What we think
The people who work in the NHS 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. However, a prolonged funding squeeze between 2008 and 2018 combined with years of poor workforce planning, weak policy and fragmented responsibilities mean that staff shortages have become endemic. As such, the workforce crisis will be the key limiting factor on efforts to boost NHS activity and tackle the rising backlog of care.
While the government has provided more funding for health and care services, it has failed to deliver a national plan to address the workforce crisis. Government responses have been limited to stop-gap measures with no national NHS workforce strategy since 2003. The 2022/23 NHS operational planning guidance instructs systems to accelerate work towards growing and transforming their workforce, but this is not an adequate substitute for the fully funded workforce plan that is urgently needed.
To create a sustainable workforce in the longer term, and to meet the government’s manifesto commitments to recruit more nurses, GPs and other health professionals, more staff need to be trained in the UK. The government has re-introduced nursing student bursaries to help with living costs and increased the number of medical school training places. These measures should help, but to have real impact sustained long-term investment is needed, accompanied by efforts to reduce student attrition and match investment to areas and professions with the greatest needs.
There are some encouraging signs of increased numbers in training, with record numbers of medical and nursing students in 2021, and evidence of progress towards the manifesto commitment to 50,000 more nurses working in the NHS by 2024/25. Nevertheless, there remain concerns about the retention of newly qualified staff. However, these measures alone will not suffice: given the time lag before new staff can be trained, the NHS also needs to recruit staff from overseas. This is recognised in the elective recovery plan, which pledges to recruit 10,000 international nurses by April 2022. This recruitment will require further 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.
However, there has been less progress in other areas, specifically in general practice where there are significant difficulties in recruiting and retaining GPs. The Secretary of State for Health and Social Care has acknowledged that the manifesto pledge to have 6,000 more GPs in England by 2024/25 is not on track and similarly the NHS target to fund 26,000 additional roles to ease the pressure on general practice is unlikely to be achieved by 2023/4.
It is important to improve the retention of staff already working in the service, especially with so many experiencing burnout and significant numbers intending to leave. To do this, in addition to the pay offer for NHS staff announced in July 2021, the NHS must focus on becoming a more attractive employer by tackling bullying and discrimination, offering more opportunities for flexible working, and embedding collective, compassionate and inclusive leadership across the NHS 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. Addressing shortages in the NHS must not come at the expense of other parts of health and care system.
The NHS is the largest employer in England, with 1.2 million full-time equivalent (FTE) staff working in hospital and community services. However, workforce shortages across all staffing groups in the health and care system are putting NHS hospitals, mental health services, community providers and general practice under significant strain. These vacancies do not affect only clinical staff but also the roles required to keep the NHS running, including leaders and managers.
Unfilled vacancies increase the pressure on staff, leading to high levels of stress and absenteeism, and high staff turnover. The Covid-19 pandemic has also exacerbated long-term issues such as chronic excessive workload, burnout and inequalities experienced by staff from ethnic minority backgrounds. While there are signs that shortages have started to improve, levels of nursing and allied health professional vacancies remain high, recruiting and retaining GPs continues to be difficult and there are significant shortages in some specialties, such as radiology. As such, there is still an urgent need to increase the numbers of people in training.
Workforce shortages are having a direct impact on the quality of people’s care but the government response so far has been piecemeal, with accountability for improving the situation unclear. The merger of Health Education England with NHS England and NHS Improvement will make responsibilities for workforce planning clearer and should make it easier to develop the strategy needed to meet current and future demand for services.
However, the size and complexity of the workforce challenge means it will require concerted and sustained action across the system on workforce planning, pay, training, retention and job roles. While guidance from NHS England and NHS Improvement describes the NHS’s role in developing ‘one workforce’ for each integrated care system (ICS) and looks to support local discussions on creating system-wide arrangements, it is not clear that the capacity or skills exist at ICS or regional levels to take this forward.
High-quality leadership is essential to developing cultures that support staff and improve care for patients. There are countless examples of compassionate leadership across the NHS, however, recent reports have highlighted the prevalence of bullying, harassment and inequalities demonstrating how these, coupled with challenging working conditions and long hours, contribute to staff burnout. To improve retention and make the NHS a better place to work, there is a need to develop collective, compassionate and inclusive leadership and supportive teamworking that values staff and meets their core needs for autonomy and control, belonging, and contribution and effectiveness.