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Train, retain, reform: does the NHS Long Term Plan provide a coherent map for the future?

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It has been a long time coming, but now the NHS Long Term Workforce Plan is with us, does it measure up? Well, if it manages to do the things it says it will do (more on this below), then yes. This could be the point at which the NHS starts to overcome the repeated workforce crises that have periodically plagued it over the past 75 years.

We’ll be providing more of a guide to the plan shortly. But for those who haven’t managed to read all 134 pages (excluding references) or get their heads round the many tables and descriptions of the modelling, the plan sets out commitments under the headings of `Train’, ‘Retain’ and ‘Reform’. It includes plans for future growth in the numbers trained, how the service hopes to improve retention, and how the workforce of the future will be different (and trained differently) to that of today. It also ticks the box that other workforce strategies and plans (most recently the NHS People Plan) have failed to do, which is set out (lots) of forecasts of future supply and demand for staff and the way in which these were derived. I should add that these forecasts also show just how unsustainable a path the NHS was on – if you think it's bad in 2023, then it will be much, much worse by 2036 if no action is taken. The `action’ the document sets out encompasses just about everyone working in health including those in government.

So, does the ‘Train’ element aim to wean the health service in England off its dependence on international recruitment? Does it end the reliance on temporary (bank) staff? It does not. If its assumptions hold true, it would greatly reduce the inflow of new international staff but it certainly wouldn’t end it. Equally, while it aims to reduce the use of agency/bank staff, it does not claim to remove it, and indeed, some use of bank staff is probably both inevitable and desirable.

'The plan also looks to reduce the number of staff leaving the service (the ‘Retain’ element), but only to levels experienced in the recent past which, given that the `Train’ and `Reform’ sections have more new to say, may be just as well.'

The plan also looks to reduce the number of staff leaving the service (the ‘Retain’ element), but only to levels experienced in the recent past which, given that the `Train’ and `Reform’ sections have more new to say, may be just as well. So, despite the radicalism of some of the measures included, the plan has avoided the temptation to claim that the current crisis can be miraculously turned round. At the broadest level the plan also looks consistent with the stated objective of shifting the balance of care towards primary and community services: workforce growth is expected to be fastest in mental health, followed by community, then primary care and, finally, the acute sector (though even here it is not trivial). This represents a major turnaround compared to recent history.

What might stand in the way of this plan becoming reality? Taken together it amounts to an enormous work programme and a work programme that includes some tricky components, not least developing and growing new workforce roles in the health care system that will mean work for policy-makers, the professions and their leaders, and regulators.

Changing the culture of the NHS as set out in the `Retain’ section has been an aspiration for a while and will remain hard. The plan is also coming at a time of enormous and prolonged operational stress in the NHS and a major change programme for NHS England and its new merged partner Health Education England. In addition, the plan has been published at a time of industrial action, that also needs resolution. Particularly for the `Retain’ element, much of the work falls to integrated care boards, which are new and still finding their feet. There will need to be resolute focus from NHS England, ICB and other system not to let some of these longer-term agendas fall behind.

'There are also elements of optimism in the plan, perhaps most of all the assumption that productivity can rise to 1.5–2 per cent a year.'

There are also elements of optimism in the plan, perhaps most of all the assumption that productivity can rise to 1.5–2 per cent a year. This is definitely not where the NHS is at the moment and the plan itself repeatedly describes this goal as ambitious. Having said that – as one might expect from a document published by NHS England – it makes clear that this can only be achieved if significant capital investment (and digital investment) is made available. Though not a plan for social care, it also makes clear that it assumes social care will at least get no worse, or words to that effect. If these critical areas of the plan don’t hold true then the NHS in England will be left relying more on international recruits and on temporary staff than the plan aims for.

It will also need money and much of that will need to come from governments of the future. However, I do not see that as a failing of the report – it is inevitable in something called a long-term plan that it is going to cross multiple parliaments.

How, with all these moving parts, can a plan set out the path for the next 15 years? Things are bound to change. The plan sets out an answer to this challenge too: it will be updated every two years. If its assumptions don’t prove accurate, then instead of drifting on regardless, there is a correction mechanism built in. Of course, this relies on future governments actually allowing this to happen so its success can only be judged over time but if they do, then it is this that holds the possibility of avoiding the boom and bust (mainly bust) that has characterised the history of the NHS workforce. Now that really would be a historic change.