Does the NHS have too few staff or too many?

‘Collocations’ are combinations of words that go together so often that they start to sound natural. For the past ten years, the words ‘NHS’ ‘staffing’ and ‘crisis’ have fitted that definition. Because, to put it simply, it was broadly accepted that the NHS just didn’t have enough staff.

That narrative was supported by the numbers. The NHS would routinely publish data showing that more than 100,000 NHS posts were vacant. Only about a third of surveyed NHS staff thought there were enough people at their organisation for them to do their job properly (NHS staff survey). And international data showed the UK was close to the bottom of league tables when it came to how many doctors and nurses we had per person.

The focus on chronic staffing shortages was so high that policy professionals would pore over the recommendations of the Migration Advisory Committee to see which NHS jobs made it onto the ‘shortage occupation list’. We would try to understand the impact of Brexit and changes to language testing rules on international recruitment from the EU, and the impact of removing bursaries for nursing students on domestic recruitment.

As staffing shortages became a defining problem for the NHS, politics and policy began to respond. Boris Johnson’s government was elected on a manifesto to recruit 50,000 more nurses and there would be commitments to recruit 6,000 more GPs.

The apogee of national action in response to the NHS staffing crisis was the publication of the first long-term NHS workforce plan in a generation. It came at no small political cost – a significant commitment device like this, which tied the government’s hands, was only politically possible because it was a personal priority for Jeremy Hunt when he accepted the job of Chancellor during an economic crisis. It also came at no small financial cost, because staffing is the single largest area of spending for the NHS.

This workforce plan would see the permanent NHS workforce rise from 1.4 million in 2021/22 to 2.2–2.3 million in 2036/37, with the modelling underpinning the plan independently verified and the plan itself reviewed every two years. It’s hard to convey just what a big deal this plan felt at the time – and how other sectors, such as adult social care, would have been hoping for their own plan to tackle their own staffing crises.

But then, at some point, the narrative started to change.

First, the ‘crisis’ collocating with the word ‘NHS’ became a productivity crisis rather than a staffing crisis, because the number of NHS staff rapidly increased after the Covid-19 pandemic, but the NHS’s output (activity such as A&E attendances and primary care consultations, for example) didn’t grow at the same pace.

Reports from the Institute for Fiscal Studies and hearings by the Health and Care Select Committee started to focus on worryingly low productivity growth in the NHS. The culmination of this argument was the Darzi report into the state of the NHS, which included punchy phrases like: Despite the highest level of hospital employment in the world, there appears to be no problem for which the CQC believes the solution is something other than to add more staff… It is this type of behaviour that has contributed to the sharp increases in staffing and falling productivity.

And things started to get real. First, news broke that the Manchester health care system was in financial straits and needed to look at its workforce bill. And then it became clear that Manchester was an outrider rather than an outlier as other parts of the NHS followed suit. The government has recommitted to its target to recruit 8,500 extra mental health workers, but this staffing growth is the policy exception rather than the rule because up and down the country NHS providers are trying to make cuts to other areas of workforce spending. Although most of this is still focused on reducing spending on temporary staff, a recent NHS Providers survey suggested that over a third of NHS frontline organisations were planning to cut clinical staffing posts to balance the books.

So here we are then. The NHS had a long-term plan to recruit and retain more staff over the next decade. And NHS organisations are planning to reduce staffing costs and, in some cases, cut staffing numbers over the next few months. Does the NHS have too many staff or too few? The answer, it would seem, is ‘both’.

Local NHS organisations are not blameless when it comes to NHS boom-and-bust workforce planning. Some local NHS directors have told me how local recruitment was driven by a need to recruit as many staff as quickly as possible from wherever they could – which led to mismatches in which services were under or over-staffed. And local NHS employers can still do much more to tackle staffing shortages by providing better working conditions and holding onto the existing staff they have.

But it is hard to plan locally when there are so many volte-faces at the national level that create this boom-and-bust dynamic (Figure 1). No wonder then that headlines from 20 years ago about an ‘appalling lack of planning by the Government which meant that trusts recruited far more staff than they could afford to pay’ could be repeated today.

Workforce planning is fiendishly difficult to get right, and the risks are not always symmetrical if you get it wrong. Train too many staff and you end up with them unemployed, underemployed, retraining or emigrating. Train too few (or retain too few) and you end up in a desperate game of catch-up as you try to restart training pipelines or boost international recruitment.

At the risk of sounding Pollyanna-ish, if a large part of the problem was the failure to plan for the long-term, then the 10 Year Health Plan has provided more clarity. The government has said that more staff and more funding cannot always be the answer to the problems facing the NHS. It has asserted that the previous 2023 NHS long-term workforce plan is ‘a fiction, and we reject it’. And it has declared that the updated 2025 workforce plan will assume fewer staff will be needed than the 2023 plan suggested.

So, if the government’s view is that technology, prevention and new models of care will require lower staffing increases than the long-term workforce plan assumed, then that detailed modelling should be spelt out in black and white so that the NHS can consequently manage its budget, its recruitment plans, and its training relationships with universities in response. If nothing else, the clarity would be welcome. As with many crises and times of uncertainty, it’s easier to get to steadier ground once you know where you are heading.