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Staffing is the make-or-break issue for the NHS in England, with workforce shortages now having a direct impact on the health service’s ability to keep up with demand. 

Last month we published Closing the gap, a joint report with The King’s Fund and the Nuffield Trust looking at the challenges facing the NHS and social care workforce. In it we make several recommendations that should be at the heart of tackling the workforce crisis. Below, we explore a key recommendation from each of the areas we looked at – but there are many more in the full report.

Speaking about the challenges facing the newspaper industry, Clay Shirky once said ‘Nothing will work, but everything might’. This is true for the health and social care workforce as well. There is no quick fix, and it doesn’t come for free, but there is a series of sensible and important steps which – together – could close the workforce gap.

1.    Offer cost of living grants to support nursing students

There aren’t enough nurses coming through training. This can’t be solved quickly, as they are highly skilled and so the training takes years, and many don’t complete it. A major reason why nurses drop out of their undergraduate training is finances. Nurses are often mature students with family or caring obligations, and undertake placements, and as a result find it hard to take on part time work. We recommend a £5,200 cost of living grant to support nurses financially and improve morale and engagement.

In her interview this month, Professor Linda Aiken explains how we should also focus on attracting graduates to nursing, saying we should ease the financial commitment that comes with doing another full-time degree.

2.    Increase pay after the current deal

Pay is not the main reason that people choose to join the NHS, nor is it the main reason people leave. However, pay and reward are tangible signs of how far staff are valued and have a clear impact on retention. Since 2010/11 pay scales in the NHS have fallen in real terms. The recent pay award is an improvement – but it ends in 2020/21.

Pay must continue to at least keep up with inflation after this point, but also keep up with pay growth in the rest of the economy. While the current pay deal may help retention and morale among staff, this can quickly be undone by pay rises that are below inflation once it ends.

3.    Make clear the universal offer to staff

The NHS must focus on how it can become a better employer and a place where staff want to build a career. Building on what already exists, the NHS needs an explicit statement of the universal ‘offer’ to staff – including, but not limited to, their legal rights. It should cover fair treatment for all staff but also what staff can expect in terms of pay and opportunity, continuing professional development, work-life balance including flexibility, and proper appraisal. 

Meaningful action on equality and inclusion must be at the heart of the offer to staff, building on existing initiatives, so that all NHS organisations have concrete action plans to tackle discrimination and inequality.

4.    Expand the role of teams in general practice

National efforts to increase the number of GPs need to continue, but the stark reality is that even with a major focus on this, we project that the numbers of GPs in the NHS will fall substantially short of demand. The only way forward is to move towards a new model of general practice with an expanded multidisciplinary team drawing on the skills of other health care professionals such as physiotherapists and pharmacists. 

In her blog, Sarah Reed looks at how these changes in primary care work in practice. Drawing on examples from projects we’ve funded, it sets out the opportunity to make a real difference, but warns that without careful implementation the intended benefits of team-based approaches are far from guaranteed.

5.    Increase ethical international recruitment in the short term

With policy action (including the ideas above), the outlook for nurse staffing shortages could be transformed over a decade – with enough staff being trained and retained domestically. But the prospects in the short term are much more worrying. 

To avoid nurse staffing shortages acting as a major brake on the delivery of the NHS Long Term Plan, international recruitment will need to play a substantial role. We estimate that an additional 5,000 internationally ethically recruited nurses will be needed each year until 2023/24. This is three times more than are currently recruited, but a third less than were recruited at times during the 2000s. This will not be easy in the context of a global health workforce shortage – and a major focus should be on transitioning away from being reliant on international recruitment in the longer term.

6.    Tackle recruitment and retention in social care

As a major employer, typically providing better pay, terms and conditions than social care can afford, the NHS has a significant potential 'gravitational pull' on the social care workforce. Finding and retaining staff is even harder in social care, where there are now 110,000 vacancies

In its recent report, the Migration Advisory Committee argues that the sector needs wider policy action than just migration to fix its many problems and that, without it, migrant workers will continue to be needed. We recommend a sector-specific visa route that works for social care. But this doesn’t solve the underlying problem.

The government needs to develop a comprehensive plan for social care funding and, in the longer term, reform funding to reflect the need for better pay and conditions for those working in social care.

Shereen Hussein talks more about the impact of retention problems in social care in her interview with us this month, explaining how a new research project aims to deepen our understanding and ability to find solutions. 


None of this is easy, but it is crucial. You can see the impact of shortages in our Chart of the Month: while activity in hospital and community health services has gone up by almost a quarter (23%) since 2010, the number of nurses in this area has gone up by just 1%. 

Writing 60 years before Clay Shirky, Alan Turning (arguably responsible for one of the main challenges facing the newspaper industry – the computer) wrote an article about the next steps for artificial intelligence. But he could just have easily been writing about the health and social care workforce when he wrote: ‘We can only see a short distance ahead, but we can see plenty there that needs to be done.’


Ben Gershlick (@BenGershlick) is Senior Economics Analyst at the Health Foundation. 

This blog originally featured in our email newsletter, which explores perspectives and expert opinion on a different health or health care topic each month.

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