The NHS Long Term Plan sets out how the health service in England will be transformed over the next decade. It promises improved services, better prevention and superior specialist care, but without the right workforce to implement these aims, are they achievable, asks Adrian O'Dowd.
Any great endeavour or good intention to improve the NHS and transform the service, stands or falls on how good the workforce is.
Most stakeholders know that getting the workforce right is critical to a successful NHS. However, there are significant problems that need addressing urgently if the NHS Long Term Plan has any chance of working.
Part of the plan includes proposals for workforce supply and international recruitment, but detail on funding and timescales is lacking until later this year when an anticipated Workforce Implementation Plan, being developed by NHS Improvement and stakeholders, emerges.
A joint briefing paper from three leading health tanks – The King's Fund, the Health Foundation and the Nuffield Trust – predicts an increase in NHS staff shortages from more than 100,000 at present, to potentially 350,000 by 2030 if the NHS continues to lose staff and fails to attract skilled workers from abroad.
The Long Term Plan acknowledges that the NHS needs to boost supply of staff, and part of the national workforce group discussions will look at a desire to improve the nursing vacancy rate from its current 11% level to 5% by 2028, in a variety of ways.
- more nurse undergraduate places;
- newly qualifying nurses being offered a five-year job guarantee within the region where they qualify; and
- developing an online nursing degree, linked to guaranteed placements at NHS trusts and primary care.
For doctors, there will be work undertaken with medical Royal Colleges to address a range of issues in medical training, such as development of generalist skills and movement between specialities. While newly qualified doctors entering general practice could be offered a two-year fellowship.
The workforce implementation plan will also set out new national arrangements to support organisations with recruiting overseas, while NHS England and the Government will seek to ensure the post-Brexit migration system provides certainty for health and social care employers.
The situation is serious, according to James Rhodes, a Partner and employment specialist at DAC Beachcroft: "Our clients are telling us that recruiting staff is a big challenge for them. They tend to have high vacancy rates for nurses, but they are also getting criticised for agency spend, which is under scrutiny".
"A number of clients in local trusts are looking at trying to pool their staff. That's a good idea in theory, but I think the practical problem with this is that not many trusts have the capacity to loan out their staff to somebody else".
Finn O'Dwyer-Cunliffe, Workforce Policy Advisor for NHS Providers, which represents all NHS hospital, mental health, community and ambulance services in England, concurs on the severity of the current position.
"We represent all 227 NHS trusts and in the last two or so years, we have started to see trusts telling us that the workforce challenge is the number one issue," he says.
"The NHS Long Term Plan is an impressive document in terms of the ambitions that are outlined, and there is a lot to like, but our first response to it was, where is the workforce to implement this?"
"For too long there has been a complacency that we will get by, but trusts are seeing this as an incredibly difficult task without a fundamental change to the size and capacity of the workforce."
Help may be at hand from doctors' regulator the General Medical Council (GMC).
It published a document last year entitled The state of medical education and practice in the UK, which acknowledged the workforce problems were being made worse by what it called a "fragmented approach to the recruitment and retention of doctors".
Research commissioned by the GMC for its 2018 report, showed that around a third of the 2,600 doctors surveyed, said they were considering reducing their hours in the next three years.
A fifth were planning on going part time and a further fifth planned to work abroad. Of particular concern, was that 21% of 45–54-year-old doctors and two-thirds of 55–64-year-olds said they intended to take early retirement by 2021.
Professor Sir Terence Stephenson, GMC Chair, says: "Doctors are telling us clearly that the strain that the system is under is having a direct effect on them. A long-term UK-wide plan is needed."
Nevertheless, the GMC remains optimistic.
The report notes that there already exist, across each of the four countries, the data and intelligence that identify where support is needed in the workforce.
"That insight is held by a range of organisations responsible for training and employing doctors, but to date it has never been brought together," says Professor Stephenson.
The GMC proposes that it build insight into the distribution of doctors, and the skills they have across the UK, by contributing to a national database of which doctors have what skills, and in which locations.
Another solution could be to accommodate the rise in international doctors wishing to sit the language test, needed to work in the UK, by increasing capacity at testing centres.
Professor Stephenson adds: "Medicine can be a fantastic career, continues to attract many talented applicants and many doctors remain highly motivated and satisfied. But the costs for some – in terms of their own wellbeing and work-life balance – are not sustainable."
Nursing is also facing significant problems in terms of ensuring enough staff.
Statistics from regulator the Nursing and Midwifery Council (NMC) show that there was a significant rise in the number of EU nurses and midwives leaving the register – between April 2017 and March 2018, 3,962 people left, an increase of 29%.
In addition, there continued to be a dramatic drop in those joining the register from the EU. Over the same period, 805 EU nurses and midwives joined the register compared with 6,382 the year before – a drop of 87%.
The Royal College of Nursing has underlined the stakes and when the Long Term Plan was published, its Acting Chief Executive Dame Donna Kinnair said: "We welcome the ambitions outlined in the Plan. But translating good intentions into better treatment and care for patients relies on having the right number of nurses with the right skills across our NHS."
DAC Beachcroft's Rhodes says: "There are a variety of factors that are causing nurses to leave the profession. At the younger end, student nurses inevitably get themselves into debt to fund their way through the necessary courses, and that is putting people off entering the profession. The rate of attrition is outstripping the rate of entry at the junior level. There have also been problems with the English language test that have held up overseas recruitment."
BARRIERS TO BREAK
Asked what the main barriers are for trusts on securing enough staff, O'Dwyer-Cunliffe says: "The overall supply is an issue. With the nursing workforce, there are at least 40,000 vacancies in the trust sector at the moment.
"There are other difficulties around the type of work that people want now. NHS central bodies have been slow to react to the changing wants and needs of the younger workforce, such as flexibility, and the fact that people are not looking for the same kind of linear career progression that was appealing to doctors and nurses for decades."
Asked how the UK might encourage and support people to stay in the NHS, Rhodes says: "There has to be a number of measures. Remuneration is always an issue. And a lot of people will be suffering the effects of stress, so tackling this and general workplace wellbeing is also an issue. There are moves to look at people returning to the profession – people who have had a career break to have children for example – and encouraging them back into the profession."
O'Dwyer-Cunliffe agrees, saying: "With GPs, there has been some success with certain recruitment schemes to rural areas, for example, sometimes using upfront payments [such as NHS England's Targeted Enhanced Recruitment Scheme, which offers trainee GPs a £20,000 'golden hello' to take up posts in hard-to-recruit areas]."
"With pay, terms and conditions, there have been some improvements for nurses over the last few years, but we have to recognise that we are coming from a really low base."
"In terms of doctors, we must recognise that there has been a real hit to morale in the medical workforce, especially with the junior doctors strike, and this needs to be addressed in a meaningful way."
"The NHS has gotten everybody together in the form of the Workforce Implementation Plan and that is happening now to address a lot of these problems. The proof will be in the pudding in terms of the recommendations that are put down and if the Government is willing to accept them."
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