The NHS workforce: how do we balance cost-effectiveness with safety?

Eavesdrop on any recent meeting of NHS human resource directors – or indeed finance directors – and you will hear talk about staffing levels and funding.

The NHS is labour intensive, and when funding is tight, staff are the inevitable focus of 'cost containment'. In this post-Francis world, things have got even more complicated. As The King's Fund's think piece on the NHS and social care workforce makes clear, workforce planners and employers must also take account of patient safety, as well as future demand and supply issues.

These overlapping and sometimes conflicting demands will have to be dealt with by the new NHS workforce planning system just getting under way in England. Health Education England will work at a national level with local education and training boards (LETBs) to deliver on its mandate from government, announced this May. Can it deliver safe and cost-effective staffing?

The first point to note is that this 'new' planning system looks a lot like the one that existed  a decade ago. In 2001 local NHS Workforce Development Confederations (WDCs) were established to bring together health sector employers and educators to determine local staffing priorities. This year's LETBs are last decade's WDCs – and WDCs only survived for a few years before disappearing in the next round of NHS reforms.

The NHS in England has a poor track record in following through with any sustained or effective approach to workforce planning. With the exception of the NHS Plan in 2000, repeated NHS reforms have given little consideration to the workforce, or workforce planning. The most recent NHS reforms barely mentioned the workforce other than GPs. Policy  focused  on the form of the new system; there was much less clarity and detail – as noted by the Health Select Committee in 2012 – on the respective roles and functions of the new agencies, or on how they would interact with each other.

Now that the form is in place, these functions will have to be finalised. This will include determining exactly what 'employer-led' means in a mixed economy of providers, and how to align the national supply of staff with local safe staffing levels.

The NHS workforce planning approach used for a time during the 1990s highlighted the risk of contributing to a national undersupply with a locally led approach to planning. When costs are constrained, individual employers can take a narrow, short-term, localised view of their future requirements, without taking sufficient account of changing demand (eg, when patients’ requirement for nursing care increases with faster patient throughput) and of labour market dynamics. The cumulative effect at national level – unless there are sufficient national checks and balances – can be a significant underestimate of future requirements for staff.

The Foundation Trust Network's recently published aggregate of individual trust business plans, for example, showed that trusts were planning a significant level of nurse recruitment in this financial year, in part as a response to safe staffing concerns, but were projecting significant staffing reductions in subsequent years. Health Education England will have to provide the national checks and balances against a backdrop of these projected reductions while also supporting the deployment of safe staffing levels.

The current clamour for national mandatory nurse staffing levels or ratios is understandable as they give some security to the workforce. Demand for 'top down' certainty is also a response to local management failing to react to concerns about growing workload -for which the Francis report is a case study. The Department of Health in England is attempting to resist the pressure for national ratios by suggesting that NICE will be charged with developing evidence-based staffing tools. However, NICE have indicated they have not even been formally requested to undertake the work.

The Department would do well to heed the key message in another recent report from The King's Fund, and lessons from other nations. The NHS in Scotland and Wales are both developing a suite of nurse staffing tools that will be mandatory at local level. Safe staffing locally and workforce supply nationally are connected. A policy focus on one to the exclusion of the other will fail.