Workforce: future trends

Demographic changes will result in more older people requiring care. The informal workforce, who provide a significant amount of unpaid care, may not be able to meet the demand – leaving a significant 'care gap'.

Informal care is unpaid care provided by family members to elderly or disabled relatives.

'Recent estimates indicate that in 2011 there were 5.3 million carers in England (10 per cent higher than in 2001)¹.'

The majority of these people provide care for 10 hours or less a week, with 1.9 million providing intense informal care for more than 20 hours per week. Carers UK estimate that by 2037, the number of carers across the UK needed could rise by 40 per cent (2.6 million people) taking the total number of people providing informal care to 9 million¹.

The numbers of disabled older people receiving informal care are also projected to increase by 60 per cent over the next 20 years, from 1.9 million in 2010 to 3 million in 2030².

1. Carers UK (2012). Policy Briefing. Facts about carers

2. Wittenberg R, Hu B, Hancock R, Morciano M, Comas-Herrera A, Malley J, King D (2011). Report. Projections of Demand for and Costs of Social Care for Older People in England, 2010 to 2030, under Current and Alternative Funding Systems Personal Social Services Research Unit

The NHS in England has always relied heavily on international recruitment of nursing and medical staff.

In the 1970s, 26 per cent of doctors in the United Kingdom were trained in another country; by 2005 this had increased to 33 per cent¹. In recent years this has levelled off with the growth in the numbers trained in the United Kingdom (see medical workforce trends). In 2012, 37 per cent of doctors on the General Medical Council’s (GMC) list of registered (though not necessarily practising) practitioners trained outside the UK; most originate from outside the European Union (EU), though the proportion coming from the EU has increased slightly in the past 10 years.

Number of doctors registered on the GMC list of registered medical practitioners as of 31 December each year, 2002-12

Source: General Medical Council data requested through FOI

The EU directive on the mutual recognition of professional qualifications is being revised to make it easier for health care professionals to work across Europe, which could also have consequences for both inward and outward migration^2,3. In the future, UK-trained graduates may also have to compete with EU-trained doctors for foundation places⁴.

In the 1990s, a shortage of nurses prompted a formal policy to recruit large numbers of nurses from outside the United Kingdom. Between 1997/8 and 2005/6, the inflow of nurses rose considerably; at its height more than 16,000 international nurses were added to the United Kingdom nursing register, over half of all new registrants. Since 2004/5 these numbers have declined as more United Kingdom trained professionals have entered the workforce and the need for international staff has eased⁵.

An increasing number of UK-trained doctors, nurses and allied health professionals choose to move abroad, particularly to Australia, New Zealand and other developed English-speaking countries. The numbers of doctors seeking to register in the United States is rising, and temporary migration to Australia is also rising¹. The number of UK-trained nurses leaving the country has risen steadily since 1994, and, despite a sharp fall in 2009/10, overall more nurses are now leaving than entering the country⁵.

Inflow and outflow of nurses from the United Kingdom, 1993-2011

Source: Royal College of Nursing (2011). A Decisive Decade: The UK nursing labour market review 2011

These professionals are moving to fill gaps in the workforce in English-speaking countries across the world.  In the United States, the Association of American Medical Colleges predicts that, at current levels of demand and supply, there could be a shortage of  up to 130,600 doctors by 2025 and 808,000 nurses by the end of the decade^6,7. In Canada, the demand for nurses is expected to outstrip supply by 100,000 nurses⁸; and projections indicate a shortfall of more than 28,000 health care workers by 2021 in New Zealand⁹.

1. Organisation for Economic Co-operation and Development (OECD) (2010). Policy Brief. International Migration of Health Workforce

2. Cable V (2012). Article. 'The tide is turning against EU bureaucracy' The Telegraph, 7 May 2012

3. NHS European Office (2012). Briefing. Mobility of health professionals across Europe

4. Smith R (2012). Article. 'Up to 1,000 new doctors could face unemployment' The Telegraph, 19 May 2012

5. Royal College of Nursing (2011). Report. A Decisive Decade: The UK nursing labour market review 2011

6. Association of American Medical Colleges Center for Workforce Studies (2008). Report. The Complexities of Physician Supply and Demand: Projections Through 2025

7. Center on Education and the Workforce (2012). Report. Healthcare. Georgetown Public Policy Institute, June 2012

8. Aiken LH, Cheung R (2008). Briefing paper. Nurse Workforce Challenges in the United States: Implications for Policy. OECD Health Working Papers, No.35

9. NZIER (2004). Discussion document. Ageing New Zealand and Health and Disability Services: Demand Projections and Workforce Implication, 2001-2021. Wellington: Ministry of Health

The medical workforce has grown substantially in the past 15 years, with an average annual growth rate of 3.4 per cent between 2000 and 2009¹.

Several workforce trends require careful planning over the next 20 to 30 years: rising numbers of women and part-time workers in some specialities: concerns that the supply of fully trained hospital doctors could exceed demand: and challenges in recruiting and retaining GPs.

Between 1960 and 2010 medical school places in the United Kingdom rose by more than 70 per cent from 2,000 to 7,889, with a subsequent increase in the number of doctors graduating from medical schools to 5,684 in 2008/9. Overall, the medical workforce has increased substantially; the number of hospital doctors alone increased by 30 per cent to 143,000 in the past decade^2,3. 

Medical (UK) intakes by gender

This graph shows the level of investment in medical training, which rose sharply from 2000 and has levelled off in recent years. The number of female medical students has grown considerably over this time period, and they now make up more than half of all medical students. This trend is expected to contribute to the rise in female doctors, as they qualify and move into postgraduate training and employment.

Source: Centre for Workforce Intelligence (2012). Report. Shape of the Medical Workforce: Starting the debate on the future consultant workforce

Medical workforce growth

Source: Health and Social Care Information Centre (2012). Data. NHS Staff 2001-11 (medical and dental)

Current trends suggest there could be 2,800 excess hospital speciality trainees at consultant level by 2020, adding £2.2 billion to pay costs if they were all appointed as consultants  at current rates⁴. At the same time, more doctors are choosing to take non-consultant grade posts, which could mitigate this risk if it continues.

The changing nature of primary care and demographic pressures indicate that more GPs will be required by 2035 to meet a doubling of the number of GP consultations⁵. These challenges could be overcome if, for example, the trend towards part-time and flexible posts continues and proposals granting trainees greater freedom to switch specialities redirects more hospital trainees towards general practice⁶.

The supply of GPs is under growing strain as the workforce ages.

'In 2010, more than a fifth of GPs were aged 55 and over; those leaving the profession rose by 7.8 per cent and surveys indicate a further 10,000 GPs plan to retire in the next five years⁵.'

At the same time, the proportion of medical trainees choosing to enter GP specialty training has fallen in the past two years and salaried GPs (who tend to work part-time) increased by a factor of 10 between 2000 and 2010  to 8,700⁵. 

In 2011, 43 per cent of all doctors in England were female, exceeding 100,000 for the first time with numbers increasing at a faster rate than male doctors. Women are expected to outnumber men at some point between 2017 and 2022, accelerating demand for flexible, part-time and salaried posts raising the prospect that more doctors may be required to provide care in future years^7,8. 

The number and composition of the consultant workforce is likely to have a substantial impact on the way health care is delivered over the next 20 years.

The NHS is heavily reliant on trainee doctors, but concerns around quality of care and calls to move towards the provision of consultant cover seven days a week have prompted a review of this model of care⁹. Growing numbers of doctors-in-training are expected to increase demand for a finite number of positions at consultant level, while changes to pension arrangements may prompt doctors to work beyond retirement age, further reducing the number of available consultant posts.

As part of this debate, the Centre for Workforce Intelligence have developed a set of ‘what if?’ scenarios modelling the effect of various changes to the current system by 2020.

The King's Fund's adaptation of data from Centre for Workforce Intelligence.

1. Organisation for Economic Co-operation and Development (2011). Web Book. Health at a Glance

2. House of Commons (2011). Record. Hansard Written Answers for 25 Jan 2011

3. The Information Centre for health and social care (2012). Data. NHS Staff 2001-2011 (medical and dental)

4. Centre for Workforce Intelligence (2012). Report. Shape of the medical workforce: Starting the debate on the future consultant workforce

5. Deloitte Centre for Health Solutions (2012). Report. Primary Care: Today and tomorrow - improving general practice by working differently

6. House of Commons Health Committee (2012). Report. Education, training and workforce planning. First Report of Session

7. General Medical Council (2012). Report. The State of Medical Education and Practice in the UK Report

8. Adams S (2012). Article. 'Part-time women doctors are a "risk" to the NHS' The Telegraph, 18 September

9. Academy of Medical Royal Colleges (2012). Report. Benefits of Consultant-delivered Care

The changing nature of disease and health care delivery provides an opportunity to restructure health care roles to meet future needs.

For example, for the increasing number of people with long-term or complex multiple conditions new specialist nurses could be needed to support community workers and health co-ordinators to integrate care across conditions and between health and social care¹. Prevention could also play a more prominent role, with lifestyle trainers and dieticians working with people in the community. With appropriate training and assessments of their appropriateness, new technologies and remote monitoring could be used.

The advent of physician assistants and advanced practitioner roles in physiotherapy, nursing and surgery are enabling staff to diagnose patients and prescribe treatments; plans are under way to extend these prescribing powers to podiatrists and physiotherapists². 

'Within hospitals, evidence suggests that hospital generalists, such as geriatricians, can provide high-quality care with shorter lengths of stay³.'

In general practice, nurse practitioners can deal with common conditions while delivering good quality of care^4,5, and pharmacists can help patients to manage medicine use⁶. Shifting routine care to other professionals could enable GPs to focus on co-ordinating care for people with chronic or complex conditions.

Professional groups may view such attempts as devaluing their role or seeking to make cost savings rather than improve patient care.

Regulatory barriers limit how health care can be delivered and prevent the reassignment of routine medical tasks from clinicians to nurses and other health care staff.

Restructuring the delivery of health and social care could enable the system to be more patient-centred and could also prove more cost-effective; however, the scale of any efficiency savings should not be overstated.

1. CSC Leading Edge Forum (2010). Report. The Future of Healthcare: It’s Health, Then Care

2. Department of Health (2012). Press release. Prescribing Powers Proposed for Physiotherapists and Podiatrists

3. White HL, Glazier RH (2011). Journal article. Do hospitalist physicians improve the quality of inpatient care delivery? A systematic review of process, efficiency and outcome measures. BioMedCentral Medicine

4. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B (2005). Research paper. Substitution of doctors by nurses in primary care. Cochrane Database of Systematic Reviews.

5. Buchan J, Calman L (2005). Report. Skill-Mix and Policy Change in the Health Workforce: Nurses in advanced roles Organisation for Economic Co-operation and Development (OECD)

6. Deloitte Centre for Health Solutions (2012). Report. Primary Care: Today and Tomorrow - improving general practice by working differently

Between 2000 and 2010 the nursing and midwifery workforce in the NHS in England grew by 26 per cent, an average of 2 per cent per year, the result of a concerted effort to reverse nursing shortages in the previous decade by increasing training places, improving staff retention and active international recruitment¹.

However, the number of nurses on the Nursing and Midwifery Council’s UK register of all practising nurses, began declining in 2008 and continued to fall in the following three years, while the headcount of qualified nursing staff working in the NHS in England only began to reduce after reaching a high of 375,505 in 2009.

Number of nurses and midwives on the UK effective register, 2000-2010

Source: Royal College of Nursing (2011). A Decisive Decade: The UK nursing labour market review 2011

A number of factors could drive a mismatch between supply and demand for the non-medical and nursing workforce.

Migration patterns

Migration patterns have changed, the number of UK-trained nurses leaving to work in other countries now outnumbers those trained outside the United Kingdom seeking to work in the United Kingdom².

Age of the workforce

Perhaps most importantly, the current workforce is ageing: 12.4 per cent of the nursing workforce is aged 55 and over (2011 figures) and the figures are even higher for some roles, for example, 24 per cent for health visitors. In midwifery, 48.6 per cent of the workforce will be eligible for retirement in the next 10 years².

Training places

Between 2010/11 and 2012/13, the number of nursing training places fell 12.7 per cent from 20,092 to 17,546 (3). From 2013 nursing education will become all-graduate entry, but it is uncertain what impact this will have. 

The number of training places in the allied health professions and pharmacy workforce is also being reduced in response to funding constraints – this may have an impact on the supply of staff in the next 20 years.

Demand for nursing and allied health professionals is expected to outstrip supply unless the number of training places is increased or recruitment outside the United Kingdom intensifies.

The Royal College of Nursing has have developed a set of ‘what if?’ scenarios to model the effect of various changes on the NHS workforce in England up to 2021/22⁴.

'What if?' scenarios

The table below suggests that at current rates the nursing workforce will fall 12 per cent by 2021/22 (scenario A). At one extreme (scenario C) improved retention of existing staff and current rates of entry would increase staff numbers by 9.5 per cent.  At the other end of the spectrum (scenario H), higher retirement, more nurses leaving to work abroad, and reduced numbers of entrants would result in 28 per cent reduction in the numbers of nurses, 99,000 fewer nurses than in 2010/11.

Source: Royal College of Nursing (2011). Report. A Decisive Decade – Mapping the future NHS workforce

1. NHS Information Centre (2012). Data. NHS Staff 2001-2011 (medical and dental): Table 1a: NHS hospital and community health service (HCHS) and general practice workforce as at 30 September each specified year

2. Royal College of Nursing (2011). Report. A Decisive Decade: The UK nursing labour market review 2011

3. Lintern S (2012). Article. 'Disaster' warning follows 12% drop in nurse training places Nursing Times, 18 September

4. Royal College of Nursing (2011). Report. A Decisive Decade – Mapping the future NHS workforce

The size and skill-mix of the social care workforce has adjusted as demand for social care has increased and the requirements of users change. In the future, the number and type of roles within the sector may undergo a major transformation as users seek more personalised care.

The numbers working in adult social care in England have grown significantly in recent years from an estimated 1.39 million in 2006/7 to 1.51 million in 2007/8¹ and approximately 1.6 million in 2010².

This is largely due to growing demand for adult social care, chiefly those employing carers through direct payments (cash payments given by local authorities enabling users to buy in care as needed), greater use of personal budgets and domiciliary care (care at home). The number of people employing carers through direct payments for adult and children’s services has risen rapidly from 7,613 in 2002 to 154,340 in 2010 and about 75,000 now hold personal budgets².

Three-quarters of adult social care jobs involve providing direct care and support, and in 2010 70 per cent were based in the independent sector. Between 2006/7 and 2009, 220,000 jobs were created in the independent sector while 20,000 jobs were lost from local authorities¹. 

Unlike the health care workforce, the overall age structure within the social care workforce is not ageing as there are growing numbers of staff in both the youngest and oldest age groups³. The workforce is predominantly female (83 per cent in 2011). In England 19 per cent of employees are non-British. However, in London and south-east England this figure rises to between 26 and 51 per cent².

Demand for social care is growing as the numbers of older people and of those with long-term conditions, learning disabilities and mental health conditions increase. 

'Estimates predict at least 1.7 million more adults will require social care over the next 15 years, which could require an increase in the social care workforce to between 2.1 million and 3.1 million by 2025^1,2.'

At present, care providers rely heavily on migrant workers (particularly in London and the South-East), and almost three-quarters of these workers come from outside Europe. Increasing demand combined with tighter restrictions on non-EU migration could lead to staff shortages⁴.

It is likely that social care roles will need to evolve in future years as high-quality care becomes more important to users and their requirements change. Direct payments, personalised care and growing integration of health and social care require new ways of working and a more flexible workforce; however, the low status and pay of social care workers are risk factors in achieving the changes needed. Unlike social workers, care workers are not regulated, but government plans to introduce a code of conduct and minimum training standards may dispel calls for a formal regulatory regime.

The workforce projections below were based on projections of demand made in 2008 by the Personal Social Services Research Unit (PSSRU) for the Department of Health. These in turn were based on government projections of the future population of England.

There are several scenarios.

• Base Case scenario – assumes that patterns of service will continue at the pattern in 2008/9 while demand for services increases as anticipated

• Maximising Choice scenario – all who wish to have  publicly funded social care provided in a highly personalised way in their own homes could do so

• Contain and Community scenario – envisages that most care and support would be provided by a largely unpaid workforce of family carers and community volunteers. The paid workforce would focus on managing these resources and on frontline professionalised support for the whole family

• Restricted Resources scenario – assumes that future resources for adult social care will be very limited. It envisages fewer but more stringent assessments and reviews, greater roles for community advice and guidance services and higher client-staff ratios in publicly funded residential care

Adult social care workforce jobs projections

Source: Skills for Care (2011). Report. The Size and Structure of the Adult Social Care Sector and Workforce in England 2011

1. Centre for Workforce Intelligence (2011). Report. Workforce risks and opportunities: Adult social care

2. Centre for Workforce Intelligence (2011). Report. The Adult Social Care Workforce in England: Key facts

3. Centre for Workforce Intelligence (2011). Report. Workforce Risks and Opportunities: Nursing and midwifery

4. Association of American Medical Colleges Center for Workforce Studies (2008). Report. The Complexities of Physician Supply and Demand: Projections through 2025

Several key drivers of change are expected to affect the wider labour market in the coming decades: technological advances, increasing globalisation, demographic and societal change and moves towards a low-carbon, environmentally sustainable economy. These could have a fundamental impact on the health and social care workforce of the future leading to:

• increasing use of social networks, remote working  and virtual teams

• greater demand for highly educated workers able to solve complex problems (interactional jobs)

• more part-time/temporary jobs, with organisations bringing in specialists for short-term projects

• increasing migration for work and availability of low-cost staff throughout the world 

• people working for longer as final salary pensions end and the boundaries between employment and retirement blur

• continued youth unemployment.

Employment patterns and attitudes across the labour force as a whole have changed in recent decades. The proportion of women in the workforce has risen, while the proportion of men and younger people in work has fallen. Increasing numbers of people now work part-time, and we expect this will shift further towards flexible, part-time and home working.

'The percentage of the population in work has changed little over the past 40 years, fluctuating between 74 and 78 per cent¹.'

Employment rates (people aged 16-64) by gender

Source: Office for National Statistics (2011). Report. Social Trends 41 Labour Market

In contrast, the composition of the workforce has altered considerably. Between 1971 and 2011, the employment rate for women rose 13 per cent, while the employment rate for men fell by 16 per cent and more people work part-time, as indicated by the overall hours worked per person, which has reduced¹. In terms of age, 25 per cent fewer 16-17 years olds are in work compared to 20 years ago, while the proportion of 50 to 64-year-olds working has increased by 8.7 per cent^1,2.

Total and average weekly hours worked in the UK

Source: Office for National Statistics (2011). Report. Social Trends 41 Labour Market

Generations X and Y (those born in the 1980s and 1990s respectively) seem to have a different approach to work. Research carried out by Ipsos MORI indicates they are more likely to value further education and training, as shown by the sharp increase in students obtaining an undergraduate degree, opportunities to network, and are happy to work for a number of organisations, in order to progress³.

These trends are likely to continue in the longer term as men and women seek a different work-life balance through part-time or flexible jobs; with greater use of technology and the ability to work remotely blurring the boundaries between office and home^4,5.

Proportion of people entering higher education

The proportion of young people entering higher education has risen dramatically in the past 20 years.

A concerted political effort to widen participation has contributed to a step change in the numbers entering higher education in England, particularly since the mid-1990s. The number of students obtaining a first degree rose sharply from 77,163 in 1990 to 275,345 in 2004 as former polytechnics were brought into the university sector⁶.

There has also been a reduction in inequality – one in five young people from disadvantaged backgrounds went on to higher education in 2009 compared to one in eight in the mid-1990s⁷. The proportion of women obtaining first degrees has more than doubled over the past 50 years, from 25 per cent in 1960 to 57 per cent in 2010/11^6,8.

Number of students obtaining an undergraduate degree in the United Kingdom (1920-2004)

Source: House of Commons Library (2007). Briefing Paper. Education: Historical statistics (1920-2004)

The graph below shows a 10 per cent increase in educational attainment among employed workers in Organisation for Economic Co-operation and Development (OECD) countries between 1995 and 2010. This is set to continue as demand for highly skilled, specialised workers increases⁹. Universities are likely to respond by reshaping programmes to meet employers’ needs more closely¹⁰.

Educational attainment of employed workers in OECD countries

Source: McKinsey Global Institute (March 2012). Report summary. Help wanted: The future of work in advanced economies

Applications to higher education

In the next 10 to 20 years, applications to higher education are likely to remain level or fall slightly in response to restrictions in funded places, higher tuition fees and an expected 11 per cent decrease in the number of 18 year olds over the next decade. However, as indicated earlier, younger people seem to place a high value on education and training and may not be deterred by the prospects of increased debt.

These trends could have a significant impact on the quality and quantity of the future workforce if it results in fewer young people, particularly women, choosing to enter higher education. Maternal attainment is strongly associated with educational achievement within families, female participation in the labour market and wider economic growth¹¹.

1. Office for National Statistics (2011). Report. Social Trends 41 Labour Market

2. Office for National Statistics (2009). Report. Social Trends 39 Labour Market

3. Ipsos MORI (2007). Factsheet. Generation Y research: employee relationship management

4. Office for National Statistics (2005). Article. Home-based working using communication technologies

5. European Labour Force Survey (2011). Labour force survey. Around 8.5 million part-time workers in the EU27 wished to work more hours

6. House of Commons Library (2007). Briefing Paper. Education: Historical statistics (1920-2004)

7. Higher Education Funding Council for England (2010). Report. Trends in young participation in higher education: core results for England

8. Higher Education Statistics Agency (2012). Statistical Bulletin. Student enrolments on HE courses by level of study, subject are and mode of study 2006/07 to 2012/11

9. PricewaterhouseCoopers (2007). Report. Managing Tomorrow’s People: The future of work to 2020

10. Henley Business School. Website. BA Accounting and Business

11. Jackson LW (2009). Discussion paper. Educate the Women and You Change the World: Investing in the education of women is the best investment in a country’s growth and development. The Forum on Public Policy Summer 2009