How feasible are the NHS Long Term Workforce Plan commitments on training?

Background 

The NHS Long Term Workforce Plan (LTWP) makes important commitments to increase training intakes across several NHS clinical staff groups in England by 2031/32. This short analysis looks at the implications of these commitments for the health care education system and wider workforce planning in England. It does not include proposed increases to GP specialty training numbers, as these occur at a later stage of the medical training pathway. 

Training clinical staff, such as doctors, nurses and allied health professionals, can be broken down into three major routes: undergraduate university training, postgraduate university training and degree-level apprenticeships – the latter being an alternative route to university training that offers the opportunity to gain a degree-equivalent qualification while working. 

Undergraduate training currently accounts for a significant majority of new higher education intakes (including undergraduate and postgraduate training and degree-level apprenticeships) in NHS clinical professions, with undergraduate students forming a majority of all enrolments in first-year courses in medicine, dentistry and subjects allied to medicine, including nursing, in England in 2021/22.  

What does the NHS Long Term Workforce Plan mean for future intakes of clinical health care professionals? 

It is useful to think about what the LTWP’s commitments to increasing training intakes imply for the wider student mix through to 2031/32. While the LTWP does not provide a breakdown of its commitments across the three major training routes, examining the trends in student enrolment numbers provides a useful starting point.  

Higher Education Statistics Agency (part of Jisc) data show that the total number of students enrolled on first-year higher education courses (including degree apprenticeships) across all subjects in England increased from around 612,000 in 2014/15 to around 646,000 in 2019/20. This was followed by a jump to 733,000 in 2020/21 before enrolments declined slightly to around 717,000 in 2021/22. The pre-COVID-19 trend from 2014/15 to 2019/20 points to an average annual growth rate of around 1.1% in first-year enrolment numbers. 

The government has not announced any new plans to expand overall student numbers, so our analysis assumes that the average annual growth rate for overall student enrolments (1.1% a year from 2014/15–2019/20) will remain unchanged between 2022/23 and 2031/32. If this assumption applies, then the proportion of first-year student enrolments in NHS clinical professions will have to rise significantly for the LTWP’s commitments to be met: 

• Training intakes to all clinical health care professions would account for around 16% (125,700 excluding the proposed increases in GP specialty training places) of the projected total of all first-year student enrolments (undergraduate, postgraduate and degree apprenticeships) by 2031/32, relative to around 11% (76,300) in 2022/23 – an increase of 5 percentage points. This implies that while 1 in 9 of all first-year students took up training in these professions in 2022/23, meeting the LTWP’s commitments would require this to rise by 50% to 1 in 6 by 2031/32. 
• Nursing and midwifery – including nurses and health visitors, nursing associates and midwives – account for nearly two-thirds (65%) of the increase in all annual training intakes proposed by the LTWP. This is equivalent to around 32,000 additional places a year in 2031/32 (around 72,400) relative to 2022/23 (around 40,400), out of a total of around 49,400 additional places a year across all clinical staff groups covered by the LTWP.  
• Training intakes to nursing and midwifery would account for around 9% of the projected total of all first-year student enrolments by 2031/32 relative to 5.6% in 2022/23 – an increase of 3.4 percentage points (Figure 1).  
• Within nursing and midwifery, the biggest share of the increase would come from registered nurse training courses (4.4% to 7.2%), with nursing associate training also registering a significant increase from a smaller base (0.7% to 1.3%). Degree apprenticeships would make up a large proportion of these increases, accounting for 28% and 50% of intakes to registered nurse and nursing associate training in 2031/32, relative to 9% and 30% in 2022/23. 
• The number of medical school places would double from 7,500 in 2022/23 (around 1% of the projected total of first-year student enrolments) to 15,000 (1.9%) by 2031/32 (Figure 1). Within this, degree apprenticeships would account for 13% of intakes to medical school in 2031/32 relative to 0% in 2022/23. 

How feasible are these commitments? 

There are at least three aspects of feasibility to consider. First, the capacity of the university system and the NHS to educate and train the additional staff committed to in the LTWP. While the LTWP commits to £2.4bn in funding for these commitments to 2028/29, how this investment will be phased in remains to be seen. Efficient allocation and use of the funding will be critical. Moreover, for the commitments to be met, universities will need to work with NHS organisations to increase the availability, quality and distribution of clinical placements. The LTWP notes that a lack of capacity and supervision has long held back growth in clinical placement numbers and commits to engaging with stakeholders to address this by better integrating placements into service design. This will require sustained discussion and action on the part of government, NHS England, NHS providers and universities. 

Second, the LTWP commitments underline an urgent need for a significant increase in trainer or educator numbers and improved retention of this workforce. Even assuming substantial increases in future training being delivered through simulation-based learning techniques, which emphasise virtual learning and guided experience, the LTWP commitments will hinge on how effectively the recently proposed Educator Workforce Strategy is implemented. This strategy provides a template for building the capacity and quality of the health care educator workforce, which is vital for the delivery of the training committed to by the LTWP.  

A third aspect is the potential supply of applicants to clinical training. Here, the LTWP is quite well timed. In 2018/19 (the last year for which these data are accessible), the majority of first-year undergraduate enrolments in medicine and dentistry (87%), and allied subjects including nursing (54%), were among those aged 18–24 years. Between 2023/24and 2032/33, this age group is projected to grow from 4.4 million to around nearly 5 million people as the relatively large birth cohorts born between the mid-2000s and mid-2010s reach adulthood. This should mean that increasing numbers of young people taking up training and apprenticeships to become NHS clinical professionals has a smaller impact on the pool of young people left to join other professions. Nonetheless, some other sectors may face challenges in recruiting sufficient numbers of university-educated workers relative to demand in the years to 2031/32 if the LTWP’s commitments are fully implemented. 

After 2032/33, the current trend reverses and the number of 18–24-year-olds is projected to fall. Sustaining the LTWP’s commitments beyond 2032/33 would require an expanding share of the country’s young people to choose health care-related degrees, with potential implications for the quality of applicants and raising questions about the impact this would have on the pool of graduates available to work in other sectors of the economy.  

Why this matters 

The LTWP’s commitment to substantially increase the number of domestically trained NHS clinical professionals is very welcome. However, the scale of the LTWP’s ambition raises questions around whether the number of training places and clinical placements can be increased at sufficient pace through to 2031/32.  

More detail is required on how the funding of these commitments will be phased and implemented, and how universities and employers will be engaged in the process. The implicit assumption that applications and acceptances to health care-related degrees will continue to rise in the coming years needs regular monitoring. Recent UCAS data, for instance, points to a significant drop in annual applicants to undergraduate nursing degrees in 2023. Only time will tell whether this represents a blip or a longer term shift in the trend in applicant numbers, which had been increasing until last year. Further, the LTWP’s proposals that apprenticeships should account for substantially higher shares of training intakes by 2031/32 are relatively untested and will rely heavily on improved recruitment and retention of the health care educator workforce.  

Boosting training numbers is vital to address chronic staff shortages and meet future demand for health care. However, it will take many years to train the new doctors, nurses and other health care professionals as envisaged in the LTWP. A relentless focus on retaining existing staff and ensuring the NHS is a more attractive place to work is therefore also essential, as is capital investment in the buildings, equipment and technology needed to support the plan. This underlines the need to ensure that the commitment to update it every 2 years is closely monitored.