The NHS in England employs 1.5 million people, with employee costs accounting for around two-thirds of NHS providers’ expenditureundefined . The NHS is the country’s biggest employer and one of the largest employers globallyundefined .
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 March 2022 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 21,000 staff that work as local planners and commissioners of health services (clinical commissioning groups, now known as integrated care boards). In addition, around 150,000 work in primary care (including general practice, community pharmacies and dentistry)undefined .
Across NHS hospital, community and primary care settings, there are 164,000 doctors in total and around 360,000 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)undefined .
2. How diverse is the NHS workforce?
One quarter (25%) 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, in most cases, 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, where 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 composition of the communities it serves – such as age, gender, disability, religion and sexual orientation. These are drawn out in more detail in our report on attracting, recruiting and retaining a diverse workforce. Hemmings N, Buckingham H, Oung C, Palmer W (2021) Attracting, supporting and retaining a diverse NHS workforce Research report, Nuffield Trust
3. What is the overall shortfall in staff in the NHS?
While the published data suggests there were 105,855 vacancies (8%) in the NHS between January and March 2022, this does not tell the whole story. Some of these vacancies are filled day-to-day by temporary staff, whereas other gaps in the rota might be caused by absences such as sick leave. Our previous analysis suggests that on a given day, around 17,000 nursing and midwifery posts (4%) may be unfilled – although this may vary over timeundefined . During the peaks of the Covid-19 pandemic, the number of staff absent from work on one day reportedly reached over 120,000undefined .
Notwithstanding the data limitations outlined above, staff shortages are distributed unevenly across the country, with the highest percentage of full-time equivalent vacancies in London (10.9%) and the lowest in the North East and Yorkshire (6.1%)undefined .
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), numbers of full-time, fully qualified GPs have fallen by over 1,700 – a decline of 6%undefined .
4. What do the shortages look like within hospital services?
The number of hospital medical staff grew substantially from 78,000 in September 2004 to over 128,000 in March 2022 – a 64% increase. Within that figure, the number of hospital consultants has risen by 89% (from 28,000 to 53,000)undefined . Nevertheless, hospitals are experiencing difficulties with medical staffing across multiple specialties and locations.
A survey from 2020 found that nearly two-in-five consultants (39%) reported a consultant vacancy within their department. This affected some specialties more starkly than others, with three-in-five (60%) of acute medical consultants reporting consultant vacanciesundefined . Such shortages may mean that there are not enough 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 between 2009 and 2020 (from 278,500 to 298,600 in February 2020). However, since the start of the Covid-19 pandemic until March 2022, the number of nurses substantially increased by over 21,100 (7%).
For specific types of nursing, the trends vary. The number of children’s nurses increased by two-thirds (67%) in the 12 years to March 2022 (from 15,100 to 25,100), while the number of learning disability nurses fell by 43% (from 5,500 to 3,100) over the same period (see chart)undefined .
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 shortagesundefined .
Mental health staff
Around 133,000 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 March 2010 and March 2022. Our recent researchundefined looked at how inaccurate perceptions and lack of clarity on the roles within mental health services can be a barrier to increasing the size of 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 2023/24undefined .
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 2021undefined . 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 2023/24undefined . Our recent report undefined 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 31,000 in March 2010 to 43,100 in March 2022. The main driver for this growth was a 61% increase in the number of paramedics since 2010. 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 groupsundefined . 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 157,000 "scientific, therapeutic and technical" full-time equivalents in March 2022. Overall this group has increased by 31% since 2010, 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%undefined .
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 288,000 in 2010 to over 379,000 in 2022 – an increase of 32%. 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 staffundefined .
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. 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 387 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 deprivedundefined . Although there are attempts to improve equity in GP supply across the countryundefined , 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 oldundefined . 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 workersundefined ; this increased to expanding staff working in general practice by 26,000 by 2023/24undefined .
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 47% between March 2010 and March 2022) and one in three school nurses (32%). Health visitor numbers have also dramatically fallen by over one-fifth (23%) in the last three yearsundefined . 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 onundefined .
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 May 2021, an estimated four in five registered nurse vacancies and seven in eight doctor vacancies were being filled by temporary staff, either through an agency or using their ‘bank’ (the NHS in-house equivalent of an agency).
While some level of temporary staffing can provide welcome flexibility to the employer and employee, 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, it was reported that NHS trusts reported spending some £2.4 billion on agency staffundefined . Using temporary staff can also be disruptive to health services and reduce the ability to deliver continuity of care to patients.
However, some vacancies remain unfilled. In such circumstances, the consequences can be even more significant, with our analysis having suggested that the NHS may have had some 1,400 unfilled doctor vacancies and up to 12,000 unfilled nursing vacancies on a given day undefined .
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”undefined . 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 gapsundefined . 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 staffundefined . 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 415. 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.
Meanwhile, the level of nursing appears to (up until the last year) have been stagnant for some timeundefined . 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 10,500 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 2000sundefined . While numbers appear to be picking up again, with the most recent data shows that over 29,000 nurses started training in 2021, issues still remain, with a high proportion of university students not completing their nursing courseundefined .
When domestic supply of staff is insufficient, then the health service has a heavy reliance on international recruitment. One-in-six (16%) of hospital and community sector staff were recorded as having a non-British nationality as at March 2022undefined . 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). Our NHS briefing analyses the benefits and pitfalls surrounding the use of overseas recruitment to address shortfalls in nursing staff numbersundefined
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 pressuresundefined . 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 663 in 2022, though the reverse pattern is seen for those joining the register from outside the EEA – showing an increase of more than 22,000 over the same period. Just since 2020, the number of non-EEA nurse joiners has increased by over 13,000. Numbers of newly registered EEA doctors have slightly increased from 1,984 in 2016 to 2,044 in 2021, whilst the number of non-EEA doctors has more than doubled (3,148 vs. 6,998), after peaking at 10,445 in 2020.
As well as recruiting new staff, it is also vital to keep the existing workforce. The number of hospital and community health staff leaving the NHS has now peaked to 12.5%, the highest level recorded since record began. We lay out the reasons for staff leaving the NHS in more detail in our recent explainers.undefined undefined
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 futureundefined . We have since set out a number of points that should be considered to help implement a successful plan for the workforceundefined .
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. While it appears the UK as a whole have relatively few staff in key groups compared to other developed countries, different countries have different levels of skill-mix, with the UK (particularly in England) employing more support staff per head compared with other nationsundefined .
Further discussion about how we compare internationally is available in our international comparison report, which highlighted the NHS as having higher bed occupancy rates, lower numbers of key staff and lower levels of capital investment compared to other high-income countries – meaning that it is likely that the NHS’s road to recovery from Covid-19 may be longer than other health systemsundefined .
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 Irelandundefined . However, recent data suggests that the NHS in England now appears to have the lowest level of GP staffing of any of the four nations, and even when looking at smaller geographical patches, most areas that suffer with the most GP shortages are within England (see map).
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 soundefined .
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 5% to 60 million by 2041undefined . Indeed, unless emerging trends in falling retention (for example) are not reversed, the situation could be even worseundefined .
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. 27% are aged between 45 and 54 and more than one in six (17.6%) 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 55undefined .
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”undefined . This was still the case in March 2022, with over 1,000 more nurses from the EU or EEA leaving than joining. Although these decreases in EU or EEA joiners have been more than compensated by the increase in recruitment from non-EU countries, this solution may not be the case in all staff groups, services and settings.
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. The persisting impact of the pandemic on the health service, coupled with present political and economic instabilities, adds to the complex web of challenges that the NHS faces.
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 shortagesundefined .
Nuffield Trust, "The NHS workforce in numbers" This explainer was first published in 2017 and has been updated regularly.