The NHS has seen significant changes in the profile of its staff as it struggles to fill widespread and growing nurse shortages. New analysis by the Health Foundation shows that the health service is increasingly having to rely on less-skilled clinical support staff to fill gaps in services when there aren’t enough nurses.

Figures also show that, in response to a severe drop-off in the supply of EU nurses since 2016, the UK has significantly ramped-up its recruitment of nurses from non-EU countries over the last year as it struggles to train enough nurses domestically.

The Health Foundation’s new research report, Falling short: the NHS workforce challenge, reveals that between March 2018 and March 2019, the NHS saw the biggest annual increase this decade in its overall workforce. But the independent charity warns that this growth masks an ongoing shift in the mix of clinical staff employed in the NHS – while numbers of doctors have increased, much-needed growth in the number of registered nurses has been outstripped by increases in clinical support staff, including health care assistants and nursing associates. While there were 4,500 more full-time equivalent (FTE) nurses, an increase of just 1.5%, the NHS employed 6,500 more FTE support staff for doctors, nurses and midwives – a 2.6% increase.

The Health Foundation says there has been an effective ‘hollowing out’ of the NHS workforce as increases in the numbers of doctors and clinical support staff are set against growing registered nurse vacancies, which rose to a record-high of almost 44,000 in the first quarter of 2019, and  growth in the level of output the NHS is delivering (including numbers of operations, consultations, diagnostic procedures and A&E visits in a year), which grew by almost a quarter (23%) between 2010/11 and 2016/17. The figures suggest that in some cases, clinical support staff are effectively filling the gaps left by the widespread shortages of nurses, raising questions of quality and safety. While the Health Foundation says changes in the mix of staff within the NHS can be positive if they reflect changes in patient need, and are underpinned by evidence-based policy, these developments appear to be a largely unplanned response to the failure to train and recruit enough nurses in recent years.  

Nursing shortages have also contributed to a growing gap in the number of nurses working in hospitals compared to those working in the community. While the number of hospital nurses has grown by 2.2%, nurses working in the community, excluding health visitors, grew by just 0.7% over the last year. At the same time, mental health nurses grew by just 0.6%, leaving the number of nurses working in community and mental health services below levels in 2014. These changes cast doubt on the NHS’s ability to make planned improvements, including to mental health services, and deliver on a key ambition to move more NHS care out of hospitals into the community.

The Health Foundation says that, as the UK is struggling to train enough new nurses domestically, the NHS will need to recruit at least 5,000 more international nurses a year until 2023/24 to prevent nurse shortages from impacting on patient care and acting as a brake on ambitions to improve the NHS. However, in 2017/18 only around 1,600 joined the NHS. With a global shortage of nurses, a continuing reliance on international recruitment places the UK in a precarious position for the future.

The UK has actively recruited nurses from non-EU countries over the last year and the Health Foundation’s analysis shows a marked increase in numbers joining the nursing register from outside the EU in 2018/19 – including 1,791 from India and 3,118 from the Philippines. How this compares to the 5,000 nurses a year required, will depend on how many of these nurses choose to work and stay in the NHS following registration. This follows an 85% fall in the number of nurses coming to the UK from countries within the EU, since the 2016 Brexit vote and changes to English language testing requirements for foreign nurses – numbers have gone from 6,382 in 2016/17 to 968 in 2018/19.

The analysis also reveals a similar trend in general practice where numbers of GPs continue to fall. Between March 2018 and March 2019, there were 453 fewer qualified, permanently employed GPs – a fall of 1.6%. It now appears almost impossible that the government’s original target of recruiting 5,000 additional GPs by 2020 will be met – to now meet the target, the NHS would need to recruit at least 6,250 GPs in the next year. As a result, temporary staff and GPs in training are making up a greater proportion of the GP workforce than ever before, and non-GP clinical staff are playing an increasing role in the delivery of care. For example, the number of pharmacists in primary care grew from 743 to 1,137 in the last year – an increase of almost 40%.

Alongside the research report, the Health Foundation has also today published a general election briefing on the state of the health and social care workforce. The Foundation is calling on the next government to recognise the urgency of the NHS workforce crisis and expand international recruitment up to 2023/24, ensuring that migration policy is not a barrier. It must also provide adequate cost-of-living support to trainee nurses and ensure that addressing shortages in the NHS does not further impact on staffing in the already-stretched social care sector.

Anita Charlesworth, Director of Research and Economics at the Health Foundation, said:

‘As the general election draws closer, the staffing crisis is the make or break issue for the NHS. Nursing shortages continue to deepen and are inevitably impacting on the front line. Services are being forced to make do with shortfalls of increasingly pressurised nurses and rely on less-skilled support staff to pick up the slack. Clinical support staff play an incredibly valuable role in the NHS if they are supported in a well-planned way, but these trends appear to be largely unplanned, reflecting the failure to recruit enough nurses. Operating without a plan means there has not been enough consideration of the impact such changes might be having on patient care.

‘While it is encouraging that politicians have made pledges aimed at addressing the workforce challenge, we need to be realistic on bold promises to greatly increase numbers of nurses and GPs quickly. Two obvious solutions to the nurse staffing crisis would be to train more nurses in this country and retain more existing staff. But the UK is struggling to grow the numbers starting nursing degrees. and while there must also be action to address this – for example, by giving nurse students the cost-of-living support that they need – it will take time to have a significant impact on the numbers of nurses. Our projections show that, with concerted policy action, the NHS might be able to retain around 11,000 more nurses by 2023/24 than at current trends. The reality is, whatever happens with Brexit, we will need more nurses from abroad than we are currently attracting to keep the NHS running. The incoming government must therefore ensure that our migration policy does not put barriers in the way of recruiting them.'

Media contact

Simon Perry
Simon.Perry@health.org.uk
020 7257 2093

Research report

Falling short: the NHS workforce challenge

Our fourth annual report analysing the staff profile and trends in the NHS workforce in England in 2018/19.

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Health and social care workforce

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We explore the health and social care workforce, how shortages are impacting on services and set out key priorities for the n...

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General Election 2019

Get the latest news, views and analysis on health and social care for the 2019 General Election

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Anita Charlesworth

Anita Charlesworth is Director of Research and Economics.

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Ben Gershlick

Ben Gershlick is a Senior Economist at the Health Foundation.

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