NHS workforce: which manifesto gets our vote?

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One year ago, we concluded – together with colleagues at the Health Foundation and Nuffield Trust – that workforce challenges had now overtaken funding as the greatest threat facing the NHS in England. Not surprisingly, the health workforce – although rather less so the social care workforce, which is also in crisis – features prominently in all three main parties’ manifestos. What are their differences and what are the implications?

The workforce crisis is complex, but for the purpose of this manifesto comparison we can keep it simple by focusing on two high-level themes: increasing the supply of staff to fill vacancies and improving retention so that staff actively want to stay working in the NHS.

Closing the Gap, our joint report with the Health Foundation and Nuffield Trust, advised that the solution needs a blend of actions, none of which can solve everything on their own. It’s getting the right mix that matters. That includes: the NHS’s ‘offer’ to attract and retain staff; training a pipeline of new staff (including cost of living grants and clinical placements); ethical international recruitment until we have sufficient ‘home grown’ staff; and transforming how different professions work together in teams.

What do the manifestos say?

All parties focus on workforce strategies, particularly including increasing the number of GPs and primary care teams, and nurses. The Liberal Democrats place the greatest emphasis on using these staff more effectively through multi-professional teamworking, while Labour will increase school nurses and health visitors as well as upping GP training places and recruiting 24,000 extra nurses. The Conservative manifesto has eye-catching, high-profile numbers of extra nurses, GPs and primary care professionals. Their headline of 50,000 more nurses raised some eyebrows as it includes the retention of 18,500 nurses already employed in the NHS – although improving retention does need to be part of any strategy for increasing nurse numbers. The Liberal Democrats point out with some justification that the Conservatives have previous form for announcing impressive but unrealistic targets, promising 5,000 extra GPs by 2020; although this time the Conservatives’ numbers may also benefit from – presumably – having sight of modelling for the imminent NHS People Plan.

All three manifestos say that some of these extra staff will come from ethical international recruitment. The Liberal Democrats’ includes streamlining arrangements for registering overseas professionals, while the Conservatives would introduce a new fast-track, low-cost NHS visa. Labour’s has least detail, simply promising to remove unspecified ‘obstacles’ to ethical international recruitment. The Conservatives’ proposals need to be seen in the context of their wider Brexit, free-movement and immigration policies (including higher charges for non-British nationals, even those employed in the NHS, to access NHS services). These could create scepticism about whether their international recruitment targets can be achieved.

All three parties also offer financial support for student nurses. The Conservatives provide most detail, offering maintenance grants ranging from £5,000 per year up to £8,000 for shortage specialties or regions, plus help with child care. The Liberal Democrats are the least generous, only offering bursaries targeted at shortage specialties. (Like the Conservatives’ range of grant levels, there is a logic in this: not all branches of nursing have shortages in training places.) Labour offers least detail but, depending on the size of the bursaries, are probably the most generous. The party offers a training bursary not only for all nurses, but also for midwives and allied health professionals – essentially returning to the previous situation, before bursaries were cut in 2017.

On staff retention, this time it’s the Conservatives who say least. They promise to improve staff morale through more funding for professional development and ‘more supportive hospital management’. Labour focuses on real-terms pay rises each year and cementing NHS terms and conditions in law, including safe staffing levels (which could be difficult, as evidence-based staffing ratios are not available for many services). The party undertakes to provide mental health support to NHS staff, to ensure a flexible working environment free from bullying, harassment and violence, and to support continuing professional development. Like Labour, the Liberal Democrats also focus on flexible working, professional development and a supportive workplace; they also add clearer career pathways and greater racial diversity in senior posts to their list. All parties undertake to sort out the current pension rules which deter some senior doctors from taking additional shifts and currently have only a ‘stop-gap’ solution.

What to make of the differences?

Overall, the differences are not huge: all parties recognise the workforce crisis and, with varying levels of detail (sometimes very little), they address a range of actions similar to our recommendations in Closing the gap. None gives sufficient detail to know if the mix of actions they propose will actually solve the problem.

If a would-be MP door-steps me, my killer questions would probably be:

  • Sometimes their figures are suspiciously headline-friendly round numbers, and in other cases figures are lacking. How do they know their proposals will be feasible and will actually cover the shortfall in staff?
  • All three main parties’ manifestos highlight social care as well as the NHS, but none really explores the interdependency of their workforces. How will policies such as international recruitment also benefit social care? How will we ensure the NHS doesn’t improve its staffing by attracting staff away from social care, just shifting the crisis of vacancies?

Meanwhile, new figures have come out showing no improvement yet in the level of vacancies and a new Royal College of Nursing survey painted a relentlessly depressing picture of nurses’ morale. The most important things we need from a new government – of any political colour – are practical, wide-ranging actions on workforce… and much more urgency.

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