Frontline staff, and the extra discretionary effort they give, are critical to ensuring the right quality of care. Evidence clearly shows that care quality and outcomes are related to staff engagement. However, the NHS is facing a series of workforce challenges it is struggling to address.
Trust leaders report that getting the right number and mix of clinical staff is proving increasingly difficult. Staff shortages across a range of specialties are putting growing pressure on service delivery. They are also forcing the temporary or permanent closure of individual services, as boards grapple with the near impossible trade off of keeping a service open or potentially risking patient safety. Growing demand and staff shortages mean NHS roles are becoming more pressured and difficult, with staff increasingly overworked and stressed. A prolonged period of pay restraint and the junior doctors dispute have also had an adverse impact.
As a result, trust chairs and chief executives now believe the workforce challenge is just as difficult as balancing the finances. Over half of chairs and chief executives (55%) said they are worried or very worried that their trust may not have the right numbers, quality and mix of staff to deliver high quality care. Most expect the situation to deteriorate over the next six months.
Trusts are working ever harder to recruit and retain the right staff, for example by recruiting from overseas. More innovatively, they have been partnering with higher education institutions to deliver student funded nursing courses and making greater use of new roles, such as advanced practitioners. At the same time they are successfully delivering the agreed priority of reducing reliance of temporary agency staff and are on track to cut the agency bill by 25% this year alone. Trusts are investing in effective leadership and positive and inclusive cultures and are striving to improve staff engagement and support staff more effectively at a time of growing pressure. They are also introducing new measures to improve working conditions as part of the implementation of the new junior doctor contract.
The level of complex change the NHS needs to deliver requires not just more capacity but also greater change management capability. Staff need to be supported and remunerated to make the professions sustainably attractive. And we need to closely monitor the impact of holding down pay for as long as is proposed. The government also needs to recognise the workforce risks posed by Brexit and ensure that coherent and credible plans are in place to mitigate them. This all needs to be underpinned by a clear, system level, workforce strategy and improved workforce planning.
The NHS in England employs just over 1.2 million people, with 1.1 million of those working across hospital, mental health, community and ambulance trusts. More than half (54%) are clinically qualified, 31% are supporting clinical staff, and 15% provide infrastructure support (see figure 3.1). It is these people who ensure delivery of high quality care 24 hours a day, 365 days a year, and they are working hard to maintain and improve the quality of that care in the face of rising patient demand, pressure to increase efficiency, and shortages of key staff.
Breakdown of staff employed across providers as of July 2016
The workforce gap
Our survey findings indicate that the workforce challenge of having the right people with the right skills in place to deliver high quality care is now as large as the challenge of balancing NHS finances. Even if we could fund increasing numbers of staff to meet the rising demand in care, under current plans the number of available trained staff will always lag behind what the NHS needs. This is particularly the case for clinical staff. In the words of one chair: “This concerns me more than the money.”
It is unsurprising that workforce concerns came through strongly in our survey. More than half (55%) of chairs and chief executives said they are worried or very worried as to whether their trust has the right numbers, quality and mix of staff in place to deliver high quality healthcare to patients and service users. Looking forward six months, this number rose to 59%, suggesting chairs and chief executives see the situation deteriorating rather than improving (see figure 3.2).
How confident are you that your trust has the right numbers, quality and mix of (clinical and non-clinical) staff in place to deliver high-quality healthcare to patients/service users?
Following the events at Mid-Staffordshire, the Francis Inquiry gave a clear message from government and the national NHS bodies that trusts should increase staffing numbers. NICE safe staffing guidance for nurses and a stricter regulatory approach to care quality followed. As a result, there was a significant increase in staff demand. In 2014, trusts reported to Health Education England that they needed 189,000 adult nurses (acute) in total, yet two years earlier they predicted they would need only 165,000. This rise in demand was unplanned and, unsurprisingly, resulted in a considerable mismatch with staff supply.
Staff shortages are putting growing pressure on service delivery. In the most extreme examples – often smaller hospital trusts, with smaller rotas and multiple sites to staff – shortages have led to the temporary or permanent closure of some marginal services. Trusts boards increasingly report themselves as having to choose between public demand to keep services open and running a risk of providing unsafe services. Acute hospital boards report that these choices are particularly difficult to make where they involve accident and emergency or maternity services where distance of patient travel can be a key issue. Similar issues apply when considering community-based beds.
Respondents to our survey consistently expressed concerns over shortage of specialist clinical staff, in all types of trust. A chair from an acute trust said: “There are simply not enough high quality clinical staff in the country to cover some specialties.” Trusts are facing recruitment challenges in the face of limited numbers of trained professionals reaching the job market, especially in rural settings.
Health Education England is working to deliver a plan to increase staff numbers and the secretary of state for health has recently announced that from 2018 there will be a 25% increase in the number of medical students. The creation of student loan funding for nurses and allied health professionals may create opportunities to increase staffing numbers to meet demand, though this is hotly debated in various parts of the service. While all these initiatives are welcomed, they have not yet demonstrated that they will consistently increase the number of trainees and clearly do not provide a quick solution. For example, it takes 12 years to turn a student into a senior doctor. There is still concern that even these increases in the number of trainees will be insufficient to maintain services, especially in the short term, given the rise in patient demand and the time taken for new staff to reach the frontline.
The approach to plugging the short-term gap between demand and supply of staff has been overseas recruitment, including 54,000 NHS staff recruited from the European Economic Area (EEA). However, Brexit has created uncertainty about overseas recruitment in future and the security of those who are already part of the NHS. There is concern that it will create further difficulties in securing required staff numbers to meet short-term requirements. In our survey, a chair from an acute trust noted that “problems in particular groups, e.g. radiologists, and Brexit, has caused ‘drying up’ of recruitment from the rest of Europe.”
Growing pressure on staff
Increasing demand on services combined with staff shortages in key areas are adding to the pressures on NHS staff. The overall measure of staff engagement within the NHS staff survey has risen over the last five years – which suggests a degree of caution is needed before being too negative. However, the survey also presents a picture of a workforce under greater stress in 2015 compared to 2011 (see figure 3.3). It also revealed that 48% of staff disagree or strongly disagree that there are enough staff at their organisation for them to do their job properly.
Percentage of NHS staff suffering work-related stress during the last 12 months:
Ensuring the right culture is in place within organisations is crucial if staff are to maximise their potential. A safe, effective and efficient environment for staff relies on an open and transparent culture. At a time of greater pressure and increasing demands on staff, this is especially important as the NHS relies on a significant amount of discretionary effort. Critically, the behaviour of organisations towards their staff is reflected in the quality of care that patients and service users receive. More specifically, there are clear correlations between staff support and engagement and patient safety.
The data on staff bullying is a real concern. There was a 9% jump between 2011 and 2015 of the number of staff experiencing harassment, bullying or abuse from other staff (in 2011, 14% of staff experienced this compared to 25% of staff in 2015). Another area of concern is the 11% drop in the numbers of staff reporting bullying (in 2011, 53% of staff said they reported it, while in 2015 this had dropped to 41%).
The picture on race equality also remains worrying. There are well-established links between organisational culture, the success of black and minority ethnic (BME) groups and levels of staff engagement. There are still higher levels of BME staff reporting that they experience abuse, bullying and harassment from patients, relatives and carers. There are also reports of greater discrimination towards BME staff, as well as blocked career progression and reduced access to training opportunities. This inequity is also reflected in the ethnic profile of those leaders running NHS organisations. Too many trust boards are disproportionately white and male.
The workforce race equality standard (WRES) has been established to systematically tackle this issue. This has identified a baseline picture of the state of race equality in the NHS, alongside a process to ensure progress is made. Early results show that the NHS is not getting the best out of all its staff, and this needs to be rigorously pursued.
Two other significant factors contributing to the feeling of growing pressure on NHS staff are the ongoing impact of squeezed pay and contract reform for junior doctors.
The government’s policy of pay restraint, which has seen pay capped at 1% since 2010, will come under increasing scrutiny if, as expected, inflation rises. The governor of the Bank of England recently warned that inflation will rise on food and other products because of the fall in the value of the pound. This will result in NHS staff earnings falling in line with rises in the cost of living, which risks further eroding staff morale.
Finally, the dispute over the new junior doctor contract has been difficult, with underlying dissatisfaction and low morale playing its part in the dispute. Effective implementation of the new contract and re-engagement of junior doctors are key challenges for trusts over the next year, along with reform of the consultant contract and Agenda for Change, which covers more than one million staff such as nurses.
Leadership and management capacity
The size of the leadership and management challenge now facing the NHS is striking. Trusts are expected to meet a wide and ever growing range of objectives and priorities, including delivering transformation and performance improvements, all within the context of constrained funding. If trusts and other parts of the health system are to rise to this challenge then staff need to work in different ways and there needs to be significant investment in change management capability.
However, leadership and frontline capacity is now limited after decisions to focus pay bill resource on frontline care. This has meant that, in many trusts, previous cost improvement programmes have led to a reduction in leadership and management capacity, particularly in middle management.
Finally, the size and scale of the leadership and management challenge is putting off many senior staff from stepping up into leadership roles, particularly clinicians. As The chief executive’s tale, our report with The King’s Fund showed, the average tenure of a chief executive working in the NHS is now around three years, and the majority of chief executives interviewed for the report said they were concerned about the attractiveness of the role to their colleagues. The abolition of the strategic health authority tier in the NHS has also removed well developed leadership and talent management programmes and approaches.
THE PROVIDER RESPONSE
In the current financial climate there has been pressure on trusts to deliver savings. Trust boards describe themselves as walking a fine line between delivering these savings, maintaining safety and quality, and ensuring staff morale. Despite the challenges, trusts have made good progress as the achievements below demonstrate:
Trusts have worked hard to plug the workforce gap in the short term by filling clinical staffing vacancies through effective external recruitment from within the European Economic Area, for example Spain and Portugal, and the rest of the world, for example the Philippines.
Workforce is a key enabler within the STPs already published, with trusts collaborating in the creation of staff banks that cover local STP areas. However, these plans are clearly at an early stage. The recently established local workforce action boards covering all STP areas will also have an important role to play, but as yet are still to get fully up and running.
Some trusts have taken innovative approaches to workforce supply, including partnering with higher education institutions to deliver student funded nursing courses. For example, Lancashire Teaching Hospitals NHS Foundation Trust and the University of Bolton have partnered on a nursing course funded by students through the student loan system. Bolton NHS Foundation Trust and Central Manchester NHS Foundation Trust later joined the partnership. County Durham and Darlington NHS Foundation Trust is working with Teesside University to create nursing courses to develop nurse practitioners and elderly care as a specialty.
Trusts are making greater use of new roles, such as advanced practitioners to deliver services such as emergency care, or nursing associates to improve productivity. Over 1,000 nursing associates will begin training this year in a new role that will sit alongside existing nursing care support workers and fully-qualified registered nurses to deliver hands-on care for patients. Health Education England has announced that there will be a second wave of a further 1,000 nursing associate trainees following huge interest in the role and high demand from trusts wanting to offer training places. Eleven sites have been chosen to deliver the first wave of training that will start in December 2016 and run over a two year period. The test sites include: St George’s University Hospitals NHS Foundation Trust, The Whittington Hospital NHS Trust, Barts Health NHS Trust, and Walsall Healthcare NHS Trust. In addition, Birmingham and Solihull Mental Health NHS Foundation Trust is using physician associates to enhance care delivered in mental health.
Trusts are using new technology to access skilled staff more effectively, for example making specialty expertise available in primary care through skype. For example, East London NHS Foundation Trust diabetes clinics are increasingly delivered over Skype to improve productivity by allowing patients to access preventative care and clinical expertise closer to their homes. Trusts are also using e-rostering software much more widely to significantly improve the efficiency and effectiveness of the highly complex task of alllocating staff to appropriate rotas. More effective rostering also enables trusts to better meet staff requests for more flexible working.
Trusts are investing in leadership – given the complexity and extent of the strategic challenges providers face, investment in developing leadership skills and capacity is vital. NHS Providers is working with the central bodies, including NHS Improvement and the NHS Leadership Academy to support the pipeline of future trust leaders through an aspiring chief executives programme. The programme has, in less than a year, seen 6 of its 28 participants appointed to permanent provider chief executive roles. All NHS bodies, under the auspices of NHS Improvement and Health Education England, have come together to develop a national framework for improvement and leadership development, which will support among other things, better system leadership skills.
Trusts have controlled pay bills, which is on average 66% of their total spend, as part of an increased national focus on workforce productivity. This focus has been seen most visibly with the introduction of agency rules and price caps. According to NHS Improvement, one year on from the introduction of the agency caps “almost three quarters of trusts (73%) have now successfully reduced their agency spend, and over half of these have reduced spend by more than a quarter.” For example, Dorset Healthcare University NHS Foundation Trust has reduced its agency spend by half following an event with staff to discuss how to promote the trust bank and reduce agency spend.
NHS Improvement reports that £600 million has been saved so far compared to if the rules and caps had not been introduced. Trusts continue to make use of the “break glass” provision to breach the caps in order to safeguard patient safety. The Carter review contains a range of other workforce productivity initiatives that trusts are expected to implement.
The workforce gap
The NHS will struggle to address both its short and long-term workforce requirements in the absence of a credible and coherent workforce strategy. As part of this, we need a workforce planning system that is able to both match demand and supply and workforce numbers to the available financial envelope. The Health Foundation report in March 2016 - Fit for Purpose? - put a spotlight on the current fragmented approach to NHS workforce policy and called for the establishment of a national strategic forum for workforce policy. This is needed to improve the quality of workforce strategy and planning at a national system level.
Failure to address workforce supply
As well as planning for the future, there is also a pressing need for adequate plans to cover shortages in the short term. The sense of urgency is heightened by the uncertainty created by the UK’s decision to leave the EU. The Cavendish Coalition, a group of health and social care organisations, have come together to work to ensure that health and social care have the staff they need to deliver high-quality services. Government needs to recognise the risk to workforce supply and service provision posed by Brexit and ensure that coherent and credible plans are in place to safeguard supply.
Growing pressure on staff
Given the pressures on the front line, it is essential to keep a strong focus on the recruitment and retention of staff to maintain a sustainable service. Long-running pay constraints, increasing demands on staff and a risk of leadership teams having insufficient 'bandwidth' to focus on supporting their teams risks a further deterioration in staff morale and further raising staff turnover rates. Staff need to be appropriately supported and remunerated to make the professions attractive.
Ensuring much greater race equality in the NHS is one area that needs particular progress. The workforce race equality standard has identified the starting point, but the NHS is still a long way off from supporting, and getting the most out of, all its staff.
Action in these areas can make a major difference. The strongest predictor of outstanding or special measures in CQC ratings is the engagement of staff. Where the people we work with believe they are valued and can influence what happens then they have the space to excel. When they feel disengaged, disempowered and disenfranchised, patient care suffers. Organisations like Western Sussex Hospitals NHS Foundation Trust, Salford Royal NHS Foundation Trust, East London NHS Foundation Trust, The Christie NHS Foundation Trust have placed particular emphasis on supporting their staff in the increasingly challenging environment this report describes. It is no accident that they have all received outstanding ratings from the CQC.
Lack of leadership and management capacity
The level of complex change that the NHS workforce needs to implement to achieve service transformation requires significant additional capacity and capability that it will be challenging to create given current resource constraints. For example, rapid and effective delivery of the Carter review savings will require NHS trusts to address current gaps in the analytical, project management and change management skills needed. The depth of senior leadership in the provider sector is also now thinly spread running increasingly unstable individual institutions, leading transformation and co-creating and delivering system-wide sustainability and transformation plans. There is a significant mismatch between the leadership and management resource available and what the NHS is asking its leaders and managers to deliver. It obviously follows that, unless we can quickly address this gap, the NHS will not deliver all that it is being asked to deliver.
Progress is also needed on ensuring there is a pipeline of emerging leaders in the NHS that are ready to take on director and chief executive roles. At the moment, there is a shortage of applicants for executive board level roles, with fears that the position is becoming increasingly tough, demanding and impossible to succeed in. This is particularly the case when it comes to attracting clinicians into senior leadership roles. There is also an emerging risk that the current pressures in the NHS will also start to impact on the number of appropriately skilled and experienced
external leaders willing to become non-executive directors, who play a key role on trust boards.
WHAT providers need
The Department of Health and its arms length bodies need to develop a comprehensive workforce strategy that takes account of what the NHS is being asked to deliver in both the medium and long term. This needs to be accompanied by an improved approach to workforce planning. Staff need to be appropriately supported and remunerated to make the professions attractive, and we need to be better at adapting and developing the NHS workforce to deliver new models of care. We also need to properly and realistically plan to deliver the government’s key priority of introducing seven day services.
The leadership challenge in the NHS is complex. Given the scale of the task we need to make sure we: have the right development and improvement framework in place, and make the role of running NHS organisations as attractive as possible to secure future leaders. We also need to create the right cultures to foster an inclusive, open and transparent environment for all staff to realise their potential.
Finally, we need to ensure that the financial envelope and regulatory regimes are aligned to support the recruitment and retention of the right numbers and mix of staff.