Snap Analysis 30 June, 2023

Reform analysis: NHS Long Term Workforce Plan

In 2017, the Government promised to set out a long term NHS workforce plan. 6 years, 4 changes of government, and 1 global pandemic later, and it’s finally here. Better late than never…

In fairness, pulling together an accurate set of projections and a comprehensive plan for the world’s fifth largest employer was never going to be an easy feat. And getting planning right means more than just forecasting future need and growing the workforce accordingly. It requires genuine alignment between the vision for the NHS’s workforce to the Service’s stated delivery ambitions — prioritising prevention over treatment, shifting care out of hospitals and into the community, and achieving parity of esteem between mental and physical health.

So how does the plan stack up? We’ll be poring over the fine print in the coming days but here’s a few initial thoughts on the plan’s three big priority areas: train, retain, and reform.

Train: Growing the workforce

The plan’s topline commitment to expand training is welcome — though the upfront costs of increasing training places (£2.4 billion) are significant — they are dwarfed by growing and unsustainable spending on temporary staffing. And the workforce areas prioritised for training increases are the right ones — general practice, dentistry, mental health and disability nursing, and clinical psychologists and psychotherapists all require sustained investment if the NHS is to realise its vision to transform care.

Alongside expansions to the “traditional” (university-based) training pipeline, there is a big emphasis on employer-based training — the NHS hopes to triple the percentage of staff trained through apprenticeships by 2031/2 and will be introducing a medical degree apprenticeship this year. The evidence base that apprenticeships increase retention, support local economic development, and diversify the workforce is growing so exploring how to boost this route is worthwhile.

However, uptake of apprenticeships (mainly in nursing) has so far been patchy — employers have argued that under the current levy scheme, training by apprenticeship does not make financial sense. The plan does not address concerns about the current apprenticeship model directly, and instead pledges to “develop an apprenticeship funding approach that better supports employers with the cost of employing an apprentice”. The principle of expanding access to medical and nursing careers is admirable, but we’ll need to see more detail on how apprenticeship expansion can actually happen.

Retain: Embedding the right culture and improving retention

Keeping existing staff in the system is the other side of the workforce expansion coin — and the planners hope that almost half of the workforce increases they project will come from improving retention. If that is the case, retention deserves more than the ten pages (out of a total of 150) that it gets here.

Much of the focus is on retaining older and more experienced staff — and there are sensible commitments to reforming the pensions system so staff can partially retire or return to work seamlessly near the end of their career. Similarly, smoothing the path for retired doctors and nurses to re-enter practice — including through the proposed Emeritus Doctor scheme — can help bring in vital, experienced staff to bridge gaps before new capacity can be brought into the Service.

However, on the big ticket retention items — improving staff wellbeing, clamping down on discrimination, harrassment, and bullying, and building a more flexible approach to working — the plan has little of substance to say. While there are many exhortations for providers and systems to review their cultures, invest in occupational health and wellbeing, and explore opportunities for flexible working, real commitments are few and far between.

Importantly, the plan is detail light on how to improve retention of staff in training and early in their careers. Expanding the training pipeline is only useful if staff actually end up working in the system and with as many as a quarter of student nurses dropping out of their degrees and record high numbers of junior doctors expressing their intention to leave the NHS, retention of younger staff needs far more attention. Working with students, higher education institutions, placement providers and the royal colleges to address this issue is a start, but a plan is needed to plug an increasingly leaky training bucket.

Reform: Working and training differently

We may be biased, but the most intriguing (controversial?) proposals in this plan come in its final section on reform. The focus here is on reforming the way in which staff are trained and then work in the system.

On the former, the plan emphasises the need to train staff more efficiently. There are promising ideas here. The high number of hours (2300) that student nurses must spend on placement is a key barrier to expanding course numbers and is significantly out of line with comparable nations (800 in Australia, 1100 in New Zealand). Reducing placement hours to 1800, and focusing on quality, not quantity in training experience is the right direction of travel — though may not go far enough.

On medical training, the NHS will work with the General Medical Council, the professional regulator, to develop proposals for a shortened (4 year) undergraduate medical degree. Reducing the length of medical training could help bring capacity into the system more quickly and deserves consideration. However, the content of medical training is as important as its length. The plan misses an opportunity to seriously challenge our increasingly specialised modelof post-graduate medical training, but commitments to mandate that all medical trainees gain experience in general practice and that continuing professional development (CPD) focuses on maintaining general medical skills are promising.

On ways of working, the plan pushes for more multidisciplinary team working and expanding new roles, physician and nursing associates in particular. Both expanding numbers in these professions and increasing their scope of practice (for instance, allowing physician associates to prescribe medication) will help free capacity for doctors and nurses to work at the top of their licence and improve access for patients. Making the most of new roles and expanding the scope of existing ones requires a real focus on CPD. And while the plan commits to "ongoing national funding for continuing professional development" it is not clear what this level of investment will be. CPD budgets have often been the first casualties in drives to contain spending, so a long-term commitment is vital here.

The elephant in the room when it comes to ways of working is the question of how to improve the NHS’s lacklustre productivity. Sizeable increases to frontline staffing in recent years have not been matched by a commensurate rise in the productivity of the Service. Concerningly, there is no real strategy here to realise the plan’s “ambitious labour productivity assumption of up to 2%.”

Improving productivity in the NHS will require three things — investment in management, physical capital, and digital capability. All three receive short shrift. There are nods to the recent Messenger Review into management, but no plans to expand the managerial workforce or extend its capabilities. Capital spending in healthcare in the UK runs at half the OECD average, leaving the system with a crumbling estate and shortages of key diagnostic equipment, but there are no commitments to reform here. On digital, the plan follows a well-trodden path in focusing on the high-tech and advanced (robotic surgery, artificial intelligence) rather than getting the basic infrastructure right.

While these priorities may be the subject of separate plans, the NHS’s track record in this area does not inspire confidence. Over the last decade, capital, digital and management budgets have been repeatedly raided to pay for increasing numbers of frontline staff. Given that the Government has not announced additional funding to cover the cost of this plan, there is a real risk that growing a larger but less effective workforce continues to be the NHS’s strategy.