The publication of the NHS Long Term Workforce Plan is a critical moment for the NHS. For years, a plan has been desperately needed to address the biggest crisis facing the NHS. Now it has finally arrived, do the projections stack up?
The figures in the plan are stark. Without major programmes to increase training and education, improve recruitment and retain more staff, NHS workforce shortages could increase from around 154,000 full-time equivalent staff in 2023 to as many as 360,000 full-time equivalent staff by 2036. Both the government and the opposition are now committed to investing in doubling medical school places, rolling out apprenticeships and training 10,000 to 24,000 more undergraduate nurses every year.
The workforce plan seeks to grow the NHS workforce from 1.4 million full-time equivalent staff (including trusts and general practice) in 2021/22 to between 2.3 and 2.4 million by 2036/37 to meet projected demand and eliminate systemic staffing shortfalls. This is an average annual increase of around 3.5% a year over the next 15 years. As the chart below shows, this is higher than the growth in the 2000s, the last period of rapid NHS workforce expansion. This growth is expected to come about through additional training, skill mix changes and improved retention rates. The plan also seeks to significantly reduce England’s reliance on international recruitment, from around 1 in 4 new joiners currently to 1 in 10 by 2036/37.
The workforce plan has been a long time in the making. There is now a once-in-a-generation opportunity to make serious progress on the endemic workforce shortages that have so long been a feature of the NHS in England.
The need for independent, long-term workforce projections
The Health Foundation is one of many organisations that has consistently called for a long-term workforce plan underpinned by the regular publication of projections of workforce supply and demand in health and social care.
Projections into the future are inherently uncertain and often met with scepticism. This is why it’s important that the projections are independently assessed, to build public trust in the analytical underpinnings of the workforce plan and greater understanding of the strengths and limitations of the workforce projections.
In the 2022 Autumn Statement, the government took the positive step of committing to including in the workforce plan ‘independently verified forecasts for the number of doctors, nurses and other professionals that will be needed in 5, 10 and 15 years’ time’.
The NHS workforce plan includes the publication of these new long-term workforce projections. These are based on modelling trends in demand and supply of health care workers, and on assumptions about the future ‘new’ supply and retention of staff. There is no single right answer to what NHS workforce demand and supply will look like over the next 15 years, but it is crucial to understand how demand and supply drivers could influence current and future policy decisions.
How the data are used, the extent to which assumptions are well evidenced and the inferences drawn from the modelling, are as important as the quality of the underlying data.
Our role in assessing the workforce projections modelling
In February 2023 Health Education England approached the Health Foundation’s REAL Centre to support the assessment process. This involved undertaking a technical piece of work to assess NHS England’s modelling approach to inform the workforce plan. We did not review the plan or any of the policies underpinning the projections.
We were given access to the draft projections and a range of model documentation and outputs, and we held a series of workshops with those involved in the projections to understand the data, assumptions and modelling approach. The assessment took place over 2 weeks in February 2023 – we were not privy to any changes beyond this point. Our full assessment and overall reflections on the modelling are also available.
With no agreed template and limited time to undertake the assessment process, we used the UK Statistics Authority Code of Practice, which sets the standards for producers of national and official statistics, to guide our approach and we specifically focused on the domains of quality and value. We identified 10 key lines of enquiry. This included the suitability of data sources, soundness of methodology, level of clarity and insight, and finally the plans for innovation and improvement.
This process of assessment, in line with the code of practice, is not the same as quality assurance of the model itself. Our process did examine whether and how the models used for workforce projections have been subject to quality assurance testing, in line with the Aqua Book principles (the good practice guide for government analytical and modelling quality analysis), but we did not undertake model quality assurance directly.
Our overall assessment at the time of our review concluded that the data sources and methods used in the model are appropriate and the assumptions used by NHS England to develop the baseline models are plausible. However, within the constraints of the time and material available, we were not able to assess whether the best modelling approach has been adopted, the extent to which uncertainty within the model has been fully considered and whether relevant external stakeholders have been sufficiently engaged through the process of model development.
We did identify three key areas for improvement in the current model. First, addressing issues of regional distribution (the projections focus on national demand and supply but geographical workforce gaps are also important). Second, recognising wider labour market dynamics and independencies, in particular the links with the social care labour market and the role of relative pay in recruitment and retention. Third, the projections are very dependent on the assumptions made about the rate of productivity improvement in the future. This is an area of considerable, inherent uncertainty and makes a big difference to the size of any potential workforce gap. It’s therefore important to explore not just historical trends but also the risks and opportunities that higher and lower rates of productivity growth present. The modelling risks being an example of optimism bias – the tendency to believe that positive outcomes are more likely than negative ones.
From February to June 2023, NHS England colleagues considered our assessment as they refined their modelling. In response, the projections presented in the NHS plan now cover a wider range of sensitivity estimates (addressing our third recommendation) for key parameters such as labour productivity improvement (1.5–2%). This enables greater transparency around the substantial uncertainty underlying the projections. Overall, in the published workforce plan, NHS England estimates that workforce demand is projected to rise by an average of 2.8% a year after allowing for productivity gains. This is consistent with other research. However, the issues of regional variation and wider labour market dynamics – most crucially how changes in relative pay might affect recruitment and retention – continue to be outside the scope of the plan.
The government’s commitment to independent assessment of this nature is very positive, and we are pleased to have been able to undertake this work. It’s clear that NHS England aims to continue to develop the approach to workforce modelling. This is just the starting point. Building in a clear process of assessment in the future, alongside the regular publication of long-term workforce projections, will be important going forward.