Closing the gap: key areas for action on the health and care workforce

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Staffing is the make-or-break issue for the NHS in England. Workforce shortages are already having a direct impact on patient care and staff experience. Urgent action is now required to avoid a vicious cycle of growing shortages and declining quality. The workforce implementation plan to be published later this year presents a pivotal opportunity to do this.

In this joint report with the Nuffield Trust and the Health Foundation, we set out a series of policy actions that, evidence suggests, should be at the heart of the workforce implementation plan. We focus on nursing and general practice, where the workforce problems are particularly severe. There are no silver bullets, but these are high-impact policy actions which, if properly funded and well implemented across the NHS, would over time create a sustainable model for general practice and help to eliminate nursing shortages. They will require investment of an extra £900 million per year by 2023/24 into the budget of Health Education England.

Explore the report

Use the contents to navigate to a specific chapter or take a look at the key messages below.

Increasing nursing numbers

  • On current trends, in 10 years’ time the NHS will have a shortfall of 108,000 full-time equivalent nurses. Half this gap could be bridged by increasing the number of nurses joining the NHS from training. This would require 5,000 more nurses to start training each year by 2021, reducing the drop-out rate during training by a third and encouraging more nurses to join the NHS once they qualify.
  • To achieve this, we recommend that the government significantly increases the financial support to nursing students with ‘cost of living’ grants of around £5,200 a year on top of the means-tested loan system. Further action, including covering the costs of tuition fees, should be taken to triple the number of nurses training as postgraduates. This is essential to address the financial problems trainee nurses face while studying that deter students from starting a nursing degree and are a factor in the high drop-out rate (attrition) during training. The availability and quality of clinical placements is another key priority for reform as part of a wider strategy to increase the numbers completing training.
  • While policy action and investment could transform the outlook for nurse staffing shortages over the next decade, the prospects until the end of the parliament are much more worrying. To avoid nurse staffing shortages acting as a major brake on the delivery of the NHS long-term plan, international recruitment will need to play a substantial role in the NHS workforce implementation plan. We estimate that an additional 5,000 internationally recruited nurses will be needed each year until 2023/24.

Team-based general practice

  • National efforts to increase the number of GPs need to continue, but the stark reality is that even with a major focus on increasing the number of GPs in training, we project the numbers of GPs in the NHS will fall substantially short of demand and of the government’s target of an additional 5,000 GPs.
  • The only way forward is to make substantial progress towards a new model of general practice with an expanded multidisciplinary team drawing on the skills of other health care professionals. The new GP contract and the NHS long-term plan support this shift, but the key issue is the speed, consistency and quality of implementation across the NHS. The workforce implementation plan needs to clearly outline how this model will be rolled out safely across the country, and at pace.

Making the NHS a better place to work

  • Beyond the specific actions on nursing and general practice, the workforce implementation plan must focus on how the NHS can become a better employer and a place where staff want to build a career. Building on what already exists in the NHS Constitution, the NHS needs an explicit statement of the universal ‘offer’ to staff – including, but not limited to, their legal rights. It should cover fair treatment for all staff but also what staff can expect in terms of pay and opportunity, continuing professional development, work–life balance and proper appraisal. Other steps to boost retention include more focus on supporting staff who are at the beginning and end of their NHS career. Meaningful action on equality and inclusion must be at the heart of this, building on existing initiatives, so that all NHS organisations have concrete action plans to tackle discrimination and inequality.
  • Pay and reward are tangible signs of how far staff are valued and have a clear impact on retention. The current Agenda for Change pay deal runs until 2021. Beyond then pay in the NHS will need to continue to rise in real terms in line with wider economy earnings.
  • Alongside pay, the NHS pension scheme is frequently cited as a barrier to retention, particularly for more experienced staff, who have been impacted by changes to wider pension policy. In many instances these staff would like to stay. The NHS should urgently look at options for more flexibility, similar to the local government pension scheme.
  • Rapidly changing patient needs and technological advances mean all frontline staff will need to adapt and enhance their skills. Current progress is much too slow. The failure to investment in the development of existing staff also sends a powerful, negative signal about the NHS’s commitment to its people and their career development. A fourfold increase in the current workforce development budget is required to accelerate change and support people.
  • Compassionate and inclusive leadership will be key to successful implementation of many of the recommendations we set out. The national arm’s length bodies also need to deliver on their pledges to change their behaviour and approaches.

Social care

  • We are highly aware of the close interrelationship between the NHS and social care. Addressing shortages in the NHS must not come at the expense of the already stretched social care workforce.
  • We therefore recommend a series of policy changes to improve recruitment and retention in social care, including a sector-specific route for international migration that works for social care post-Brexit, as current proposals will not be adequate. More fundamentally, we recognise that workforce challenges in this sector reflect its poor pay, terms and conditions. This can only be addressed by government – first through additional funding in the 2019 Spending Review, and in the longer term through comprehensive reform of adult social care funding

Workforce planning in the future

With policy action and investment, our analysis suggests the workforce challenges facing the NHS are not inevitable. But the cause of our current workforce problems goes deeper than individual policy failures. The workforce has not been a policy priority: responsibility for it is fragmented nationally and locally, the information the NHS needs to understand and plan its workforce remains poor, and the NHS has not invested in the leadership capability and skills needed to manage the workforce effectively. The government cannot continue to view education and training as an overhead cost to be minimised. The forthcoming NHS workforce implementation plan needs to address not just specific policy areas but also the roles, responsibilities, skills and capabilities needed across the system for more effective workforce planning. But above all, it is a plan that needs to be properly funded.

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Related content



Digital Communications Assistant,
The King's Fund
Comment date
15 January 2021

Hi Marie,
Thanks for getting in touch. The workforce implementation plan has been renamed as the People Plan and published on the NHS England website. You can find it here:

Hope that's helpful!

Best wishes,


Marie Urhahn

Student, Heidelberg University (Germany),
Comment date
14 January 2021

I'm preparing for a presentation about the NHS and I was wondering if the workforce implementation plan has already been published. I couldn't find it during my research.
Thanks in advance for helping me out.
Kind regards

Nikki Smiton

The King's Fund
Comment date
14 January 2021

Good morning Geraldine! I am sending you a link to our long read on NHS hospital bed numbers which I hope answers any questions:
However, you are welcome to come back to us if you need anything further - you can email the Library enquiry service here:

Geraldine Martinsen

Comment date
13 January 2021

Hi there can someone please tell me why there are close to 1.7 million people working in the NHS and only 165,000 beds in the whole of the UK?

Fed up nurse

Community mental health nurse,
Comment date
17 September 2019

No mention of bullying which is rife in the NHS, not just by managers, but by peers and staff. Also, why are the majority of the authors of this report male in a female dominated profession? Childcare, flexible working etc are big issues for nurses. Plus 12 hour shifts increase the risk of heart disease by 60+ per cent so I refuse to do them, and that significantly reduces the wards/units I can work in. My health's been damaged enough in this profession. Try doing a long shift on a ward with underfloor heating with no breaks, drinks or even time to go to the toilet. One HCA tipped me off to take ibuprofen a couple of hours in to reduce your feet swelling. Then we have ridiculous levels of paperwork, why do I need to spend an hour completing one risk assessment when I used to be able to provide the same information in 20 minutes? I'm an experienced, skilled and versatile nurse, who is leaving the NHS and I'm not even getting an exit interview, there is no interest in improving staff retention. Oh, and try paying mileage properly instead of ripping nurses off, and maybe offer free parking on a site where you're not going to get mugged/attacked. One of my a&e colleagues leaving work was brutally beaten by a patient's family because their aged relative had died, and someone had to be blamed. Not reported in the press of course.
Finally, I'm leaving a team with 28 vacancies out of 35 staff. The few staff not leaving are on long term sick. Recently I've been covering 1000 community mental health patients as the only nurse. That leaves me professionally exposed. Why would I stay? I'm paying to retrain to leave the profession entirely, and in the meantime will do agency work. And yes senior management, the unions and the cqc know. It will be months before the cqc report comes through.

Nick Pahl

Society of Occupational Medicine
Comment date
21 April 2019

We believe that all NHS staff, not just doctors, should have access to quality-assured Occupational health support, including clinical leadership from an accredited specialist in Occupational Medicine. NHS Employers recommends that OH services should enable and facilitate the following:

Prevention of ill health caused or exacerbated by work.
Timely intervention, including early treatment of the main causes of sickness absence in NHS staff.
Rehabilitation to help staff stay at work or return to work after illness.
Fitness for work assessments to support organisations to manage attendance and ill health retirement.
The promotion of health and wellbeing using work as a means of improving health and wellbeing, and using the workplace to promote health.
Training to promote staff health and wellbeing to managers.

Can the authors reply why a Occupational health was not highlighted?

Chris Sterry

FLASh (Families Lobbying and Advising Sheffield
Comment date
25 March 2019

As usual The King's Fund have undertaken an indepth analysis of the situation within Health Care, but not only with regards to the Health Care Workforces, but also the inter-relationship of workers in Social Care. There has been some funding within health, but not of sufficient amounts, but in Social Care this is not so, due to the reductions in funding to all Local Authorities, which in turn is related to the funding specific in Social Care. One should not be part funded by some increases while the other is not only not seeing someincreases in funding, but reductions in an ever increasing Market Need.

Are the Government listening or is all attention with Brexit. Even if it is Social cannot be left to founder, as this will have great implications to Health Care.

As a means of communication the Petition - Pay all employed carers the Living Wage, as been created, which if it is noticed by Government and appopriate actions taken, it could have some part of a solution to the ever increasing crisis within Social Care and its relation to Health Care.

So please see the following

You may be aware that there is a crisis within Social Care, an even greater crisis than that within health. This because a crisis in Social Care will have a great impact on health making the health crisis even greater.

Please could you consider supporting the Petition – Pay all employed carers the Living Wage. Petition link

I am involved in this Petition project based on the Care Workers within the Care Industry.

This industry is in crisis, as is the Health Service, but within Social Care this crisis is even greater. This in turn will create even more pressure on all aspects of the Health Service. Therefore, action is needed to minimise the Social Care crisis and pay paid carers a reasonable wage is one of these actions, so there is now a petition.

Please, therefore, could you support the Petition - Pay all employed carers the Living Wage Flash, (Families Lobbying & Advising Sheffield), a group of family carers of relatives with Learning Disabilities and/or Autism in Sheffield are concerned at the state of Social Care, not only in Sheffield, but throughout the UK.

We all know that there is a major crisis in Social Care not just in Sheffield, but all over the UK. This is in a large part due to the lack of persons willing to come into the Care Industry, of which the low pay is a prime factor.

Parliament are aware and have formed a Cross Party Committee to look at funding, recruitment and pay for Care Workers in the Care Industry.

The Government currently have a recruitment campaign for the Care Industry ‘Every Day is Different’… .

However, there is no mention of pay.

Please therefore, could you consider the following #pay #employed #wage #funding #government #serviceproviders #living

Could you look at promoting the Petition - 'Pay all employed carers the Living Wage, created by FLASh (Families Lobbying & Advising Sheffield).

Petition link

Please sign this Petition, however, until you then click the signature verification link in the resulting email your signature will not be valid and will therefore not count re supporting the Petition cause.

More information!Aq2MsYduiazglWxA60JAY_2cpvN8

We need this Tory Government to end Austerity Cuts to Local Authorities and then increase the Grants to these Authorities so they can fund Care Service Providers to be able to pay their care workers at least the Living Wage.

Please also see the HFT report 'Sector Pulse Check',!Aq2MsYduiazglXuM7Duz6HOYXvsv

The care sector needs to recruit 128,000 new workers each year to replace those who retire or leave, new research has found.

The study (…) by the Care Association Alliance and law firm Royds Withy King found that one in three workers leave the sector every year – the highest turnover rate of all job sectors in the UK.

If the Petition attains 10,000 signatures, the Government will respond and if 100,000 signatures, it will be considered for debate in Parliament.

Please support and share with your work colleagues, family & friends, Social Media, MP and Local Councillors.

For any further information Chris can be contacted on

Thank of you

Chris Sterry
Vice-chair of FLASh

Cidalia Eusebio

Itu nurse,
Comment date
22 March 2019

Thank you for this in depth analysis of the nursing workforce. As a nurse interested in this topic I am quite concern with the future of the nursing workforce. Analysing some of the facts I could add some further suggestions that I think would need to be consider :
Specialized areas of nursing: there are areas within nursing (ex: intensive care, neonates, emergency care and others) that required much more clinical time and experience plus specialized courses to progress to a band 6. Shouldn't those specialties areas be recognized differently?
From my experience working in intensive care I also noted that as soon you get a band 6 job ( within 3-4 years in itu or even more) there is not clinical development towards reaching a band 7 level (except if you follow the management or educational role ) and most of the staff leave for other band 7/6 positions within a year. There is no protected time for us to develop other areas that are important within nursing such us:research, education, quality improvement, ppi, innovation projects.
There is also a considerable number of collegues deciding to move abroad to countries such us: USA, Australia and New Zealand due the financial compensation.
More detail structured pathways in the nursing career are necessary.
Other strategies need to be implemented to guarantee that students keep choosing nursing as a profession (free nursing studies for NHS healthcare assistants as long as they remain in the NHS for 5 years and other possibilities )
Further understanding of nursing workforce is needed in order to guarantee that future strategies will be implemented successfully. I am happy to discuss this topic further.

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