Bill Clinton famously said ‘it’s the economy stupid’. In the case of the NHS delivering high quality, efficient care on a sustainable basis, we could sum that up with ‘it’s the workforce stupid’. This is a statement of the obvious, so it is shocking to see how little policy and leadership focus is often devoted to the core asset: the people who dedicate their working lives to delivering care in the NHS.
The Health Foundation has a long tradition of supporting people to develop improvement skills and put that into practice across a wide range of NHS providers and care pathways. Many of the people we supported in the early days have gone on to be leaders in their field. In our August newsletter, we shared the stories of people we have been able to help to make an impact and how they have gone on to spread their learning.
But all too often people point to the struggles they face in delivering improvement on the ground. The ambition to improve care is deeply rewarding but sometime isolating, and it can feel like change is achieved despite the system not because of it.
It is also clear that there are systemic issues across the NHS that need to change if the service is to move from pockets of best practice to a consistently supportive culture that fosters high quality, efficient care. Over the last two years we have developed a programme of work to look at one of those systemic issues: workforce policy and planning.
Our 2016 report, Staffing matters; funding counts, found that the ability of the NHS to deliver its services is being compromised by staff shortages, planning inadequacies and an inability to make best use of the skills of its available workforce. It identified significant challenges to the NHS in England including substantial staff shortages in nursing and primary care. However, these are not isolated problems. Rather, they are symptoms of a more fundamental fault line. The approach to planning for the million-plus NHS workforce in England is not fit for purpose and there is no overall discernible strategy to ensure that the NHS has the workforce it needs.
Our work on productivity, A year of plenty, showed that this absence of overall strategic approach was having a real impact with falling labour productivity across the NHS. Higher levels of consultant productivity were clearly associated with the availability of nursing and support staff; health care is delivered by teams and siloed planning has not served the system well. Our analysis highlighted that the growth in consultants had dramatically outpaced other workforce groups, with virtually no real recent growth in nursing numbers over the last seven years.
A year on, and our new report, Rising pressure: the NHS workforce challenge, shows that the effects of this lack of a coherent and comprehensive workforce strategy continue to be apparent, and, if anything, the situation is worse.
While the overall size of the NHS workforce increased between 2015/16 and 2016/17, the numbers of nurses (particularly in the community and mental health) and GPs have fallen. This is of concern given the importance of primary care and community health services for the NHS’s ambition to transform services, as outlined in the Five year forward view. There is no immediate or easy end in sight to nursing or GP shortages across the NHS, which reflect the systematic problems I mentioned earlier; but there is also a new important actor to consider. Brexit has not created these problems but our analysis – identifying a 96% drop in the number of EU nurses registered with the Nursing and Midwifery Council since summer 2016 – is a reminder that we can’t continue to rely on international recruitment as a bail out for policy and planning failures. In her blog, GP Heidi Phillips puts forward her thoughts on ways to help combat the recruitment crisis in primary care by moving more medical training into the community.
Never has it been more important to have aligned management of training, recruitment and retention. While providing more training places for nurses, reducing attrition from training, and increasing retention are all identified in national rhetoric, there is a substantial gap between headline statements on one hand, and actual policy implementation and local delivery on the other.
This gap between rhetoric and reality is growing. In England this year, about 1,220 fewer students started nursing degrees than the year before, taking numbers back to 2015 levels, despite all the intentions to expand training.
There’s also been a shift in the age profile of nursing students. The number of students under 20 starting nurse training is 6% higher, but there are around 10% fewer people aged 20 and over starting a nursing degree. While apprenticeships will offer an alternative route into nursing for some applicants, this will take several years to deliver at scale. And it is not yet clear if this will tap into an alternative pool of applicants, or just an alternative route for current applicants, with worrying concerns for areas such as mental health and learning disabilities, which are much more reliant on mature students.
Despite recent policy emphasis on improving staff retention, our recent analysis highlights that workforce stability in NHS providers (measured by the percentage of staff that stay at an NHS trust in a given year) has fallen from a median of 89% in 2010/11, to 85% in 2016/17. The variation in stability between trusts has also increased. Improving care if there are high levels of workforce churn is obviously much harder to achieve.
Our case study this month looks at one trust focusing on helping their workforce develop personal resilience and stress management techniques, in the hope that this will improve staff engagement and retention. Sharon Allen from Skills for Care also gives us an overview of the key issues around recruitment and retention for the social care workforce.
There is no quick fix to these problems but the absence of a sustained and nationally focused approach to workforce policy and planning, compounded by the ongoing disconnect between identified staffing needs and funding decisions, prevents effective and coordinated policy interventions. Without major improvements, those who are focusing their efforts on improving care locally will be operating with one hand tied behind their back. Local action is incredibly powerful but it needs national leadership to create the conditions in which it can flourish.
Anita Charlesworth is Director of Research and Economics at the Health Foundation, @AnitaCTHF