With bonfire night over most of us are now counting down to Christmas – letters to Santa being carefully crafted and party outfits bought. For the team at the Department of Health (DH) the festive period looks much less appealing. Over the next six weeks they have to conclude a seemingly intractable spending review agreement with the Treasury and manage the planned strike action by junior doctors.
Of course the problems of the spending review and the dispute with junior doctors are not disconnected events. Both are profoundly and fundamentally connected. Five years of relative austerity in the NHS and a hospital system in financial meltdown have inevitably impacted on morale and stress. The government wants to reform doctor’s working patterns but has no money to throw at the change.
However these negotiations end, one thing is crystal clear – we cannot have a sustainable, affordable, high quality health system if we don’t address the underlying workforce challenges. Having the right people, with the right skills, committed to the service and working together effectively as a team is the cornerstone of everything the NHS does.
Around two thirds of the NHS’ £100bn plus budget is spent on pay. The Five Year Forward View maths of £8bn extra government funding with £22bn efficiency savings are predicated on that pay bill staying under control. The new models of care and Carter efficiency savings depend on major changes to the way people work across the system. Keeping control of the pay bill, while motivating staff for change, is an enormous task. Of course success or failure is in large part down to the leadership out in the service, but those at the centre can help or hinder.
How to help?
The answer must be for the politicians and senior leadership at DH to set themselves a new year’s resolution: to take a once in a generation chance to tackle the problems of workforce supply. The combination of mounting agency spend, staff vacancies, minimum safe staffing levels and the funding squeeze mean now is the time to look carefully at supply. England does not produce enough staff to run our health care system on a sustainable basis. Moreover, the needs of the population are changing profoundly and the training system has not kept up. The divide between health and social care looks well past its sell-by date – pooling budgets is great, but of fundamental importance is a re-examination of the skills and boundaries between different parts of the workforce. For most patients integrated care means having fewer people involved in the delivery of their care. We need a more flexible workforce trained to manage more of people’s needs holistically.
The OECD has just published new comparative statistics on health systems. For the UK it is not a comforting read – yes we provide excellent access to care (a point the Commonwealth Survey focuses on given its US purview and the deep-seated problems of access there). But the UK does comparatively badly on outcomes of care and population health. Looking below the headlines the workforce picture is also interesting – we run our system with relatively few doctors and nurses but we pay those we have well by international standards. Other studies show that we are one of the countries most reliant on staff who have trained abroad:
'Self sufficiency': % of new supply of nurses from home/international sources 1990-2014
This is not new; it is deeply ingrained in our approach to workforce. We are in fear of ‘over-training’, worried about what economists like me call supplier-induced demand (i.e. the more doctors you have the more health care is used) and wasting the cost of training if some people don’t go on to work in health care. We also have a long tradition of migrant workers in the NHS and those individuals have made an enormous contribution – rightly marked for the first time this year with Windrush day.
This orthodoxy requires a re-think. The last couple of years should have finally brought home that under-training is a false economy. As the £3bn plus agency bill shows, it is not serving the NHS well.
Over the next few years the focus needs to be on nursing. We should think – as teaching has done - about new training models to fast-track more people with science based first degrees into nursing programmes. And as we argued in our spending review submission, spending on training should not be cut – we need to expand our training programmes. But, given the financial outlook the time has come to review the package of state support to nurses and consider opening up this degree programme in line with the rest of higher education. While university fees are expensive, one of the biggest barriers to study is funding living costs. More support for these day to day costs for those from low income backgrounds should be part of any package of reform.
At present around one in five applicants for nursing is turned away. Those young people don’t get the chance to fulfil their career dreams. In the main they will enrol on other degree courses, take on the student debt but have to look for other careers. Meanwhile the NHS can’t recruit enough nurses and is pushed overseas – often with training costs borne by less well-off countries. This doesn’t seem to be a model that is working for anyone. These are difficult times and easy options are thin on the ground. Difficult times require a heightened level of maturity from both political and professional leaders. If we're going to deliver a sustainable health system with better outcomes, policy makers need to recognise staff as assets rather than problems, and the professions recognise that their future interests are tied to making a success of the system in which they work.
Anita is Chief Economist at the Health Foundation.