NHS workforce: our position

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Part of The King's Fund position

Staffing is the make-or-break issue for the NHS in England: urgent action is required to avoid a vicious cycle of growing shortages, increased pressures on staff and declining quality of care for patients.

What we think

The staff working in the NHS are its greatest asset and are key to delivering high-quality care. However, a prolonged funding squeeze combined with years of poor workforce planning, weak policy and fragmented responsibilities have resulted in a workforce crisis. Staff are working under enormous strain as services struggle to recruit, train and retain enough staff. Without urgent action to address this, the aspirations of the NHS long-term plan will not be met, and quality of health and care will deteriorate.

In the short term, the immediate workforce shortfall is so severe that it can only realistically be managed by recruiting staff from overseas, including ethically recruiting 5,000 nurses a year. This cannot be achieved without a supportive immigration policy, which should include the government accepting the recommendations of the Migration Advisory Committee to make it easier to recruit staff from outside the UK.

To create a sustainable workforce in the longer term, more staff need to be trained domestically. This will require additional investment or resources being diverted from other budgets, recognising the consequences that this would have on the ambitions to improve (or even sustain) existing services.

It is also important to improve the retention of staff already working in the service. To do this, the NHS must focus on becoming a better employer, for example by tackling discrimination and inequality, providing an attractive employment offer including more opportunities for flexible working and embedding collective leadership across the NHS that is compassionate and inclusive to create cultures in which staff want to work and build their careers.

Any strategy for shoring up the NHS workforce cannot be viewed in isolation from the need to invest in and support the wider health and care workforce, including people working in social care and in voluntary and community sector organisations. Addressing shortages in the NHS must not come at the expense of other parts of the system. 

The 2018 NHS staff survey found that over the past twelve months one in eight staff experienced discrimination at work.
Source: NHS staff survey 2018

The context

NHS hospital, mental health and community providers in England are reporting a shortage of almost 100,000 staff.
Source: NHS Improvement and The King's Fund

The NHS is the largest employer in England, with around 1.1 million full-time equivalent (FTE) staff working in hospital and community services. There has been no national workforce strategy for the NHS since 2003 despite a deepening workforce crisis. NHS hospitals, mental health services and community providers are reporting a shortage of more than 100,000 FTE staff, severely affecting key groups such as nurses. Shortages of GPs and other staff working in primary care and community services are putting ambitions to deliver more care out of hospitals at risk.

Current shortages look set to worsen. The government’s efforts to increase the number of nurses in training have so far been unsuccessful, and Britain’s decision to leave the EU appears to already be having an impact. For example, the number of nurses and midwives from Europe leaving the Nursing and Midwifery Council's register has risen from 1,981 in 2015/16 to 3,333 in 2018/19, while the number joining fell by 90 per cent. General practice is also under strain with a shortage of 2,500 FTE GPs; projections suggest this gap could increase to 7,000 within five years if current trends continue.

There is currently a vicious cycle in which unfilled vacancies put pressure on staff, prompting some to leave and thereby creating even more pressure on the remaining staff. As the Care Quality Commission has highlighted, workforce shortages are already having a direct impact on the quality of people’s care, and NHS waiting times standards are now routinely missed.

The size and complexity of the workforce challenge is such that addressing it will require consistent and concerted action across the system on workforce planning, pay, training, retention and job roles. Wider policies on immigration and Brexit also need consideration, particularly in the short term.

The NHS long-term plan recognised the scale of the challenge and set out a number of measures to address it, including the establishment of a cross-sector national workforce group. An interim People Plan was published in June 2019, but contains insufficient detail for us to have confidence that it will lead to robust solutions. A full People Plan is to be published following the government’s next Spending Review, when the total investment available for education and training is due to be confirmed.

Culture and leadership will play an essential role in improving retention and making the NHS a better place to work. Evidence and experience from high-performing health systems demonstrates that compassionate, inclusive leadership enables teams to deliver better patient care.

Key spokespeople on NHS workforce

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Suzie Bailey

Director of Leadership and Organisational Development

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Alex Baylis

Assistant Director of Policy

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Siva Anandaciva

Chief Economist

Sally Warren

Director of Policy

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