Plan B: What the forthcoming NHS workforce strategy should not ignore

The NHS published its first long-term workforce plan in 2023, which detailed plans to grow the workforce while also retaining more staff, reform ways of working, and improve workplace culture. While the need for such a plan was evident, there were some important lessons on how realistic its aims were, and some key assumptions were missed. Not even two years later, the government’s 10 Year Health Plan rejected the growth in staff numbers outlined in the workforce plan, calling it a ‘fiction’. A new 10-year workforce plan is expected to be published next spring.

Where the previous workforce plan assumed that delivery of NHS services would remain largely the same (but at a larger scale), this government wants to reshape the way the NHS delivers care and align a new workforce plan with its priorities for the health service. These include moving care from hospital to community, from analogue to digital, and shifting the focus from sickness to prevention. All of these have implications for where and how staff work, and will inevitably influence any modelling the plan contains. This long read sets out some priority areas to consider for the next iteration of the plan.

Focus on making the domestic training pipeline more efficient

The 2023 plan detailed substantial expansion to domestic training, including a doubling of medical school places and a near-doubling of adult nursing trainees. We expect increases to be more modest in the new plan. Scaling back is sensible – indeed, some of the aims of the old plan are already falling behind (see chart below). However, this should not happen to the point where the new plan risks forecasting an undersupply of staff, otherwise the NHS may encounter the problem of inflating an already expensive temporary staffing bill.

We have long argued that there should be a focus on reducing attrition during training, promoting participation in the NHS, and reducing staff leaving early on in their careers. Our previous work has highlighted the scale of these challenges – and the incoming plan should understand the differences between professions, as well as strategies for reducing attrition and early-career leavers to a more desirable level. Getting to grips with these issues would provide near-immediate benefits to the NHS – unlike training new staff, which has a time lag – as well as giving a better return for the taxpayer on the £5 billion investment into clinical training.

The new plan must also suggest ways to appropriately set up clinical placements and training capacity to provide more experience of working in community settings. Ambitions to move care out of hospital are not new, but have previously fallen short, in part by failing to properly consider plans for the workforce. While there is recent work on what demand for community services could look like, the workforce plan will need to invest in staff that can actually deliver it – one key challenge being to reverse the fall in district nurse numbers. In addition, the next phase of the medical training review should describe how training programmes can be redesigned around providing care closer to home. 

We don’t know enough about retention

Retention of NHS staff will continue to be a challenge. While some churn of staff is inevitable (due to retirement, for example), there needs to be better routine data detailing why staff leave the NHS prematurely, and where they go next. This is inadequately understood, yet data fields already exist in electronic staff records that could be better completed, meaning valuable insights that could help design better interventions are being missed.

We found an apparent link between progression and retention. Around one in five nurses leave NHS hospital and community services within the first two years, compared to one in 10 midwives. Of the nurses that stay, nearly two-thirds (64%) remain at Band 5 after two years, but only 8% of midwives remain at the same level, with over three-quarters (78%) progressing to a Band 6. The exact reasons for these staff leaving remain unclear, but this risk should be appropriately accounted for in the modelling, given that lack of career progression is well-evidenced as a factor affecting retention.

Research from other commentators established that sickness absence plays a significant part in the likelihood of staff leaving their role – both for physical and mental health reasons. Local exercises to help identify those at a higher risk of leaving can be carried out too, like the analysis undertaken at Medway NHS Foundation Trust – electronic staff record data held by trusts can be hugely valuable in predicting those most at risk of leaving.

Don’t forget about the international workforce that has already been recruited

The NHS has long relied on overseas staff to fill workforce gaps. Indeed, the previous Conservative government used this as a key lever to achieve its flagship ambition of increasing the number of nurses – the biggest clinical staff group – by 50,000. 30% of all nurses working in the NHS in England now have a non-UK nationality (up from 15% in 2009).

Now, the 10 Year Health Plan states that it will reduce international recruitment to less than 10% of all joiners to the NHS workforce. This is highly ambitious: even throughout the likes of Brexit, Covid-19, and more recent changes to immigration rules, the proportion of non-UK nurse joiners to the NHS remains far above this level (see chart below), though it has fallen in the last year.

The increasing proportion of non-UK leavers (most notably, nurses from India, the Philippines and Nigeria) is particularly concerning. There have been recent indications this has been on the rise – and the NHS can’t afford to lose staff unnecessarily in this way, particularly as they are likely to have, on average, a longer length of service (10 years for non-UK and non-EU nurses) than their UK counterparts (eight years). Reducing dependence on overseas staff will be slow, given the time taken to train new staff domestically and how quickly improvements can be made to existing training pipelines. Plans should account for this lag and include realistic scenarios of how gaps will be filled in the short-to-medium term.

How can plans actually translate into getting the staff the NHS needs?

Mechanisms will need to be designed and implemented to start improving the current situation regarding the domestic training pipeline and retaining staff. But little is known about the long-term effects of policies already in place, as we have noted in the case of recruitment and retention premia. It would be wise to get a grip on what is happening elsewhere, such as with the NHS bursary tie-in scheme in Wales and how this has changed patterns of student attrition, participation in the NHS, and early-career retention.

We have previously called for the government to consider a student loans forgiveness scheme for clinical graduates joining the NHS, with fees being written off in return for years of service. Other models could also be considered, such as preceptorships (this could be paid employment during training, for example) or tie-ins (free or subsidised education for students in exchange for commitment to employment). This could be tested and evaluated at a smaller scale, initially targeting areas or settings where staff are most needed.

On the retention side, building on the vision in the 10 Year Health Plan, there should be proactive measures to help staff who are feeling burnt out or are off sick. Developing better return-to-work policies, promoting more flexible working and improved access to support networks may help. On top of this, revisiting the pay framework to allow opportunities for staff to consistently progress earlier in their careers should be considered.

“Show me the money”

The previous government committed to an extra £2.4 billion, but only for the expansion of training places as per the old plan. Other commentators noted that this would not have covered the additional costs of employing and retaining more staff (which would inevitably increase the wage bill), nor had consideration been given to how non-staffing costs, such as the possibility of upgrading capital and technological infrastructures, were expected to change.

This time around, any staffing projections must be in line with the amount of money available for training, pay and retention within the first years of the plan covered by the Spending Review. It is also crucial to fully estimate the additional costs that will be required to deliver the remainder of the plan and provide a range of assumptions where the outlook is uncertain. Not only this, but any policy interventions to help improve the situation should be costed. Knock-on effects to employers must be considered too, such as the job guarantee scheme for new nursing and midwifery graduates, which will potentially mean more posts will need to be funded by organisations that are already cash-strapped.

The NHS is nothing without its staff. While planning the size and shape of the future workforce comes with a large degree of uncertainty, refreshing the long-term workforce plan provides a valuable opportunity to reset the direction and the focus of how to recruit and retain the staff the NHS needs. But the government must confront the reality of what this will cost and not shy away from introducing bold interventions, otherwise meaningful change will remain out of reach.