Executive summary


This is the fourth annual NHS workforce trends report published by the Health Foundation. In it, we analyse the changes in the size and composition of the NHS workforce in England in the context of long-term trends, policy priorities and future projected need. The key findings are as follows.

Staff working in NHS hospitals, mental health and community services

  • The number of full-time equivalent (FTE) staff working in the NHS in England increased in 2018/19 by 2.8% (almost 30,000 extra FTE staff). This is the fastest rate of increase in the NHS workforce this decade, but there are marked variations for different staff groups.
  • Over the past decade, the proportion of the health service clinical workforce who are registered nurses has fallen, as numbers of doctors employed in NHS hospitals, mental health and community services have grown at a faster rate than nurses.
  • 2018/19 saw a continuation of this trend: there was a 2.5% increase in the number of FTE doctors, while the number of FTE nurses grew by just 1.5%. Over the past 5 years the number of FTE doctors has increased by 10%, while the number of FTE nurses has increased by just 3%. At the beginning of the decade there were 3.0 nurses per doctor in the NHS, but this figure has now fallen to 2.6.
  • The last decade has also seen a major change in the mix of nurses and clinical support staff (including health care assistants and nursing assistants). In 2009/10 there were equal numbers of nurses and support staff, with one clinical support staff member for every FTE nurse in the NHS. By 2018/19, the number of support staff per FTE nurse had risen 10% to 1.1 FTE per nurse.
  • This skill mix change continued last year. In 2018/19 the NHS employed 6,500 more clinical support staff to doctors, nurses, and midwives, which represented a 2.6% increase. This compares to 4,500 more FTE nurses, an increase of just 1.5%.
  • Changes in skill mix within the NHS may reflect a range of factors: changing patient needs, technological developments and legislative changes to allow some staff groups to expand the scope of their practice. In many cases, skill mix changes are implemented well, being policy- and evidence-led, with effective programmes to support teams – for example, the introduction of nurse practitioners and pharmacy prescribing.
  • It is important that quality and safety are at the forefront of any skill mix change. There is cause for concern about skill mix changes being introduced in an unplanned way in response to negative factors – such as cost pressures or recruitment difficulties – rather than positive drivers of improvement.
  • Last year’s staffing increases were unevenly distributed across different parts of the NHS. Ambulance staff numbers grew by 5.1% in 2018/19, while the numbers of doctors working in hospital and community health services grew by 2.5%, compared to a less than 1% increase in the numbers working in general practice, including locums and registrars.
  • Within nursing, the number of FTE nurses employed in children’s nursing grew by 2.7%, but mental health nursing numbers grew by just 0.6% and community nursing service numbers (excluding health visitors) by just 0.7%. The NHS long term plan ring-fences funding for community and mental health services. But, judging by changes in the nursing workforce, translating this funding commitment into increased capacity at the front line has been, and will be, a significant challenge.
  • The combined number of nurses working in community and mental health services in 2019 remains below nurse staffing levels in 2014, although higher than the lows experienced over the last 4 years, but demand has risen due to population growth, increasing need and the commitment to improve these services.
  • The NHS long term plan and Advancing our health: prevention in the 2020s both emphasise the importance of health promotion and disease prevention and research suggests school nursing services provide cost-effective prevention. Despite this, in 2018/19 the number of school nurses fell by a further 3.1% to just 2,220 FTEs across England.
  • As in recent years, the largest percentage increase was among managers (6.2%) and senior managers (5.7%). The number of managers and senior managers has now increased for 29 consecutive months, although this is in the context of large reductions in numbers in 2013/14.
  • While the NHS is experiencing significant staffing pressures, the issues in social care are even greater and the outlook is concerning. Registered nurse jobs in adult social care have decreased by 10,400, or 20%, since 2012, and by 2% between 2017/18 and 2018/19.

The changing general practice workforce

  • Alongside investment in community and mental health services, The NHS long term plan prioritises investment in general practice. In 2016 the General practice forward view set a target to increase the number of GPs by 5,000 by 2020, compared with the number working in the NHS in England in 2014. The target is now that this will be reached ‘as soon as possible’.
  • However, the number of people working as fully qualified, permanently employed FTE GPs continues to fall – there was a 1.6% decline from 27,834 in March 2018 to 27,381 in March 2019. Temporary staff (locums) and doctors in training (registrars on placement) are making up a greater proportion of the GP workforce, rising from 19% in 2018 to 21% in 2019. The growth in temporary and training staff means that overall GP numbers increased by 0.9% last year. But it is almost impossible to see how the original target for 5,000 extra GPs could be met by 2020; if this is to be reached over and above 2015 numbers the number of qualified permanent FTE GPs would need to increase by 6,250 next year.
  • The number of patients that each FTE qualified permanent GP is responsible for continues to grow, increasing from 2,120 to 2,180 over the past year. Given the ageing population, the rise in chronic disease, and the aim to support more people’s health needs within the community, general practice services will need to continue to widen the skill mix of their workforce in order to match need and ensure patients can access care.
  • There are now more non-GP clinical staff working in general practice in England than GPs. Nurses form an important part of the team in most general practices, with around one nurse for every two GPs. In 2018/19 the number of practice nurses fell by 0.4%, but this was more than offset by an increase in the number of advanced practice nurses (9.8%). Advanced practice nurses now account for 22% of the nurses working in GP practices, compared with 17% in 2015. 
  • Alongside the expansion in nursing, within general practice other professions are playing an increasing role in the delivery of care. The past year has seen an almost 40% growth in the number of FTE pharmacists working in general practice, from 743 to 1,029. 
  • This is a trend that will continue with the new contract for general practice, agreed in January 2019, which commits to grow the number of staff from other professions (pharmacists, physiotherapists and paramedics) by 20,000 by 2023/24. Additional funding of £900m has been ring-fenced for this purpose. 
  • The growth in the UK of registered pharmacists per 1,000 population has been the second highest of EU-15 countries. As a result it has gone from being below both the OECD and EU-15 averages to above both of them.

Training new nurses

  • The 2018/19 workforce statistics confirm that nursing remains the key area of shortage and pressure across the NHS. The modest growth in nurse numbers has not kept pace with demand, and nursing vacancies increased to almost 44,000 in the first quarter of 2019/20, which is equivalent to 12% of the nursing workforce. Research by the Health Foundation, The King’s Fund and the Nuffield Trust projected that, without major policy action, the gap between the number of FTE nurses that are needed to keep up with demand and those available to the NHS could grow to 100,000 in a decade’s time.
  • To prevent nursing shortages growing further, urgent action is needed to increase the numbers of nurses in training, reduce attrition and improve retention.
  • In 2017, the government set out its intention to grow nursing undergraduate places by 25%. This year, the number of applicants to nursing courses in England increased for the first time since the NHS bursary was withdrawn in 2017. This 4.6% increase reversed 2 years of decline in which the number of applicants fell by almost a quarter. The number of applicants in England has now risen to 40,780, but nevertheless it remains below the figure for 2017.
  • Scotland, where the NHS bursary has been retained and its value increased, has seen a 6.7% increase this year, taking the number of applicants to its highest ever level.
  • Applications tell part of the story, but as applications have historically significantly exceeded the number of places available, the key issue for the NHS is not so much how many people apply, but rather how many students actually start training (acceptances). In 2018, there were only 80 fewer acceptances in England despite a 13.6% fall in applications compared with 2017.
  • The total number of applicants accepted onto nursing courses starting in 2019 will not be known until the Universities and Colleges Admissions Service (UCAS) releases the end-of-cycle statistics. In the latest set of figures, released 28 days after A-level results day, the number of applicants from England who have been placed at universities in the UK is up by 3.9%, at 21,030. This is below the number of students accepted in 2016, but the second highest number of students starting a nursing degree this decade. It is still some way short of the additional 4,000 people in training by 2023/24 pledged in the NHS long term plan.
  • If the NHS is to reduce vacancies and grow the pool of qualified nurses to recruit from, the forthcoming NHS people plan will need to set out measures that will rapidly expand the number of people starting undergraduate nursing degrees in England. The 2019 data show that there are different patterns of applications and acceptances by age, branch of nursing and geography.
  • New data looking at trends in nurse training between 2014 and 2018 show that the numbers starting mental health and learning disabilities nursing fell significantly in 2017, by 10% and 30% respectively. All continuously running learning disability courses have fewer students in 2018 than in 2014. This is in contrast to children’s nursing, where around two-thirds (63%) have increased in size. We also see that fewer over-25s started nursing degrees in 2018 compared with 2016, particularly impacting learning disability and mental health courses.
  • Overall trends can also hide pressure points in different areas of the country. Adjusting for population size London and the South East are in the bottom three regions for the number of acceptances to study nursing and the top three for the number of vacancies per 100,000 people.
  • A relatively high proportion of students who start a nursing degree do not graduate within 3 years – either dropping out completely or putting their studies on hold. The latest data show that attrition remains high despite government commitments to reduce it. One in four nurses who were expected to graduate in 2018 did not do so, and this was highest for learning disability courses.

International recruitment

  • One consequence of the failure to train, recruit and retain domestic nurses is that the UK is, and will continue to be, heavily reliant on international recruitment to maintain care quality and access. Previous research by the Health Foundation, The King’s Fund and the Nuffield Trust found that the NHS will need to recruit at least 5,000 nurses a year internationally to avoid a substantial further increase in unfilled posts. The latest data available suggest that in 2017/18 the NHS recruited just 1,600 nurses internationally.
  • Since 2016 and the referendum on the UK leaving the European Union (EU), as well as changes to English language testing requirements, there has been a rapid decline in nurses joining the Nursing and Midwifery Council (NMC) register from the EU, but some increase in non-EU international inflow – mainly from India and the Philippines. Overall, the number of international nurses joining the NMC register grew last year, although it is still below the level in 2016/17. How this compares to the 5,000 nurses a year required will depend on how many of these nurses choose to work and stay in the NHS following registration.


  • This analysis further highlights the deeply embedded challenge of skills shortages in key areas of the NHS – nursing, GP services, and community and mental health services. The effect of these shortages is increasingly felt through problems with access and quality, and this is rippling out to other sectors – notably social care and the nursing home sector.
  • Our analysis of the nursing workforce this year reinforces several points: the UK has relatively few ‘new’ nurses graduating from higher education compared to other OECD countries; in England NHS nursing numbers have not changed markedly over the last few years; attrition during undergraduate nurse education continues to be persistently high; and reliance on international recruitment, which has ebbed and flowed, is on the up again, but with non-EU source countries now being the target.
  • Against this background of supply-side issues, continuing concerns about relatively low increases in student nurse numbers in England become even more pronounced. Without radical and concerted action in the forthcoming NHS people plan, there is a very real risk that the additional funding committed to the NHS by the current and previous prime ministers will not deliver tangible improvements in care.

Box 1: Recent changes in staff numbers

Our analysis focuses on long-term trends in the number of staff working in the NHS and how these trends have changed over the most recent financial year. Due to the importance of NHS staff, new data is frequently published detailing the numbers of staff working in the NHS. The latest NHS workforce statistics at the time of publication (data 21 November) reinforce the long-term trends we highlight in this report. Overall growth of the workforce was 3.0%. Nurse numbers grew at just half the rate of support staff (for doctors, nurses, and midwives) at 2.0% vs 4.0%. The lack of growth for nurses working in community services continued, with a fall of 0.2%, while in mental health services there was some growth (1.7%) although levels remain below those in 2014. We set out some of these recent changes in Table 1, but our report as a whole focuses on a consistent basis on changes over financial years.

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