Workforce planning remains a missing link in the NHS long term plan

7 Jan 2019

Stephen Bevan, Director, Employer Research and Consultancy

In today’s coverage of the NHS long term plan, much of the focus has been on the scale of its ambition to invest in, grow and join up mental health services, maternity care, prevention, GP services and community care. Of course there will be more forensic questions about how the extra £20.5bn by 2023 will be spent and the policy and clinical priorities which will inform these decisions.

But there is one major area (aside from the small matter of a Green Paper on social care) which, despite being critical to the delivery of the plan, is noteworthy today because of the lack of detail. Many commentators have already noted that the workforce strategy which is needed to set out how the long term plan will be delivered, and by whom, will not be available until later in the year. Given that the NHS workforce, its skills, its engagement and its agility will be a vital enabler or barrier it’s worth looking at three of the biggest issues which a workforce strategy will need to address if it is to play its part in making sure that the long term plan is a success.

One is workforce engagement and wellbeing. Keeping a diverse workforce of 1.2m people motivated and engaged is never straightforward but doing so is essential if the quality and continuity of care which patients and taxpayers expect is a constant challenge.

At one level, engendering a sense of purpose, meaning and vocation is less challenging in the NHS than in many other organisations but the pressure and scrutiny which the NHS has been under, and the workload pressures which have borne down on so many parts of the service, frame the challenge which NHS leaders have in harnessing the energy and commitment of NHS staff. The latest NHS Staff Survey results show the size of the task. Among the 487,000 respondents in 2017:

Fewer than in previous years were happy with the quality of work and care they were able to deliver;
Almost 40 per cent (a growing proportion) reported feeling unwell due to work-related stress;
Just over 29 per cent reported witnessing potentially harmful errors, near misses or incidents in the month before the survey;
Over half (53 per cent) reported attending work when ill in the last three months;
Fewer than a third (31 per cent) agreed that there were enough staff to the job properly.

Most leaders and HR professionals in the NHS are already well aware of these views and are busy deploying the organisational development, learning and development, reward and team building interventions at their disposal to ensure that staff are equipped to deliver. But the scale of the task remains very substantial and staff will need to see that their part in the long-term plan is acknowledged and invested in rather than taken for granted.

Another significant challenge is the productivity question. Defining and measuring productivity in the NHS has always been tricky, especially given that the ‘outputs’ of healthcare such as ‘quality’ or a health episode prevented by early intervention are almost impossible to quantify. Yet with additional resources being added into the service the efficiency with which these resources are deployed will be both a political and a clinical question.

One problem is language. For many healthcare professionals the term ‘productivity’ sounds like an insensitive call by politicians to work harder. For other NHS staff and some patients it also feels like a drive to reduce costs and, perhaps, an elevated risk of cutting corners or rationing care.

Part of the answer lies in empowering local staff to drive improvements, and there have been good successes here. For others productivity means adopting more technology and innovation in the way that healthcare is delivered. Here, as IES research to evaluate the NHS Innovation Accelerator Programme has shown, the answer lies in ‘smart’ diffusion of new ways of working which embrace both technology and staff know-how and commitment. In any case, part of the way the success of the long-term plan will be judged will be on how it balances the need to drive efficiency and quality of outcomes.

Perhaps the most pressing workforce headache, however, is workforce planning - matching the rapidly changing demand for a highly skilled workforce with the supply of skills available. This represents one of the most complex workforce planning challenges of any UK organisation and the baseline starting point does not look pretty. The King’s Fund has gone as far as saying that ‘the workforce challenges in England now present a greater threat to health services than the funding challenges’.

This is a big deal, of course, because the supply of skills cannot be turned on like a tap – training places need to be planned, funded, filled and the throughput deployed effectively and in concert with local needs. It is currently estimated that 1 out of 11 NHS posts are vacant (about 100,000 vacancies) with the equivalent number in social care sitting at 110,000. These mismatches can take some time to resolve, and ‘disruptors’ such Brexit uncertainty, the removal of training bursaries, and changes to UK migration policy, only complicate the task of getting the right skills available to local NHS managers when they need them. And even with staff in post, offering sufficiently flexible working arrangements and retaining and developing the prime talent will always be a battle in an increasingly buoyant labour market.

Workforce planning in this environment is partly about understanding how demographic, epidemiological and technological factors will affect the pattern and number of skills that will be needed. In work for Cancer Research UK IES looked at the future non-surgical oncology workforce needs if a ‘best practice treatment model’ was adopted. It highlighted key skill gaps that agencies such as Health Education England (HEE) should be targeting.

IES also identified that the growth in the over-85s population represented the biggest draw on NHS resources and that NHS organisations where this risk was compounded by a reduction in EU-born nurses and midwives were likely to face the biggest resourcing ‘squeeze’ in the coming decade.

We also know that, in addition to the ageing population, the growth in the number of people with multiple conditions will also feed through into more complex healthcare and skill needs. Already 24 per cent or 14.2m people are living with two or more health conditions and this is forecast to grow rapidly in parallel with the timeframes of the long-term plan. Co-morbid mental health problems, for example, raise total health care costs by at least 45 per cent for each person with a long-term condition and co-morbid mental health problem.

In this context workforce planning can feel daunting. At IES, we have 50 years of experience of supporting NHS employers to do this well, professionally and in a way that supports rather than dictates local decision-making. We have many resources which employers can draw upon, both in terms of core techniques and advice set in the context of Brexit, for example. So while most will welcome the government’s injection of extra funding into the NHS, the absence of an accompanying workforce strategy that gives leaders and clinicians the confidence that the skills will be there to deliver, it means that it’s only possible to rouse two cheers for the plan so far. It remains a work in progress.

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Any views expressed are those of the author and not necessarily those of the Institute as a whole.