Act Today, Plan Tomorrow: In anticipation of the workforce plan

By Kate Harper, Director of Research, Insight and Thought Leadership

 

Overview

The NHS workforce plan is possibly one of the most eagerly anticipated documents in the NHS’s history. It is seen as the solution to the persistent workforce shortages that are challenging the sector and hampering recovery from the Pandemic. 

The NHS vacancy rate in the fourth quarter of 2022 stood at 8%, around 13,000 more than at the same point in the previous year – up to a total of around 124,000[1]. Of these, 43,600 were nursing vacancies (11% of the nursing workforce). Government pledges to grow the workforce – while successful in terms of target numbers – have not managed to keep pace with growing demand which has been impacted by the pandemic and the backlog of care which the system is now trying to manage – challenges which none of us could have foreseen.

However, the high vacancy rate is not solely a product of the pandemic.  In fact, higher vacancy rates were reported before the pandemic. They are more a product of the fact that demand for healthcare continues to grow at a pace which is faster than our ability to supply qualified healthcare professionals to deliver the services we need. The pandemic simply amplified the problem. This situation is made all the more difficult by the way we train healthcare professionals and the delay between starting training and these individuals appearing in the workforce (assuming that they do not drop out during their studies or decide to take the skills they have learned elsewhere).

What the sector wants to see today is a workforce plan for training the workforce needed to address the current workforce gap and predicted future trends based on growth in demand for healthcare. And they also want to see commitment to funding the plan.

As with other workforce providers serving the needs of the NHS, NHS Professionals is keen to learn what the workforce plan contains and what the implications might be for us. However, we are not looking at this through rose tinted glasses. We do not expect the plan to be the panacea for all workforce ills and we actually believe we probably already instinctively know what it will say and what the challenge ahead will be. So, what are we expecting and what are we doing about it?

 

What has been promised

In the Government’s Autumn Statement 2022 on 17 November 2022, Chancellor Jeremy Hunt said a comprehensive workforce plan will be published in 2023. He said the plan will “include independently-verified forecasts for the number of doctors, nurses and other professionals that will be needed in 5, 10 and 15 years’ time, taking full account of improvements in retention and productivity.[2]”

But this is not the first time that work has been undertaken to understand future workforce requirements. Framework 15 – first published in 2014 and then updated in 2017, provided a first attempt to predict workforce needs for the future (over a 15-year time horizon) as a means of guiding investments, decisions and actions around workforce planning. The criticism levelled at the report was, however, its failure to provide specific workforce numbers and projections. It is exactly this that people want to see in the long-awaited workforce plan.   

It is not our place to discuss the political challenges and ramifications – or indeed speculate on whether the Workforce Plan will, actually, be one and the same as the refresh of Framework 15 that has been commissioned from Health Education England by the Department of Health and Social Care in July 2021[3]. We expect, however, that the research that is done in support of the Framework 15 refresh will form the basis of the plan and will cover:

  • where we are now
  • what people tell us they want from the future of care, work, and education
  • the likely impact of key drivers of change on future demand and supply such as demographics and disease, science, and technology
  • the shape of the workforce required to deliver our ambitions for 2037
  • some actions we can all take now to bring the desired future closer
  • the big strategic choices that need to be made nationally if we are to realise a fundamentally different future vision rather than just roll forward the past.

On paper, it would appear a relatively straightforward task to model healthcare demand based on growing populations and then ‘uplift’ the workforce requirement accordingly. That, however, is to ignore completely the fact that we are at a momentous point in the NHS’s history with the development of statutory Integrated Care Systems and a clear mandate for cross-system working. Yes, the cynics will say we have been here before and true integration wasn’t realised then and is unlikely to be realised now. But all evidence is showing an ambition and will at operational level to collaborate and change – partly because there is a collective understanding that the way we are working today is not working for the population – and partly because the pandemic showed us that working collaboratively is not just possible, it is game changing. It is also the case that we know that continuing to work in the  way we do today is inefficient and unaffordable. This means that the future workforce plan needs to model a future which has yet to take shape.

 

What are we expecting to see?

The last publication of Framework 15 suggested[4]:

"The future is necessarily uncertain, and we should therefore plan for uncertainty. …. Our best chance of success is to base our long-term workforce strategy primarily on the anticipated needs of future patients, rather than just stated service visions, which may or may not come to fruition”. P. 15

As a result of the above, we are not expecting a workforce plan that will model future workforce predictions based on ‘how we do things today’. Jeremy Hunt’s indication that the plan will take ‘full account of improvements in retention and productivity’ will inevitably mean that the model will be based on modelling around system integration which will give rise to new care models and spawn demand for new roles and different skills (which we discuss in our paper: New Roles in Integrated Healthcare. What can we Learn from the Rest of the World?).  We expect, therefore, that implied in the plan will be efficiency savings and productivity improvement targets with implications for closer system working (including back office efficiency savings, better patient flow through integrated care pathways, emphasis on prevention, activities for keeping patients out of hospitals with support in the community and the ability to share/mobilise staff across systems in a more agile way). 

In an interview with the BBC, the Prime Minister has committed to funding the ‘largest expansion in training and workforce’ in its history[5]. This move was inevitable – simply because we know that demand is increasing/changing as populations age and healthcare science means there is significantly more potential for medical interventions to improve and preserve quality and longevity of life.  Saffron Cordery, the Deputy Chief Executive of NHS Providers, has said[6]:

“We know that when it comes it will be a very significant commitment of funding from the government because what we are talking about is setting out the number of training places and the number of staff that the NHS needs over the next decade or so”.

The independently verified forecasts which we know have been submitted have suggested the sector is currently operating with a deficit of around 154,000 full time staff – a figure that could grow to 571,000 by 2036 if action is not taken now to train more staff. 

 

What do we know/has been said?

Market conversation suggests that the plan sets out the need for:

  • Growing the domestic supply of healthcare professionals and reducing reliance on overseas staff. This was also confirmed by the Prime Minister in his recent BBC interview
  • Reducing reliance on external agency staff;
  • Training more clinical professionals (doctors and nurses) via Apprenticeships which focus on ‘training on the job’ and provide added workforce capacity through the period of training. Again, confirmed by the Prime Minister. Other reports suggest that up to one in ten doctors and a third of all nurses could be trained through apprenticeships in the future[7];

There are also views that the report proposes shortening nursing degrees by six months to 2.5 years and medical degrees to 4 years. 

We have had affirmation that the plan will not focus on modelling ‘more of the same’ from Dr Navina Evans, Chief Executive of Health Education England and Chief Workforce Officer of NHS England. In a recent speech to the King’s Fund Tenth Annual Workforce Summit (22nd March 2023, London), she set out a clear case for the workforce plan supporting a workforce that is ‘fit for the future’ – with that future being one in which prevention and managing patient care in the community will feature large. She said that, despite plans to shift more care to the community, the percentage of nurses and midwives working in the acute sector was the same in 2021 as it was 20 years earlier – 80%. This thinking was also reinforced by her colleagues Jo Lenaghan on the panel session – One Workforce: Reframing our Thinking’ at this year’s Confed Expo event.

Dr Evans also reinforced the linkage between demand for care and workforce supply – not in a linear sense, but in terms of altered demand choices which take full account of how people want to live and receive healthcare and how people want to work. The key drivers are geodemographic (population make-up, growth and health at the local level) and workforce trends such as the bulge in the 18 year old population over the next few years which will create a unique opportunity to attract a new generation of workers into the healthcare sector – not necessarily into clinical roles, but across the breadth of all workforce roles. In this sense, it is easy to see why apprenticeships emerge as a powerful means of maximising the opportunity from this once in a lifetime demographic boom. 

Technology will also shape the future of healthcare. It is expected that AI will give healthcare staff ‘the gift of time’ – increasing productivity, the ability to collaborate and the ease with which decisions can be made. It will also provide mechanisms for people to engage more fully with their own healthcare and shape how care is demanded.

The final driver she discussed was ‘social change’: how people want care to be delivered, young people’s expectations of education and training, the relationship between work and personal lives and expectations around the quality of life.

And what about the workforce to deliver all of this? Inevitably, she said, we will need more of everything (doctors, nurses, allied health professionals, managers and estates professionals). The workforce will also need to be more agile to deal with change and ‘doing things differently’’ with an implication for developing ‘pluripotenial’ (i.e. generalist skills as well as specialist which permit people to work across different settings through the system).  Current staff will need a skills/competency uplift and be regulated to perform a wider range of tasks. We will need to build on the work already underway at ICS level to create new roles that support patient pathways (such as nursing associates and physician associates), and we will need to create new pathways into employment to engage new workers – regardless of their career stage. 

She also talked about a relentless focus on retention – and the importance of ‘growing our own’ and reducing our reliance on the international labour market. 

She concluded that the challenge is about creating shared solutions to shared problems which is not about ‘pointy headed people’ sitting in a room somewhere coming up with a plan – but about all players working together to effect change.

 

What is NHSP’s approach?

Although the details of how plans will manifest themselves at a local level will take time to emerge (and some of this will depend on the funding made available and commitment to growing the numbers of healthcare professionals we need) – the direction of travel is already well understood. To grow workforce capacity we will need to recruit more people, train more people, and organise our resources in a way that optimises the utilisation of the workforce we already have. 

Recruitment

We are already working with clients to develop  ‘recruit, train, deploy’ models to fill newly created roles and bring new staff into the workforce. This means engaging with different talent pools, particularly young people, and selling the benefits of the NHS. And that doesn’t just mean designing job adverts for different geodemographic groups (although that is part of what we are doing): it is also about taking time to understand different audiences, design recruitment approaches that appeal to them, and building out the NHS employer brand in a way that speaks to their ambitions. We also recognise that operating at ICS level will improve efficiency and support the design of more integrated strategies for working with different groups within the local workforce.

We recognise that reliance on international recruitment is something about which we must all be cautious but know that, in the very short-term, ethical international recruitment is a mainstay of workforce expansion.

Training

The establishment of the NHS Academy at this juncture was no accident. We know that the demand for additional capacity, and the emergence of new ways of working across systems, will create considerable demand for training and education.  First and foremost for NHS Professionals, being able to support our flexible workers in a way that ensures their skills and abilities are ’fit for purpose’ is a recognised part of our mission. Whether that be training that broadens skills and allows them to undertake a wider range of tasks, training in new skills (such as digital or virtual ward) or even training in roles that will support capacity growth (such as mentors and assessors) we know that these wider skills sets will ensure our flexible staff are able to fill critical workforce gaps. We are also playing an increasing role in providing training to support the growth of the substantive workforce such as our Support Worker recruit/train/deploy services and programmes which allow those that trained overseas to transition into the NHS.

Optimisation

The pandemic demonstrated the importance of having vehicles that can support the deployment of staff across systems in a flexible and agile way. As integrated working becomes more of a reality staff will need to work across traditional boundaries and in different settings making the need for cross-system deployment more of a reality. NHSP’s provides this type of solution – with the added value of it being able to add capacity to the whole system and drive a reduction in agency spending. By managing the temporary supply chain at a regional rather than individual Trust level – it becomes far easier to control supply and therefore drive down costs. It also establishes a vehicle for ‘sharing’ resources laterally (e.g. between Trusts) and vertically (e.g. between acute, primary and community). 

We have also developed a range of solutions to improve retention on the bank (including loyalty schemes and providing our bank workers with access to training and support – including mental health and financial wellbeing support). And our focus on retention doesn’t stop here: we are also working with clients to find creative ways of using the bank to provide alternative flexible employment for those thinking about leaving and/or having retired including the creation of Reservist programmes and legacy nurse mentoring schemes. 

Ultimately, NHSP is not waiting for the workforce plan to take action. We are already taking action and responding to the challenges that we know will come about as a result of the need for increasing capacity and changing the way we work. Once the plan is published, we will align our current strategy to the strands of activity that the plan prescribes. In the meantime, we are choosing to act today and plan tomorrow.

 

[1] NHS Vacancy Statistics, England, April 2015 – December 2022, Experimental Statistics, NHSE, 2nd March 2023
[2] HM Treasury, Autumn Statement 2022, 17 November 2022, p26
[3] “The NHS Workforce in England”, House of Commons Library Research Briefing, Katherine Garratt, 12th May 2023.
[4] Framework 15: Health Education England Strategic Framework, 20124-29, updated February 2017, Health Education England,
[5] NHS plans: Sumak says expansion means ‘more doctors, nurses, and GPs’, 25th June 2023
[6] NHS England workforce plan delayed amid rumours of cost issues,  The Guardian, 29th May 2023
[7] NHS workforce plan set to expand use of nurse apprenticeships, Nursing Times, 10th May 2023