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Long read

The NHS Long Term Workforce Plan explained

On 30 June 2023, the NHS long term workforce plan (Long Term Workforce Plan) was published, setting out the long-term strategic direction for the NHS workforce in England.

In this explainer, we set out the main commitments in the plan and provide our view of what they might mean, highlighting the opportunities and challenges for the health care system as the plan is put into practice.

Why is a workforce plan necessary?

What is workforce planning?

Successful workforce planning for the NHS ensures that it has the right number of staff, with the right skills and competencies, in the right place, at the right time to deliver services that provide the best possible patient care and meet demand, within an affordable budget.

Why is workforce planning important for the NHS?

A range of factors have an impact on the demand and supply of suitably skilled and qualified health care staff. A long-term national approach to NHS workforce planning is important. In addition to the factors affecting the demand for health care, it takes a significant amount of time to train health care professionals, people’s expectations of the workplace can shift over time, and competition in the labour market will evolve over time. A workforce plan will ensure that actions to tackle these factors in the short, medium and long term can be assessed against the current and likely future need for staff.

Years of poor and largely absent workforce planning in England have contributed to significant challenges across the health care workforce. Increases in staff numbers – particularly in the acute sector – have failed to keep pace with increased demand for care and have not improved productivity. Organisations across the health care sector have long been calling for the government to publish a long-term workforce plan for the health care system, with independently verified projections of future demand and supply. This transparency will help the public and the sector hold national politicians and system leaders to account for providing the workforce the health care system needs to support patients.

Background to the workforce plan

The NHS has not seen a workforce strategy since the early 2000s. As the NHS staffing crisis worsened over the 2010s, the then Secretary of State for Health and Social Care Jeremy Hunt commissioned Health Education England to publish a draft workforce strategy for consultation in December 2017, which did not progress beyond the closing of the consultation in March 2018.

In 2019, NHS England published an interim People Plan, which marked the beginning of a new strategic process on planning for the NHS workforce but did not include forecasting or details on funding. The final NHS People Plan, published in 2020, had no long-term focus and did not constitute a workforce plan or strategy. In 2021 and 2022, Jeremy Hunt, then Chair of the Health and Social Care Select Committee, supported calls for a long-term workforce plan to be published in full as part of the passage of the Health and Care Act, supporting an amendment for stronger workforce planning.

The publication of the plan has been repeatedly delayed.

What does the plan do?

Published on 30 June 2023, the NHS long term workforce plan sets out the case for long-term change for the NHS workforce, and outlines plans to address an expected shortfall of between 260,000 and 360,000 staff by 2036/37.

The actions set out by the plan build on existing ambitions to increase the NHS workforce – such as existing plans to expand medical school places and start new medical schools; to increase the number of nurses working in the NHS by 50,000 by 2024; to improve monitoring of staff morale; to increase flexible working options for NHS staff; and to support former staff to return to practice. The plan is designed with the idea of building on such changes, and seeks to ‘ensure the NHS has the workforce it needs for the future’.

The Long Term Workforce Plan sets out the case for taking a more strategic, long-term approach to NHS workforce planning. It outlines this approach and proposes actions to be taken locally, regionally and nationally in the short to medium term to address current and future workforce challenges. The actions set out in the plan fall into three identified priority areas.

Train: growing the workforce through increasing education and training, as well as increasing the number of apprenticeships and alternative routes into health care roles.

Retain: working to improve culture and leadership across NHS organisations and better support staff throughout their careers to ensure that the NHS keeps more of its staff.

Reform: improving productivity among the workforce by ensuring staff have the right skills to take advantage of new technologies that will provide patients with the care that they need more efficiently and effectively, and by expanding enhanced, advanced and associate roles to offer modernised careers, with a stronger emphasis on the generalist and core skills needed to care for patients with multimorbidity, frailty or mental health needs.

The plan sets out the case for change by identifying the rising demographic pressures, changing burden of disease, high number of vacancies across the NHS workforce, and the NHS’s firm reliance on temporary staffing and international recruitment to fill service gaps and ensure safe staffing levels.

Using a modelling approach that aims to understand current and future workforce demand and supply shortfalls, the plan acknowledges the uncertainty in planning for the medium to long term.

The modelling begins with the 2021/22 financial year, and runs through to 2036/37. It is based around five care settings (acute, mental health, ambulance, primary care, and community) and eight staff groups (medical, nursing and midwifery, allied health professionals, the ambulance service, support to clinical, infrastructure support, general practice and ‘other’).

The NHS has committed to review the model and the plan, publishing refreshed projections and further updates on the plan every two years. This will be important in ensuring that the proposals in the plan remain achievable and relevant over the next 15 years, and will serve as an important correction mechanism if modelling assumptions do not prove to be accurate.

The National Audit Office is set to carry out an independent assessment of the modelling behind the Long Term Workforce Plan, and consider whether NHS England’s current approach to workforce modelling, and the models themselves, are a reasonable basis for regular strategic workforce planning.

What does the workforce plan aim to achieve?

The plan could lead to an extra 60,000 doctors, 170,000 more nurses and 71,000 more allied health professionals in place by 2036/37, on top of current levels.

Train

The ‘Train’ section makes up the bulk of the commitments set out in the plan. The modelling in the plan estimates that compared with 2022, there will need to be an overall increase of between 50 and 65 per cent in domestic education and training across the eight staff groups by 2030/31, to reduce the current significant reliance on international recruitment and temporary staffing, and close the workforce shortfall. The plan seeks to increase both the number and proportion of registered NHS staff working in primary and community services – tying into the goal of delivering more NHS care outside hospitals and investing more in prevention and early intervention. The plan’s actions to boost training and education are based on a set of assumptions about demand, productivity and retention over the modelling period.

Clinical staff

The plan aims to double medical school places to 15,000 by 2031/32, and increase the number of GP speciality training places by 50 per cent to 6,000 by 2031/32. It commits to initially growing GP training places by 500 in 2025/26. There are also plans to pilot a medical degree apprenticeship – a previously announced initiative – and an ambition to have 2,000 medical students training through this route by 2031/32. The plan also outlines proposals to shorten medical students’ time in medical school from five years to four years, with the aim of bringing people into the workforce more efficiently, ‘so that in future students undertaking shorter medical degrees make up a substantial proportion of the overall number of medical students’.

Nursing

The plan outlines a need to increase adult nursing training places by 65–80 per cent by 2030/31, with training places increasing by 41 per cent to almost 28,000 over the next six years. On mental health nursing and learning disability nursing specifically, the plan sets out an ambition to significantly increase training places by 93 per cent and 50 per cent respectively, by 2031/32, with some of these increases (13 per cent and 16 per cent respectively) seen by 2025/26. These two areas of the nursing workforce are facing the most severe shortages.

The plan also outlines an ambition for more registered nurses to train through an apprenticeship route – rather than the current standard route of undertaking a traditional undergraduate degree –so that by 2028/29, 20 per cent of nurses qualify through this route, as opposed to the current 9 per cent. The plan also seeks to train more midwives (5 per cent of the annual intake for training) through apprenticeship routes.

This nursing growth builds on the expansion already planned as part of the 2019 government manifesto commitment to the 50,000 Nurses Programme. When this programme was announced without a workforce plan to support it, there were questions around whether meeting such headline-focused targets would be adequate in meaningfully solving the issue of nursing workforce shortages. Plans to increase staff numbers based on the targets calculated by the modelling go much further than previous partial initiatives like the 6,000 more GPs and 50,000 more nurses commitments – the former of which has not been on track for some time.

Allied health professionals

Plans to boost the numbers of allied health professionals (AHPs) suggest that more than a third of AHPs could train through apprenticeships as opposed to undergraduate degree routes, compared to 6 per cent now. The plan aims for at least 80 per cent of operating department practitioners, therapeutic radiographers and podiatrists, 25–50 per cent of paramedics, diagnostic radiographers, occupational therapists, dieticians, prosthetists and orthotists, and up to 5 per cent of speech and language therapists and physiotherapists to train through apprenticeships by 2031/32.

Public health

Plans to expand the public health workforce only cover as far as 2023/24, with an aim to expand training places by 13 per cent, working with national, local and regional systems partners to address the demand and supply challenges of the public health workforce.

The plan covers the pharmacy workforce employed by the NHS, and primary care and community pharmacy contractors delivering funded services in the NHS. It confirms that all newly qualified pharmacists will be independent prescribers, states an ambition to continue expanding the clinical role of community pharmacy professionals in patient care pathways, and outlines plans to expand training places for pharmacists by nearly 50 per cent to around 5,000 places by 2031/32.

Dentistry

The plan seeks to expand dentistry training places by 40 per cent so that there are more than 1,100 places by 2031/32, and to explore measures such as a tie-in period to encourage dentists to spend a minimum proportion of their time delivering NHS care in the years following graduation.

A line graph showing that Between 2022 and 2031, the training intake for district nurses is planned to increase by 152 per cent, compared to 13 per cent for midwives

Non-registered workforce

There are some NHS staff groups that require no formal registration with a professional regulator, such as health care support workers. The plan predicts that among the non-registered workforce, the biggest shortfall will be in health care support workers, and the plan states that NHS England will look to run recruitment exercises at scale for entry-level NHS jobs, and will work in partnership with Jobcentre Plus where appropriate, including continuing a national recruitment programme. The plan does not acknowledge that if the NHS seeks to boost the numbers of health care support workers in this way, this needs to be done in co-ordination with the social care sector – otherwise the NHS will be in direct competition with the social care sector for the same staff.

Reducing reliance on international recruitment and temporary staffing

The plan outlines the requirement to reduce the NHS’s over-reliance on international recruitment and temporary staffing, and expects a decrease in both these factors through implementing education and training expansion. This expansion would lead to an anticipated decrease in international recruitment from the current 24 per cent of all new joiners across the NHS (excluding dentistry and community pharmacy) to 9–10.5 per cent a year by 2036/37, and in reliance on temporary staffing in full-time equivalent (FTE) terms from 9 per cent in 2021/22 to around 5 per cent from 2032/33 onwards.

The plan notes the importance of temporary staffing solutions in providing flexibility for staff and an opportunity for extra income. The plan notes that over the next 15 years, the NHS will need to further strengthen its approach to offering a blended career, where staff have the flexibility to work in an NHS bank, but that this should not be the only route to staff having a working pattern that suits them. The plan aims to reduce agency expenditure in secondary, community and mental health providers as shortfalls reduce.

Apprenticeships

Placing a significant focus on the expansion of apprenticeships, the plan introduces the development of an apprenticeship funding approach that supports employers with the cost of employing an apprentice. It sets out an ambition for 22 per cent of training for clinical staff to be through apprenticeship routes by 2031/32. A commitment for joint work between NHS England and government intends to ensure that any changes to NHS England’s apprenticeship funding approach are supported by, and align with, wider government apprenticeship funding policy. The plan states that integrated care systems (ICSs) will be supported to develop local apprenticeship strategies that maximise benefits from changes to funding approaches.

The King’s Fund view

The plan for increasing the supply of NHS staff includes much to be welcomed. It is the most comprehensive, detailed and transparent long-term workforce plan in living memory. The plan’s proposals for delivering the increase in staffing numbers – in particular, through more apprenticeships – appear feasible. Of course, setting out the numbers is in some ways the easiest bit: the devil will be in the detail of implementation, for example, how the NHS will develop sufficient capacity to manage these additional staff. Funding is yet to be decided beyond 2025 and will depend on future central government Spending Reviews, and the assumptions behind the numbers are so far untested. The promised biennial reviews of the plan, its projections and updates are therefore essential.

As the plan progresses to implementation, we would like to see a greater emphasis on working with professions and (in relation to support workers) the social care sector. Integrated care boards (ICBs) should be supported to develop their roles and make workforce planning less centralised. The opportunity the plan presents – to train and recruit a workforce for a future NHS that is more balanced across hospital, community and primary care – should not be missed.

Retain

The plan notes that without embedding better culture and improving staff retention, NHS workforce shortfalls will persist. Much of the commitment around retention simply reinforces elements of the NHS People Promise and the NHS People Plan – for example, encouraging NHS organisations to undertake cultural reviews to understand how working environments could be improved for staff.

Perhaps the most concrete proposal on retention is the plan to modernise the NHS pension scheme, with the Department of Health and Social Care introducing reforms so that staff can partially retire or return to work seamlessly and continue building their pension after retirement if they wish to do so. It is hoped that this will incentivise more NHS staff to work more flexibly and remain in the workforce for longer. This proposal builds on changes to pension tax arrangements already announced by the government in the Spring Budget 2023, which came into effect in April 2023. These allow some NHS staff to continue working later into their career without incurring high tax bills. The plan also commits to continuing the ongoing national funding allocated for continuing professional development (CPD) for nurses, midwives and allied health professionals, and the previously announced plans to improve childcare support to help NHS staff to stay in work, through changes made in the Spring Budget for working parents over the next three years.

Many of the proposals on retention fall to ICBs and employers to implement locally and on an individual workplace level, for example, developing and implementing plans to invest in occupational health and wellbeing services, reviewing people management systems, and ‘making better use’ of national tools to inform improvement plans.

The King’s Fund view

The plan recognises the importance of improving retention and the significance of culture and leadership to do this. However, there have already been reviews and other significant developments affecting NHS leadership that make this point. To make the necessary changes to leadership and culture, NHS England and partner agencies must prioritise this issue.

The plan expects action to be driven locally, with the plan considered a minimum requirement for local partners to build on. This approach aligns with NHS England’s new operating model, which delegates more responsibility to local health systems and reduces direct intervention from national organisations.

The plan’s proposals on retention do not address the immediate ‘here and now’ issues contributing to high attrition rates across the NHS, and there is a risk that any improvements in retention do not occur at the rate required to meet the overall supply targets set out in the plan.

It is logical that local employers should take the lead role in improving retention and developing organisational cultures. However, given current pressures on services and staff, the plan is lacking detail on how NHS England, national partner agencies and local systems should and will support local employers, including on provision of skilled organisational development capacity. It also does not engage with the important role that the Department of Health and Social Care can have in retention by determining pay, terms and conditions.

Reform

The ‘reform’ section of the plan focuses on ‘working and training differently’ to improve productivity. This will be achieved through building teams with flexible skills, changing education and training to deliver more staff in roles and services where they are needed most, and ensuring staff have the right skills to take advantage of new technology.

Teams with flexible skills

There is a focus in the plan on expanding enhanced, advanced and associate roles to offer modernised careers, with a stronger emphasis on the generalist and core skills needed to care for patients with multimorbidity, frailty or mental health needs. This includes setting out the path to grow the proportion of staff in these newer roles from around 1 to 5 per cent of the NHS workforce, by ensuring:

  • by 2031/32 more than more than 6,300 clinicians start advanced practice pathways each year

  • increasing training places for nursing associates – staff that support registered nurses to deliver patient care – to build a workforce of 64,000 nursing associates by 2036/37

  • increasing training places for physician associate – staff who support doctors in the diagnosis and management of patients –  to establish a workforce of 10,000 by 2036/37.

The plan also seeks to grow the number and proportion of NHS staff working in mental health, primary and community care by 73 per cent by 2036/37, to meet the ambition to deliver more preventive and proactive care across the NHS. These measures appear to be a concerted effort to boost capacity in out-of-hospital settings.

Technology

Actions already being undertaken by NHS England to adopt the use of artificial intelligence (AI) innovations are highlighted in the plan. These include supporting the government’s Foundation Model Taskforce (which was launched to support businesses and developers build better AI systems, and to procure the technologies for public services) to optimise implementation across the NHS, and reviewing initial evaluations from various pilots to provide evidence of risks that need to be assessed. NHS England has committed to convening an expert group to identify advanced technology that can be used most effectively in the NHS, building on the findings of the Topol Review.

New approaches to medical education

A key feature of the reform section is new approaches to medical education, with proposals to support medical schools to move from five or six-year degree programmes to four-year degree programmes that meet current General Medical Council (GMC) standards. This feature aims to ‘bring people into the workforce more efficiently’. There are also plans for piloting a new model for newly qualified doctors: an internship programme that will shorten undergraduate training, allowing medical students to graduate six months early and enter a six-month renumerated internship programme.

The plan also marks the need to address geographical inequity, and how the location of medical training posts does not always mirror current or future patient need, leading to inequitable access to services. Highlighting the entrenched inequalities in the distribution of staff, the difficulty of attracting and retaining staff in ‘disadvantaged’ areas and the need to ensure additional posts are aligned to areas of greatest need is a welcome step.

The King’s Fund view

The ‘Reform’ section is the longest section of the plan – more than 30 pages. It gives a long and diverse list of national initiatives, such as encouraging nurses to participate in research, developing healthy-weight coaches, and creating 10 clinical fellow posts for sickle cell disease. Despite the high level of detail, there is little connection to what the overall change will be for frontline staff and patients. There needs to be transformation in both the education of health care professionals to foster kinder environments within which to learn and in the conditions for care in practice.

Much of this section of the plan focuses on how NHS England will develop national education and training arrangements now that it has incorporated Health Education England. It will be important to develop the vision for what the workforce of the future should look like, eg, how roles will develop and fit together, how they will work with patients and 21st-century technology. This section of the plan was also an important moment to say how the NHS got to its current point. Adding more roles and new professional training to the system will not on their own achieve the desired changes, as there is currently insufficient capacity to support change and develop organisations.

Amid all the other detail, the plan is based on ambitious and uncertain assumptions for improved labour productivity above the long-term trend – realism about the required investment in buildings, technology and equipment must happen if the plan is to realise those productivity gains. There is surprisingly little detail on how the productivity goals will be achieved. It is good to set ambitious aims and productivity clearly does need to improve, so this is an area where NHS England should prioritise providing greater clarity.

Implementing the plan and risks to delivery – The King’s Fund view

Funding

The government has stated it will invest more than £2.4 billion to fund the 27 per cent expansion in training places by 2028/29, on top of current education and training budgets. However, the funding required to implement the entire plan beyond 2028/29 is unclear. Because governments do not set out spending commitments or set departmental budgets more than three to five years in advance, or across parliaments, there will be significant cost pressures for future governments to meet to ensure the plan is implemented fully.

The ambitions in the plan will have consequences for the day-to-day spending of the NHS, for example, the salaries of the new health care staff once they have been recruited into the system. While these costs are hard to predict due to uncertainties regarding attrition, changes to pay settlements and career progression, they will be significant, and need to be factored into the NHS’s long-term workforce and financial planning.

NHS England and government need to be realistic about the required capital investment in buildings, technology and equipment if the plan is to realise those productivity gains, particularly if the plan hopes to meet its targets on increasing primary care and community staff. Overall, it is clear that significant amounts of funding will be required each year as the plan is implemented, and questions around cost pressures and future availability of funding will likely persist and need to be considered by future governments.

Tackling retention

The plan does not deal with the ‘here and now’ issues of retention across the NHS, therefore, there is a risk that improvements in retention do not occur quickly enough meet the overall supply targets set out in the plan. The plan is also based on ambitious and uncertain assumptions for improved labour productivity above the long-term trend.

Training timeframe

The plan’s proposals on training and education give projected workforce figures up to 2036/37, that seek to address the estimated shortfall of between 260,000 and 360,000 staff if no action is taken. As the plan focuses largely on increasing training places, and most of the increases will not begin until 2025, the impact on staff numbers will take time to materialise and have an impact on patient care and staff experience. There is a risk that current staff levels will not be sufficient to assist in supporting the training of the increased numbers of staff in training, for example, nursing students on clinical placements, and FY1 doctors who require supervision.

While expanding shorter training schemes, eg, those for midwifery and physician associates, will show results sooner, most of the proposals and initiatives outlined in the plan will not appear or take effect for years, which is important given the urgent need to address current NHS workforce issues. Quicker results could be achieved if there was more focus on retention, but there is much less in the plan in terms of new commitments and concrete action in this area – meaning that the NHS will remain dependent on international recruitment and temporary staffing for the foreseeable future.

Attracting GPs

Beyond an increase in training places, the plan should also be clearer on how exactly it will attract more medical students into general practice. Previous attempts to boost GP numbers have not been hugely effective, with difficulties in achieving recent targets. Without targeted action to attract medical students, and improve conditions for staff working in general practice, the plan may fail to deliver the proposed increase in GPs.

Apprenticeships

The plan marks a significant cultural shift to increasing in the use of apprenticeships to train health professionals. There is a need to acknowledge the levels of societal adjustment required – and potential resistance – as people get used to increasing apprenticeship routes into careers.

Taking forward local actions

Many of the proposals on ‘retain’ and ‘reform’ understandably place responsibility on ICSs to take action at a local level. With ICBs still finding their feet, there are questions over whether these systems will be equipped or ready for the scale of work required to improve retention and enact reform in their NHS services. NHS England will need to provide local systems with the leadership and accountability to take forward actions on retention and reform successfully.

Responsibility for delivery

It will take the effort of multiple organisations for the plan to be delivered successfully. National government must work with NHS England, ICBs, professional regulators, education and health care providers to ensure the commitments are delivered. As the plan is intended to be used as part of NHS planning for the next 15 years, it will likely need to be accepted and approved by future governments, as an ‘NHS plan’ accepted by the government of the day, rather than a government-led plan.

What does the plan not do?

The Long Term Workforce Plan has been predicated on an assumption that access to social care services will stabilise and improve over the next 15 years, and this is factored into its proposals. It recognises that registered clinical professionals in the social care sector are critical to the overall provision of services, and assumes that the proportion of newly trained staff who move into non-NHS health and care settings will remain in line with current trends.

However, beyond this, the plan does not cover the social care workforce. Workforce challenges in social care have a knock-on effect for the entire health and care system and the people who rely on social care services, contributing to delayed discharges, increased waiting times for treatment, and greater pressure on emergency and acute services. Without a sister workforce plan for the social care sector (which currently has 152,000 vacancies), there is a real risk that the ambitions set out in the Long term Workforce Plan will not be achievable.  
 
The long-term nature of the plan means that it does not address the urgency of the issues facing health care in the here and now, and many of the actions set out in the plan will not begin to have an impact until autumn 2025.

In 2023, members of professions from various sections of the NHS workforce – including paramedics, nurses, junior doctors, consultants, physiotherapists, and radiographers – have taken strike action resulting in hundreds of thousands of appointments and operations being cancelled, further prolonging people’s waits for treatment. The Long Term Workforce Plan does not address NHS workforce pay – one of the reasons NHS workers are taking strike action. Without action to respond to workers calls for better pay, terms and conditions and to turn around the trend in the numbers of staff leaving the NHS workforce, there is a risk that the plan’s long-term proposals to grow the workforce will not be sufficient, as high numbers of staff will continue to leave their professions and this will impact workforce numbers. Therefore, more action is required from government alongside this long-term plan, with new, ring-fenced commitments to address the NHS workforce retention crisis.

The Long Term Workforce Plan sets out projections for the numbers of additional staff that will be needed in 15 years’ time. However, at this stage, those numbers should not be read as targets, which the NHS must hit exactly. They are based on prediction and assumptions and are for now inherently inexact – but with each biennial update, the numbers should become more precise. For now, they indicate the scale of change likely to be needed rather than showing the exact staff numbers.

Conclusion

The publication of the NHS Long Term Workforce Plan is an essential first step in solving the NHS workforce crisis. The plan is well overdue, and we welcome it. The publication signals a new direction towards improved long-term workforce planning, and the process of the plan’s implementation will be crucial in determining its success.

Many people have been calling for a long-term workforce plan for years, and no previous government or NHS plan has looked as long term or provided transparency on future staffing projections as this one has. The commitment to reviewing the plan every two years is important and significant – lack of this to date has allowed the workforce crisis to drift deeper and deeper.  
 
At a time when many aspects of the health and care system requiring long-term planning and investment have been neglected, the NHS Long Term Workforce Plan stands out as a rare attempt to make good decisions now that will impact the quality of, and people’s access to, care in the future.  
 
The plan does not provide all the answers to the deeply entrenched NHS workforce crisis, and how it will be delivered is uncertain and, in places, built on assumptions. Many aspects of the plan will need further consideration and planning, and we would welcome more detail on specific implementation plans, including on how the plan will be funded in the future, to ensure that it can fully deliver.  
 
In the future, we hope to see similar long-term thinking in other areas of health and care.

Event

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