Written evidence submitted by The Health Foundation (WBR0060)

Question of interest: What long term projections for the future health and social care workforce are available, and how many more staff are required so that burnout and pressure on the frontline are reduced? To what extent are staff establishments in line with current and future resilience requirements?

About the Health Foundation  

The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. 

Our aim is a healthier population, supported by high quality health care that can be equitably accessed. We learn what works to make people’s lives healthier and improve the health care system. From giving grants to those working at the front line to carrying out research and policy analysis, we shine a light on how to make successful change happen. 

Acknowledgement

We are grateful to academic researchers at the Personal Social Services Research Unit (PSSRU) for contributing emerging findings from a recent ‘pulse’ survey of social care workers, focusing on COVID-19 impacts, which informed this submission. More information about the unit’s research on recruitment and retention in the social care workforce, which is funded by the Health Foundation, can be found here.

Summary of key points

•                                                                                                                                                                                                             Workforce issues were the single biggest challenge in health and social care even before the COVID-19 pandemic. Our estimates suggest that the NHS will face a shortfall of 115,000 full-time equivalent staff in England alone this year, with this gap projected to rise to 370,000 by 2030/31 in the absence of major shifts in workforce policy. Pressures are even higher in social care, with the sector having an estimated 122,000 vacancies at any given time.
•                                                                                                                                                                                                             These numbers have serious implications for workforce stress levels and burnout. Recent work by the Commonwealth Fund and the Health Foundation showed that among 1,001 UK GPs surveyed, a majority are not satisfied with their workloads and find working in primary care very stressful. NHS waiting lists are very long, which places enormous pressure on staff.
•                                                                                                                                                                                                             With nursing being the most glaring NHS workforce shortage area, increases in nurse stress and burnout levels in the COVID-19 pandemic present a major challenge. In a recent Royal College of Nursing survey, 76% of nurses reported increased stress levels during the COVID-19 pandemic, with 85% also reporting increased stress levels for colleagues. Younger nurses were more likely to report heightened stress levels relative to older colleagues.
•                                                                                                                                                                                                             Burnout is also a major issue in social care. Emerging evidence from a ‘pulse’ survey of social care workers undertaken by researchers at the Personal Social Services Research Unit (PSSRU) points to the pandemic having driven sustained increases in workload and stress levels for social care staff.
•                                                                                                                                                                                                             These concerns cannot be addressed without major changes in workforce strategy which accounts for regional variation. The NHS People Plan 2020/21 is a start but leaves many questions unanswered. A coordinated long-term workforce plan, complemented by well-researched workforce models for health and social care, is the need of the hour.

Context

The 2.5 million people who comprise the health and social care workforce in England alone play a key role in supporting people who are sick or in need of care. Protecting and valuing their wellbeing is vital to a well-functioning health and social care system. How these staff feel and what they say to their patients, families and friends is also important to perceptions of the system. Access to high quality care relies heavily on having a skilled health and care workforce in a position to deliver in times of need.

COVID-19 is putting unprecedented pressure on the health and social care workforce. However, even before the pandemic, staffing was the biggest single challenge for the NHS and social care in England, and was having a direct impact on patient care and staff experience. In recent years, rising workforce shortages and stagnant pay have led to increased pressures. Workforce growth in the decade up to 2018/19 was just half that of the decade before, and even this growth was not equal across different staff groups.

Workforce shortages are looming

Even before accounting for the impact of COVID-19, based on data from February 2020, we estimate that the NHS is projected to face a shortfall of 115,000 full-time equivalent (FTE) staff in England alone this year. This analysis assumes that the number of staff in post follows the average trend since 1995/96 and that the number of additional funded posts grows in line with health care activity growth. Based on current trends and without major changes in long-term workforce strategy and planning, the current NHS workforce gap is projected to double over the next five years and to exceed 370,000 by 2030/31 (Table 1).

Nursing is the key area of shortage, with the NHS in England alone going into the COVID-19 pandemic with vacancies in about one in ten registered nursing posts – about 40,000 full-time equivalents. Without shifts in policy, this shortage could double by 2023/24 and exceed 100,000 by 2028/29. In the last five years, nurse numbers have grown at just one-third of the rate of both doctors and clinical support staff, while the number of nurses in community and mental health services remains below 2014 levels despite growing demand. These findings have major implications for nurse stress levels and burnout rates. In a recent Royal College of Nursing survey, 76% of nurses reported increased stress levels during the COVID-19 pandemic, with 85% also reporting increased stress levels for colleagues. Younger nurses were more likely to report heightened stress levels relative to older colleagues.

Recent work by the Commonwealth Fund and the Health Foundation showed that a majority of 1,001 UK GPs surveyed are not satisfied with their workloads and find working in primary care very stressful. In particular, only 6% of UK GPs reported feeling ‘extremely’ or ‘very’ satisfied with their workload, the lowest among the countries surveyed. 60% of UK GPs also reported finding primary care work to be ‘extremely’ or ‘very’ stressful (a proportion second only to Sweden in the survey). Increasing recruitment and retention to general practice is viewed by policymakers as necessary both to improve access to general practice for patients, and working conditions for staff. In this light, GPs’ perceptions of high workload and stress levels, coupled with the stated intention of a significant minority of GPs surveyed to reduce their clinical hours (49%), or to leave the workforce altogether by changing career (15%) in the next 3 years, presents a challenge.

While the NHS is experiencing significant staffing pressures, workforce issues in adult social care are even greater and the outlook is concerning. Data from Skills for Care show that the social care vacancy rate in England rose from 5.5% in 2012/13 to 7.8% in 2018/19. The number of social care vacancies increased by 54% in this period and the sector has an estimated 122,000 vacancies at any one time. Currently the adult social care workforce employs around 1.5 million people in 1.65 million jobs in England. Skills for Care estimates suggest that if the workforce grows in proportion to the number of people aged 65 and over, then the required number of jobs in social care will increase by 520,000 (32%) by 2035 (Table 1). This is consistent with Health Foundation analysis in 2018, which projected that 458,000 additional full-time equivalent social care staff would be needed by 2033/34 to meet the expected growth in demand for social care.

Table 1: Projections of NHS and social care workforce requirements (2020 – 2035)

Source: Health Foundation analysis of workforce and vacancy data from NHS Digital and Health Education England and Skills for Care analysis of the adult social care workforce. Note: The NHS projections are for Hospital and Community Health Services (HCHS) staff working in NHS organisations and do not include staff working in primary care, including GPs and practice nurses. These projections do not account for any COVID-19 impacts.

*The NHS estimates are for 2020/21 and the Skills for Care estimates are for 2019/20.

**The NHS estimates are for 2033/34 and the Skills for Care estimates are for 2035.

Impact of COVID-19 on the NHS workforce

Even before COVID-19, in order to meet the 18-week standard for newly referred patients and to clear patient backlogs, the NHS would have needed to treat an extra 500,000 patients a year for the next 4 years. Such waiting lists place enormous pressure on NHS staff causing stress and burnout.

When it comes to nurse supply, the disruption to international travel caused by COVID-19 presents a significant short-term challenge to the NHS and social care. NMC data reveal that the UK saw a sharp (97%) reduction in new registrations from nurses trained outside the EEA in April 2020 (from 1,348 in March to only 35 in April). This could lead to increased workload pressures and stress levels for nurses currently working in the UK, particularly in the event of future waves or local spikes of COVID-19 and increased seasonal pressures in the autumn and winter.

Recent Health Foundation analysis suggests that around 7.9% of GPs in England are at high or very high risk of death from COVID-19. Nearly one in ten GP practices (9.4%) are run by a single GP. Patients at these practices are disproportionately vulnerable to disruption in care should these GPs fall ill or die as a result of COVID-19. Almost one in three (32.7%) of these single-handed GP practices are run by a GP at high or very high risk from COVID-19. In the absence of these GPs seeing patients face-to-face, 710,043 patients would be affected and potentially dispersed to other GP practices, increasing workload and burnout issues faced by other GPs.

Impact of COVID-19 on the social care workforce

As at 31st March 2020, Skills for Care survey estimates suggested that 25% of social care staff were unable to work due to COVID-19 (based on 211 providers surveyed), most commonly as they had to self-isolate due to symptoms or living with someone showing symptoms. These staffing shortfalls may have contributed to increased stress levels for those continuing to work.

More recently, in a ‘pulse’ survey of social care workers undertaken by PSSRU researchers in July and August 2020, a majority of 294 respondents reported that their workload had increased ‘a lot’ (59%) or ‘a little’ (21%) since the onset of COVID-19. A majority of respondents also reported that their role had made them feel ‘a lot more’ (43%) or ‘a little more’ (38%) tense, uneasy or worried since the onset of the pandemic. This emerging evidence points to the pandemic having driven sustained increases in workload and stress levels for social care staff (respondents included staff from care homes as well as domiciliary care workers).

Implications of Brexit

As at 4 September 2020, the Immigration and Social Security Co-ordination (EU Withdrawal) Bill 2019-21 had been approved by the House of Commons and was under consideration by the House of Lords. The Bill poses a challenge to the supply of workers from the EU, as it seeks to end the current system of freedom of movement between the UK and the EU. In June, the Health Foundation wrote to the Public Bill Committee to support the idea of a ‘social care visa’ and the introduction of a transition period for social care workers before the new immigration system comes into effect.

In place of this, a new points-based immigration system for people moving to the UK from both EU and non-EU countries will be put in place in January 2021. At the time of writing, care workers and home carers from both EU and non-EU countries are not eligible for work visas under this proposed new immigration regime. This is a major concern for social care. Skills for Care data suggest that workers from EU and non-EU countries accounted for 8% and 9% of England’s social care workforce in 2018/19, with regions such as London having significantly higher shares (14% and 25%). As it currently stands, the post-Brexit immigration regime raises serious questions for England’s social care workforce stability. Migrants are vital to the social care workforce. Increasing barriers to people coming from the EU to work in social care could imperil the delivery of care services in England, with adverse implications for workload and burnout levels among the existing workforce.

New polling commissioned by the Health Foundation and conducted by Ipsos MORI during July 2020 found convincing public support for a ‘social care visa’ to allow people to come to the UK to work in social care jobs that are unlikely to meet the salary or qualification requirements imposed by the new immigration system. 77% of respondents supported a sector specific visa, with only 9% of people opposed.

What can be done?

The NHS Long Term Plan, and the Interim NHS People Plan, both recognised the need to address workforce challenges, including reducing staff stress and isolation levels. The recently issued We are the NHS: People Plan 2020/21 acknowledges the relevance of line managers and teams promoting measures to enhance staff wellbeing and reduce staff stress and burnout. However, the plan does not set out how existing shortages will be addressed in the medium term, which is particularly concerning at a time when our recruitment of nurses from abroad has dropped dramatically.

In the absence of clarity from the government regarding the funding which will be available to expand the NHS workforce in the coming years, further detail is unlikely to follow until next year. Our research highlights gaps in our understanding of the factors which drive recruitment and retention in the workforce as a whole.

This points to a strong need for well-researched workforce modelling which can facilitate analysis of policy impacts in the medium to long term. This will be a primary focus for the REAL Centre, which the Health Foundation is setting up to provide independent, objective and impartial evidence relating to long-term issues in the health and care system

While the NHS does at least have a short-term workforce plan, there has been no corresponding planning in social care, which has suffered from decades of political neglect and the devastating impact of COVID-19 on care users and staff. With the winter ahead likely to be as challenging for social care as it tends to be for the NHS, increased staff stress and burnout levels are likely to continue to be major concerns. A comprehensive workforce plan for both the NHS and social care is needed now more than ever.

Sept 2020