Getting the next workforce plan right: eight insights from our research

The government’s 10-Year Health Plan sets out wide-ranging reforms intended to improve NHS services over the long term. The reforms are framed around three ‘shifts’ – hospital to community, analogue to digital and sickness to prevention. The plan acknowledges successful delivery will depend above all on NHS staff. The government has promised full details of how the workforce is to be expanded and enabled to support these changes in a workforce plan, expected soon. 

Here, we set out eight insights from our research for the new workforce plan: the assumptions it should rest on, the capabilities needed to deliver it, the policy levers that shape staff supply and the wider workforce dynamics on which delivery depends.

Box 1 (below) sets out the government's commitments on workforce. These pose a clear challenge: the workforce plan must underpin near-term targets in access and performance – many of which imply higher activity in the hospital sector – while also enabling a longer term shift in where and how care is delivered. The sections that follow explore some of the implications of these ambitions in the context of our previous analyses.

The size, location and shape of the NHS workforce should be influenced by the future health needs of the population. Our analysis of long-term growth in demand suggests that the workforce plan needs to be realistic about the likely increase in services as the population grows older, both in the hospital and community sectors.

In our most recent update, we estimate that the number of people living with major illness (conditions or combinations of conditions with the greatest impact on mortality and health care demand) will increase by 2.6 million to 9.3 million people by 2040, compared with 6.6 million back in 2019. There will be increases in the number of working-age people with major illness (rising from 3 million to 3.7 million), but the bulk of this increase will be among people aged 70 years and older. Based on current evidence, we estimate that even with significant progress in reducing risk factors (such as smoking and obesity), the increase in people without major illness will not be enough to offset the overall growth in the burden of major illness by 2043 driven by ageing.

This means there will be significant increases in the volume of conditions managed in both primary and secondary care (Figure 1). There will be large increases in the number of people living with chronic pain, type II diabetes, dementia, anxiety and depression, conditions typically managed in primary and community care. The government hopes that this demand will be met at neighbourhood level by ‘existing staff working differently’. But there is a clear need for increases in some groups of staff working in the NHS, for example GPs, where the number of registered patients per full-time equivalent GP has risen by 15% between 2015 and 2024. 

Boosting GP numbers will require policies that both increase GP training numbers and reverse the trend in poor GP retention (see section 6). This means GP numbers will need to rise at a faster rate than other parts of the clinical workforce. Over the past decade, the number of specialist clinicians has grown substantially, while GP numbers have remained relatively flat and have not kept up with population growth. This risks compromising the system's ability to deliver the continuous, preventative and community-based care that the 10-Year Health Plan's shifts depend on. 

Recruiting and retaining more GPs should therefore be a central priority of the workforce plan. Data from the Commonwealth Fund’s international survey of primary care physicians from 2022 underlines how acute the pressures on GPs in the UK have become relative to other high-income countries: 71% of UK GPs report their job as 'very' or 'extremely' stressful (the highest of the 10 countries surveyed, alongside Germany), 91% say their workload has increased and just 24% are 'very' or 'extremely' satisfied with practising medicine – the lowest of any country in the survey. Around a third of the most stressed UK GPs say they plan to stop seeing patients regularly in the near future.

The size and composition of the NHS workforce needed to deliver the 10-year plan will depend on how fast reforms can moderate demand for care and on whether productivity can increase – meaning more activity can be delivered by smaller increases in staffing or through changing the mix of staff skills and improved team working. That includes shifting activity to settings that can deliver care more efficiently (for example, more care delivered outside hospital where appropriate), redesigning pathways to reduce avoidable admissions and unnecessary follow‑ups, and improving flow through hospitals (including reducing length of stay and increasing day‑case activity). 

In the 10-year plan, the government commits to a 2% annual growth target for productivity over the next 3 years. This is optimistic by historical standards. Between 1996/97 and 2018/19, annual productivity grew by 0.6% on average, before the pandemic caused a large drop. Some of the 2% target plausibly reflects scope for recovering pandemic-era losses rather than sustained productivity growth. But the size of any remaining recovery margin is uncertain and catch-up gains diminish as productivity returns toward its pre-pandemic baseline. 

Sustaining 2% across the full 3-year horizon would require performance materially above the long-run trend, not just a continuation of recovery. In 2025, the Health Foundation and the Strategy Unit gathered the views of experts from policy, academia and the NHS. Assuming the continuation of current trends, the experts’ combined central estimate for annual productivity growth over the next 5 years was 0.7%, significantly below the government’s target. Over the longer term, optimism was slightly higher, at 1.0% annual growth over the whole decade.

Independent scrutiny of the productivity modelling underlying the plan would strengthen credibility. It is not yet clear whether the modelling behind the new plan will be externally assessed or updated as evidence on productivity emerges. 

Policymakers often hope that changes to skill mix – such as expanding the role of nurses, pharmacists and allied health professionals – will help boost productivity and efficiency. The 10-Year Health Plan reflects this, with a deliberate approach to optimising the mix of skills in teams designed to improve value for money while protecting quality and safety. But evidence from general practice, which has seen a large-scale increase in the deployment of a broader range of skilled staff since 2019, suggests that changed skill mix does not automatically improve productivity nor always improve access or quality.

Since 2019, the Additional Roles Reimbursement Scheme (ARRS) has driven a more than fourfold increase in non-GP and non-nurse direct patient care roles (such as pharmacists, physiotherapists, social prescribers, care coordinators). While there has been a rise in the number of appointments per registered patient since the pandemic, this growth has been considerably smaller than the expansion in the workforce. One explanation is that GPs and nurses provide considerably more appointments per full-time equivalent staff member than other direct patient care roles (Figure 2).

The 10-Year Health Plan describes the shift to digital as ‘among our clearest routes’ to productivity gains, anticipating that increased use of digital technology across the NHS will free up staff time to deliver more clinical care. There is genuine cause for optimism: evidence suggests digital tools can reduce administrative burden for clinicians, freeing time for direct patient care. But our research suggests the workforce plan must avoid both overstating the time technology will save and underestimating the staff and management capacity needed to implement it.

Analysis based on a rapid evidence review of the impact of new technologies on staff time found mixed evidence. Some technologies, for example digital barcoding of drugs or equipment, were more likely to show evidence of a positive impact on staff time than others, such as robotic surgery or electronic health records. Studies that reported no or negative impact on staff time found that new technology often made existing tasks more time-consuming or added tasks to existing work. Factors associated with successful implementation were investment in capability to engage users and redesign processes, the training and backfilling of staff, evaluation and quality improvement.

While there are certainly opportunities for automation technologies to reduce pressures on the NHS, we should not expect them to plug workforce gaps or compensate for a historical lack of long-term workforce planning. Even if time is freed up by new technology, our survey work with clinicians cautions against the assumption that it will automatically be used for patient care. We asked clinical staff how they would likely use a hypothetical hour of freed-up time. 27% of survey respondents said patient care or direct clinical activity, followed by reduction of overtime (17%) and quality or service improvement (13%). When asked about 3 hours of freed-up time, the highest ranked choice was quality or service improvement (48%). This suggests explicit planning will be needed if freed-up time is to be used for clinical care. Allowing more time to be spent on activities such as training, quality improvement or research could indirectly improve productivity by increasing the quality of jobs and boosting retention. 

Beyond these near-term implementation challenges, AI raises a more fundamental question for long-term workforce planning. AI is likely to fundamentally reshape how health care is delivered in future. Big questions remain over the clinical and administrative roles that may change over the next decade and how – and the new roles needed to implement, oversee and govern AI systems in health care. This presents significant uncertainty and the workforce plan should acknowledge this rather than locking in assumptions about workforce composition that might not survive contact with rapid technological change. Building in regular review points and adaptive mechanisms, so that training pipelines and skill-mix assumptions can be updated as the evidence matures, would be more credible than a single, fixed projection. Rigorous and rapid evaluation of promising new technologies is essential to understand their potential benefits and their impacts on staff and patients.

Management will shape the delivery of the 10-Year Health Plan – for better or worse. It will not be possible, for instance, to have a digitally-enabled service without a management workforce that is sufficient in number and has the skills, experience, job control and motivation to lead and support change. 

The contribution managers make to innovation and improvement is recognised in the draft NHS leadership and management framework. The framework is based on the 2022 Messenger Review of NHS leadership and management, which the government has promised to implement. A finalised framework is still expected. The government has also promised to create a College of Executive and Clinical Leadership, which is in the early stages of development. 

At present the capacity and capability of managers varies across the country. In the best performing provider organisations, managers are at the forefront of change efforts – leading and supporting front-line improvement teams, disseminating learning about promising innovations and ensuring people have the skills and time they need to drive change. However, this is not the case everywhere. In some organisations, especially those under significant pressure to improve operational performance, core managers find themselves locked in fire-fighting mode, often lacking the time, space, permission and sometimes capability to lead and support change. 

The new NHS workforce plan will need to set out how the NHS management workforce will be developed in future, alongside that of other NHS professions. Given that the NHS is likely to be under-managed at present, a clear national approach for strengthening the capability and capacity of NHS managers, is necessary and overdue. 

To support the work of national policymakers and local system leaders to strengthen the management workforce, the Health Foundation is working with York University on research to understand the current state of NHS management capacity and capability. This research, due to report later in 2026, pays particular attention to the role of managers in the delivery of innovation and improvement. 

Historically, progress against government targets to boost staff rely heavily on recruiting workers from outside the UK. In 2025, a third of NHS staff joiners had a non-UK nationality. The government's most recent goal is to reduce the proportion of new recruits from non-UK backgrounds from 34% to 10% by 2035, promising that the new workforce plan will set out how the NHS will achieve this. This shift partly reflects growing concerns about the long-term sustainability of the global health care labour market, as more high-income countries compete for an internationally mobile health workforce.

Significantly reducing reliance on international recruitment will be a challenge. In nursing, the largest part of the clinical workforce, the share of new registrants on the Nursing and Midwifery Council (NMC) register trained outside the UK has not once fallen to the 10% target in the 35 years since 1990/91, and has been highly volatile (Figure 3). Despite a 78% year-on-year drop in the number of nursing visas granted in 2024/25, non-UK nurses still made up 39% of new registrants, showing how challenging the government’s goal on international recruitment is.

This boom-and-bust pattern in international recruitment for nursing reflects the UK’s longstanding under-investment in training enough domestic nurses to meet its own needs, with NHS-funded international recruitment used as a fast and relatively cheap way of filling that gap. Periods of intense activity have been followed by sharp falls as funding has been withdrawn and vacancies have closed; recent visa changes have largely affected social care rather than the NHS and illustrates how sensitive the NHS's nursing supply has been to levers outside the health system itself. Hitting and sustaining a 10% ceiling would be without precedent and risks widening, rather than narrowing, future nursing gaps unless matched by a commensurate step up in domestic training and retention.

Improved staff retention is associated with better outcomes for patients and increased productivity. It is also one of the fastest and most cost-effective ways to increase effective workforce supply, compared with relying primarily on training new staff (with long lead times) or recruitment (which can simply shift shortages around the system).

Recent data show some improvement: NHS England reported that 10.1% of hospital and community health service staff left in the 12 months to September 2024, down from 12.5% in the 12 months to September 2022. Department of Health and Social Care evidence to the NHS Pay Review Body also notes that published leaver rates for non‑medical staff fell to 9.6% in the year to March 2025. Even at these levels annual churn is large – and ‘leavers’ are not necessarily lost to other sectors. Health Foundation analysis suggests that around 43% of NHS nurse leavers continue working in nursing roles elsewhere in health and care – including in social care, nursing homes and the independent sector – underlining that the issue is often where nurses work (and on what terms), not whether nursing skills exist in the system. 

Policies to increase retention will need to be developed for different staff groups. In general practice, for example, analysis has found that for every five additional GMC-licensed GPs, NHS general practice lost one full-time equivalent GP per year between 2015 and 2024. Many newly-qualified GPs are not entering the NHS workforce or leaving within the first 10 year of qualification, signalling a major retention challenge. Although important, the workforce plan will need to do more than continue the existing policy of increasing GP trainees. It will need to address how to retain existing GPs, with a particular focus on women, who now represent 58% of all GPs, and international medical graduates, who now represent around half of all GP trainees, but are more likely to face a range of additional challenges finding roles compared with UK-trained doctors. Across staff groups, levers to improve retention are well evidenced: flexible working, clear routes into career progression and continuous professional development, safe staffing levels and targeted support for those most at risk of leaving. 

To be effective, these need to be grounded in the systematic assessment of staff priorities, including through staff surveys, so that the plan can learn what is actually shifting retention and adjust accordingly.

Fundamentally, retention depends on making the NHS a better place to work – reducing the administrative burden on clinicians and tackling the operational failures routinely experienced by staff, particularly in general practice.

Pay levels, pay structures and the processes that determine them have been largely peripheral to national workforce planning, including in the 2023 NHS Long Term Workforce Plan. Yet pay potentially shapes whether people enter NHS roles, whether they stay, how many hours they work and whether staff move between sectors and employers. Treating pay as separate from workforce strategy risks weakening the credibility of workforce projections, particularly where the plan relies on improved retention, higher participation or shifts in workforce mix.

NHS workforce planning takes place within a wider labour market that the health service does not control. The size and composition of the workforce the NHS can recruit and retain is shaped by what is happening in adjacent sectors – particularly social care and public health – and by national policy on pay, immigration and training that cuts across all three. A workforce plan that treats the NHS in isolation will struggle to deliver the 10-Year Health Plan’s ambitions to shift care into the community and to focus on prevention, both of which depend on workforces that sit outside the NHS itself.

Interdependencies with social care are the most direct. Social care is vital to millions of older people and disabled people, and can also alleviate pressure on the NHS. But since 2009/10, social care funding has not kept pace with rising demand and cost pressures. The social care workforce is poorly paid, contributing to high turnover and persistent poverty and deprivation among care workers. The supply of care workers remains fragile and recent changes to immigration policy have led to a steep fall in international recruitment. While government legislation to improve pay and conditions via new Fair Pay Agreements in adult social care has potential to boost workforce recruitment and retention from 2028, success is not guaranteed. Future changes to the pay and conditions within the social care workforce will also need to be carefully monitored for their impact on the NHS workforce, given their interdependencies. 

NHS staff working more closely and in more integrated ways with social care colleagues is a longstanding ambition. But national policy has done little to enable this. Although the two workforces are comparable in size, they are organised and rewarded very differently: social care staff are employed by around 19,000 mostly for-profit providers, or directly by people drawing on care. And progression, pay and wider terms and conditions are materially poorer than in the NHS. These structural differences make genuinely integrated working difficult in practice. The neighbourhood health agenda and shifting care into the community will therefore rely in part on the success of planned workforce reform in social care – including whether Fair Pay Agreements deliver the recruitment and retention gains they promise. The NHS workforce plan should be explicit that its community ambitions are conditional on this reform succeeding and should set out how NHS and social care workforce planning will be coordinated rather than run in parallel.

The same logic extends to prevention, where the NHS's ambitions rest on a public health workforce weakened by a decade of constrained funding. An expansion in preventative activity in the NHS will likely be needed, but local authority funded prevention services are vital and remain under huge strain. Last year’s real-terms increase in the public health grant was a welcome reversal of recent trends, but public health funding per head remains significantly below 2015/16 levels. The chronic underfunding of the public health grant has meant that specialist workforces, like those working in substance misuse treatment, declined significantly and will take time to rebuild. Restoring the public health grant to 2015/16 per person levels should be a high priority, alongside cross-government action to improve health.

Coordinating workforce planning across these sectors was meant to fall in large part to integrated care boards (ICBs), given a central role in the first NHS Long Term Workforce Plan to lead local workforce planning across providers and, in principle, across health and care. Since then, ICB running-cost reductions have cut materially into that capacity, raising real questions about whether they can still convene system-wide workforce planning, hold local providers to account, or align NHS and social care workforces in the way the neighbourhood health agenda assumes. The new workforce plan should identify the body that holds this local coordinating role and what capacity it needs.

A robust and adaptive workforce plan is critical to delivering the government’s 10-Year Health Plan. To do so it must navigate a fundamental tension: underpinning near-term targets that imply sustained hospital activity, while enabling a longer term shift in where and how care is delivered. 

This will require realism about the plan's foundations. Demand for health care will grow across both hospital and community settings, and productivity growth will depend on sustained investment in estates, IT and management capacity, not just new models of care. Digital technology offers real potential, but the evidence cautions against assuming time savings will materialise quickly or translate automatically into more clinical care.

Getting the supply-side right is equally important. Reducing reliance on international recruitment at the scale intended will require both expanded domestic training and a step change in retention. Pay policy should be integrated into workforce strategy rather than treated as a separate annual negotiation. And given that the NHS's community and prevention ambitions also depend on the social care and public health workforces, which face their own acute pressures, the plan cannot be developed as a closed NHS exercise.

Finally, the plan will need to be credible in its oversight and delivery – willing to be independently scrutinised, honest about the assumptions it rests on, and clear about accountability when those assumptions do not hold.