What we think
The staff working in the NHS are its greatest asset and are key to delivering high-quality care. This has been exemplified more than ever throughout the Covid-19 pandemic with staff demonstrating remarkable resilience and commitment. However, a prolonged funding squeeze combined with years of poor workforce planning, weak policy and fragmented responsibilities have resulted in a workforce crisis. Despite this, there has been no national NHS workforce strategy since 2003.
The pandemic has underlined how staff often work under enormous strain as a result of workforce shortages. The NHS Long Term Plan recognised the need to address this but was not supported by a detailed workforce plan. Since then, a number of reports have highlighted the urgent need for action but this has been limited to stop-gap measures rather than the comprehensive strategy that is needed.
Given the time lag before new staff can be trained, the NHS needs to prepare to recruit at least 5,000 nurses a year from overseas. The NHS has continued to put arrangements for international recruitment in place during the pandemic, but it is unlikely to achieve the scale needed until travel restrictions are lifted. It will also require a supportive immigration policy, building on the recently streamlined health and care visa process and arrangements for mutual recognition of qualifications with other countries.
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 domestically. The government has re-introduced student bursaries to help with living costs and announced additional investment in training places. These measures should help but 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 also encouraging signs that a desire to be part of the fightback against the pandemic may be leading to higher numbers of applications for training places.
It is also important to improve the retention of staff already working in the service, especially with so many staff suffering from burnout and significant numbers, particularly nurses, intending to leave. To do this, the NHS must focus on becoming a better employer, for example by tackling bullying and discrimination, as well as providing an attractive employment offer, including 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. During the pandemic, many former staff heeded the call to return to work in the NHS in its time of need; these staff could present a great opportunity to accelerate progress on improving retention, if the NHS provides the right incentives and support to make them want to stay after the pandemic recedes.
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 NHS is the largest employer in England, with nearly 1.2 million full-time equivalent (FTE) staff working in hospital and community services. NHS hospitals, mental health services and community providers are now reporting a shortage of nearly 84,000 FTE staff, severely affecting key groups such as nurses, midwives and health visitors. 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 (Beech et al 2019). 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.
Unfilled vacancies increase the pressure on staff, leading to high levels of stress, absenteeism and turnover. This has been compounded by the Covid-19 pandemic which has exacerbated long term issues such as chronic excessive workload, burnout and inequalities experienced by ethnic minority staff.
There are some signs that shortages are starting to improve although levels of vacancies remain high and the need to increase the number of nurses and allied health professionals in training continues to be urgent. Britain’s decision to leave the European Union also appears to 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 2,838 in 2019/20, while the number joining fell by 90 per cent over the same timeframe.
As the Care Quality Commission has highlighted, workforce shortages are having a direct impact on the quality of people’s care, while NHS waiting times standards have been routinely missed for a number of years, with the consequences of Covid-19 now exacerbating this.
The size and complexity of the workforce challenge is such that addressing it will require concerted and sustained action across the system on workforce planning, pay, training, retention and job roles. Yet, the response so far has been piecemeal and accountability for improving the situation remains unclear. The NHS Long Term Plan recognised the scale of the challenge and promised a comprehensive workforce implementation plan later in 2019. An Interim NHS People Plan was published in June 2019, but it contained little detail. Despite promises in the Conservative Party manifesto to deliver 50,000 more nurses, 6,000 more GPs and 6,000 other primary care professionals, the full NHS People Plan was not published until August 2020. This was another stop-gap measure; while it contained some welcome measures to support the health and wellbeing of staff and tackle discrimination, it only covered the remaining seven months of 2020/21 and did not include an implementation plan or targets for delivering additional staff, although the government did announce more funding for undergraduate training places. The government has announced proposals for new health and social care legislation, but the workforce proposals included in it fail to address the need for a comprehensive strategy with accountability for improvement.
High quality leadership is essential to develop 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 and harassment, demonstrating how this 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.