The workforce crisis engulfing the health and care system is well documented. In the NHS, increases in staff numbers are not keeping pace with demand for staff and services. In 2021/22, for the first time, the number of people working in adult social care in England fell, and there are now 165,000 vacancies.
Staffing shortages are the biggest limiting factor of the pace at which health and care services can recover from the impact of the Covid-19 pandemic and provide care for the growing number of people on waiting lists, many of whom are experiencing long waits, be that for hospital treatment or social care support in their communities. As the gap between the number of staff working in the health and care system and the number of staff needed to meet demand grows, there is a risk that quality of care deteriorates and patient safety issues increase. For many staff working across the sector, staff shortages contribute to ill health and burnout, further exacerbating the crisis.
The workforce crisis has been a prominent issue for years, but there has been little concerted action from governments to tackle the challenge. Given this long-running gap in solutions from national politicians, The King’s Fund and Engage Britain commissioned Bill Morgan1 , a political adviser, to consider why politicians have failed to act, where only they can, to deliver the workforce that the health and care system – and its patients’ and people who draw on care and support – needs. His report, NHS staffing shortages; why do politicians struggle to give the NHS the staff it needs?, focuses on the role of politicians in workforce planning and delivery.
In this long read, we look to place his report in a wider policy context, looking more broadly, to briefly consider the range of actions that the long-needed and often-promised comprehensive workforce plan for health and care needs to cover. For those leading on workforce away from national policy, this long read provides a brief overview of the key factors to keep in mind to act comprehensively across the range of levers to grow and support the workforce.
Given the wider political environment and the prospect of a general election in the next couple of years, the issues covered in this long read should help to inform how successful any political party’s plans for heath and care can be – as without adequate and well-supported staff, who will deliver their ambitions?
Health and care is fundamentally a people business, delivered by people, for people; the people who work across health and care are its greatest asset and are key to delivering high-quality care. This has been evident throughout the Covid-19 pandemic with staff demonstrating remarkable resilience and commitment, but this came at a high cost to their health and wellbeing.
However, since 2010 a prolonged funding squeeze combined with years of poor workforce planning, weak policy and fragmented responsibilities mean that staff shortages have become endemic. The workforce challenge is a complex one and looks different for different sectors and different staff groups. For some sectors, such as social care organisations, it’s recruitment and retention challenges that are leading to falling staff numbers. For others, such as hospital nursing, staffing levels have started to increase although challenges around staff burnout remain. And in primary care, shortages of GPs are being mitigated to some degree by additional roles being introduced. Any workforce plan will need to recognise and support that complexity across services and staff groups, so it will not only need to think about the numbers of staff but how staff are working with each other and with patients. Staff will need access to expert change management to be supported to implement new ways of multi-disciplinary and cross-organisational working to be supported to deliver efficient and effective services for patients and people who draw on care and support.
So, what is needed?
The health and care workforce
The health and care workforce is large and varied and includes those working in health care, public health and social care. The NHS alone offers more than 350 different careers. People can be employed by the public sector (in NHS trusts or local authorities), and many hundreds of thousands are also employed in charities and businesses that include large corporates and thousands of small organisations (for example in the social care sector). Some are employed directly by people drawing on care and support.
The health and care workforce is hugely diverse, with 82 per cent of the social care workforce and 77 per cent of the NHS workforce female. Staff from Black, Asian and minority ethnic backgrounds make up 23 per cent of the social care sector and 22 per cent of the NHS. Around 20 per cent of NHS staff declared they had a disability in the latest NHS Staff Survey. But this strength in diversity is not reflected at more senior levels in health and care and too often the experience of staff from Black, Asian and minority ethnic communities does match that of their white colleagues.
Transparency in workforce planning assumptions
After several years of resisting calls to be required to publish projections of future demand and supply of the health and care workforce, in the Autumn Statement in 2022 the Chancellor committed the government to such independent projections for the NHS. As Bill Morgan argues in his report, it would be hard to provide perfectly accurate projections given the complexity of factors and the time period involved in assessing future demand and supply of specialist roles. It is, however, possible to create a projection of ranges of future demand and supply that would allow actions in the short, medium and long term to be assessed against the current and likely future need for staff.
'Transparency in workforce planning requires clear assumptions about the potential contribution of a whole range of factors'
One of the benefits of the transparency of long-term planning assumptions and trajectories is that published forecasts would help to provide a shared understanding for the multiple players involved in complex workforce planning so they could pull together. It would also enable national politicians and system leaders across health and care to be held to account for action. Transparent workforce plans may also help politicians and other leaders make only commitments, for example, of waiting times for hospital treatment or to see a GP, that can be delivered with the staff available.
Transparency in workforce planning requires clear assumptions about the potential contribution of a whole range of factors – domestic training, international recruitment, measures to increase retention, skill mix and new roles, for example – as these all contribute to the demand and supply of suitably skilled and qualified staff. The recent commitment by the Chancellor to such a plan for the NHS is welcome, but workforce planning must extend to social care too.
Training and international recruitment
The training pipeline – for doctors, nurses, allied health professionals and other staff across health and care – takes many years to complete and relies not just on universities and other further education providers but on the health and care system being able to provide good-quality education placements. This requires joined-up thinking across education providers and the health and care system about the future need for staff and the current capacity to train and support staff well. The merger between NHS England and Health Education England with a single workforce and people directorate is an important opportunity to ensure that joined-up thinking.
International recruitment will always play a part in the health and care workforce. Bill Morgan’s report argues that immigration has not be used strategically and that politicians have failed to use this key lever effectively. International recruitment must follow a code of practice to ensure that any international recruitment is carried out in an ethically responsible manner. Successful use of international recruitment also requires other steps to create a supportive immigration policy, building on the streamlined health and care visa process and arrangements for mutual recognition of qualifications with other countries. The health and care system benefits hugely from its international recruits but more needs to be done to ensure the culture of workplaces are supportive of the global workforce in health and care.
Retention: it’s not just about pay
An important part of recruitment and retention is ensuring staff are fairly rewarded.
In social care, low pay has been an issue for years, with a sector that recruits at, or very near, the National Living Wage. Employers in the sector are predominantly from the private or voluntary sectors, but the public sector purchases most adult social care and the fees that it can afford to pay puts clear limits the ability of employers to pay at a level that attracts, recognises and rewards staff appropriately. It has been the case for several years that other sectors such as retail can reward staff with better pay than the social care sector, and with more experienced care staff paid just 7p an hour more than new recruits, there is a high risk that skills and experience leave the sector. Governments have made little effort to address these issues: the most recent White Paper on social care does not address pay levels.
While low pay has long been recognised as a challenge in social care, the current cost-of-living crisis is bringing the issue more to the fore across the wider health and social care system. After a decade of public sector pay restraint, with pay freezes or increases not keeping up with inflation, some staff in the NHS are finding it increasingly difficult to make ends meet with their current salary levels. Some NHS staff already need to access food banks, a sad fact that is likely to get worse as the cost-of-living crisis intensifies over the winter.
'After a decade of public sector pay restraint, with pay freezes or increases not keeping up with inflation, some staff in the NHS are finding it increasingly difficult to make ends meet with their current salary levels.'
Moving beyond pay, the current tax rules around NHS pensions mean that many more-experienced clinicians across the NHS are changing their working patterns to avoid high tax liabilities. This can include not working overtime, reducing their hours or leaving the workforce completely. If the government wants to keep the vital capacity and contribution of experienced clinical staff, it needs to fix the NHS pension scheme.
While important, pay and pensions are not the only reasons people stay in or leave a job in health and care. Among the many other contributing factors are the culture of a team and organisation, the wider benefits available, the prospects of career progression, which can all contribute to how attractive an employer is. Increasingly, flexible working is seen by staff as a critical factor in how attractive an employer is. With stress and burnout and a desire for improved work-life balance as key factors in staff leaving or reducing hours, increased flexibility can be a significant incentive for people to remain working in health and care. Some employers are innovating to offer broader benefits and support, such as free car parking, access to childcare, 24/7 on-site catering facilities, and better access to training and progression.
More than a numbers game, getting the culture and leadership right
Supporting the workforce isn’t just about training the right number of staff or resolving the pension question. High-quality leadership is essential to develop workplace cultures that attract and retain staff, allow them to be the best they can be, and improve care for people accessing services. There are countless examples of compassionate leadership across health and care. However, reports over a number of years have highlighted the prevalence of bullying, harassment and inequalities within the health and care sector demonstrating how these, coupled with challenging working conditions and long hours, contribute to staff burnout. The most recent NHS Staff Survey reports that 46.8 per cent of staff felt unwell as a result of work-related stress and 34.3 per cent felt burnt out because of their work.
To improve retention and make health and social care a better place to work, the sector needs leaders who practise collective, compassionate and inclusive leadership and supportive teamworking that values staff and meets their core work needs for autonomy and control, belonging, and contribution and effectiveness.
The health and care workforce is one of the most diverse workforces in England, but the experience of staff from minority ethnic backgrounds does not match that of their white colleagues. Too often staff from ethnic minority backgrounds report far worse experiences than their white colleagues on witnessing or experiencing bullying and harassment, and availability of training and opportunities to progress. Other staff groups, such as those with disabilities, also report a working environment which fails to support them and their skills. To ensure that all staff can be their best at work, serious attention needs to be given to improve diversity and inclusion at every level of the system, in national policies through to everyday practice in teams – from listening to staff and collecting regular data to understand staff experience, to taking action to address inequalities.
Productivity and skill mix
Ensuring that staff are using the skills they have in a way that best supports people accessing health and care services, will play an important role in increasing productivity. This isn’t about a fantasy productivity target that bears little resemblance to what is possible – while there can and should be ambition about delivering health and care services, it needs to be rooted in realism about what can be delivered, what is possible and what it takes to deliver change in working practices and system processes.
'Changes are rarely only technical in nature – they also involve people changing how they practice at work and behave, and implementation needs to be approached with this in mind.'
Supporting productivity should be about ensuring that there is strategic investment in infrastructure that allows staff to work efficiently and effectively. This can stretch from the basics of having buildings and equipment that are safe and functional, to adopting digital innovations that support staff and people to engage with health and care services in different ways and working flexibly across organisational boundaries. Hand in hand with the need to invest in the right infrastructure, being successful in developing new models of care and working practices needs skillful change management to ensure staff and people using services engage with and inform the change. Changes are rarely only technical in nature – they also involve people changing how they practice at work and behave, and implementation needs to be approached with this in mind.
Another way to think about improving productivity is to think about using the skills available within the workforce differently. Thinking creatively about redesigning roles or developing new roles can also help to improve patient and user experience and outcomes, if implemented carefully. Maximising the potential of community pharmacy to meet the health care needs of local communities is a good example of using skills already available in a different way, which better supports patients and improves job satisfaction. In redesigning roles, staff groups and patients need to be engaged and involved so they feel confident about the new models of care.
Action at all levels
The temptation is, of course, to think the workforce challenge is either too large and complex to be fixed, or that until national politicians act, nothing can be done. But this is far from true. Certainly, there are key interventions that only national politicians can deliver, be that around international recruitment, funding or national pay deals. But health and care leaders can also make significant progress.
Leaders at all levels of the health and care system are committed to better supporting their staff and good progress has been made by many. Some leaders – of integrated care systems, of provider collaboratives and of individual organisations – are working creatively across service and organisational boundaries to attract, train and retain staff differently. Leaders recognise the need to grow the local workforce as a whole – this is reflected, for example, in shared efforts to support the social care workforce locally. Employers – large public sector employers or small private or voluntary, community and social enterprise (VCSE) organisations – are looking at their own employment practices and putting measures in place to attract and support staff differently – for example, improving their offer on flexible working or redesigning the induction support provided to young people entering the workforce to improve retention.
Leaders in health and care are increasingly recognising the crucial contribution of the VCSE sector, particularly its activities to support community groups. But the system must do more to value and nurture this invaluable work and take steps to support the sector to be sustainable and resilient. Multi-year funding can be game changing for the resilience of the sector, and to the support it can provide within local communities.
Service improvement ambitions matched to the available workforce
The debate about the performance and sustainability of health and care is often reduced to a question of money and beds – are there enough of either? However, both are really proxies for the most important question – are there enough staff? It is staff that most of the health and care budget is spent on, and it is staff who care for people in multiple settings across the system. It is unsurprising that the key period of growth in NHS funding – the New Labour spending commitments from 2002 to 2010 – was matched by large increases in the number of staff working in the NHS and that as result, there were significant improvements in performance, including shorter waiting times and new A&E targets. From 2010 onwards, demands on health and care services and the available workforce began to diverge and performance and outcomes began to slip backwards.
'The ask of the health and care system in terms of service delivery and improvement needs to match the workforce available to deliver those services, or it simply won’t happen.'
A key lesson from the past two decades of funding growth is that the first question to ask about any promise of service improvement in health and care services – from a national politician or a local leader – is ‘Where is the workforce to deliver that?’ Then asking if the time to design and deliver those improvements, to develop the necessary skills and engage with staff to successfully deliver change has been recognised? The ask of the health and care system in terms of service delivery and improvement needs to match the workforce available to deliver those services, or it simply won’t happen.
The size and complexity of the workforce challenge in health and care means there will need to be concerted and sustained action across the system – on workforce planning, pay, training, retention, productivity, job roles and creating workplace cultures – that demonstrates staff are valued. While some action is needed in the long term, it is also possible to act in the short term to better support the workforce in the health and care system.
Responsibility for some issues sits with national politicians and they need to act, for example, on funding and international recruitment, but leaders at all levels within health and care should address the workforce crisis as a collective responsibility, taking action nationally, regionally and locally. Most crucially, for any delivery commitments made nationally or locally, leaders must know that staff are available and well supported to deliver on those commitments.