The NHS employs 1.7 million people across the UK. It is the country’s biggest employer and ranks at number five globally.
Of that 1.7 million people, some 1.2 million are employed by England’s NHS. Despite the huge scale of its labour force, it is increasingly apparent that the NHS in England doesn’t have enough staff.
Here we lay out the facts on current NHS staffing shortages in England, the costs of filling the gaps with agency staff, and the problems that lie ahead due to demographic change and the likely impact of Brexit.
1. What kinds of staff make up the NHS workforce?
The NHS is heavily reliant on professional staff with high-level clinical skills that take many years to acquire. There are around 140,000 doctors (around 11 per cent of the total) and around 300,000 nurses and midwives (around 25 per cent), as well as less well-known disciplines such as health care scientists, physiotherapists and occupational therapists.
2. What is the overall shortfall in clinical staff in the NHS?
The National Audit Office (NAO) found there were about 50,000 vacancies across all types of clinical staff in 2014. They estimated that there was a shortfall of 5.9 per cent between the number of staff that NHS organisations said they needed (and had budgeted for) and the number of staff actually in post.
The NAO report drew on figures from 2014 and was the last study to look across all NHS staff, but more recent data suggests the position has worsened.
New analysis in December 2017 shows the NHS has at least 36,000 full-time equivalent nursing vacancies, and the number could be as high as 42,000.
There are staff shortages across the whole of the NHS in England, and some particular pressure points in areas where the workforce needs to expand rather than contract. The aspiration to move services out of hospital to provide care closer to home, and to offer new models of care delivery, depend on an expanding and thriving primary and community care workforce.
3. What do the shortages mean for hospital staffing?
Figures published by the Nursing and Midwifery Council in July 2017 showed that more nurses and midwives left the professional register in the previous year than joined it. Newer NMC figures from April 2018 show that the total number of nurses and midwives on the register have gone down further in the year to March 2018. Numbers had been growing since 2012/13, peaking in 2016 at 692,556. The NMC register covers all qualified nurses and midwives in the UK, including those outside the NHS and those not working but maintaining their licence to practise.
Data from a recent written parliamentary answer shows that the number of nurses joining the NHS has fallen in the past year, and NHS Digital data requested by the BBC in January 2018 showed that over 33,000 nurses and health visitors left the NHS in the year to September 2017 (10.5 per cent of the profession) – over 3,000 more than how many joined the health service during the same period.
Both the nursing and midwifery professions have an ageing demographic (see charts below). More than half of nurses are older than 45, with a third aged between 45 and 54 and 13.6 per cent 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 Royal College of Midwives estimates there is a 3,500 shortfall in the midwifery workforce in England.
However, pressures are not limited to older age groups: the net reduction includes a growing number in their mid-forties. Apart from retirement, the most common reasons for leaving the register were dissatisfaction with working conditions and an inability to deliver care of the right standard.[7,8]
The number of hospital medical staff has grown substantially from 87,000 in 2004 to 113,500 in March 2017. Within that figure, the number of hospital consultants has risen by more than half – up from 30,650 in 2004 to 47,816 in March 2017.
Nevertheless, hospitals are experiencing difficulties with medical staffing in a number of specialties and locations.
In July 2017, a survey by the Royal College of Paediatrics and Child Health (RCPCH) revealed that 20 per cent of paediatric trainee positions, and 25 per cent of more senior trainee posts, are vacant.
The Royal College of Physicians reported in March 2017 that 84 per cent of their members were experiencing staffing shortages across the team, with rota gaps occurring on a regular or frequent basis. 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.
Compounding the problem, fewer junior doctors are now choosing to move straight into specialist training after their first two years’ foundation training. The proportion has fallen from 71.6 per cent in 2011 to 50.4 per cent in 2016. Of those who do not choose to move into specialty training, more are taking a career break or planning to work abroad and fewer are looking for non-training service posts in the NHS.
Mental health staff
Staffing shortages are particularly severe in mental health services. There are more than 20,000 vacancies for mental health staff in the English NHS, which is nearly 10 per cent of the funded posts.
The largest group of clinicians are registered mental health nurses, but their numbers are in decline. There has been a 12 per cent drop in the number of nursing posts between 2009 and 2016 and, of the remaining 67,800 posts, 11 per cent are vacant.
In mental health medicine, there has been some growth in recent years but at a slower pace than the general expansion of the medical workforce.
Too few newly qualified doctors are choosing to train in psychiatry, and one-third of consultant psychiatrists are working outside the NHS within five years of completing specialist training. Mental health services are also highly reliant on non-UK doctors.
The Secretary of State for Health has 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, enabling faster access to a range of therapies and services and the elimination of out-of-area treatment.
Despite year-on-year increases that have seen ambulance staff numbers increase from 30,400 in 2010/11 to 32,400 in 2015/16, there is a nationwide shortage of ambulance staff, with employers competing with each other to attract scarce paramedics with “golden hellos” and relocation packages. In April 2015, the Migration Advisory Committee, a non-departmental public body that advises the Government on migration issues, acted on advice that the paramedic vacancy rate in England was 10 per cent and added paramedics to the relevant shortage occupation list.
4. How are shortages affecting staff delivering care close to patients’ homes?
Family doctors (GPs)
The NAO data on clinical staff shortages does not include GPs or practice nurses, but a survey by the BMA published in December 2016 found that a third of GP practices reported at least one vacancy for a GP partner, with similar vacancies for salaried GPs and practice nurses.
Currently, GPs are leaving faster than they can be replaced, with figures published by NHS Digital showing a net reduction of 1,252 (full-time equivalent) family doctors in practice at the end of March 2017 compared with the previous year.
The General Practice Forward View, NHS England’s plan for primary care, intends to boost the number of family doctors by 5,000 in the next few years, but there is consensus across the organisations representing GPs that this target will be difficult to reach.
The number of practice nurses has hovered around the 23,000 mark for several years, equating to 15,000 full-time posts as eight out of 10 practice nurses work less than full time. In March 2017 there were 15,528 full-time equivalent practice nurses, but for the first time this number represented a decrease, of 225 (1.4 per cent) since March 2016. Nearly a third of these staff are over 55 years old.
Community health nurses
Within community health services, after a period of steady growth the number of community nursing posts fell by 8 per cent between 2009 and 2014, with district nursing posts reduced by nearly half over the same period. The decline continued to 2016, leaving fewer than 6,000 qualified district nurses in post.
Unless this position is reversed, the ambition to deliver more care closer to home in the community will not be achieved.
5. What are the financial implications of these shortfalls?
One indication of a worsening position is the 16 per cent rise in vacancy adverts reported by NHS Digital from March 2016 to March 2017.
In addition to the recruitment costs associated with high turnover and vacancy levels, the extra money hospitals have to pay for temporary staff, either through agency or locum staff, is a huge drain on overstretched finances.
The NHS spent £2.9 billion on agency staff in 2016/17 – down from £3.6 billion in 2015/16, but still £700 million more than in 2009/10.
In 2015 agency nurses cost, on average, about £39 per hour, compared with around £27 per hour for a bank nurse (the NHS in-house equivalent of an agency) or £11 per hour for a band 5 staff nurse, and £16 per hour for a band 7 ward sister on the payroll. Even when employer costs are added, permanent staff working at plain-time rates are a much more cost-effective solution for employers.
About a third of the expenditure on temporary staff goes on medical locums who can command very high premium rates and, despite concerted efforts made by employers since October 2015, still cost the NHS around £1.1 billion per year. Changes to the tax treatment of locum doctors were introduced in April 2017 with the intention of controlling costs further, but it appears that salaries have risen by an average of 6.3 per cent since these staff were moved from payment through personal service companies to PAYE (pay as you earn).
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 medical and other 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.
In addition to the threat posed by the ageing demographic of nurses and midwives highlighted above, the NHS’s reliance on staff from overseas puts it in a vulnerable position as continued uncertainty over the impact of Brexit remains.
In 2014, staff from overseas accounted for around 35 per cent (14,600) of hospital consultants, 22 per cent (8,000) of GPs and an estimated 14 per cent (47,000) of nurses. The largest source of non-UK trained doctors has traditionally been South Asia, with many overseas nurses coming from the Caribbean countries, Africa and the Philippines.
Following a curb on non-EU migration, in recent years there has been a significant focus on recruiting staff from the European Economic Area (EEA), with 9.3 per cent of doctors and 6.8 per cent of nurses now from EU countries.
The proportion of EU nurses rose dramatically between 2009 and 2014, and by 2015/16 almost a third of newly registered nurses in the UK had trained in the EEA. Since the June 2016 EU referendum vote, however, nursing registrations by EU nationals have plummeted. There was a 67 per cent rise in how many EU nurses and midwives left the register in the year up to September 2017 compared to the year before, while the number joining the register from the EU dropped by 89 per cent.
These two charts below show how many newly qualified NHS doctors and nurses are from the EEA and how many are from further afield.
The problems facing the NHS are likely to be compounded by staffing shortages in social care, which will almost certainly be exacerbated by Brexit. Social care employs almost as many people as the NHS – 1.6 million across the UK. The social care workforce currently includes around 90,000 EU nationals and could face a shortfall of as many as 70,000 workers by 2025/26 if net migration from the EU is halted after Brexit. Care staff are typically less highly qualified and paid less than their NHS colleagues. With earnings in sterling, settling or remaining in the UK may become less attractive, even if residence and employment rights can be assured.
- NHS Digital (2017), NHS Workforce Statistics – July 2017, Provisional statistics. NHS Digital.
- NHS Digital (2017), NHS Workforce Statistics – May and March 2017, Provisional statistics. NHS Digital.
- National Audit Office (2016), Managing the supply of NHS clinical staff in England. National Audit Office.
- Health Service Journal (4/12/17) ‘Nursing vacancies top 36,000, official analysis reveals’.
- NHS Digital (2018) Nurse and health visitor numbers, September 2012 to 2017. NHS Digital.
- Royal College of Midwives (2017), State of maternity services 2016. Royal College of Midwives.
- Royal College of Nursing (2016), The UK nursing labour market review 2015 and 2016. Royal College of Nursing.
- Nursing and Midwifery Council (2017), The NMC register 2012/13 - 2016/17. Nursing and Midwifery Council.
- NHS Digital (30/06/17), NHS HCHS workforce statistics. NHS Digital
- Royal College of Paediatrics and Child Health (2017), Rota compliance and vacancies. The Royal College of Paediatrics and Child Health.
- Royal College of Physicians (2017), Physicians worried about future patient safety, whistleblowing and rota gaps. Royal College of Physicians.
- BMJ Careers (8/2/17), ‘Half of doctors don’t go straight into specialty training’
- Health Education England (2017), Stepping forward to 2020/21: The mental health workforce plan for England. Health Education England.
- National Audit Office (2017), NHS Ambulance Services. National Audit Office.
- British Medical Association (2016), Survey of GPs in England. British Medical Association.
- NHS Digital (2017), General and Personal Medical Services, England As at 31 March 2017, Experimental statistics. NHS Digital.
- The King’s Fund (2016), Understanding quality in district nursing services. The King’s Fund.
- NHS Improvement (2017), Quarterly performance of the NHS provider sector: quarter 4 2016/17. NHS Improvement.
- Royal College of Nursing (2015), NHS pay scales 2015-16. Royal College of Nursing.
- NHS Improvement (2017), Agency controls: £1 billion saving and new measures. NHS Improvement.
- The Times (23/10/17), ‘Locum pay up 6.3 per cent since tax dispute’
- Edwards N (2016), The NHS workforce crisis may be irreversible. Nuffield Trust.
- NHS Digital (30/06/17), NHS HCHS workforce statistics. NHS Digital
- Nursing and Midwifery Council (2/11/17) ‘Increasing number of nurses and midwives leaving profession highlights major challenges faced by health and care sectors'
- Dayan M (2017), Getting a Brexit deal that works for the NHS. Nuffield Trust.
Nuffield Trust (2017). "Facts on staffing and staff shortages in England". Nuffield Trust. www.nuffieldtrust.org.uk/resource/the-nhs-workforce-in-numbers
*Amended on 2/11/17 with new figures on EU nurses and midwives who have left the register in the year before September 2017.
*Amended on 5/12/17 with new vacancy figures for registered nurses in the NHS in England.
*Amended on 17/1/18 with new NHS Digital data on nursing staff levels.
*Amended on 26/4/18 with new NMC data on nursing and midwifery levels.