This report is the Health Foundation’s annual assessment of trends in the NHS workforce. It examines changes in the overall staff profile of the NHS and identifies key trends. This is the fourth such report. Our aim over time has been to build progressively on each annual assessment to provide a long-term picture of trends and changing profiles, while also taking a year-by-year look at specific ‘pressure points’ that warrant more detailed attention.

For this annual cycle, we continue with the primary aim of providing long-term trends and analysis to place immediate NHS workforce challenges in the appropriate policy and planning context. This is the last annual report that will be published in this format. It will be replaced in the future with more rapid periodic evidence updates and analysis on NHS workforce issues, reflecting both the increased speed with which some workforce data are available and the rapidly changing NHS funding and policy environments. The Health Foundation will complement these evidence updates with more in-depth analysis of key health workforce issues that are clear and pressing national priorities.

Recent years have seen major staff shortages with national debate focusing on their negative impact on NHS services. The Health Foundation has contributed to informing debate, emphasising the need for more effective targeted funding, more responsive and flexible workforce planning, and investment that is focused on improved staff productivity and retention.

Staff shortages continue to dominate the discourse in 2019. Early in the year, the Health Foundation, in collaboration with The King’s Fund and the Nuffield Trust, published Closing the gap – a joint report on the NHS workforce, in the context of the 10-year plan for the NHS. The joint report argued that staffing was ‘the make-or-break issue for the NHS in England’. It pointed out that shortages are already having a direct impact on patient care and staff experience, and that without significant funding and policy action the staff shortfall was likely to become more pronounced, notably in nursing and primary care.

The joint report highlighted nursing and general practice as two critical areas, and made a series of recommendations. These included using the skills of other staff – including pharmacists and physiotherapists – much more widely in general practice, a ‘radical expansion of nurse training’, and an increase in international recruitment. The report also noted that the workforce implementation plan due to be published to underpin the 10-year plan would present ‘a pivotal opportunity’. In this review, we return to some of the detailed analysis conducted for Closing the gap.

At the time of developing this report, we are awaiting the forthcoming NHS people plan. The Interim NHS people plan was published in June 2019. It set out the ‘vision for people who work for the NHS to enable them to deliver the NHS long term plan but it was broad-brush in nature, and awaiting fuller analysis, stakeholder engagement and costing. We do not focus in any detail on the interim plan in this report.

Recent independent analysis of the state of the NHS workforce has reinforced the key points made by the Health Foundation and its partners. In May, the Migration Advisory Committee (MAC) was charged with assessing which occupations should be on the Shortage Occupation List (SOL), and therefore eligible for active international recruitment. It reported a ‘vast increase’ of applications for nurses and doctors. These occupations are currently provisionally on the list, after lobbying from the professions and employers. The MAC recommended that nurses should be included on the SOL, noting that a ‘significant number of stakeholders reported difficulties in the recruitment of nurses. Vacancy rates have been rising, even with increased employment, and they ranked relatively highly in the shortage indicators.’ More recently, in October 2019, the MAC’s recommendations that all medical practitioners, occupational therapists, psychologists, radiographers, speech and language therapists, and social workers be added to the SOL were implemented by the government. In this report we will give more attention to active international recruitment and its vital role in shoring up NHS nurse staffing levels.

Another analysis, published by the House of Commons Library in May, noted that there had been overall growth in the workforce in recent years, but significantly slower growth in nursing staff than in most other NHS occupations; it also highlighted that, since 2015, the number of GPs had fallen. A more recent House of Commons Library briefing on international workers in the NHS noted that 87% of NHS staff in England are British, and 5.5% are nationals of other European Union (EU) countries – totalling just over 65,000 staff. While the overall percentage of EU staff has remained at 5.5% since the EU referendum, the number of EU nurses has been in decline, and the number of EU nationals joining the NHS workforce has also been falling.

The deep-rooted problem of staff shortages was also reinforced by the NHS Pay Review Body. In its July 2019 report, it noted that:

‘The workforce gap we recognised in our last report persists and continues to create unsustainably high levels of vacancies, work pressures and potential risks to patient care… The trends in the nursing workforce are a particular concern with increasing nursing vacancy rates and substantial declines in the number of people applying for nursing degrees in the last 2 years in particular from mature students who represent 60% of entrants.’

Over the past year, an additional workforce challenge has emerged, as the impact of the pension cap has led to some senior doctors retiring early, or reducing their working hours. This is reportedly having an effect on waiting lists. The government has recently signed off a short-term scheme to try and alleviate the problem for clinicians. Similarly, a proposed ‘fix’ to the scheme has been out for consultation. NHS Employers has responded that the proposal ‘should apply to all NHS employees, to ensure the NHS Pension Scheme can continue to be used as a central part of the overall reward offer to attract, recruit and retain staff’ and that, as proposed, it will ‘only partly meet the forthcoming objectives set out in the NHS England/Improvement People Plan’.

Workforce challenges are also highlighted in social care. Both the NHS and social care employers recruit from the same pool for many care-giving roles. Recent analysis shows that the estimated number of adult social care jobs in England in 2018 was 1,620,000, of which 1,225,000 (76%) were direct care staff jobs and another 84,000 (5%) were regulated professionals, including 41,000 registered nurses (these are nurses not working in NHS). While overall numbers were up by 1.2% on the previous year, registered nurse jobs in adult social care have decreased by 10,500, or 20%, since 2012. Projections based on the analysis found that if the adult social care workforce grows proportionally to the projected number of people aged 65 and over in the population, then the number of adult social care jobs will increase by 36% (580,000 jobs) to around 2.2 million jobs by 2035.

Much of the emphasis on workforce analysis focuses on the supply side – on trends and numbers, on vacancies and workforce flows. It is also important to keep in mind that the workforce is the means of achieving safe, effective and timely care. This is particularly important when the continued, more rapid growth in activity in comparison to workforce is noted. For example, as shown in Figure 1, while ‘output’ (including the number of operations, consultations, diagnostic procedures and A&E visits in a year) grew by almost a quarter between 2010/11 and 2016/17, the number of nurses grew by less than a tenth of that.

Figure 1: Service output and FTE nursing staff numbers in the NHS Hospital and Community Health Service, 2010/11–2016/17

Source: NHS Digital, NHS Workforce Statistics; ONS, Public service productivity: healthcare, England. Note: output is cost and quality adjusted activity

The impact of staff shortages on existing staff in terms of increased workload, job-related stress and ‘burnout’ is also a cause for concern. For example, the most recent NHS Staff Survey highlighted that only a third of NHS workers felt there were enough staff for them to do their jobs properly, and that reported stress levels are at a 5-year high, with 40% of respondents reporting work-related stress within the last 12 months.

Detailed analysis of Staff Survey results by the Picker Institute and The King’s Fund, published in 2018, highlighted that NHS staff workplace experience was associated with sickness absence rates and spend on agency staff and staffing levels, indicating that the workforce was ‘overstretched and supplemented by temporary staff’ which was negatively affecting staff wellbeing. It also noted that there were negative associations between patient experience and workforce factors, including ‘higher spend on agency staff, fewer doctors and especially fewer nurses per bed, and bed occupancy’. The report concluded that care quality was at risk from staffing issues, observing that: ‘Staff-reported experience was correlated with patient feedback in several areas, notably between staff perceptions of care quality and patient experience, indicating that staff and patients’ perceptions about quality of care are consistent.’

Further concerns about the impact of workload on staff were highlighted in the report by the Care Quality Commission (CQC), State of care, published in mid-October 2019. The CQC reported that ‘Growing pressures on access and staffing risk creating a “perfect storm” for people using mental health and learning disability services’, with a national shortage of nurses in these areas. It also noted that, more broadly across health and social care, ‘access and staffing are presenting challenges across all care settings, with geographic disparities’ and also regional variation in the ability of services to recruit and retain staff. The CQC report points to workforce solutions related to the development of new roles and an emphasis on upskilling existing staff, including advanced nurse practitioners, nursing associates, physician associates, pharmacists, district nurses, mental health practitioners and social prescribing workers, working within GP practices.

This report builds on those of previous years to provide analysis of longer-term trends and insights into the changing NHS staff profile. It also focuses specifically on the critical NHS workforce issues that have been repeatedly identified in recent years: nursing shortages, and shortages of staff in general practice and primary care. We first present an overview of the NHS workforce in England, before examining trends in the supply of student nurses. Next, we examine the international flow of health professionals and place the UK in an international context. Finally, we focus on staff retention, before summarising the key workforce challenges that will need to be considered in the development of the full NHS people plan.

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