Workforce implementation plan: Five key issues to look out for

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Back in November 2018, The King’s Fund came together with the Nuffield Trust and the Health Foundation to set out the current state of the NHS workforce and five tests for the (at that time) forthcoming NHS long-term plan. In the event, the long-term plan did not so much ‘fail’ these tests as decide to not take the exam: the answer on workforce was instead pushed back to an interim workforce implementation plan, now overdue, and a final plan towards the end of 2019 after the Spending Review.

There has been a lot of water under the bridge since November: the long-term plan itself, a new GP contract packed full of workforce implications, and in March, a full joint report from us in the think tanks to name but three. With Dido Harding, the Chair of NHS Improvement who is leading the workforce plan, having made clear national bodies do understand just how important this workforce plan is, the latest signs – aka ‘leaks’ to the national press – suggest that the first instalment (the interim plan) is about to come out. What should we expect from it and where might the gaps be? I’m going to pick out five things here.

The first two relate directly back to our November tests and to our report in March, and confront the immediate crisis in the workforce. Firstly, as we recommended, it looks like the plan will endorse a new drive on recruiting nurses from abroad – 5,000 a year according to a leak (which, to be clear, should be ethically recruited). This is not where anyone hoped to end up, but for the next few years there is simply no way the gaps in the nursing workforce can be filled without it. Even with it, we cannot remove all the current and forecast shortages. This does mean that the NHS trusts must continue every effort to boost recruitment and retention but not at the expense of social care, practice nurses or indeed, nurses working in the voluntary sector.

Secondly, while we need to maintain every effort to raise the number of GPs in England – not least by keeping the ones we have – the GP contract recognised the reality that this will not be enough and signalled 20,000 extra staff in primary care, pulling on professions like pharmacy and physiotherapy where the national picture looks more positive. This is not about backfilling GPs: these other professions are key players in a team-based approach to primary care that makes the best use of everyone’s clinical skills (whether GP, pharmacist, physiotherapist or other) and provides high quality care to patients. Both step changes in international recruitment and a new approach to team working in primary care won’t happen by themselves and the interim plan needs to fill out both of these commitments with more detail on how they will be achieved.

Thirdly, all the signs are there that the interim plan will say the right things on a more inclusive, compassionate approach to leadership and culture in the NHS. Overly hierarchical, often looking to apportion blame and insufficiently inclusive, everyone agrees that the historic approach to culture and leadership needs to change. While we will applaud the plan if it sets out to tackle this long-standing set of problems, this does need to come with a big caveat: we have heard promises of change before, and some of the unhelpful behaviours have come from the regulators themselves. So while it is important to again reiterate the changes that need to be made, this time this needs to come with clearer actions and commitments, that have some deadlines and that can be measured (how much and by when, by whom).

Where do we fear the gaps may be? Part of the reason for having an interim and a final workforce plan is that the education and training budget is not part of the additional £20.5 billion promised for the NHS. We have to wait until the Spending Review later this year (Brexit permitting) before we will know what the government is planning on training. This could easily push the final workforce plan into 2020. While it is true that some elements of training (for more doctors, for example) is already beyond the lifetime of the 10 years covered by the long-term plan, many critical elements such as continuing professional development (CPD) and retraining for existing staff are not. Having a year’s gap between the long-term plan and the final workforce plan designed to implement it might be acceptable if the NHS was awash with staff. But it is not: so delaying decisions on what in some cases are relatively small budgets by NHS standards (such as CPD) in the hope the Chancellor may fork out more money may be a poor trade off.

Lastly, NHS England and NHS Improvement have already stated that they see integrated care systems as local leaders and co-ordinators on workforce. Similarly, primary care networks are intended to carry a lot of the weight on workforce delivery in general practice. Yet neither integrated care systems or primary care networks are actual ‘organisations’ with clear responsibilities, powers, budgets, staff (you are probably getting the point here). National bodies need to set out a clear set of responsibilities on the workforce that stretch from national oversight down to local delivery and ensure that local systems (and national ones, come to that) are quickly equipped with the tools and capabilities they need. Otherwise the good intentions – whether on nurse recruitment, multi-disciplinary teams in general practice or turning over a new leaf on culture and leadership – will remain just that: good intentions. It perhaps goes without saying that the workforce crisis in health and care is simply too deep and too pressing for any more failed attempts at reform.



Comment date
03 June 2019

Dear Judy, I'm afraid the practice exit interviews is very poor. Yes, these are taking place; they simply have to because organisation policy says so. And no, upper management does not take them seriously and no further learnings take place. Utter complacency at the HR levels too.
I worked for a third sector organisation with staff rotation higher than 50%, with exit interviews being a standard be practice but these would be brushed under the carpet cuz most commonly identified areas for reasons to leave were not something that organisation was willing to address including bullying culture. As a result days and years would go by with new people coming and going, middle management suffering the most from stress, fatigue, burnout and low morale.


Comment date
13 May 2019

Yet again this all makes very sad reading in one respect as we have heard similar for so long now with little change other than another review to look at the review of a previous review.
Overall there is little doubt of individuals good intentions but overall there are still too many managers that cannot manage - and the sad fact seems that the system allows them to remain in place or be promoted out of harms way. There seems to be no 'stick' for others watching.

Shakil khan

Primary care
Comment date
12 May 2019

Can I ask you All and the author that where’s the nurses stand?
Wouldn’t be better if they have mentioned and recognised nurses as Advanced Practitioner (ANP) which they currently performing their job effectively along with GP in a best and safe way.

Josephine Mullin

Director of Policy and Strategy,
College of Optometrists
Comment date
10 May 2019

We agree that primary care will be made more accessible by using the skills of professionals such as pharmacists and physiotherapists as part of a team based approach to primary care. It is not widely recognised that optometrists can also play a valuable part in the primary care team and, as a consquence, are often overlooked. Examples of what optometrists can do include managing minor eye conditions and monitoring stable glaucoma, and some optometrists have independent prescribing rights. By using their skills, referrals to the hospital eye service and post-hospital care outpatient appointments can be significantly reduced.

Judy Scott

Comment date
10 May 2019

Can we get some information on the results of exit interviews with the various different professions to see what messages they are giving about why people are leaving their professions other than just reaching retirement age - I assume every trust and Social Care organisation is required to do such interviews and building a local and national picture based on actual interviews would help work out what the contributory reasons to leaving actually are, as opposed to what we think they might be.

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