The reasons why staff are leaving are well documented (burnout, lack of work–life balance, low pay etc), and the direct impact on patients is obvious – staff shortages are one of the main reasons why there is a backlog of care. But these headlines mask nuance. They hide the areas where staff shortages are even more acute than the average, and they obscure the indirect impact on patients. Where are these areas, what are the impacts, and will the NHS Long Term Workforce Plan help?
Acute staff shortages
There is variation in staff shortages within regions across England. For example, coastal communities have 15% fewer consultants and 7% fewer nurses per patient, while deprived areas have fewer GPs per patient. Variation can also be seen within roles, with a 23% increase in overall nursing FTE since 2009 hiding falls in learning disability nursing and community nursing.
Given the ageing population in many coastal communities, the association between deprivation and poor health, the aim to shift more care from hospitals into the community, and the rising number of diagnosed learning disabilities in England, it is possible to conclude that demand for services is high and/or increasing in all these examples. So the fact that these areas are even more short-staffed than the average is deeply concerning.
The reasons why some areas experience greater staff shortages are varied. Looking at region, staff shortages in general practices in more deprived areas are higher for doctors than other staff, maybe due to the location of medical schools, or perhaps indicating that staff on higher salaries prefer to live and work in more affluent areas. Within roles, the perceptions of certain roles (‘learning disability nurses are not ‘real’ nurses’), or the challenges these roles bring (high unpaid overtime and travel in community nursing) can put people off entering or staying in these roles. These acute shortages could also be self-perpetuating – a vicious cycle where shortages increase pressure on staff, so more leave, so the shortages increase even more.
Will the NHS Long Term Workforce Plan help?
The Long Term Workforce Plan aims to ‘align additional posts to areas of greatest need’, for example by expanding digital training to enable wider participation in historically underserved regions. It also plans the greatest expansion in roles where demand is highest (eg, the learning disability nursing training intake is planned to double by 2031). This tailoring of supply to demand is a positive step, though sustained funding (and working with systems to understand where demand is highest) will be required to implement it.
Indirect impact on patients
Firstly, lack of management staff is damaging NHS performance. Managers and senior managers make up only 3% of NHS staff, compared to 11% of the overall workforce. Since 2009, the number of NHS FTE managers has only increased by 4%, despite a 9% increase in the overall population (and a 27% increase in the 65+ population), leading to an inevitable increase in demand for NHS services. Without sufficient managers, hospitals are less efficient and clinical staff have to spend more time on managerial and administrative tasks and less time on patient-facing care.
Secondly, high vacancy rates and more staff leaving means that the makeup of the workforce is becoming more junior and less experienced. Over the past five years, the proportion of doctors at the most junior levels (core training, Foundation Year 1 and Foundation Year 2) increased from 21% to 26%, and the proportion of nurses with under five years’ experience increased from 19% to 24%. Without enough experienced staff, patient care takes longer, and the experienced staff that remain have to spend more time training so have less time with patients.
Thirdly, staff shortages mean that hospitals must plug the gaps with agency staff. Between 2018/19 and 2021/22, spending on agency staff increased by £600 million (23%). Without adequate permanent staff, continuity of care suffers, and money is spent on agency staff that could be spent delivering other services to patients.
Will the NHS Long Term Workforce Plan help?
Disappointingly, the NHS Long Term Workforce Plan does not contain any aims to recruit or retain additional managers, despite acknowledging their important and expanding role. There are also limited plans to retain experienced staff, though new career progression paths for some staff groups might help. The plan does aim to reduce temporary staffing from 9% in 2021/22 to 5% from 2032/33. This is welcome, although long-term investment to recruit and retain permanent staff will be needed to plug the gap that agency staff currently fill.
Without sufficient staff, the NHS cannot provide the care it or the public wants. This needs to be a priority for every political party going into an election year. The King’s Fund has made recommendations on how to improve recruitment and retention. See our election priority on Making careers in health and social care more attractive for further information.