Fixing the NHS workforce

The Government recently released its long-awaited plan for solving deep-rooted staffing problems in the NHS. 

The Week takes a look at whether it can deliver. 

Why do we need a workforce plan?

The NHS is not coping. There are now 7.4 million people on NHS waiting lists in England. Nearly 40% of patients spend longer than four hours waiting in A&E (the target is 5%). Hospital wards are almost at capacity; ambulance waiting times are near an all-time high. One of the main causes of these problems is chronic understaffing. There are about 112,000 vacant posts in NHS England, out of a workforce of 1.27 million: nearly one in ten posts are unfilled. On current trends, the shortfall will reach 260,000 by 2037. The UK is already behind most of western Europe in the number of doctors and nurses per people in the population (it has 3.2 doctors per 1,000 people, compared with 3.4 in France and 4.5 in Germany).

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Why is the problem so bad?

According to a study by The King's Fund, the health think-tank, there are a number of underlying issues. Firstly, planning the healthcare workforce is intrinsically difficult. It takes three years to train a nurse, a minimum of eight years to train a GP and about 15 years to train a consultant. While each cohort is being trained, things change: technology, demography, laws (the EU's Working Time Directive, for instance, created the need for about 12,000 new junior doctors). Secondly, the UK has long had a "tendency towards undertraining". The NHS has been understaffed since its very beginning, and has always relied on foreign-trained doctors and nurses to fill the gaps (see box). Training is expensive. It costs more than £60,000 to train a nurse and £500,000 to train a consultant. And critics argue that the Treasury has always focused too much on the upfront costs of training, and not nearly enough on the costs incurred by failure to train enough staff.

What sort of costs are those?

In purely financial terms, NHS England spends a vast amount on temporary staff: £9bn in 2021-22, according to analysis by the Labour Party (the entire NHS England budget is about £153bn). Beyond that, vacancies contribute to a deteriorating work environment, thus making staff more likely to leave and creating a vicious cycle. According to a recent University of Bath report, the main reasons why staff leave the NHS are stress (66%) and shortage of staff/resources (62%).

What does the new plan promise?

The key objective of the Long Term Workforce Plan is to deliver more than 300,000 extra doctors, nurses and other health professionals to NHS England by 2037. The Government aims to achieve this rise in three key ways: training, retention and reform. In terms of training, it aims to double the number of medical school places from 7,500 to 15,000 by 2031; to increase GP training places by 50% to 6,000 by 2031; and to add 58,000 nurse and midwife training places (nearly doubling them) in the same timeframe, including 5,000 mental health and learning disability nurses. Dentistry places are also set to be expanded by 40%. The idea is to reduce reliance on agency staff and international recruitment; in theory, foreign staff would be reduced from nearly 25% of the medical workforce now to 10% in 15 years. There are also plans to expand the role of apprenticeships in the NHS, for both doctors and nurses, and to cut some medical degrees down to four years.

What about retention and reform?

The aim is to keep 130,000 more staff in the health service over the next 15 years (about 170,000 left last year). The strategies for this include reforming the pension scheme to make it easier to retire partially or return to work, and increasing opportunities for professional development. Improving childcare support is also mentioned. The Government promises to reform the NHS and make it more efficient by taking advantage of tech and AI innovation, as well as expanding the use of associate positions (such as nursing associates, physician associates and other support staff).

How will it be funded?

A total of £2.4bn of extra funding has been earmarked for the plan over the next five years, although of course this depends on future governments sticking to the figures promised; it is due to be refreshed every two years. The idea is that the plan will also generate a lot of savings, for example by reducing payments to agency staff. The funding is targeted primarily at training and staff rather than improving infrastructure. The indirect spending from the plan, however (and its biggest commitment) would be in future salaries: pay to increased numbers would "dwarf" the initial £2.4bn, says Nicholas Timmins of the Institute for Government.

What has the response been?

It was cautiously welcomed by NHS employers, unions and medical experts, most of whom believe that a staffing strategy is long overdue. The general consensus seems to be that the plan is impressively ambitious, but doubts remain about the practicalities.

What sort of practicalities?

Will there, for instance, be enough people to take up the training places? While medicine courses are wildly oversubscribed, applications for nursing courses have fallen sharply this year. And will there be enough professionals to train them? Consultants and other training professionals are already in short supply. The elephant in the room, though, is pay, which was omitted from the plan. The author and former NHS doctor Adam Kay said that leaving it out, after months of strikes on the issue, was "borderline laughable". The plan also assumes that the current problems in social care provision, which place great pressure on the NHS, will stabilise. Even so, despite these reservations, the Long Term Workforce Plan represents a move away from the short-termism that has dominated NHS policymaking for far too long.