The NHS workforce provides healthcare, free at the point use, to over 55 million people in England. As pressure on services and staff mounts, a workforce gap has developed. A fresh approach to the workforce is needed.

Our diagnosis

  • Mounting pressure
    Rapidly rising demand and constrained funding is leading to mounting pressure across health and social care services. 

  • The workforce gap
    Many provider trusts – hospital, mental health, community and ambulance services – are struggling to recruit and retain the staff they need to deliver high-quality care for patients and service users. There are very big gaps in some places. This workforce gap is a fundamental strategic issue which is undermining provider sector performance and risks preventing the delivery of service transformation. Two thirds (66%) of trust chairs and chief executives told us workforce is the most pressing challenge to delivering high-quality healthcare at their trust. There are three key factors contributing to the workforce gap.

  • Recruitment and retention
    Provider trusts are the employers of staff and have a responsibility to make their organisations great places to work. There is more that trusts can do. But recruiting and retaining staff has become more difficult as the job gets harder, training budgets are cut, and prolonged pay restraint bites. When asked for the biggest challenges to recruitment and retention at their trust, 60% of trust chairs and chief executives cited work pressure and 38% cited pay and reward. There is a gap between the staff available for recruitment and retention and the staff trusts can persuade to work for them.

  • Funding
    Even if there were no supply shortages of staff, and provider trusts had no difficulty recruiting and retaining staff to work for them, trusts may still be unable to afford to employ the staff they need to deliver high-quality services given low growth in the public funds the provider sector has been allocated relative to rising demand for services.

Closing the workforce gap

  • Domestic supply
    The supply of domestic staff needs to grow substantially. The government has recognised this and plans to expand medical education, boost the number of nurses and other healthcare students, and open up new routes into healthcare careers such as apprenticeships. However it is not yet clear that these initiatives will close the workforce gap and, in any event, it will be several years before we see significant numbers of extra staff available for provider trusts to recruit and retain.

  • International supply
    In the absence of quick fixes to domestic supply, there is a continued need for provider trusts to recruit and retain staff from the EU and the rest of the world to mitigate the workforce gap. In a recent survey, 85% of trust chairs and chief executives told us that it will be very important or important for their trust to recruit from outside the UK over the next three years. Uncertainty linked to Brexit was seen by chairs and chief executives as the main barrier to the recruitment of non-UK staff over the next three years with more than one in three (38%) mentioning this issue. This is followed by professional regulatory requirements, including language testing (32%), and then current immigration policy and charges (16%). There is opportunity for NHS-wide cooperation on international recruitment.

  • Making the NHS a great place to work
    Provider trusts must do all they can to foster positive and inclusive cultures, tackle bullying, improve the experiences of black and minority ethnic staff, and offer staff greater flexibility. At the same time, action at the national level is needed to address growing work pressure on staff, reverse cuts to training budgets, and to adequately fund the promised end to pay restraint. There is an opportunity for national promotion of the NHS as place to work.

  • Workforce development and productivity
    The answer to the workforce gap is not only about more staff. It is also about providers delivering services in new ways with staff working differently and more flexibly. The workforce gap is not static and can be narrowed, though not eliminated, by trusts undertaking workforce development and improving productivity. National-level support is needed for trusts to make changes at pace and scale.

  • Leadership development
    Provider leadership capability is being stretched thinner and thinner, just at a time when it’s most needed, to maintain and improve current performance, help close the workforce gap, develop the workforce and enhance productivity, and deliver service transformation. National-level action is needed to secure the pipeline of future leaders and ensure that once in post they are supported to lead trusts to address the challenges faced.

Ensuring a coherent and credible approach

  • A coherent and credible approach to workforce at the national level
    The Department of Health and its arm’s-length bodies, Health Education England, NHS Improvement, NHS England, and the Care Quality Commission (the NHS national bodies), need to acknowledge the scale of the workforce gap and develop and communicate a coherent and credible workforce strategy with plans and policies to support provider trusts to recruit and retain the staff they need. In our recent survey, 90% of trust chairs and chief executives are worried or very worried about whether the Department of Health and the NHS national bodies’ approach to workforce strategy, planning, and policy will support their trust to recruit and retain the staff they need. This is deeply concerning. If the ministerial board on workforce is to be the key forum overseeing and coordinating NHS workforce strategy, planning, and policy, it needs to communicate effectively about its work, seek input from a wide range of opinion, be transparent about its work programme and be seen to engage effectively with provider trust leaders.

  • A new partnership between the national and local levels
    There is a big question for the longer term about which elements of workforce strategy, planning, and policy are best dealt with at the national level and which would be better devolved to a more local level. The answer to this is not yet clear. But, in light of the current challenges, this needs to be explored at speed and opportunities for a more responsive and flexible workforce identified and realised.

Survey findings

In order to gain insight into the workforce challenges facing provider trusts, we carried out a survey of our members. We received 149 responses from chairs and chief executives of NHS trusts and foundation trusts, representing more than half (51%) of all NHS secondary care providers in England. All types of trusts and regions were represented in the survey responses. The findings are set out in the charts below.

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