also contribute to the medical rotas. The summary separately details the staff employed within the current Neonatal Intensive Care Units (NICU) and for Hospitals who operate Special Care Units (SCU) and Local Neonatal Units (LNU) staff work mixed rotas in association with general paediatric units. For clarity, these staff numbers are therefore not purely related to Neonatal service. Where relevant, staffing numbers also include staff who contribute to the South Wales Neonatal Transport rota.

Age Profile:

The graphs below indicate the broad age range of staff within Paediatric Services within the South Wales Health Boards. It is not possible to separate out Neonatology medical staff and so the graphs include all staff within Paediatric services and Neonatology. As the staff numbers are small in some areas the data has been extrapolated in broad ranges so that individuals are anonymous and data protection is maintained.

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As would be expected, 75% of the Consultant workforce is aged between 40 and 55, and 91% of the Doctors in Training are under 40. However it is worth noting that 53% of the Career Grade doctors are between age 50 and 60.

It can also be seen that the feminisation of the Paediatric medical workforce will increase in the future, as evidenced in particular, by the gender breakdown of the Doctors in Training.

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According to the Inquiry into Neonatal Care in Wales (National Assembly for Wales: Health, Wellbeing and Local Government Committee (2010)): “there was considerable evidence that problems in recruiting, retaining and training medical staff required to deliver the service remain a major challenge”.

According to a recent review undertaken by the All Wales Neonatal Network, “Draft Capacity Review 2013”:

o The activity and therefore pressure on the South Wales Network has been substantially higher in 2012 than in 2011, which has an impact on workforce requirements and capacity.

o Recruitment of medical staff to junior and middle grade positions is difficult and the number of posts filled varies at different times.

o Staff numbers needed for each tier of the rota have been clearly defined for the first time in the 2010 BAPM Standards for Hospitals Providing Neonatal Care.

o The level of compliance at Tier 2 is universally poor and a cause for major concern. The number established on rotas in July 2012 was inadequate and together with the high number of posts unfilled due to failed recruitment makes matters worse.

o As at November 2012 there was still a shortfall in nursing establishments to meet All Wales Neonatal standards despite the fact that establishments have increased since July 2011.

The Deanery has advised as part of their proposed Reconfiguration of the Paediatric Training programme, proposals to reduce the number of neonatal posts at each level from 2014; e.g., ST1-3 reducing from 22 in 2013 to 11 in 2020.

Impacts of EWTD

Feminisation of Paediatric workforce and consequential impact of maternity leave and “less than full time” doctors; as evidence exists that female doctors are more likely to work less than full time hours than their male counterparts

Generation X and Generation Y doctors generally work fewer hours than previous generations; and perception changes to work-life balance expectation impacting on choices trainees make (Fraher, E.2010)

Aging nursing workforce, loss of senior expertise in next few years


The main objectives of the workforce for Neonatal services are based on the following:

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The workforce requirements to deliver the hospital services in the model are as set out by the British Association of Perinatal Medicine (BAPM) 2010 and the All Wales Neonatal Standards – 2nd Edition and included within the agreed clinical model. These staffing levels cover medical, advanced nurse practitioner, nursing and therapy requirements by type of neonatal unit ie Neonatal Intensive Care Unit (NICU), Local Neonatal Unit (LNU) and Special Care (SCU).

The detailed staff requirements to meet the standards are included within the Service Model, however, in summary, this means:

Neonatal Intensive Care Units (NICU)o A nursing ratio of 1:1 is provided for babies requiring Neonatal

Intensive care.o At Tier 3 all consultants should be identified neonatal specialists.

There is a neonatal consultant 24/7 on-call rota, separate to general paediatric cover at Tier 3 with a minimum of 7 staff.

o At Tier 2 there is a separate neonatal rota 24/7 with a minimum of 8 staff, made up from the following:

o paediatric ST4-8, speciality doctors, other non training grade doctors, ANNPs ( with appropriate additional skills and training), resident neonatal consultants.

○ At Tier 1 there is a separate neonatal rota with a minimum of 8 staff, made up from the following:

o paediatrics ST1-3, ENNPs or ANNPs, speciality doctors o However combined rotas which cover paediatrics and neonates require

a minimum of 11 participants on a rota.

Local Neonatal Units (LNU)o A nursing ratio of 1:2 is provided for babies requiring High Dependency

care. o At Tier 3 the LNU unit has a minimum of 7 consultants on the on call

rota. A minimum of one Consultant has a designated lead interest in neonatology.

o The LNU has 24-hour 7 day availability of a paediatric/neonatal consultant who can evidence expertise in neonatal care based on training, experience, CPD and on going appraisal.

o At Tier 2 the LNU may have a shared rota with paediatrics, with a minimum of 8 staff, Staffing will be made up from the following:

o paediatric ST3-8,specialty doctors, other non training grade doctors, ANNPs, resident paediatric/neonatal consultants.

o At Tier 1 the LNU has a separate rota with a minimum of 8 staff who do not cover general paediatrics in addition, made up from the following:

o paediatric ST1-2, GPST1 or FY2, Speciality doctors, ENNPS or ANNPs, non training grade doctors

o Where local neonatal units regularly provide intensive care, and/or have a very busy paediatric service, and/or have neonatal and paediatric services that are physically a significant distance apart, then the above staffing levels should be enhanced.

Special Care Units (SCU)

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o A nursing ratio of 1:4 is provided for babies requiring Special Care.

o At Tier 3 there are a minimum of 7 consultants on the on call rota with a minimum of one consultant with a designated lead interest in neonatology.

o At Tier 2 there is a shared rota with paediatrics with a minimum of 8 staff.

o At Tier 1 the rotas should be EWTD compliant with a minimum of 8 staff who may cover paediatrics in addition, made up from the following:

o paediatric ST1-3, GPST1 or FY2, speciality doctors, ENNPS or ANNPs, Non training grade doctors

A workforce that is flexible enough to meet the needs of the service, as required

Rotas will be designed to meet European Working Time Regulations

The workforce must be fit for purpose, sustainable and affordable

Medical Training and clinical supervision will meet Deanery/General Medical Council requirements

Nurse training and education will meet competencies outlined by BAPM in ‘ Matching knowledge and skills for Qualified in Speciality (QIS) Neonatal Nurses (2012)and RCN ‘Competency, education and careers in neonatal nursing, (2011)

Improved recruitment and retention of high calibre, appropriately skilled clinical staff

Improved staff wellbeing, job satisfaction and enrichment More flexible clinical workforce through the increased development of

advanced practitioner roles Improved succession planning for nursing


The outcome of the scenario modelling has evidenced a requirement to continue to provide Neonatal Intensive Care in three Units. High dependency care will be provided in an additional 1-2 sites – they will be co-located with the consultant led obstetric services and the number(s) and location(s) will be dependent upon the outcome of these discussions and option appraisal. The allocation of cots between the sites will need to be determined once the obstetric option is confirmed. The modelling has identified staffing required to support this as:

An additional 4.5 consultant posts to support the reduction in numbers of the middle grade rotas. Because of the nature in which paediatrics and neonates cross cover it is assumed these could also cover Paediatric.

A fourth rota would be required to run the additional 4th/5th site between 08:00 – 24:00. A combined rota with paediatrics would be required between 24:00 – 08:00.

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Depending upon the cot allocation, a fifth rota may be required. This will be determined at later stage.

It should be noted that, whilst the simulation modelling has identified these additional posts as consultant posts we would need to undertake a coordinated workforce plan across the Health Boards within the South Wales Programme to determine how best to meet this need. As identified in section 8 below, innovative workforce solutions will include further development of the Advanced Neonatal Nurse Practitioner to support the change within the multidisciplinary team. These options will be fully explored during implementation to deliver the best overall workforce solution for the future.

6.0 Outcome of EWTD Compliance

As there is no proposed change to the composition of the 3 Neonatal Intensive Care Units, it is not deemed necessary to undertake any rota analysis. Any necessary change to rota will be undertaken in the normal way and will be tested for EWTD compliance.


The need to improve the quality of training and change the way training is delivered to junior doctors has been explained and remains a similar need as in other specialist services.

The last 5 years have seen the introduction of a national “Neonatal Nurse Competency Framework”. This framework provides standards which, when integrated with defined education pathways, can be utilised for practice development across the range of neonatal nursing levels. (BAPM)

Specialised neonatal nursing requires knowledge and skills not already developed by registered nurses and midwives new to the specialty.

BAPM has overseen work to produce a Neonatal Nurse Competency Framework, for the teaching and assessment of skills for neonatal nurses. This was published in April 2012 (Matching knowledge and skills for Qualified In Speciality (QIS) Neonatal nurses: A core syllabus for clinical competency. This means that neonatal education throughout the United Kingdom should be standardised for the first time

All new nurses and midwives should undertake an induction programme which relates specifically to the fundamental care of the neonate and their family. (BAPM) and all nurses involved in direct clinical care, will have undertaken a newborn life support course as recommended by the Resuscitation Council UK. (BAPM)

The Wales Neonatal Network has reviewed and researched the role and education provision for the Advanced Neonatal Nurse Practitioners (ANNPs). Currently the formal training is through a Masters level course with the most advanced course being held in Southampton. Typical training period is 12

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months, followed by 3-6 months supernumerary clinical practice to consolidate skills.


As stated above, one of the key workforce objectives of the South Wales Programme is that the workforce should be flexible enough to meet the needs of the service, as required. This greater flexibility is required to underpin optimum service and safe, high quality and sustainable care.

A recent Wales Neonatal Network review of the ANNP and ENNP states that innovative workforce solutions must be sought to address staffing of neonatal units to ensure a sustainable service for the future. Across the UK ANNPs have a well established role in neonatal units and are shown to provide safe and effective neonatal care, capable of replacing junior doctors on either tier 1 or tier 2 rotas, depending upon their level of experience.

A recent survey undertaken by the Wales Neonatal Network found that 54% of current nursing workforce want to remain working holistically and do not want to progress to ANNP level. Holding a course in Wales would improve uptake for those interested in progression to ANNP level and further works need to be undertaken to understand the overall training numbers.

Enhanced Neonatal Nurse Practitioners (ENNPs) have enhanced nursing skills and potential to take on additional roles, which include some elements of the traditional medical role. The development of these roles should be supported and workforce planning undertaken to ensure effective career development. In Wales there are no ENNPs working on medical rotas and the general consensus is that nurses do not want to develop in this way. Current training modules are more focussed on developing the skills for nurses to provide more holistic care to the neonate as part of a nursing role.

Opportunity to expand the role of non registered workforce to support registered nurses in the special care environment are being developed across the UK and the Neonatal network will be considering options to take this forward in Wales.

9.0 Workforce Risk

Inability to recruit junior doctors leading to the need to source locums. This would have an impact on the cost and the quality of service delivery.

That Wales would continue to be seen as an unattractive place for junior doctor training. This would not alleviate the current recruitment difficulties.

A range of contractual risks:-- That staff will not be prepared to work flexibly across Health

Board boundaries within clinical networks.- That staff will not be prepared to move with the services where

this is required.- Contractual constraints associated with current arrangements

i.e. Consultant, SAS, and Junior Doctor Contracts.

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- Unknown effects of impending UK wide negotiations around a new consultant and junior doctor contract.

Retention issues and turnover BMA & Royal College view on new ways of working. Lead in time to train Advanced Practitioners in non medical grades and

insufficient numbers of nurses willing to take on this role. Appropriate career pathways and support networks for Advanced

Practitioner Cost of investing in workforce within current financial climate

References: Inquiry into Neonatal Care in Wales (National Assembly for Wales: Health, Wellbeing & Local Government Committee (2010))

All Wales Neonatal Network, “Draft Capacity Review 2013”:

Centre for Workforce Intelligence Paediatrics Medical Specialty Workforce Factsheet

Workforce Summary NHS Wales 2011, Rhydian Owen

Facing the Future: A Review of Paediatric Services RCPCH2011

“Cutting Time? How Hours Spent in Clinical Care vary for General Surgeons

in different generations” (Fraher, E. 2010)

15.4.2013, Produced by the Workforce Work-stream in Association with Planning Leads & CRG

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Appendix 1TOGETHER FOR HEALTH - SOUTH WALES PROGRAMME

WORKFORCE WORKSTREAMTERMS OF REFERENCE

Updated January 2013

1. PurposeThe purpose of the Work-stream is to provide professional workforce/human resource advice into the engagement and consultation phases of the South Wales Programme.

2. Objectives/Work PlanThe objectives of the Work-stream will include the following:

Produce baseline Workforce Information from all Health Boards into composite report to feed into the Planning Work-stream modelling process

Compile Consultant Age Profile for each specialty Gather data on Advanced Nurse Practitioner roles for each specialty Collate and provide relevant information on high level workforce key issues

which impact on the areas of service delivery e.g., changes to medical education and training

3. MembershipSouth Wales Programme Team Workforce Lead/Chair of Work-stream

Julie Cassley

ABMU Health Board Geraint Evans/Sharon Vickery Obstetrics LeadCwm Taf Health Board Angela Lloyd Paediatrics LeadCardiff and Vale University Health Board

Julie Cassley Neonatal Lead

AB Health Board Julie Chappelle/Cathy Brooks A&E LeadWAST Hilary Caffrey WAST Lead

Workforce leads are required to liaise with appropriate Planning and Finance lead for the Specialty and feed any discussions into the regular Workforce Work-stream meetings.

Workforce leads are required to keep Workforce Information Schedules updated for their Specialty area and feed these into Programme Workforce Lead/Chair (JC) centrally as they are updated.

4. Reporting Arrangements The Programme Workforce Lead will report into the South Wales Programme Team. Each of the local Work-Stream Leads will report into their respective Workforce Directors.

5. Meeting ArrangementsThe Work-Stream will meet on a fortnightly basis. Meetings will take place on a Monday at 11.00 am wherever possible. Every other meeting will be held by telephone conference to minimise travel. Local Workforce Leads are asked to submit agenda items prior to the meeting to the Chair.

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