Nuffield Trust – Written evidence (FFF0042)

Designing a public services workforce fit for the future

The Nuffield Trust is an independent think tank studying health and social care. We aim to improve the quality of health care in the UK by providing evidence-based research and policy analysis and informing and generating debate.

From ambulances to nursing homes, we have seen how the availability, training, and allocation of staff are central to both the difficulties faced today and the change needed in the future. The challenges and principles the Committee lays out are very relevant in these sectors, and we hope this submission will help its consideration of the UK’s largest public services.

Key points

The NHS needs to improve its approach to recruiting and planning staff, tackling both the bottlenecks which stop more from being trained and unacceptable attrition rates.

• In the short term, it will remain necessary to continue to recruit staff from overseas. The UK must consider how it remains competitive with restrictions and costs on migration, and whether the new provisions for social care will really allow the staff we need to arrive.
• There has recently been a serious and worrying loss of social care staff. While this is likely due to poor pay and conditions, and vaccine mandates, we need to understand better what pushes people away.
• Digital technologies providing care remotely have great potential, and can lead to staff gaining new skills as services are connected. However, they can leave out those unable to use them. Skills in knowing who they are suitable for, and managing the tensions that result, are vital. Poor pay and conditions in social care can mean that upskilling staff in this sector encourages them to leave.
• Recent extra NHS funding to employ different types of professional in general practice has the potential to boost capacity and foster joint working. But early signs are troubling: support and investment are needed to stop these from being isolating jobs that cause high turnover.

1              Recruitment, retention, and training

1.1.                   Improving the approach to training and planning for the NHS

The NHS in England suffers from a chronic shortage of several key staff groups, with a lack of nurses and GPs presenting particularly fundamental problems to the running of the service.[1] This has been a repeated tendency over decades. It is among the biggest obstacles to the recovery and expansion of healthcare after a covid-19 pandemic which has demanded extreme efforts from many workers. A permanent improvement to planning and training is overdue.

Workforce planning in England has traditionally tried to land “a jumbo jet on a pin”, eliminating any risk of an oversupply as well as an undersupply rather than recognising the uncertainty in supply and demand for staff.[2] We should seek to build in a margin for error to avoid costly gaps.

However, simply feeding in more trainees is not necessarily the best option. Losses and attrition on the path to becoming an NHS professional are widespread. For instance, one estimate suggests that out of every five adult nurse training places commissioned, fewer than three full-time equivalent staff enter the NHS.[3] We have recommended that commissioners of professional courses and placements set conditions on the quality, success and balance of the training, informed by accurate monitoring of attrition.[4]

For some professions, there is currently a lack of incentive for universities to provide more places and courses. While medical school numbers are determined by government, this is not the case for most health and social care education programmes. The Office for Students provides funding to universities where course costs cannot be met through fees alone. This attempts to account for the clinical equipment, supervisors, and experiences required. However, to incentivise more places for the right courses, we support the recommendation that the Office for Students reviews funding rates, giving consideration to support for socially desirable professions such as nursing.[5]

A lack of placements during higher education for health professions is also a bottleneck. Pressure on services makes it harder to offer these. There are specific issues in the NHS with a lack of transparency on where funding for clinical placements,[6] and huge differences in funding levels between staff groups which tend to favour trainee doctors, whose salary is subsidised unlike other groups.[7],[8]

1.2              Attracting and retaining staff from different backgrounds and places

There is also a challenge to ensure that training and placements are in the right places and the right settings. Rural areas and social care at home often suffer especially from shortages. As education informs expectations, national, regional and local bodies should work closely with universities and placement providers to ensure that staff are trained in the kinds of services and the areas of the country where they will be needed.[9]

The moral and legal cases to increase the diversity and inclusivity of the workforce are indisputable. In healthcare, there is also a robust evidence base demonstrating the benefits, including: improved quality of care for patients; a more sustainable workforce supply; and increased efficiency of services.[10]

Apprenticeships have the potential to support wider participation: they are popular with older entrants, attract people from diverse backgrounds[11], and present an opportunity to recruit more locally. However, in the NHS, the model has been delayed and some of the numbers have been lower than intended. While new funding was announced to support nurse apprenticeships in August 2020, it will be important to monitor how this affects the numbers being provided. It appears currently that the coordination and flexibility of the system could be greatly improved.[12]

An estimated 5% of jobs in social care in England are held by regulated professionals; the majority of jobs providing direct care (76%) are filled by roles such as care workers which do not require a qualification. [13] For these roles, it is the general attractiveness of the sector as a place to work, as opposed to the availability of qualified staff, that is the key limit on recruitment. Yet despite social care being recognised as a low pay sector for over 20 years, there are no further ambitions to improve pay within this parliament, a notable absence in the government’s social care white paper.[14] In comparison, Scotland has benchmarked care worker pay to NHS Agenda for Change band 2; France increased pay by 13-15% per hour for domiciliary care staff.

1.3              Ethical recruitment from overseas in the short-term

In the short and medium term, attracting staff from overseas is vital to addressing staffing shortages and meeting workforce goals.[15] The potential numbers are large. Some 49,000 nurses were recruited to the UK in a four-year period in the early 2000s.[16]

Perceptions around quality of life, working conditions, and opportunities can all be important factors in the decision to migrate. Professional motivations appear more common from migrants from higher income countries: pensions, pay and public services are more common for those from poorer countries. Our work on overseas nurses suggests barriers and incentives include: perceived levels of discrimination; visa restrictions to reunite with family; length of the recruitment process; and feedback loops from those currently here to source countries.[17]

The organisations recruiting may also need help given the initial costs and administrative burden involved. The upfront costs in recruiting from a nurse from overseas is likely to be around £10,000 to £12,000. This equates to only around £1,000 per year – or 3% of the mean annual nurse salary – if considered over the typical average NHS career of a nurse from outside the EU.[18] Previous financial support from NHS England & NHS Improvement appears to have helped overcome some of these barriers. There needs to be a mechanism – with Integrated Care Systems likely to be key – to support smaller providers with fees and associated administration, for this important source of staff to work for all settings, including general practice and social care.[19] 

The introduction of care workers to the Shortage Occupation List and health and care visa will allow employers to sponsor care workers on a minimum salary of £20,480 per year. However, in the independent sector the mean annual salary remains at £17,900 per year, so – aside from the recruitment costs – it is unclear whether this is a viable route to addressing workforce shortages.

The Code of Practice for the international recruitment of health care personnel aims to avoid active recruitment from lower income countries with pressing health workforce challenges. Data show there has been, at times, significant passive recruitment from countries on the no-active-recruitment list. In the spirit of inclusion and recognising individuals may be escaping difficult situations, we believe some level of passive recruitment may be acceptable. However, compensation for the loss of clinical assets should be considered.[20]

1.4              Improving our understanding of retention

While the proportion of staff leaving the NHS and social care appeared to have fallen at the start of the pandemic, the numbers now exiting these services are on the rise. And this worrying trend is expected to continue.[21] For specific staff groups we know what some of the key reasons for leaving are. For nurses, retirement, personal circumstances and too much pressure were the most commonly selected reasons.[22] For GPs, burnout, issues around job satisfaction and physical working conditions are often cited. [23]

The national average vacancy rate for social care roles climbed from 7.5% pre-pandemic to 9.5% in January 2022.[24] Specifically, the recorded data suggest a decline of 42,000 in the number of social care staff in the 6 months to the end of October 2021. Our research, suggests that the true scale is more likely to be in the region of 50-70,000 staff.[25] The likely key drivers for this loss of staff include the mandatory covid-19 vaccine for care home staff  and poor pay and working terms and conditions compared to competing industries. [26],[27] In our research we also heard that burnout from the ongoing pandemic was a particularly acute concern for registered managers[28], as well as changes to immigration rules following Brexit.[29] We are concerned that social care is at risk of system failure if urgent action is not taken to alleviate unsustainable workforce pressures.

Our understanding of the numbers leaving and the reasons for this is still limited. This represents a huge missed opportunity for services to learn about how to better retain staff, including the potential implications for diversity, equality and inclusion given the levels leaving – and reasons for it – vary between staff groups.[30]

The actions required include increases in the level of pay and the enforcement of legal minimums; pay-scales which reflect seniority and years of expertise; clear opportunities for progression; consistent standards of training and ongoing professional development; better terms and conditions, and better leadership.

2              Transforming workforce effectiveness

2.1              Digital tools improving access and quality

There are numerous examples of digitally enabled access in health care including e-consulting technologies offering digital access to GP services; video enabled remote outpatient services and at an earlier stage of development, remote assessments in A&E.

These technologies work well for some patients and in some clinical situations, offering convenient and timely access to a consultation that can fully meet their needs.  But research during the Covid Pandemic highlights the risk of inequalities for people who lack skills or resources to engage with digital technology, and inefficiencies when people end up needing face to face care anyway. [31] To anticipate or mitigate health inequalities it is essential that the use of technology is driven by the needs of the population, and interventions are co-designed with the people that will use them.

Findings from the NIHR funded Remote by Default care in the Covid 19 Pandemic study highlight inequalities and tensions that occur when staff use overly rigid approaches to digital care and do not account for the variation in patients’ abilities, attributes and problems – from deprived communities with limited English skills, to mothers who cannot look after children while Skyping a doctor.[32]

We recently carried out an in-depth evaluation of five digital innovations in primary, secondary and domiciliary care in East London.[33] We found that practical, hands-on training is essential for staff to feel confident to recommend and support patients to use technology effectively. This could also include support to provide care remotely. Building in enough time and resources for workforce training is essential for making best use of technology.

2.2              Training staff to get the most from technology

The 2019 review for the health secretary by Dr Eric Topol, Preparing the Healthcare Workforce to Deliver the Digital Future, set an ambitious agenda for training staff to use digital technologies and to interpret and communicate their outputs.[34]  But training is also needed to develop staff skills to understand and manage the human–technology interface in the face of the issues discussed above.  In addition to skills in assessing which technologies suit a patient, health care staff – particularly receptionists – need skills in negotiating with patients to agree a service offer which balances the needs with the patient’s own preferences and the capacity available.

2.3              Using digital technologies to train and upskill the workforce

Our recent work in East London included looking at digital skills in remote monitoring for social care staff. We highlighted the potential of digital technologies as opportunities for skills development.[35]

Using remote monitoring technologies can help staff develop a variety of skills that can improve job satisfaction and help them move towards new career pathways. The development of ‘digital’ skills was seen not as a goal in itself but as a gateway to broader skills including the medical knowledge and communication abilities needed to monitor the health of service users as well as delivering social care.

The use of digital technologies around remote monitoring can also foster more flexible staff who have the potential to move more easily across different sectors such as health and social care. However, with poor pay, progression and conditions rife in social care there is a risk that staff move onto more attractive roles in other sectors and contribute to increased staff turnover.

Using digital innovations to upskill staff in this way requires buy-in and support from all the different health and care services linked by the technology. In our pilot, the limited engagement with health care professionals restricted the extent to which the innovations could be effective in making care pathways more efficient.[36]

3              Transforming existing workforce structures

3.1. Health and social care workforce integration

Each of the UK nations has prioritised integration between health and social care in recent years:[37] each of the other three has published an integrated, long-term workforce strategy[38],[39],[40], but England has not. There has been no workforce strategy for adult social care in over a decade.

Improved integration between the health and social care workforces is thought to improve quality of care, person-centred care, efficiency, and staff skills development and retention.[41] Our NIHR-funded research pointed to many instances during the pandemic where care workers took on additional duties usually held by other professions, including dressing wounds and providing verification of deaths, and playing a more active role within multidisciplinary teams.[42]

Ambitions for an integrated skills passport, joint continuous development and joint roles across health and social care are outlined in the integration white paper.[43] However a key barrier to integrated working is the disparity in pay, terms and conditions, which remain generally much worse in social care and are associated with widespread shortages.[44]

The Health and Care Bill as it stands does not set out meaningful action to address the severe and worsening crisis in social care.[45] Along with measures to address the disparity in pay and working conditions, we argue along with the Health Foundation and King’s Fund that annual transparent, independent projections should be published annually to inform and support workforce planning at national and local levels, and to help ensure the workforce is better able to meet the needs of patients in future.[46]

3.2              Additional Role Reimbursement Scheme

The new NHS ‘Additional Role Reimbursement Scheme’ creates a funding stream through which to broaden the number and skill mix of staff in general practice, and to integrate its workforce with other community health services particularly pharmacy, physiotherapy and mental health services.[47]

Defining these roles locally, rather than nationally, is likely to lead to the best results. This may look like, for example using population health data to decide whether to employ a mental health worker with expertise in drug and alcohol dependence.

A roundtable of primary care network leads held by the NHS South, Central and West Commissioning Support Unit noted the risks of alienation and turnover among early recruits.[48] If they are to work well, these roles must be carefully designed to avoid overly isolated working without peer support.  They also require oversight and support from experience clinicians and significant investment in organisational development to build links between these new community clinicians across team and organisational boundaries.

4.4. Creating user-centred public services: personal budgets in health and social care

Personal budgets, giving people with ongoing needs money to employ people to support them, have been a major feature of successive initiatives to try to foster more user-centred health and social care. Our forthcoming research funded by the NIHR into social care during the pandemic provides several insights into the experiences of personal budget holders in this extraordinary time.

We heard that by the end of the second Covid-19 outbreak, some councils, personal assistants and people holding personal budgets had developed relationships to allow more flexibility than usual about what kinds of activities were paid for, for how long and at what time. This tended to happen where there was already a good degree of trust in the relationship between the council and the personal budget holder, rather than in other areas which simply relied on more transactional models looking at number of hours of support per week.

During the pandemic, many people employing personal assistants were left without appropriate support in scenarios where their personal assistant needed to shield or self-isolate, meaning a lack of timely joined-up support. We heard that they felt largely forgotten by central government when it came to the provision of Covid-19 testing for their personal assistants. In order to receive PPE for their personal assistants, personal budget holders were asked to complete the same risk assessment forms which had been issued to national care providers, which were not proportionate. It is critical that commissioners have a good understanding of individuals’ needs, develop trusting relationships which accommodate flexibility and a more person-centred approach where possible, and ensure that all guidance is tailored to be user-centred.

February 2022