In the balance: Lessons for changing the mix of professions in NHS services

The history of the NHS is filled with examples of changes in professions within the service and the balance between them. In fact, the mix of professions within the NHS has been in flux since its inception in 1948, when around four in nine staff were ‘domestic and maintenance’ and only around one in 30 were doctors. More recently, the expansion of nursing associates, advanced practitioners, physician associates, clinical pharmacists and the Additional Roles Reimbursement Scheme (ARRS) in general practice have affected the balance of professions. 

Multiple reasons are cited for seeking to reshape the workforce, including to address staff shortages, financial constraints and changing health needs. But doing so does not guarantee a higher standard of care, better patient experience or improved cost-effectiveness. In fact, if poorly designed and implemented, changes in the mix of staff could increase demand, cost more, threaten the standard of treatment and fragment care. 

This report, commissioned by NHS Employers, first outlines the current context. We then look at past initiatives to reshape the NHS workforce, drawing out some consistent lessons that might be useful today, while recognising that each initiative has its own challenges and opportunities. We conclude our report with recommendations. 

It was not within the scope of the research to question the merits of individual professions or determine the ‘right’ level or balance of new or emerging roles. However, in late 2024, the government announced an independent review of the physician associate and anaesthesia associate professions’ terms of reference, considering the safety of the roles and their contribution to multidisciplinary health care teams. 

The shifting balance of professions within the NHS

The scale of change in the NHS has at times been dramatic. For example, in hospital services, while both professions have grown significantly, the number of nurses per doctor in hospital has fallen from 4.3 in 2000 to 2.8 in 2024. In general practice, the expansion of non-medical roles has caused the ratio of fully qualified permanent general practitioners (GPs) to other clinicians to fall from 1:1.1 in September 2015 to around 1:2.6 now.

The NHS in England appears to have taken skill-mix changes further than most countries and, within the hospital sector specifically, the NHS has one of the broader professional mixes. Other countries have also seen changes in skill mix, with many new roles being developed elsewhere and subsequently introduced to the NHS. While comparisons with other countries need to be treated with caution, there are some interesting differences. For example, England employs more clinical support staff – relative to the number of doctors and nurses – than Wales and Scotland. 

Additionally, England and Scotland seem to have been recruiting more advanced roles in nursing compared with Wales and Northern Ireland. Doctors and nurses account for two in five (39%) hospital staff in England, while in Italy they account for nearly two-thirds (63%) and in Austria they account for almost three-quarters (72%).

The 2023 NHS Long Term Workforce Plan highlighted the workforce challenges facing the NHS, in terms of both numbers and the mix of skills needed. Projected relative increases vary significantly between staff groups. Nursing associates are, by some margin, expected to see the largest relative increase by 2036/37, reaching around 14 times the current level (or over 3% of the clinical workforce, up from 0.4% in 2022). Physician and anaesthesia associates and advanced practitioners are projected to grow to around six times the current level (the former from 0.2% to 0.6%, and advanced practitioners from 0.6% to 2.0%). 

However, in absolute terms, the largest growth across professionally qualified clinical staff is expected for adult nurses, with an increase of around 105,000. But considering the overall size of the NHS workforce and the established professions, the shifts outlined in the Long Term Workforce Plan to 2036/37 will have a relatively small impact on the overall balance of staff groups.

Key lessons on reshaping the workforce

The recent workforce initiatives we looked at for this research each appear to have some distinct opportunities and challenges, given the extent to which they involve new or established professions and the nature of the services that they are being introduced to. Also, the number and balance of staff have evolved in various ways, including through:

• creating new roles (‘innovation’ )
• increasing the depth of existing jobs (‘enhancement’ )
• moving tasks from one profession to another (‘delegation’)
• expanding the breadth of a job, sometimes resulting in the replacement of an individual with someone from another profession (‘substitution’) .

Given this, there is a risk in conflating the different policies and practice on changing skill mix. However, some themes and considerations – discussed below – were consistent in the published evaluations of the initiatives we looked at.

Design, planning and recruitment

Careful design of new and emerging roles is essential. Previous initiatives to introduce roles have often been hindered by employers not having the time or capacity to carefully design the roles within the team, integrate them into wider workforce plans and redesign patient pathways and triage protocols. At times this has led to new and emerging roles being asked to see patients inappropriate for their skillset. A detailed understanding of the skills, knowledge and scope of practice of both existing staff and those being integrated into the workforce is necessary, but ascertaining levels of clinical experience, which vary considerably within emerging roles, has often proved challenging.

Past initiatives have also shed light on additional challenges related to ‘onboarding’, ensuring that the necessary physical infrastructure is in place to accommodate new employees and embedding the cultural change needed to effectively integrate new and emerging roles. More broadly, local clinical, human resource (HR) and business management capacity is crucial for overcoming these design, planning and recruitment challenges.

There are risks that the supply of more staff jeopardises workforce plans. Ambitions around increasing annual education and training intakes – including a doubling of medical school places and nursing associate training places – are bold. However, concerns have been raised that capacity for educational and practical learning opportunities, employers’ demand for and sponsorship of trainees in these roles, and the supply of trainees could be bottlenecks when scaling up certain roles. Evidence suggests that the educational content and experience for those in training for specific roles may not always adequately prepare them for the tasks they will be expected to perform.

Ongoing supervision, management, training and integration

Ongoing supervision, management and training is crucial for the implementation and development of new and emerging roles. However, there have been high-profile shortcomings such as some general practices reportedly employing physician associates without the necessary supervision. Additionally, one study found that a quarter of advanced clinical practitioners did not have access to clinical supervision. National bodies and employers also often overlook the extent of future training and development needs and the potential costs associated with that.

High workloads, difficulty in protecting supervision time, a lack of continuity in line management and insufficient motivation or experience to provide effective supervision have been cited as some of the underlying causes of supervision issues. Certainly, the expansion of the workforce is placing additional demands on senior doctors to educate and supervise. In the survey we carried out for this research, the capacity to supervise physician associates and advanced clinical practitioners was regularly among the top constraints that different groups of respondents mentioned.

However, there are promising lessons regarding the use of peer support and mentoring to contribute to the broader ongoing support and development of those in new and emerging roles.

The integration of new and emerging roles with other professions and effective teamwork are also key. However, some staff can react to the introduction of such roles with challenge and resistance. The role of clinical champions is well established and, in relation to the nursing associate role, a cultural change agent (for example, a practice development nurse) was considered pivotal in embedding and clarifying the role within organisations, educating staff about including the scope of practice, and raising its profile.

Tensions with established professions can stem from concerns about the quality and safety of care provided by the new and emerging roles, but can also arise from a lack of understanding and awareness of the roles, fears of role substitution or replacement and competition between professions for the same limited educational and supervision opportunities. The lack of attention to fairness in pay across professions, with some new roles having relatively high starting salaries compared with established professions, even if their subsequent pay progression opportunities are lower, risks worsening tensions.

Regulation, funding and public acceptance

A lack, or belated introduction, of statutory regulation of some emerging roles, such as physician and anaesthesia associates, has been a barrier to their implementation. This places additional responsibility on staff and employers, who then have less assurance on the suitability of an individual’s qualifications and previous experience. Our survey found that more than three in five doctors, three in five staff in emerging roles and four in five staff in leadership or managerial roles saw regulation and certification requirements (or lack of ) as a constraint to the implementation of physician associates. Since our survey, from December 2024, the General Medical Council (GMC) have taken responsibility for regulation of physician (and anaesthesia) associates.

Central financial salary support, with its clear financial appeal to providers, has been cited as a driver for the expansion of new and emerging roles. But this may be distorting local decisions, as the salary costs that providers meet differ significantly from the total costs, including any central support, from a taxpayer perspective. Such central funding has taken different forms, including national funding to support the training of nursing associates, and various forms of salary reimbursement. 

In general practice, three-quarters (78%) of the growth in staff in general practice over the past five years has been through the Additional Roles Reimbursement Scheme (ARRS), which covers the cost of salaries for additional roles for practices. This means that the effective average annual salary costs for practices to employ an existing salaried GP and a general practice nurse have been approximately £106,000 and £49,000, respectively, compared with £0 for a clinical pharmacist or physician associate (for example) and – due to a separate education and training tariff – £0 for a GP registrar.

Public awareness and understanding of most emerging roles appear to be limited. If a person is to receive care, they need to give their consent to the treatment, which must be an informed decision. However, poor public understanding can undermine this. Previous introductions of emerging roles suggest that having confidence in adequate supervision of the staff member in an emerging role by more experienced health care professionals can increase the likelihood of patients providing informed consent to treatment. Existing literature also suggests that patients are supportive of emerging roles when they can identify a positive impact on the timeliness, quality and personalisation of their care as a direct result of the involvement of an emerging role.

Conclusion and recommendations

The NHS already employs a broad array of staff. The ambition around new and emerging roles is to expand further, although the impact of this on the overall balance of professions is not projected to be vast. Undoubtedly, reshaping the workforce poses challenges, and introducing new roles typically adds complexity and additional effort to integrate and coordinate them accordingly.

A recent paper examining advanced practice nurses across European countries found that successful implementation depended on a tripartite approach between service managers, practitioners and educators. The paper also suggested that the implementation process for this could take 15 to 20 years. 

The lessons for organisations looking to redesign their workforce, as highlighted in our previous research commissioned by NHS Employers on this topic, still seem relevant today. That said, the emphasis in the current context might be different. For example, more priority might be needed now around the careful definition (and dissemination) of scope of practice and competencies as part of the lesson about how to build roles.

Some of the explanation for why these lessons have not all been applied is related to the fact that responsibility falls on regional and national bodies, as well as organisations themselves. In Chapter 3, we provide further recommendations on how they can support frontline organisational development capacity, increase public awareness and generate realism around educational capacity, regulation and ensuring financial support
does not inadvertently distort decisions. 

Certainly, central bodies can contribute to improvements in various areas highlighted in this report, including the dissemination of good practice, which stakeholders reportedly benefited from around the implementation of clinical pharmacists in general practice. Across different new and emerging roles,  stakeholders perceive the Department of Health and Social Care and NHS England as pivotal in promoting uptake and setting the agenda around changes in skill mix.

A variety of emerging roles have been introduced into the NHS before significant issues have been addressed. A proactive approach to addressing challenges around reshaping the workforce is necessary to prevent negative consequences for patient care, staff wellbeing and productivity. And before any efforts to introduce new roles or reshape the workforce, national and local bodies must also seek to resolve any issues with
established roles.

Read the full report