Green shoots? Charting the progress and challenges of training the NHS clinicians of the future

Growing the domestic supply of NHS staff is crucial in ensuring a sustainable clinical workforce. This has been long recognised but progress in recent years has been patchy. It is therefore welcome news – especially against a gloomy landscape – that recent figures on student intakes and training fill-rates suggest the pipeline of new staff is improving.

But in this blog – which draws on our NHS staffing tracker – we caution against complacency. Certainly some challenges still need overcoming, not least around inequalities and the effect that Covid-19 is having on training. 

Rising numbers in clinical education and training posts

There has been an increase in university applications and numbers starting training for clinical roles, with nursing being one such example. For this latest intake (2020/21), there were 11,000 more nursing applications than in 2019/20, and the number of placed applicants increased by over a quarter (28%) to the highest level since reporting began in 2010/11.

On top of this, nursing degree apprenticeships have doubled and 3,400 people started nursing associate apprenticeships over the same period (albeit they still fell short of the ambition of 7,500 new nursing associates by March this year). As noted in our recent report on mental health nursing, the announcement of additional funding for employers for both new and existing apprenticeships – intended to support the intake of up to 2,000 apprentices every year over the next four years – is likely to make apprenticeships a more viable route for employers.

There was already an intention to boost medical school places for 2019/20 by 1,500 from 2018/19. But due to the chaos surrounding this year’s A-level results day, the government agreed to lift the cap on medical courses for the 2020/21 intake, which saw the highest number of students placed to study medicine to date (see chart).

Further along the medical training path, the proportion of medical specialty training places that are filled has also increased from 2018 to 2020. This increased uptake of training posts by those junior doctors that have completed their early (foundation) years is particularly notable for psychiatry (up by 20 percentage points) and paediatric medicine (up by 15 percentage points), although medical practitioners remain on the Migration Advisory Committee’s shortage occupation list.

Clinical education in a time of Covid

Getting people to join training routes is not in itself sufficient, and there are ongoing challenges to ensure a high proportion complete their course and join the NHS.

Considering that attending university is costly, students rightly expect a supportive and enjoyable educational experience. Covid-19 has already affected university education, with staff having to reshape how teaching is delivered by, for example, moving from face-to-face contact time to a more blended approach of online lectures and classes that students physically attend. And the GMC’s latest annual training survey results show that the pandemic has significantly disrupted the provision of formal medical training.

Reducing attrition and increasing subsequent participation in the NHS may end up being tougher than we now realise, despite the surge in the numbers working in the health service in recent months. Even before these challenges, we highlighted the “leaky” nature of the training pipeline with the issues around attrition and subsequent participation reiterated – with one estimate suggesting that out of 100 adult nurse training places commissioned, only 58 full-time equivalent staff enter the NHS.

There are also risks in terms of future supply of students. According to a survey completed by young people who had considered nursing, one of the reasons why they opted against it was because of working hours and pressure of the job. If anything, the pressure of Covid-19 for those already working in the NHS has led to staff experiencing extraordinary levels of burnout. This may reinforce perceptions that working conditions in the NHS are as bad as prospective students may have feared.

Addressing inequalities in training and education

Despite the recent uptick in numbers in clinical training and education, further work is needed to ensure broad participation in NHS careers. Indeed, only by attracting people from all backgrounds and regions can we ensure sufficient numbers are being trained.

There are some recent policies that seek to reduce inequalities in training and participation, such as introducing new medical schools in areas where it has been historically difficult to recruit doctors, with another aim being to widen the social profile of new students. As described earlier, financial incentives have also been offered for apprenticeships, which generally appear to be popular with older entrants and attract people from diverse backgrounds.

Taking a long-term view

Interestingly, visitors to the NHS health careers website more than doubled during the first wave of the pandemic – suggesting increased motivation in pursuing a career in health care. That said, there are still some underlying issues relating to attitudes towards clinical roles that shouldn’t be overlooked simply because Covid-19 had proved to be a temporary catalyst to promoting careers. For example, we recently highlighted that while many recognise the value of a caring profession, those motivating factors were often not enough to overcome the barriers that exist to entering the profession.

While the increases in numbers going into education and training posts are welcome, there are both long-standing and novel obstacles to ensuring a sustainable domestic supply of clinical staff. The pandemic has reminded the country of the importance of clinical staff and so overcoming those barriers – nationally and regionally and irrespective of the trainee’s characteristics – and building on the positives we have seen is a matter of great importance.