Workforce is a top concern for trusts up and down the country, and the workforce challenge is now equal in scale to the NHS financial challenge. Although different trusts face different pressures, the sector as a whole is finding it increasingly difficult to recruit and retain sufficient staff with the skills and experience needed to meet the rising demand for services. Trusts are also struggling to match the staffing levels they require with the finances available. Even if money were not a constraining factor, insufficient staff have been trained within the UK to meet current and projected demand. These shortages impact directly on the safe and sustainable delivery of high quality care, with trusts finding they are increasingly having to close or suspend services for short periods of time or altogether.
The provider challenge
Workforce now the top concern
The growing set of workforce challenges facing NHS providers are now the biggest concern of trust leaders. As a chief executive from an acute provider stated in our survey: “It is the only thing that keeps me awake at night. It speaks to our capacity to provide safe quality of care to patients”.
There are a range of concerns, many of which are captured in summary form in figure 4.1 below, and explored in further detail in this section.
Our survey showed that well over half of trusts (57%) are 'worried' or 'very worried' about their current ability to maintain the right numbers of staff – clinical and non-clinical – to deliver high-quality care (see figure 4.2). When asked what the picture would look like in six months’ time, their level of confidence decreased and 61% were 'worried' or 'very worried'.
Matching workforce with funding
The pressures on workforce and funding are intertwined. Trusts are struggling to match the staffing levels they require with the finances available, and there are no quick fixes. Even if money were not a constraining factor, insufficient staff have been trained to meet current and projected demand. And, where staff can be recruited, trusts cannot afford to employ them and balance their books.
The workforce picture for healthcare providers continues to be one where NHS needs a strategic, planned solution to the triple-headed problem of ensuring a supply of staff, meeting rising demand and affordability.
Pressure and morale
Frontline services faced intense and persistent pressure this winter, throwing into sharp relief the impact of staff shortages and rising demand on the morale of the workforce. Staff battled to manage, not only the highest ever A&E attendances, but the knock-on effect across the health and social care system. A range of reports have illustrated the impact of these pressures on staff. For example, the Royal College of Physicians highlighted the risk of staff burnout. In the words of one consultant:
I have never before known a time when consultant colleagues are constantly exhausted, trainees so disillusioned (as director of medical education, I receive daily visits and emails from trainees who want to talk about leaving medicine) and hospitals under unremitting clinical and financial pressures. Of course, problems with recruitment also apply to other healthcare professionals – particularly nurses.
The latest General Medical Council training survey shows, for example, that over half of all doctors in training say they work beyond their rostered hours at least weekly, and more than a fifth claim working patterns regularly leave them short of sleep.
These morale issues are reflected in NHS staff survey feedback. While the survey results overall have held up well despite the increasing pressure, there are worrying individual results. These show that over 70% of staff are working extra hours and 37% of staff report feeling unwell due to work related stress in the last 12 months prior to the survey.
The NHS staff survey and our survey showed concern over the number of staff needed to do a proper job. The following issues impact on this:
- Specialty shortages - the shortage of staff in some specialty areas, such as emergency medicine, nurses and midwives, presents particular difficulties for the delivery of services such as A&E and maternity. Also, there are also major shortages in non-acute services with a 13% decrease in full-time equivalents mental health and community nurses and a 42% drop in district nurses employed between 2009 and 2016 in the NHS.
- Recruitment and retention - sustained pressure on the frontline can lead to extremely stressful working conditions which, combined with the ongoing pay freeze, are beginning to have an adverse impact on trusts’ ability to recruit and retain some staff groups. This has been clearly highlighted by the independent pay review bodies, and NHS Providers has called for an agreed strategy, covering the life of this parliament, to end ‘pay restraint’ . The issue was raised throughout the general election and has now become a matter of political debate with many politicians arguing for a clear plan to end pay restraint.
- Brexit - the triggering of Article 50 is also having an adverse impact: currently the rights and status of 161,000 European Economic Area (EEA) staff working in health and social care are unclear; at the same time it is yet to be decided whether and how the NHS will be able to recruit from the EEA in future. Recent evidence from the Nursing and Midwifery Council shows a 96% year-on-year drop in the number of EEA nurse registrations, though factors beyond Brexit may have an influence here.
Workforce shortages impact directly on the safe and sustainable delivery of high quality care. Trusts are finding that they are increasingly having to close specialty services for periods of time or altogether. In many places, they are finding it difficult to fill rotas, requiring extensive use of agency staff or asking existing staff to fill gaps and work longer or extra shifts.
NHS workforce pressures are substantial. However, there are some developments which may, in the medium and long term, help the supply pipeline flow again and manage some of the workforce costs:
- Agency spend - Despite the substantial pressures, there is continued progress on reducing agency spend, with the latest figures indicating a saving of £700m since the price caps were introduced in October 2015. This makes a helpful contribution to the NHS bottom line, and also to the quality and safety of NHS care.
- Training - although applications for nursing had fallen by 23% as of January 2017, universities remain confident that they will fill the available places with students of the right quality, despite the changes to nursing bursaries.
New and more staff – NHS trusts have embraced the new nursing associate role, and are taking steps to boost the contribution of apprenticeships to the NHS workforce . The government is also consulting on expanding the number of medical students by around 25%. However there is significant trust concern that expansion will take time to deliver and may not be affordable.
- New and more staff – NHS trusts have embraced the new nursing associate role, and are taking steps to boost the contribution of apprenticeships to the NHS workforce. The government is also consulting on expanding the number of medical students by around 25%. However, there is significant trust concern that expansion will take time to deliver and may not be affordable.
- Local initiatives – faced with the prospect of ongoing staff shortages more trusts are taking the initiative locally, with schemes to improve long term workforce supply. These range from making links with local colleges which include guaranteed employment at the end of courses to forming relationships with local secondary schools to promote careers in the NHS.
What providers need
- A realistic, joined-up, long-term workforce strategy which ensures that frontline organisations have the right number of staff with the right skills in the right place to deliver high quality care within the allocated financial envelope. This will require a more coordinated and effective approach to national workforce issues between the different elements of the national NHS level system.
- Given persistent staff shortages, a credible and coherent plan to plug the short-term gap as well as a sustainable plan for workforce numbers that matches the projected NHS funding envelope.
- Urgent clarity on the status of current EU nationals working in the NHS and an immigration system that allows the NHS to recruit the staff it needs.
- An appropriate match between what is asked of the NHS and the funding available to alleviate the stress and pressure on NHS roles and to ensure that we are not consistently asking NHS staff to do the impossible.
- A strategy to move away from seven years of pay restraint to ensure that NHS roles are appropriately rewarded and remain attractive.