The NHS in England employs 1.5 million people across the UK. It is the country’s biggest employer and one of the largest employers globally.
1. What kinds of staff make up the NHS workforce?
The NHS is heavily reliant on professional 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 – 1.1 million full-time equivalents (as at September 2018) – 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 18,000 staff that work as local commissioners of health services (clinical commissioning groups).
In addition, around 130,000 work in primary care (general practice).
Across NHS hospital, community and primary care settings, there are around 150,000 doctors in total and over 320,000 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.
2. What is the overall shortfall in staff in the NHS?
The number of vacancy adverts on the main recruitment website for the NHS suggested 94,000 full-time equivalent advertised vacancies in hospital and community services alone between July and September 2018. This equates to an estimated shortfall of 8 per cent (around 1 in 12 posts).
The highest numbers of advertised vacancies (in absolute terms) are in ‘nursing and midwifery’ – at nearly 40,000 – and ‘administrative and clerical’, which has over 20,000.
In primary care, and against an ambition set in 2016 to increase GP numbers by 5,000 by 2020, numbers have fallen by 290 (full-time equivalent) – a decline of 1 per cent.
3. What do the shortages look like within hospital services?
The headcount of hospital medical staff grew substantially from 87,000 in 2004 to 119,000 in September 2018 – a 37 per cent increase. However, within that figure, the number of hospital consultants rose by 64 per cent (from 30,650 to 50,275).
One recent survey found that over half of consultants (53 per cent) and two-thirds of junior doctors (68 per cent) said that there were ‘frequently’ or ‘often’ gaps in hospital medical cover that raised significant patient safety issues.
Where gaps in rotas mean there are not sufficient senior medical staff to assure the quality and safety of training, junior doctors may be withdrawn from hospitals, reducing the staffing complement even further.
The number of full-time equivalent adult nurses has fluctuated in recent years but, on average, numbers have increased by less than 1 per cent a year since 2009 (from 169,400 to 183,000 in November 2018). For other nursing groups, the trend has been anything but static, with the number of children’s nurses increasing by over half (53%) over those nine years (from 15,100 to 23,100), while the number of learning disability nurses fell by 41% (from 5,520 to 3,280) over the same period.
Mental health staff
Around 200,000 people are substantively employed by the NHS to care for people who need mental health services. The largest group of clinicians are registered mental health nurses, but their numbers are in decline. There was a 11 per cent drop in the number of nursing posts between November 2009 and 2018.
In 2017, then Health Secretary Jeremy Hunt announced a significant training plan to reverse the decline and expand the numbers of qualified and associate staff working in mental health by 19,000 over the next four years.
Year-on-year increases saw full-time equivalent ambulance staff numbers rise from 30,000 in November 2009 to 37,100 in November 2018. The main driver for this growth was a 45 per cent increase in the number of paramedics since 2009, which offsets a fall in the numbers of ambulance technicians by 3 per cent. As well as this, ambulance support staff have grown by a fifth over the same period.
Scientific, therapeutic and technical staff
The wider professionally qualified clinical and scientific workforce account for a large proportion of hospital and community staff, with around 140,000 "scientific, therapeutic and technical" full-time equivalents (as at September 2018). Overall this group has increased by 17 per cent since 2009, although the trend has been inconsistent between professions.
4. What do the shortages look like for staff delivering care close to patients’ homes?
As mentioned, against a 2016 ambition of increasing GP numbers by 5,000 by 2020, there has been an actual slight decline. 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 deprived.
The number of practice nurses has hovered around the 23,000 mark for several years, equating to 16,000 full-time posts, as eight out of 10 practice nurses work less than full time. Over a third of these staff (36 per cent) are over 55 years old.
Community health nurses
There have been some headline-grabbing figures on the fall in community matrons and district nurses. But rather than being a simple, certain problem of plummeting numbers, the drop in these vital workers is much more uneven – and we still can’t quite be sure exactly what’s going on.
5. What are the implications of these shortfalls?
Many of the shortfalls in staff are filled day to day. In NHS trusts, an estimated 80 per cent of nurse vacancies and 90 per cent of doctor vacancies are being filled by temporary staff, either through an agency or using their ‘bank’ (the NHS in-house equivalent of an agency).
6. What is the outlook for the future?
Whereas financial problems can be solved by more 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 so.
The level of demand for health care is expected to continue to increase, and therefore so will the need for staff. The population is expected to increase by a further 11 per cent to 62 million by 2041. 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 worse.
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. A third are aged between 45 and 54 and one in seven (13.6 per cent) are between 55 and 64. In midwifery the position is even starker, with a third of midwives already over 50 and eligible to consider retirement at 55.
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 report with 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.”
That said, in their report published in December 2018, the General Medical Council suggested there was “see no evidence yet of an impact from the Brexit referendum on the overall numbers of licensed EEA graduate doctors.”
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