Currently, 1.4 million people work in the NHS and a further 1.6 million in social care; together this accounts for one in ten of the working population. Staff will always be the health and social care system’s most valuable resource, yet we enter the new Parliament with significant workforce challenges ahead: many feel undervalued, there is a misalignment between existing ways of working and the needs of patients, and there are problems with attracting and retaining high quality leaders.
Successful workforce planning should ensure that we have the right number of staff with the right skills in the right place at the right time, but this is not currently the case in the health and social care sectors. The workforce has been trained to work within a model based on acute episodes of care, yet the greatest demands on the system today come from people with multiple long-term conditions, many of whom are frail and elderly. They need care to address a multiplicity of mental and physical health challenges, as well as their social care needs. This misalignment is bad for staff – who feel poorly equipped to do the job asked of them – and bad for the people they support, who receive suboptimal care.
Developing more generalist skills in secondary care, more specialist skills in primary care and more resources in primary and community care – to support the growing burden of multiple conditions – would be an important way forward, but we have seen precisely the opposite clinical workforce trends.
Between 2004 and 2014 the number of hospital doctors grew by 44 per cent and whilst the number of GPs per 100,000 head of population in England increased from 54 in 1995 to 62 in 2009, it has now declined to 59.5. Between 2001 and 2011 the number of community nurses also fell by 38 per cent. Nursing and GP vacancy rates are rising and there is a growing dependency on agency staff.
Cuts in social care also mean that the sector is facing growing workload pressures. Poor terms and conditions, coupled with demanding yet sensitive tasks, make it difficult to retain staff. In domiciliary care alone, around 30 per cent of staff leave their jobs each year. By 2025 there could be a shortfall of over 600,000 care workers.
Problems are not confined to the clinical and care workforce. The NHS has well-documented difficulties in recruiting and retaining good leaders. A recent study found that almost a third of hospital Trusts had at least one board-level position that was not permanently filled. This may be related to the complex environment in which Trusts operate: a recent Nuffield Trust analysis on the impact of the Francis Inquiry on hospitals revealed a burdensome culture emanating from regulatory bodies.
Any attempt to address recruitment and retention problems within the NHS must stem from actions that address the complex, top-down, and often blame-centred, culture within which staff work. Tackling this may mean moving away from an overreliance on targets or constant monitoring by regulators and commissioners. It will also require a more coordinated approach to fostering and nurturing talent.
The problems facing the NHS workforce will not be solved by single policy interventions. Some decisions, such as the setting of stringent and high profile targets, like the four-hour A&E waiting time target, may actually make problems worse, in this case leading to an unhealthy and onerous reporting culture.
What’s more, political pledges to recruit a specific number of doctors and nurses, whilst seemingly attractive, may do more harm than good. Unrealistic targets miss opportunities to deploy staff differently and manage gaps in the workforce in other ways. For example, in some places the gaps in the GP workforce may best be filled by pharmacists, nurses and health care assistants, with more active support from secondary care specialists. In others areas, where, say, there are a high number of GPs retiring, more GPs may be a critical part of the solution.
Politicians can help by setting clear strategies and supportive regulatory frameworks for developing a flexible and responsive NHS workforce, including negotiating adequate pay for staff. NHS England’s Five Year Forward View set out a compelling vision for how care models will need to adapt in the future, but this requires big changes in the NHS workforce, which must be driven locally and supported nationally.
This essay was originally written by Candace for Health policy priorities for a new Parliament, a collection of essays published jointly by the All-Party Parliamentary Health Group and The King’s Fund.