The NHS in England employs 1.5 million people, with employee costs accounting for around two-thirds of NHS providers’ expenditure1. The NHS is the country’s biggest employer and one of the largest employers globally2.
Despite the huge scale of its labour force, it is increasingly apparent that the NHS doesn’t have enough staff to meet demand. Here we lay out the facts – in so far as the existing data allow – on size and structure of the current NHS workforce. We highlight the extent of current shortages and their effect, and outline some of the workforce pressures that lie ahead.
Please note that the latest data in this workforce explainer reflects the staffing levels as at February 2021 and represents a snapshot in time. More up to date information can be found in our staffing tracker, which is regularly refreshed alongside key staffing and training targets for the health service.
1. What kinds of staff make up the NHS workforce?
The NHS is heavily reliant on professionally qualified clinical staff, which account for around half of all employees. Other key staff groups include those working in central functions, dealing with the NHS’s property and estates, and supporting clinical staff.
The vast majority of NHS staff – 1.2 million full-time equivalents – work in ‘hospital and community services’ (HCHS) as direct employees of NHS trusts providing ambulance, mental health and community and hospital services. This group also includes the 19,000 staff that work as local commissioners of health services (clinical commissioning groups). In addition, around 140,000 work in primary care (including general practice, community pharmacies and dentistry)3.
Across NHS hospital, community and primary care settings, there are 160,000 doctors in total and around 350,000 nurses and midwives. These two groups – while large – constitute only just over a third of the total workforce. This highlights the multi-disciplinary nature of the NHS, with its reliance on others such as health care scientists, physiotherapists and occupational therapists.
These figures focus on staff directly employed by NHS organisations including general practice. In addition, these employers will have indirectly employed staff, for example, through paying a company to provide particular services, such as laundry, catering and cleaning. As well as this, some NHS services are delivered by non-NHS organisations, with those that report data on the workforce totalling 56,000 full-time equivalent staff directly employed in independent healthcare providers in England (though this is likely to be an underestimate)4.
2. How diverse is the NHS workforce?
Almost a quarter (23%) of NHS staff are of Asian, black or another minority ethnicity, compared to 13% of all working-age adults in the UK. However, these proportions vary considerably by staff group and staff grade. Across some professional staff groups (namely nurses and health visitors, ambulance staff and scientific, therapeutic and technical staff), Asian, black, mixed and those categorised as any other ethnic minority are less likely to hold a post at Agenda for Change band 6 or above (equivalent to experienced paramedics and clinical psychology trainees) compared to their white colleagues (see chart). This pattern is particularly evident for bands 8 and above (such as paramedic consultants and consultant psychologists), where ambulance staff and nurses with a reported black ethnicity are half as likely to work at this grade, and Asian nurses and those with an ethnicity categorised as “other” were only a quarter as likely to hold senior nurse positions.
There are many other characteristics to consider to ensure that the NHS workforce is sufficiently diverse and reflects the diverse community of the patients it serves – such as age, gender, disability, religion and sexual orientation. These are drawn out in more detail in our forthcoming report on attracting, recruiting and retaining a diverse workforce.
3. What is the overall shortfall in staff in the NHS?
There were around 76,500 full-time equivalent advertised vacancies in hospital and community services alone between January and March 2021. This equates to an estimated shortfall of 6% (around 1 in 16 posts). That said, there is no single, robust data on the level of vacancies in the NHS, with these figures based on aggregated data submitted by individual NHS trusts to NHS England5.
These shortages are distributed unevenly across the country, with the highest percentage of full-time equivalent vacancies in London (8.5%) and the lowest in the North East and Yorkshire (3.9%)5.
In primary care, and against an ambition set in 2016 to increase GP numbers by 5,000 (and, more recently, the Government commitment of 6,000 more GPs by 2024/25), numbers of full-time, fully qualified GPs have fallen by over 1,800 – a decline of 6%7.
4. What do the shortages look like within hospital services?
The number of hospital medical staff grew substantially from 87,000 in September 2004 to nearly 124,000 in February 2021 – a 43% increase. Within that figure, the number of hospital consultants has risen by 83% (from 28,141 to 51,490)8. Nevertheless, hospitals are experiencing difficulties with medical staffing in a number of specialties and locations.
A previous survey from 2019 found that two-in-five consultants (40%) and nearly two-thirds of senior trainee doctors (63%) said that there were daily or weekly gaps in hospital medical cover.9. While we don’t have data on what this looks like currently, any gaps in rotas mean that there are not sufficient numbers of senior medical staff to assure the quality and safety of training, meaning junior doctors may be withdrawn from hospitals, reducing the staffing complement even further. The Covid-19 pandemic has had a significant impact on workloads and working patterns of medical staff, with one in six doctors reporting that one of the main changes from the pandemic was the change in their rotas.
The number of full-time equivalent nurses has fluctuated in recent years but, on average, numbers have increased by less than 1% a year from 2009 until 2020 (from 281,400 to 298,600 in February 2020). However, since the start of the Covid-19 pandemic until February 2021, the number of nurses substantially increased by 11,500 (3.4%).
For specific types of nursing, the trends vary. The number of children’s nurses increased by nearly two-thirds (65%) in the 11 years to February 2021 (from 15,100 to 24,800), while the number of learning disability nurses fell by 41% (from 5,500 to 3,210) over the same period (see chart)10.
In 2015, nurses were added to the list of shortage occupations by the Migration Advisory Committee (a non-departmental public body that advises the Government on migration issues), albeit initially on a temporary basis. This list was refreshed in October 2019, in which nursing still featured as a role experiencing significant shortages11.
Mental health staff
Around 125,000 people are substantively employed by the English NHS to care for people who need mental health services. The largest group of clinicians are registered mental health nurses, but their numbers have been in decline. There was a 5% drop in the number of nursing posts between February 2010 and February 2021. Our recent research12 looked at how inaccurate perceptions and lack of clarity on the roles within mental health services can be a barrier to increasing this workforce.
In 2015, the Migration Advisory Committee added core psychiatry training to the list of occupations experiencing a shortage of staff. The psychiatry specialty training fill rate was only 58% in 2017, but had improved to 100% in 2020. That said, the refreshed shortage occupation list cites all medical practitioners as a profession experiencing workforce gaps.
Psychologists, a key group of mental health staff, have also been added to the list of occupation shortages. Their numbers would contribute to the mental health implementation plan to have an additional 8,130 psychologists and psychotherapists working in mental health by 2023/2413.
In 2017, a significant training plan was published which intends to reverse the decline and expand the numbers of staff working in mental health by 19,000 by 202114. While current numbers of mental health staff seem to have exceeded this aim, there is also an ambition in the 2019 mental health implementation plan for an additional 26,000 staff to work in mental health services by 2023/2413. Our recent report 16 on participation and progression in psychology careers included recommendations for enhancing awareness of different roles and professions that psychology graduates can especially contribute to.
Year-on-year increases saw full-time equivalent ambulance staff numbers rise from 30,000 in September 2009 to 42,300 in February 2021. The main driver for this growth was a 50% increase in the number of paramedics since 2009. However, it is difficult to understand the trend over the same time period for ambulance support staff due to changes in how the data was collected.
Despite the net increase in the workforce, there is still a shortage of ambulance staff, with employers competing with each other to attract scarce paramedics with “golden hellos” and relocation packages.
Historically, ambulance staff have reported negative experiences in the NHS staff survey relative to other staff groups17. This group scored consistently lower on matters of equality, diversity and inclusion; health and wellbeing; morale; and working in a safe environment, amongst others.
Scientific, therapeutic and technical staff
The wider professionally qualified clinical and scientific workforce account for a large proportion of hospital and community staff, with over 153,000 "scientific, therapeutic and technical" full-time equivalents in February 2021. Overall this group has increased by 29% since 2009, although the trend has been inconsistent between professions. For example, while the number of operating theatre staff has increased by 50% and radiography staff by a third the number of chiropody/podiatry staff (those that deal with foot problems) has fallen by 12%18.
Clinical support staff
The clinical support workforce are frontline staff who are typically not registered professionals, but deliver a large proportion of hands-on patient care. Numbers in this group have risen from 280,000 in 2009 to over 370,000 in 2021 – an increase of 31%. Our recent research looks specifically at mental health support staff, where we found that the same promise of good working conditions and training and development to all NHS staff was often not afforded to support staff19.
5. What do the shortages look like for staff delivering care close to patients’ homes?
There has been no progress against the 2019 target set by the UK government to increase the number of GPs by 6,000 by 2024/25. This follows failure to make any headway against a 2016 ambition to increase the number of GPs by 5,000 by 2020. In fact, the data shows that since 2019 there has been a decline of 220 fully qualified, permanent GPs working in England. Previous analysis suggests practices that reported data in more deprived areas have fewer GPs per person on their list than those in less deprived areas. On average there were 1,869 patients on GP lists for each doctor in the least deprived fifth, compared to 2,125 in the most deprived20. Although there are attempts to improve equity in GP supply across the country21, these initiatives must be able to constantly identify and monitor areas with the greatest patient need.
The number of practice nurses has hovered around the 24,000 mark for several years. This equates to 17,000 full-time posts as seven out of 10 practice nurses work less than full time. Over one-third of these staff (35%) are over 55 years old22. In early 2019, NHS England initially committed to fund 20,000 more staff in primary care, including pharmacists, physiotherapists, paramedics, physician associates and social prescribing link workers23; this increased to expanding staff working in general practice by 26,000 by 2023/2424.
Community health nurses
Since 2009 there have been significant falls in the level of nursing in community health services. In particular, the falls over this period are equivalent to over two in five community matrons and district nurses (with numbers declining by 45% between February 2010 and February 2021) and nearly one in three school nurses (29%). Health visitor numbers have also dramatically fallen by one-fifth (20%) in the last three years25. We previously looked at the wider community nursing workforce in more detail highlighting that the trend in these vital workers has varied between the different roles. We still can’t quite be sure exactly what’s going on26.
6. What are the implications of these shortfalls?
Many of the shortfalls in staff are filled (albeit temporarily) day to day. Data based on 50 NHS trusts suggest that in the two years to August 2020, an estimated three in four (76%) registered nurse vacancies and 80% of doctor vacancies were being filled by temporary staff, either through an agency or using their ‘bank’ (the NHS in-house equivalent of an agency).
Even where vacancies are filled there can be negative consequences. While efforts have been made to manage the cost of temporary staff, it can still be a huge drain on overstretched finances. As at the end of 2019/20, NHS trusts reported spending some £3.5 billion on temporary staff27 - up from £3.2 billion in 2018/19. Using temporary staff can also be disruptive to health services and reduce the ability to deliver continuity of care to patients.
However, many vacancies remain unfilled. In such circumstances, the consequences can be even more significant. The independent regulator of health services highlighted that “workforce shortages are having a direct impact on the quality of people’s care. These shortages must be addressed”28. A report published by the Health & Social Care Select Committee highlighted the link between vacancies and staff burnout (which has been exacerbated due to Covid-19 pressures), with overstretched staff taking on additional hours to fill current staff gaps29. It argued that chronic excessive workload will not be tackled until the service has the right number of people.
7. How did we get to this situation?
When the NHS was established in 1948, it was supported by around 144,000 staff30. The trends in levels of staffing throughout the history of the NHS have been variable across time periods and professions. Due to changes in how data are collected over time, piecing together the long-term trend is difficult, but the available information suggests a growth in hospital doctors has been by far the most dramatic and consistent. In 1949, there were 3,300 people per hospital medic or dental staff, but this has declined to approximately 500. The trend in the level of GPs per head of population – as far as we can tell – appears less consistent, with falls in the number of staff in relation to the population in the 1960s and more recently, but with increases in the interim.
Meanwhile, the level of nursing appears to (up until the last year) have been stagnant for some time31. The government’s ambition for 50,000 more nurses over a 5-year period appears to be a challenging goal to achieve, with historical data suggesting that there is no precedent of this level being reached in the last 70 years. That being said, the number of nurses has increased by over 11,000 within the last year alone, which is promising progress.
It has been well documented that, over the last few decades, the demand on the health service has risen dramatically. This, in part, can be attributed to a growing and ageing population, as well as advances in medicine and technology that have enabled a wider range of healthcare services to be provided. In addition, there have been specific pressures to increase staff in response to safe staffing guidelines, and to meet the targets as detailed in key policy documents such as the GP Forward View and the NHS Long Term Plan. Where the NHS has failed to keep pace with the increased demand for staff by managing the inflows and retention of its workforce, gaps have appeared.
A key factor contributing to the shortfalls has been a failure to train sufficient numbers of staff. This has been particularly pronounced for nurses, where there was a large decline in the number starting nursing after the early 2000s32. However, numbers appear to be picking up again, with the most recent data shows that over 23,000 nurses started training in 2020 – an increase of 5,000 since 2012 (when numbers starting training were at its lowest). As well as this, the impact of Covid-19 on NHS staff has not seemed to deter prospective students from applying to study nursing, with applications in January 2021 up by one-third since the previous year.
When domestic supply of staff is insufficient, then the health service has a heavy reliance on international recruitment. Nearly one-in-seven (15%) of hospital and community sector staff were recorded as having a non-British nationality as at December 202033. However, the supply of these staff has fluctuated over time. Higher levels of recruitment have often been driven by national targets and support in response to unforeseen additional demand for staff (such as following the Francis Inquiry and safe staffing guidelines, and, more recently, due to the Covid-19 pandemic).
Conversely, lower levels have been in part due to a shift towards creating a sustainable domestic supply acknowledging ethical concerns about recruiting from less developed countries, more restrictive immigration policies and slower expansion in the number of posts in response to financial pressures32. More recently (as a result of Brexit), nurses who trained in the EU and want to work in the UK are now subject to the same application process as those who trained outside the EU. This has implications, for example, for the fees and the skills and knowledge tests that have to be undertaken for those looking to join the UK nursing register.
Data for the UK as a whole suggest that the number of newly registered nurses from the EEA has plummeted from 9,389 in 2016 to 913 in 2020, though the reverse pattern is seen for those joining the register from outside the EEA – showing an increase of nearly 10,000 over the same period. Numbers of newly registered EEA doctors have slightly increased from 1,981 in 2016 to 2,268 in 2020, but the number of non-EEA doctors joining the UK register has more than trebled (from 3,148 to 10,445).
As well as recruiting new staff, it is also vital to keep the existing workforce. Although the number of nurses leaving the NHS increased every year from 10.5% in 2012 to 11.7% in 2017, the trend has since reversed, with fewer nurses having left in September 2020 than any other year (9.6%).
More discussion on how we have ended up with shortages are included in our 2018 paper on the lessons from history on the workforce, where we argue that the workforce has often been neglected or not prioritised in previous NHS policies and plans, and pick out three key lessons for avoiding such mistakes in future35.
8. How do we compare to other countries?
Comparisons with other countries must be treated with caution due to differences in, for example, geographies, service design, and data. However, it appears the UK as a whole (the level at which data is published) have relatively few staff in key groups compared to other developed countries. For instance, per head of population, the UK has fewer than half as many nurses as Norway (8 nurses compared to 18) and is among the lowest in terms of levels of doctors36. Further discussion about how we compare internationally is available in our international comparison report, which concluded that “the NHS performs neither as well as its supporters sometimes claim nor as badly as its critics often allege”37.
Looking at the four health services in the UK suggests that England is lagging behind for some key staff groups. In particular, while Scotland has historically had more GPs per person – which may be explained, in part, by its rurality, with more GPs required in areas of lower population density – a decade ago England had higher levels than in Wales and Northern Ireland38. However, data for 2018 suggest the NHS in England now appears to have the lowest level of GP staffing of any of the four nations.
9. What is the outlook for the future?
The staff shortages we detail in this short explainer represent a real cause for concern for the NHS. Whereas financial problems can be solved by increasing funding, it is far more difficult to solve workforce ones: when clinical professionals leave, they are not easily or quickly replaced. As a result, we and other commentators argue that the workforce crisis is just as critical as the financial one, if not more so39.
The level of demand for health care is expected to continue to increase, and therefore so will the need for staff. The population in England is expected to increase by a further 11% to 62 million by 204140. We published a report in November 2018 alongside The King’s Fund and the Health Foundation setting out forecasts for the possible demand for future staff, suggesting that the gap between staff needed and the number available could reach almost 250,000 by 2030. Indeed, unless emerging trends in falling retention (for example) are not reversed, the situation could be even worse41.
There is also a threat posed by the ageing demographic of staff for some groups. For example, in the nursing professions there is a large cohort fast approaching pensionable age. 28% are aged between 45 and 54 and more than one in six (17.4%) are aged 55 and over. In midwifery the position is also stark, with four in 10 midwives already over 45 and eligible to consider retirement at 5542.
The NHS is reliant on staff from overseas, putting it in a vulnerable position as continued uncertainty over the impact of Brexit remains. As we highlighted in our March 2019 report with the other health think tanks, “already a net inflow of nurses from the European Union (EU) into the NHS has turned into a net outflow: between July 2017 and July 2018, 1,584 more EU nurses and health visitors left their role in the NHS than joined”32. This was still the case in December 2020, with 600 more nurses from the EU or EEA leaving than joining.
The data we have used in this explainer captures changes to workforce trends that may have been influenced by the government’s response to Covid-19. Whilst we still cannot say with certainty (at the time of publishing) whether the pandemic will exacerbate some of the longer-term issues mentioned above, it’s likely that these pressures will add a further layer of complexity to the challenges the NHS faced before the pandemic hit.
In any case, as with all the levers for supplying and retaining staff, urgent and concerted action is needed if the NHS is to have the number of staff it needs. This is more crucial than ever, given the overwhelming stress and burnout that many current NHS staff have faced during Covid-19 and will likely continue to experience as the health service starts to work through the backlog of patient care that was postponed during the peaks of the pandemic.
Despite this, the main recommendations in our report with the other health think tanks published prior to the Covid-19 pandemic still ring true – reiterating that staffing is the make-or-break issue for the NHS in England, and setting out a series of policy actions that, evidence suggests, should be at the heart of plans to address current and predicted shortages32.
Nuffield Trust, "The NHS workforce in numbers"