This long read was produced during the 2019 General Election.
- The number of people employed by NHS providers in England this decade has grown at just half the rate of the 2000s, despite growing need. As a result, the NHS reports a workforce shortage of around 100,000 staff.
- The issues in social care are even greater and the outlook is concerning. Workforce shortages stand at around 122,000, with a quarter of staff on a zero-hours contract.
- Our projections, with the King’s Fund and the Nuffield Trust, suggest that without concerted policy action and dedicated investment, NHS shortages could grow to up to 200,000 by 2023/24, and at least 250,000 by 2030. Nursing remains the key area of shortage (of over 40,000) – and this could double by 2023/24 and grow to over 100,000 by 2028/29.
- The number of nurses has grown at just one-third the rate of both doctors and clinical support staff in the past 5 years. Within nursing, the number of nurses working in community and mental health services in 2019 remains below 2014 levels.
- This is partly caused by a failure to train enough nurses. In 2011 the number of training places was reduced by more than 10%. The removal of the nurse bursary in 2017 was designed to allow higher education to expand places but it has had limited impact on the number of students in training. Numbers are far below the 25% expansion planned, one in four nurses don’t complete their studies in the expected time and there are fewer mature students training in areas of mental health and learning disability.
- Cost of living is a significant barrier for many. Nursing students tend to be older, have more financial commitments, and NHS training precludes undertaking other part-time work. We have recommended offering ‘cost-of-living grants’ of around £5,200 a year to help this.
- Despite a 2015 target for 5,000 additional GPs by 2020, the number of qualified permanent GPs has fallen. As a result, the number of patients per GP continues to grow, from 2,120 to 2,180 last year alone.
- One consequence of the failure to train and retain staff is that the UK is heavily reliant on international recruitment. This needs to continue: at least 5,000 nurses sourced from abroad a year need to be recruited until 2023/24 to reduce shortages. In 2017/18, the latest data available, just 1,600 nurses from overseas joined English NHS trusts. We do know how many overseas nurses are registered in the UK and therefore potentially available to work in the NHS. There are 33,000 EEA nurses on the register. In 2018/19, 3,400 more nurses came to the UK from outside the EU than in 2017/18. This follows an 85% fall in the number coming to the UK from the EU in recent years.
- The social care sector employs a quarter of a million people from beyond the UK. Some areas of the country are particularly reliant; 40% of social care staff in London are from overseas. International recruitment is vitally important for social care and a restrictive immigration policy will make this harder.
- As a major employer, typically providing better pay, terms and conditions, and career progression than social care can afford, the NHS has a significant impact on the social care workforce. More must be done to support social care – for instance, matching pay increases in the NHS would cost £1.7bn by 2023/24.
Note: All staff numbers referred to in this long read are full-time equivalent (FTE) unless otherwise stated. The FTE measure takes into account not just the number of people working, but also the hours they work, allowing us to compare like-for-like and understand the amount of care delivered.
As well as any informal care we receive, the 2.5 million people across England working in health and social care are the people who provide care when we are sick or in need and support us to be healthy. Workforce present the biggest single challenge facing these sectors.
High quality care depends on having the right mix of people, with the right skills and values, in the right place at the right time. But in recent years staff numbers have not kept up with rising demand, pay has been constrained and pressure has grown.
These staff are also a vital part of the economy. How they feel and what they say to their patients, families and friends is important to perceptions of the health and social care system. It shapes public and political sentiment about health and social care.
While the FTE number of people working in the NHS in England in 2018/19 increased by the fastest rate this decade (2.8% – almost 30,000 extra staff), this mostly reflects slow growth in the years preceding it. Workforce growth this decade has been just half that of the decade before, and growth has not been equal among different staff groups.
Research by the Health Foundation, the King’s Fund and the Nuffield Trust projected that, without major policy action, overall shortages of staff could exceed 250,000 by 2030.
These challenges will not be helped by an additional issue: the impact of tax rules on pensions above a certain threshold. This has led to some senior doctors retiring early or reducing their hours, reportedly affecting waiting lists. A proposed ‘fix’ to the scheme is out for consultation, and the government and NHS England have recently taken some short-term action for clinicians – but this will impact all staff. NHS Employers has responded that the proposal ‘should apply to all NHS employees, to ensure the NHS Pension Scheme can continue to be used as a central part of the overall reward offer to attract, recruit and retain staff’.
The current picture
Nurses in England
Nursing remains the key area of shortage across the NHS in England. The growth in nurse numbers has not kept pace with demand, and nursing vacancies (the gap between the number of staff and the need for them) increased to almost 44,000 in the first quarter of 2019/20 – 12% of the nursing workforce.
This is despite continuing growth in health care activity. While ‘output’ (the number of operations, A&E attendances, etc) grew by almost a quarter between 2010/11 and 2016/17, the number of nurses grew by just 1%.
These issues have been further impacted by high numbers of nurses leaving the NHS – 33,000 (10.2%) in 2018/19 up from 27,000 (8.5%) in 2010/11. Our analysis suggests that improving this rate to that seen in 2010/11 could result in an additional 11,000 nurses by 2023/24, than current trends, similar to the 12,400 additional nurses through better retention by 2025 pledged in the NHS long term plan. Along with concerted policy action, including increasing the number of newly qualified nurses by a third, this would allow the NHS to close half its nursing shortages domestically, with 5,000 nurses from overseas then required to broadly half the total vacancy rate to 5%.
Nursing numbers have also not kept pace with other staff groups over the past decade. Nurses are a shrinking proportion of the clinical workforce, as numbers of doctors employed in NHS hospitals and community services have grown at a faster rate. Over the past 5 years the number of doctors has increased by 10%, while the number of nurses has increased by just 3%.
The last decade has also seen a major change in the mix of nurses and clinical support staff (including health care assistants). In 2009/10 there were equal numbers of nurses and support staff; by 2018/19, the number of support staff per nurse had risen 10%.
Within nursing, the number of nurses employed in children’s nursing grew by 2.7% in 2018/19, but mental health nursing numbers grew by just 0.6% and community nursing numbers (excluding health visitors) by just 0.7%. The NHS long term plan ring-fences funding for community and mental health services. But translating this into increased capacity has been, and will be, a significant challenge. The number of nurses working in community and mental health services in 2019 remains below levels in 2014 despite demand rising due to increasing need, and the commitment to improve these services.
Changes in skill-mix within the NHS – for example, the introduction of nurse practitioners and pharmacy prescribing – have the potential to improve quality and safety if evidence-led, well-planned and implemented effectively. But it is important that these changes are driven by a desire to improve quality and not simply a short-term response to system challenges – such as cost pressures or recruitment difficulties.
Equally important is how front-line teams are supported to embed these changes and the context in which they occur – the time, resources and cultural changes required cannot be underestimated.
Preventing nursing shortages from growing further requires urgent action to increase the number of nurses in training. The UK lags behind many other countries when it comes to the number of nurses we train, resulting in high reliance on international staff and pernicious staff shortages.
This year, the number of applicants to nursing courses in England increased for the first time since the NHS nurse bursary was withdrawn in 2017. This 4.6% increase reversed 2 years of decline in which the number of applicants fell by almost a quarter. The number of applicants in England has now risen to 40,780, but it remains below 2017 levels. Scotland, where the NHS bursary has been retained and its value increased, has seen a 6.7% increase this year, recording the highest ever number of applicants.
Applications have historically significantly exceeded the number of places available, so the key issue is how many students actually start training (acceptances). In 2018, there were only 80 fewer acceptances in England despite a 13.6% fall in applications compared with 2017.
At this point in 2019, the number of applicants from England who have been placed at universities in the UK is up by 3.9%, at 21,030. This is below the number of students accepted in 2016, but the second highest number of students starting a nursing degree this decade. It is still some way short of the pledge to increase places by 25% made by the government in 2017.
These issues are particularly serious in learning disability and mental health nursing. The number of acceptances in mental health and learning disabilities nursing fell signicantly in 2017, by 10% and 30% respectively. All continuously running learning disability courses have fewer students in 2018 than in 2014. Fewer over-25s started nursing degrees in 2018 compared with 2016, particularly impacting learning disability and mental health courses.
This is compounded by the fact that attrition remains high. One in four nurses who were expected to graduate in 2018 did not do so, and this was highest for learning disability courses. Research has found that finances are ‘by far the most significant concern for students in all years of study’ and the number one factor cited by students for the high drop-out rate during training. The time demands of clinical placements make it hard for nursing students to take paid work alongside studying full time. We and others have recommended offering ‘cost-of-living grants’ of around £5,200 a year to help with this.
Overall trends can also hide pressure points in different areas of the country. Adjusting for population size, London and the South East are in the bottom three regions for the number of acceptances to study nursing and in the top three for the number of vacancies per 100,000 people.
General practice in England
In 2015 the government set a target to increase the number of GPs by 5,000 by 2020, now updated to be ‘as soon as possible’. However, the number of people working as fully qualified, permanently employed GPs continues to fall – with a 1.6% decline from 27,830 to 27,380 in 2018/19. Temporary staff and doctors in training are making up a greater proportion of the GP workforce, rising from 19% to 21% over the year. The growth in these staff means that overall GP numbers increased by 0.9% last year. But it is impossible to see how the original target for 5,000 extra GPs could be met by 2020; requiring an increase in the number of qualified permanent GPs of 6,250 next year.
Due to falling numbers of GPs and the rising population, the number of patients that each qualified permanent GP is responsible for continues to grow, increasing from 2,120 to 2,180 over the past year alone. This is clearest in the most deprived areas: on average, a GP working in one of the most deprived areas (where health needs are greater) can expect to be responsible for 370 more patients than a GP working in one of the least deprived areas.
Change in skill-mix is also happening in general practice. There are now more non-GP clinical staff working in general practice than GPs. While the number of practice nurses is falling, this is more than offset by an increase in the number of advanced practice nurses (+9.8% in 2018/19), who now account for 22% of the nurses working in GP practices, compared with 17% in 2015.
Other professions are also playing an increasing role in the delivery of care. 2018/19 saw an almost 40% growth in the number of pharmacists working in general practice, from 743 to 1,029. The growth in the UK of registered pharmacists per 1,000 population has been the second highest of EU-15 countries. As a result, the rate has gone from being below the OECD and EU-15 averages to above both of them.
This is a trend that will continue with the new contract for general practice, agreed in January 2019, which commits to growing the number of staff from other professions (pharmacists, physiotherapists and paramedics) by 20,000 by 2023/24.
Given the ageing population, the rise in chronic disease and the aim to support more people’s health needs within the community, general practice will need to continue to widen the skill mix of the workforce to meet growing need.
Pressures in emergency departments have affected waiting times for non-urgent care in hospitals, while some of the increases in waiting times for cancer are also the result of shortages of diagnostic equipment and in the associated workforce.
One consequence of the failure to train, recruit and retain enough domestic nurses is that the UK is heavily reliant on international recruitment of doctors and nurses, more than most OECD countries. The UK is a ‘net importer’ of health care professionals.
Previous research found that the NHS in England will need to recruit at least 5,000 nurses a year internationally to avoid a substantial further increase in unfilled posts, compared to around 1,600 in 2017/18. Since 2016 and the referendum on the UK leaving the EU, there has been a rapid decline in nurses joining the Nursing and Midwifery Council (NMC) register from the EU, but some increase in non-EU inflow – mainly from India and the Philippines.
Overall, the number of international nurses joining the NMC register grew last year, although it is still below the level in 2016/17. 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.
Adult social care
While the NHS is experiencing significant staffing pressures, the issues in social care are even greater and the outlook is concerning. Workforce shortages stand at around 122,000, with 1,100 people estimated to leave their job every day – an annual leaver rate of almost a third – and a quarter of staff on a zero-hours contract.
Recent analysis shows that the estimated number of adult social care jobs in England in 2018 was 1,620,000, of which 1,225,000 (76%) were direct care staff jobs and another 84,000 (5%) were regulated professionals, including 41,000 registered nurses.
While overall numbers of staff were up by 1.2% on compared to 2017/18, nursing jobs in social care have decreased by 10,400 (20%) since 2012, and by 2% in 2018/19. Skills for Care notes that this decline could be related to recruitment and retention issues, ‘but also may be a result of some organisations creating “nursing assistant” roles to take on some tasks previously carried out by nurses’ – a similar issue as in the NHS.
If demand for the social care workforce grows proportionally to the projected number of people aged 65 and over, then the number of social care jobs will need to increase by 36% to around 2.2 million jobs by 2035.
International recruitment is even more important in social care, and a restrictive immigration policy will make this harder. More than 90% of care workers earn below the proposed £30,000 salary threshold that could be required to obtain a visa after Brexit. People with non-British nationality account for around 17% of the social care workforce in England – and around 40% of the workforce in London.
Both the NHS and social care employers recruit from the same pool for many roles. As a major employer, typically providing better pay, terms and conditions, and career progression than social care can afford, the NHS can have a significant ‘gravitational pull’ on the social care workforce. Health care assistant roles in the NHS can be extremely attractive to staff in social care and there is a 7% gap between pay for nurses in adult social care and in the NHS. Over the next few years this will rise further, with basic pay for NHS nurses increasing including pay progression. To match pay increases in the NHS in social care would cost around £1.7bn by 2023/24.
Priorities for the next government
This analysis further highlights the deeply-embedded challenge of skills shortages in key areas of health care. This issue impacts on access and quality and has a ripple effect out to other sectors – notably social care. Without radical and concerted action, there is a real risk that despite additional funding, and a sensible strategy in the NHS long term plan, the health service will not be able to deliver tangible improvements in care.
There are three key actions that the next government needs to take:
- To avoid nurse staffing shortages acting as a major brake on the delivery of the NHS long term plan, the government will need to expand international recruitment up to 2023/24.
- It is essential to address the financial problems trainee nurses face while studying, through increasing the cost of living financial support to nursing undergraduates.
- Addressing shortages in the NHS must not come at the expense of the already-stretched social care workforce. The government will need to consider a sector-specific route for international migration that works for social care post-Brexit, and funding towards increasing pay for social care workers.