There is broad consensus that a well-designed equitable placement system for nursing and allied health professionals (AHPs) can support positive change in the quality of education and training for the future nursing workforce. No system can perfectly suit all purposes across a system as complex as the NHS. This notwithstanding, a well-designed system of complementary mechanisms has a role to play in supporting improvements in the quality, value, effectiveness and efficiency of placements.
In designing any system, it is difficult to know the scale of change required without a clear understanding and agreement of the strategic aims and objectives. There are multiple factors to consider, and these are briefly discussed in this article.
Purpose
First and foremost, the placement system needs to redefine its primary purpose. Whether this is equitably allocating resources, improving pathways, driving efficiency, improving effectiveness or increasing placement capacity, the purpose must be clearly defined and understood by all parties. It needs to be a fair, equitable and accountable system that emphasises the need to match capacity and resources with opportunities for learners, across a multiprofessional healthcare economy.
The fragmented nature of placement capacity has led to an increase in local negotiations and contractual arrangements. There has been limited partnership between higher education institution (HEI) providers owing to competition/business drivers. Historically, there has been the accrual of placements based on territorial, personal and historic arrangements, and professional relationships. However, these service arrangements restrict national system growth. Within HEIs there are internal pressures, and medical and health faculties have been viewed as financial engines. Any arrangement that prioritises local financial arrangements at the expense of the body corporate is not appropriate. The current capacity issues across nursing and AHPs are critical.
Consistency of approach across the system, accompanied by realistic expectations and appropriate incentives, will help all parties work towards the agreed primary objective. To utilise all available learning opportunities (on a fair share basis) will optimally prepare learners for their future professional roles.
The placement management system need not be identical across all regional or disciplinary settings—a mix of approaches is likely to be more effective to meet some priorities. The different approaches must all support the same purpose, with complementary incentives and controls.
The level of complexity required in the nursing system will vary, dependent on the primary purposes. Some objectives may be met with a simpler system, while others may be better met with a more detailed one. Where complexity is unavoidable, it must still support the key purpose. Regional placement data should be easy to understand and accessible to all agreed agents. Placement data would be a required input.
With the focus on increasing capacity, the primary objective will change from simple management and allocation to regional capacity building and capacity utilisation to increase placements. Within the regions and nursing specialties there is greater and lesser demand, which varies cyclically. The regional data system will complement internal systems. This data product needs to be a multiprofessional collection that builds on the Student Data Collection (SDC) system. This will assist capacity forecasting in the short and long term.
By introducing this to the already established data collections, it ensures that partners are able to plan and financially prioritise the education required to meet the needs of the future workforce. It can work simultaneously through:
Emergent issues
Tariffs
Key actors in the NHS have argued that payment mechanisms should work well beyond organisational boundaries. There are aspects of the tariff system that work well. It is hard to identify the best aspects of the current placement financial arrangements without a clear strategic priority of what the system should achieve in the medium and long term. A complete overhaul of the system may not be required—focused adjustments to some areas may be sufficient and in the best interests of provider stability. The issues that have emerged are:
It could be argued that using the tariff as a lever to increase capacity is the way forward. However, trying to solely use the payment system to meet this objective will inevitably lead to an evermore overly complex system that is ultimately unable to deliver. There will always be conflict between different objectives and, without a clear priority, decisions become more difficult, if not impossible. Tariffs are only one part of the whole system. A tariff is a lever to increasing placement capacity but is not the only factor that needs to be considered. Tariffs can support future design, including granularity (the level of detail needed to build increased staffing capacity) and incentives. However, the benefits of the approaches and technologies are not fully realised, owing to regulatory and infrastructural constraints, and lack of evidence-based guidance identifying which approaches and technologies are most effective in achieving a variety of outcomes.
Technology enhanced placements (TEPs)
HEIs and the integrated learning co-ordinators at those institutions are responsible for designing these programmes. This has resulted in a variety of approaches and technologies being applied. Regulators and professional bodies need to develop an evidence-based guidance framework to help inform development, delivery and investment in blended learning programmes by:
Despite the immediate benefits to be derived from implementing TEPs, there are several issues related to finance and quality. Tariff payments do not fully follow activity, if TEPs form a recognised virtual part of a placement, which counts towards learning hours, then the funding should follow. In relation to quality, there has been no evaluation as to how meaningful these approaches are. There have been evidence reviews (Council of Deans of Health, 2013) on the effectiveness of innovative technologies for clinical skills development and blended learning approaches; however, the long-term benefits are unclear.
A national system
In future, the placement system needs to match capacity and resources, with opportunities for learners across a multiprofessional healthcare economy provided on a fair, accountable and equitable basis and on a regional basis.
This need not be identical across all regional or disciplinary settings—a mix of approaches is likely to be more effective to meet some priorities. The different approaches must all support the same purpose, with complementary incentives and controls. Regional data sharing should be delivered by regional partnership bodies. The partners would be the relevant HEI and these bodies would be chaired by Health Education England. Regional placement data should be easy to understand and accessible to all agreed agents. Placement data would be a required input, HEIs will be paid only for system registered placements.
If this can be achieved, all parties can benefit and a system that is, in essence, parochial can become a truly national system built to grow and benefit all.