“There is a workforce gap... which is creating an unsustainably high level of vacancies, work pressures and potential risks to patient care.”
NHS Pay Review Body (2018)
The English NHS’s 1.4 million staff account for most of its budget, are crucial to everything the service does, and determine the quality of the care it provides. Managing a workforce of this size is inherently complex, requiring accurate forecasting of how many staff are needed and policies aligned to recruit, train and retain staff accordingly. The task is made all the more complex by the evolving nature of health care and the need to respond to the changing health needs of the population.
Yet the workforce has frequently been either neglected or treated as an afterthought in NHS strategic policies and plans. Report after report identifies deficits in workforce planning at local and national levels (House of Lords, 2017; Boyle and others, 2017). For example, a parliamentary committee recently noted that its members:
“are concerned by the absence of any comprehensive national long-term strategy to secure the appropriately skilled, well-trained and committed workforce that the health and care system will need over the next 10–15 years. In our view this represents the biggest internal threat to the sustainability of the NHS.” House of Lords (2017)
We identify here three lessons that can be drawn from this rather poor history.
You can’t change the model of care without changing the workforce to support this
“We can design innovative new care models, but they simply won’t become a reality unless we have a workforce with the right numbers, skills, values and behaviours to deliver it.” NHS England (2014)
Health policies and guidance that suggest changes in the model of care will not be successful unless they explicitly consider the workforce implications, both in terms of numbers and skills. This was clearly acknowledged in the 2014 Five Year Forward View. Yet two-thirds (30/44) of the Sustainability and Transformation Plans (STPs) produced in 2016 to make this national vision a local reality contained no detailed workforce plan to ensure the right staff would be there to deliver on the service changes they outlined (Boyle and others, 2017).
History is littered with examples of what can happen when the workforce is forgotten. In 2016, a parliamentary committee concluded that “no coherent attempt has been made to assess the headcount implications of a number of major policy initiatives such as the seven-day NHS” (Public Accounts Committee, 2016). As a consequence, progress on seven-day services, a flagship manifesto policy of the last government (Conservative Party, 2015), has been slow and patchy.
But perhaps the starkest examples are the failed attempts to shift care outside of hospital. In 2006 the Department of Health published Our health, our care, our say, which set out the ambition to shift a significant proportion of care out of hospital. This goal has been reiterated again and again since. Yet, in fact, in the eight years following the 2006 publication, the number of hospital consultants increased by almost a third (32%) compared to just a 5% increase in GP numbers (see chart).
This was, in part, a legacy of the workforce targets set in the NHS Plan which, despite saying that “changes in primary care will help ease the pressure on hospitals”, aimed for nearly four times the growth in the consultant workforce compared with that of GPs (Department of Health, 2000). The imbalance was never properly addressed. As a result, general practice was left under more and more pressure even as services out of hospital were supposed to do more. A Nuffield Trust review concluded that this policy is unlikely ever to be realised unless the staffing picture shifts (Imison and others, 2017).
Build in a margin for error to avoid costly gaps in the professional workforce
Workforce planning in England has traditionally tried to land “a jumbo jet on a pin” (Dickson, 2007) – it has aimed for exact numbers as targets for staffing and recruitment rather than recognising the uncertainty in supply and demand for staff. Moreover, national bodies have actively sought to avoid delivering an oversupply of staff. In addition, in recent years, workforce plans have been driven by financial plans which have consistently underestimated expenditure and, therefore, actual demand for staff.
Predicting the exact demand for, and supply of, staff is inherently challenging, with a large degree of unpredictability. Factors outside the ability of the NHS to control or predict have had a huge impact. For example, the EU referendum vote and new language tests for nurses meant the numbers migrating to the UK fell by thousands year on year (The Health Foundation, 2018), while the Francis report into failures at Stafford Hospital meant demand for nurses jumped as hospitals tried to return to a safer level (Buchan and others, 2017).
However, history shows that the financial and quality implications of an undersupply are not the same as for an oversupply of staff. For instance, in 2017/18 trusts spent £5.4 billion on temporary staffing, much of which could be eliminated with sufficient supply of permanent staff (NHS Improvement, 2018). The implication, given the difficulty in hitting a precise target, is that policymakers should err on the side of an oversupply.
Recent history also suggests a pervasive optimism bias. Forecasts have tended to overestimate the number of staff that will be available, and underestimate the number that will be needed. This latter phenomenon is, in part, due to workforce plans being linked to agreed financial plans, which tend to overstate likely cost reductions. For example, in 2012 the NHS forecast that the demand for adult acute nurses would fall by over 6,000 staff to around 169,000 by 2018. Subsequent forecasts suggested this was a vast underestimate of demand: a year later the NHS uplifted its prediction for demand by some 10,000, followed by more than a further 14,000 by the time it made its forecast in 2014. In reality, even by 2015, the actual level of demand had risen above this higher prediction (see chart).
The underestimate of the future demand for adult acute nurses was compounded by overly optimistic predictions on the supply of staff. In 2015, Health Education England’s supply forecast was for between 181,000 and 193,000 by 2018. In reality, the most recent count of adult nurses – 179,000 – is below even the ‘worst case’ scenario.
The costs and benefits of contractual changes are often not as expected
Under the pay modernisation programme of the early 2000s, the Department of Health succeeded in getting a vast number of staff on to new contracts. However, the experience of the development, negotiation and implementation of these contracts offer some key lessons for the future.
The NHS Plan
The NHS Plan, a 10-year strategy for the health service published in 2000, outlined significant changes to how the NHS was to be organised and outlined the need for more and better paid staff using new ways of working. The Plan recognised that such reforms would require ‘pay modernisation’. This resulted in three new contracts, introduced in 2003 and 2004, covering consultants; general practice; and, under the Agenda for Change contract, nurses, other health care professionals and infrastructure support staff.
The first is that the effect of financial incentives can be hard to predict. In the first three years GP services cost £1.76 billion more than was expected when the contract was negotiated. One of the main causes of the overspending was the failure of the Department of Health to accurately predict how well practices would perform against the new Quality and Outcomes Framework (QOF), which paid them extra for meeting quality targets (National Audit Office, 2008).
Secondly, where the key parties involved are not aware of goals or not incentivised to meet them, changes might fail to have the impact hoped for. For example, the Department of Health’s business case in 2002 estimated that Agenda for Change would result in net savings over the first five years of at least £1.3 billion. However, the Public Accounts Committee deemed this to have been unrealistic as trusts and staff were not required to achieve any efficiency improvements as part of the implementation (Public Accounts Committee, 2009). Similarly, a survey suggested that only half of NHS trusts were clear about the aims of the consultant contract (National Audit Office, 2007).
Lastly, contracts need to be based on an accurate understanding of current working practice. Prior to development of a new consultant contract, research suggested that consultants were working on average between 50 and 52 hours a week. However, the Department of Health modelled the new contract based on a diary exercise from 2000 which suggested that consultants were working only 47 hours. Factoring in the intention to decrease consultants’ workload, funding of the new contract was then based on consultants working an average of 43 hours a week. This assumption proved to be an underestimate: consultants worked more and therefore cost more, with the National Audit Office (2007) finding that 84% of trust chief executives thought the resulting costs were not covered by the money available.
Clinical grading was introduced in 1988 with the intention of rewarding nurses for providing front-line care and offering an alternative career development route to moving into management or education. The system moved all nurses on to grades with pay dictated by tasks performed rather than rigid job titles.
Reforms to nurse pay a decade earlier also highlight that pay reform is difficult to define, difficult to cost, and inherently challenging. The clinical grading framework introduced in the late 1980s allowed for different interpretations of tasks such as 'supervision' and 'being in charge'. The result saw employers try to manage the spiralling cost of having nurses in more senior grades than they had envisaged, while individual nurses sought to ensure they were not missing out on the pay increases that some of their peers were receiving. As a result, around 100,000 decisions on grades were contested and it took until 2003 for all of the claims to be dealt with (O’Dowd, 2008).
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Buchan J, Seccombe I, Gershlick B, Charlesworth A (2017) In short supply: pay policy
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Health Foundation (2018) Large drop in the number of new nurses coming from the EU to work in the UK. Chart. https://www.health.org.uk/chart-large-drop-number-new-nurses-coming-eu-work-uk
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NHS Improvement (2018) Performance of the NHS provider sector for the year ended 31 March 2018. https://improvement.nhs.uk/documents/2852/Quarter_4_2017-18_performance_report.pdf
NHS Pay Review Body (2018) NHS Pay Review Body: Thirty-First Report 2018. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/720321/NHSPRB_2018_Report_Executive_Summary_Web_Accessible.pdf
O’Dowd A (2008) ‘Nursing in the 1990s’. Comment, Nursing Times. 12 May. www.nursingtimes.net/nursing-in-the-1990s/1330344.article#
Public Accounts Committee [House of Commons Public Accounts Committee] (2009) NHS Pay Modernisation in England: Agenda for Change. TSO, London.
Public Accounts Committee (2016) Managing the supply of NHS clinical staff in England. https://publications.parliament.uk/pa/cm201516/cmselect/cmpubacc/731/731.pdf
Palmer W and Imison C (2018) "Lesson 3: Don’t treat the workforce as an afterthought", Nuffield Trust comment. https://www.nuffieldtrust.org.uk/news-item/lesson-3-don-t-treat-the-workforce-as-an-afterthought