The NHS in England employs 1.5 million people. It is the country’s biggest employer and one of the largest employers globally1.
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 2020 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 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 February 2020) – 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 130,000 work in primary care (general practice)2.
Across NHS hospital, community and primary care settings, there are around 150,000 doctors in total and over 330,000 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 totaling 55,000 full-time equivalent staff directly employed in independent healthcare providers in England (though this is likely to be an underestimate)3.
2. What is the overall shortfall in staff in the NHS?
There were around 100,000 full-time equivalent advertised vacancies in hospital and community services alone between October and December 2019. This equates to an estimated shortfall of 8.1% (around 1 in 12 posts). That said, there is no single, robust data on the level of vacancies in the NHS, with these figures based on published vacancy adverts on the main recruitment website for the NHS4.
These shortages are distributed unevenly across the country, with the highest percentage of full-time equivalent vacancies in London (10.7%) and the lowest in the North East and Yorkshire (5.5%)4.
The highest numbers of advertised vacancies (in absolute terms) are in ‘nursing and midwifery’ – at over 35,000 – and ‘administrative and clerical’, which has over 17,000.
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 1,800 – a decline of 6%6.
3. What do the shortages look like within hospital services?
The headcount of hospital medical staff grew substantially from 87,000 in 2004 to over 125,000 in February 2020 – a 44% increase. Within that figure, the number of hospital consultants has risen by 73% (from 30,650 to 52,922)7.
Nevertheless, hospitals are experiencing difficulties with medical staffing in a number of specialties and locations. Approximately one in 10 specialty postgraduate medical training posts go unfilled, though this varies regionally. 11% of places in the North West went unfilled in August 2019, compared to 3% in London.
One recent survey 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 cover8. 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% a year since 2009 (from 167,200 to 191,600 in February 2020). For other nursing groups, the trend has been anything but static. The number of children’s nurses increased by over half (60%) over those 11 years (from 14,900 to 24,000), while the number of learning disability nurses fell by 41% (from 5,550 to 3,260) over the same period9. 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 shortages10.
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 12% drop in the number of nursing posts between November 2009 and February 20209.
In 2015, the Migration Advisory Committee added core psychiatry training to the list of occupations experiencing a shortage of staff. The psychiatry fill rate was only 58% in 2017, but this was substantially improved to 86% in 2019. 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 Health Education England’s mental health strategy to have an additional 4,200 allied health professionals working in mental health by 2021.
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 202012.
Year-on-year increases saw full-time equivalent ambulance staff numbers rise from 30,000 in November 2009 to 39,500 in February 2020. 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 – from April 2019, they were categorised differently to identify the care setting of such staff in more detail13.
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.
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 140,000 "scientific, therapeutic and technical" full-time equivalents in February 2020. Overall this group has increased by 23% since 2009, although the trend has been inconsistent between professions. For example, while the number of pharmacy and operating theatre staff have both increased by over a third and radiography staff by a quarter, the number of chiropody/podiatry staff (those that deal with foot problems) have fallen by 15%14.
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, 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 deprived15.
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. A third of these staff (32%) are over 55 years old16. In early 2019, NHS England committed to fund 20,000 more staff in primary care, including pharmacists, physios, paramedics, physician associates and social prescribing link workers17.
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 42% between September 2009 and February 2020) and nearly one in three school nurses (30%). There have also been dramatic falls in health visitor numbers in the last three years14. 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 on19.
Unless this workforce is sufficient, the ambition to deliver more care closer to home in the community will not be achieved.
5. What are the implications of these shortfalls?
Many of the shortfalls in staff are filled (albeit temporarily) day to day. In NHS trusts, an estimated 80% of nurse vacancies and 90% 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) 20.
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 2018/19, NHS trusts were forecasting spending some £5.8 billion on temporary staff compared to a planned spend of £5 billion. 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”21.
6. How did we get to this situation?
When the NHS was established in 1948, it was supported by around 144,000 staff22.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 have been stagnant for some time23.
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 2000s24.
When domestic supply of staff is insufficient, then the health service has a heavy reliance on international recruitment. 13% of hospital and community sector staff were recorded as having a non-British nationality as at June 201925. However, the supply of these staff has fluctuated over time. Higher levels of recruitment have often been driven by national targets and support and in response to unforeseen additional demand for staff (such as following the Francis Inquiry and safe staffing guidelines). 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 pressures24. Data for the UK as a whole suggest that while the number of newly registered nurses from the EEA has increased since 2012, numbers of newly qualified EEA doctors have fallen over the same time period, from 3,000 to 2,000. This is contrasted by an increase in the number of new non-EEA doctors joining the register in recent years.
As well as recruiting new staff, it is also vital to keep the existing workforce. Generally speaking, the rates at which staff leave the NHS workforce has worsened in recent years, with the issue being particularly stark for nurses. A joint briefing on the health care workforce by the Health Foundation, The King’s Fund and the Nuffield Trust cited that the number of nurses and health visitors leaving the NHS increased by 25% from 2012 to 2018, from 27,300 to 34,10024.
Further 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 future28.
7. 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 doctors29. 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” 30.
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 Ireland31. 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.
8. 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 so32.
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 204133. 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 worse34.
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%) 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 5535.
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”24.
That said, in a report published in December 2019, the General Medical Council stated that the number of licensed EEA doctors had in fact increased since the EU referendum – from 21,539 in 2016 to 22,280 in 201937.
The data we have used in this explainer pre-dates any changes to the workforce that were likely to have occurred because of Covid-19. Whilst we cannot say with certainty (at the time of publishing) whether the pandemic will exacerbate the 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. With that in mind, our report with the other health think tanks reiterated that staffing is the make-or-break issue for the NHS in England – setting out a series of policy actions that, evidence suggests, should be at the heart of plans to address current and predicted shortages24.
Nuffield Trust, "The NHS workforce in numbers"