All the main parties want to increase NHS staff numbers and there have been some eye-catching pledges – 50,000 more nurses and 6,000 more GPs promised by the Conservatives, real-terms pay increases every year for NHS staff by Labour, and a patient premium to attract clinical staff to shortage areas from the Liberal Democrats. All three parties intend to improve financial support for student nurses.
It is good news that the scale and depth of the NHS workforce crisis is now acknowledged across the political spectrum, and it is right to have ambitious plans to tackle it.
But pledging numbers is the easy part. How do the different proposals stack up?
The Liberal Democrats have said they will end the GP shortfall by 2025, while there is a pledge of 6,000 more GPs from the Tories and 5,000 more GP training places from Labour.
There is already an NHS England commitment dating from 2016 to increase the number of GPs by 5,000 by 2020. But so far GP numbers have flat lined, so the new ambition to secure thousands more family doctors over the next parliament seems fraught with difficulty.
The number of permanent, fully qualified full-time equivalent GPs declined between September 2015 and June 2018 and has only recently begun to recover. The latest workforce figures (for September 2019) show 34,862 GPs – only 400 more than four years ago. If you look at the total number of GPs, the picture looks a little healthier at first glance, with numbers rising by 4,000 over the same period. The disparity stems from the substantial proportion of GPs who choose to work part time, such that you need to employ four GPs to get the equivalent of three full-time practitioners.
In our joint work in March with the King’s Fund and Health Foundation, we argued it simply will not be possible to bridge the gap in GP numbers over the next five years. We identified that pharmacists and physiotherapists will be important in compensating for the shortage of GPs, as well as bringing specialist skills in medication and muscular-skeletal problems. The last decade has seen a five-fold increase in the number of pharmacists and double the number of physiotherapists working in general practice, but numbers remain tiny – 1,249 for pharmacists and 47 for physiotherapists.
Verdict: All the parties’ ambitions are a huge stretch.
There is a reported 40,000 shortage of nursing posts in trusts, so Labour’s ambition to recruit 24,000 more nurses and the Conservative aim to recruit or retain 50,000 more nurses are both laudable. The Liberal Democrats commit to a national workforce strategy – less eye-catching but arguably more strategic.
To fulfil their pledges, all three parties will rely on a mix of increasing student numbers, supporting and retaining staff better and recruiting from overseas.
Question marks hang over all three approaches. While the NHS could do more to keep staff in post, and Labour’s pledge to increase pay would undoubtedly help, the major factors affecting nurses’ decisions to leave the profession are stress, unsustainable workloads and feeling unable to provide the right quality of care.
Training places could be expanded, and we were pleased to see that our recommendation of providing £5,000 per year in cost of living support for student nurses has been taken up by the Conservatives, with full restoration of student bursaries promised by Labour. The Liberal Democrats have said they will restore bursaries initially for student nurses training in mental health and learning disability – reflecting the extreme fall in their numbers since bursaries were abolished in 2016.
Between 2000 and 2005, nursing numbers grew by 46,500. That unprecedented achievement would have to be repeated and exceeded to hit a 50,000 target in one parliament – bumping along well below the 10,000 required annually is much more typical. In the last decade, nursing numbers have grown by only 3.5 per cent.
So overseas recruitment is not just an option, it is an absolute necessity. We have argued that at least 5,000 nurses need to be recruited each year, for the next five years, to help close the gap. The Liberal Democrats would cancel Brexit – preserving freedom of movement and ensuring that staff could continue to come here from the EU. But it remains “completely unclear” how the Conservatives’ NHS visa policy to continue to hire doctors and nurses from abroad, and Labour’s exemptions for NHS trusts, would impact the health service.
Verdict: Laudable but implausible.
Where should the extra NHS staff work?
All main parties intend to give greater priority to mental health services and to move care out of hospital and into the community where possible. This implies both a growth and a rebalancing of the workforce outside hospital, which presents its own challenges.
A 2018 plan to recruit 20,000 more mental health staff has been spectacularly unsuccessful to date. Although there are 2,000 more community mental health nurses than a decade ago, there has been a fall of 5,000 among other mental health nurses, and there are very high vacancy levels for both nursing and medical staff.
Within community settings, the picture is bleak. Overall community nurse numbers have fallen 13 per cent since September 2009, down to 35,000. The number of district nurses, described by the Royal College of Nursing as an “endangered species” in 2015, has virtually halved in the last decade. It is good to see a Labour commitment to recruit 4,500 health visitors and school nurses as NHS health visitor numbers are back below the level recorded ten years ago, while school nursing, always a small specialty, has in that time lost a quarter of its staff.
Verdict: Scarce staff are currently in the wrong place for the future.
The prospects of the NHS and social care are completely intertwined, and neither looks rosy. The staffing shortages in social care are at least as severe as those of the NHS, and set to worsen under Brexit and with the points-based migration system envisaged by the Conservatives.
Paradoxically, all parties are pledging to reform social care and extend its reach to more people. We calculate that this will require an additional 90,000 social care workers, and that special migration arrangements will be needed to maintain existing services and extend them.
Labour acknowledges the 100,000 vacancies in social care, and plans to offer better, fairer contracts to home care workers. They also want to set up interdisciplinary working between primary, mental health and social care services. The Liberal Democrats have the clearest vision of the workforce steps needed to improve social care – they plan to create a new professional body for care workers with a clear career pathway, continuing professional development and better pay. The Conservative manifesto does not address the social care workforce at all.
Verdict: No party has established how many social care workers are needed to deliver their ambitions for this sector.
Johnson F (2019) “More, more, more: do election pledges on the NHS workforce stack up?” Nuffield Trust comment.