Supplementary written evidence submitted by the Health Foundation (WBR0108)

Ahead of the Select Committee’s forthcoming evidence sessions on Wednesday 24th February, to discuss workforce planning and projections, we have compiled a short summary of our projections for the NHS and social care.

We hope the information below is useful background ahead of the session, and the figures help to put the workforce challenges in context. We look forward to discussing these issues in greater detail with Committee members at the evidence session.

Key points:

• The NHS workforce gap in 2020/21 was 115,000 FTE. This is projected to double over the next five years and to exceed 475,000 FTE staff by 2033/34 (see Figure 1 and Table 1). This does not account for any potential impacts of the COVID-19 pandemic, which will take more time to quantify and understand.
• To go beyond simply keeping pace with expected activity growth, to be able to meet rising expectations for the quality and range of care provided and for services to adopt new technological advances, the NHS in England is likely to require workforce growth of 3.2% a year over the next 15 years. This implies a requirement of a projected 179,000 additional FTE staff by 2023/24, rising to 639,000 additional FTE staff by 2033/34 in this ‘modernised scenario’.
• The Health Foundation and the Institute for Fiscal Studies projected that 458,000 additional FTE social care staff would be needed in England by 2033/34.
• In 2019, our analysis of trends in NHS nurse and GP supply and concluded that the NHS in England faced a shortfall of 108,000 FTE nurses by 2028/29.
• Achieving the government’s target of employing 50,000 NHS nurses by the end of the parliament will only be possible with sustained investment and policy action on domestic supply, including a marked improvement in retention of the current nurse workforce.
• If recent staffing trends were to continue, we projected that the NHS in England would face a shortfall of 7,000 FTE GPs in 2023/24 and the shortfall would increase to 11,500 FTE GPs by 2028/29.

NHS workforce demand and supply: Hospital and community health services

• In previous research in 2018 – Securing the Future – the Health Foundation and the Institute for Fiscal Studies estimated that to meet expected increases in demand, the NHS in England faced a projected shortfall of 440,000 FTE staff by 2033/34 in hospital and community health services. This analysis assumes that the number of staff in post follows the average trend since 1995/96 (growth of 1.6% a year between

1995/96 and 2018/19) and that the demand for staff grows in line with health care activity growth (projected to increase by around 3.2% a year up to 2033/34).

• In another report in 2019 - Closing the Gap – the Health Foundation, the King’s Fund and the Nuffield Trust used updated data and reported that based on existing trends, the projected NHS workforce shortfall would be 250,000 FTE by 2029/30. The report emphasised that the shortfall could rise to 350,000 FTE by 2029/30 if retention rates continued to fall due to emerging increases in early retirement and if the numbers of international recruits and newly trained staff joining the NHS did not increase sufficiently. This was highlighted to be a threat to patient access and quality of care and a major risk to the deliverability of The NHS Long Term Plan.

• The Health Foundation further updated this analysis last year. Based on recent staffing trends up to February 2020 and without major changes in long-term workforce strategy and planning, we estimated that the NHS workforce gap in 2020/21 was 115,000 FTE. This is projected to double over the next five years and to exceed 475,000 FTE staff by 2033/34 (see Figure 1 and Table 1). This does not account for any potential impacts of the COVID-19 pandemic, which will take more time to quantify and understand. As above, this assumes that the number of staff in post follows the updated average trend since 1995/96 (growth of 1.7% a year between 1995/96 and 2019/20) and that the demand for staff grows in line with health care activity growth (projected to increase by around 3.2% a year up to 2033/34).

• It is worth noting that NHS staff numbers in England have increased at a faster rate in recent years. The latest NHS Digital data show that FTE staff numbers increased by 3.7% in the year to February 2020 and by 4.1% in the year to October 2020. However, the demand for staff will also have increased substantially over the last year due to the COVID-19 pandemic.

Figure 1: Projected supply of and demand for NHS staff, 1995/96 to 2033/34

Source: Health Foundation analysis of workforce and vacancy data from NHS Digital and Health

Education England • Note: These 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.

• In Securing the Future we also estimated that to go beyond simply keeping pace with expected activity growth, to be able to meet rising expectations for the quality and range of care provided and for services to adopt new technological advances, the NHS in England is likely to require workforce growth of 3.2% a year over the next 15 years. This implies a requirement of a projected 179,000 additional FTE staff by 2023/24, rising to 639,000 additional FTE staff by 2033/34 in this ‘modernised scenario’.1 This would include 171,000 extra nurses and health visitors and 343,000 extra professionally qualified clinical staff.

Social Care demand and supply

• While the NHS is experiencing significant staffing pressures, workforce shortages in adult social care, which employs around 1.5 million people in 1.65 million jobs in England, are even greater and the outlook is deeply concerning. In Securing the Future, the Health Foundation and the Institute for Fiscal Studies projected that 458,000 additional FTE social care staff would be needed in England by 2033/34 to meet the expected growth in demand for social care. This is based on PSSRU modelling projections of activity growth of 2.2% a year in social care up to 2033/34. These projections are consistent with Skills for Care research, which suggests that if the social care workforce in England 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). However, the projections do not account for increases in the demand for social care due to COVID-19, which emerging evidence suggests could be substantial.

• Further, data from Skills for Care show that the social care vacancy rate in England rose from 4.4% in 2012/13 to 7.2% in 2019/20. This is indicative of a long-term increasing trend in workforce shortages in the sector, which has an estimated 112,000 vacancies at any one time. Emerging data from Skills for Care suggest that there has been a slight decline in vacancy rates in social care since the COVID-19 pandemic hit, but it is too early to determine whether this will persist.

1 The corresponding numbers from our updated analysis based on February 2020 data are: a requirement of a projected 188,000 additional FTE staff by 2023/24, rising to 656,000 additional FTE staff by 2033/34 in the ‘modernised scenario’.

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.

Nursing

• The key area of NHS workforce shortages, nursing accounts for one in four full-time equivalent (FTE) jobs in the NHS hospital and community health services, but close to one in two vacancies. In 2019, Closing the Gap analysed trends in NHS nurse and GP supply and concluded that the NHS in England faced a shortfall of 108,000 FTE nurses by 2028/29, not accounting for fluctuations in international recruitment, if recent staffing trends were to continue. This is because the existing trends suggest that the number of nurses leaving the NHS will substantially exceed the number expected to join domestically – either following initial training or on return to the NHS from another role or a period out of the labour market.

• Our analysis in Closing the Gap suggested that the projected NHS nurse staffing gap could be halved if 5,000 additional nurses were to start training each year by 2021 and if the student attrition rate were reduced by a third, with more nurses encouraged to join the NHS after they qualified. We also found that international recruitment would continue to an important short-term recruitment channel, with the NHS needing an additional 5,000 internationally recruited nurses each year up to 2023/24 to reduce registered nursing vacancy rates from over 11% in 2019/20 to 5% by 2023/24. In a best-case scenario of sustained improvements in the numbers of nurses being educated and employed by the NHS, coupled with reduced student attrition rates and policy efforts to retain NHS nurses, we projected that it would be possible to expand the supply of nurses in England so that it broadly matches demand from around 2028/29 onwards (‘increase after policy action’).

• In a more recent report – Workforce pressure points – we updated our analysis above with a focus on the government’s 2019 general election target of hiring 50,000

additional registered nurses in the NHS by the end of the parliament. Our conclusions were largely unchanged – the results of the updated ‘best’ case scenario are captured in Figure 1. Our analysis suggests that increasing the number of nurses in the NHS by 50,000 will mean that nursing growth matches future demand growth. This would reduce the pre-existing nurse staff shortfall significantly to around 8,000 FTE nurses by 2024/25. If the expansion in nurse training in the ‘increase after policy action’ is sustained and retention rates improve, it would be possible to close the nursing workforce gap over this decade and achieve a small excess of supply.

Figure 1: Nursing demand and supply projections for England based on policy action to increase the supply of nurses, 2018/19 to 2028/29

Source: NHS Digital, UCAS and NMC data and authors’ analysis in Workforce pressure points (based on ‘Closing the gap: key areas for action on the health and care workforce.’ Health Foundation; Overview – March (2019), Figure 4)

Note: The chart shows demand after the impact of improved productivity, which we include in our ‘increase after policy action’ but not ‘current trend’ scenarios. As a result, demand is lower (by 4,000 in 2024/25 and 8,000 in 2028/29) than in our scenario based on current trends. Data are updated to June 2020, but we do not account for any short and long-term effects arising from the COVID-19 pandemic.

• Achieving 50,000 nurses target: Our analysis suggests that achieving the government’s target of employing 50,000 NHS nurses by the end of the parliament will only be possible with sustained investment and policy action on domestic supply, including a marked improvement in retention of the current nurse workforce. We also conclude that the 50,000 target is “top down”, is not planning based, does not give any attention to which types of nurses are most required and where, and will be insufficient to meet increased demand. To facilitate a shift to a more sustainable, long term approach, the REAL Centre commissioned work around a model of nurse supply in 2019. This project aims to enable projections of the future nursing workforce supply in England under alternative policy scenarios over a 10 to 20-year timeframe, with initial projections likely to be available later this year.

GPs

• Our analysis of GP numbers in Closing the Gap found that even with a major focus on increasing the number of GPs in training, the number of GPs in the NHS would fall substantially short of demand and of the government’s stated target of a net increase of 5,000 in GP numbers in the NHS Long Term Plan. If recent staffing trends were to continue, we projected that the NHS in England would face a shortfall of 7,000 FTE GPs in 2023/24 and the shortfall would increase to 11,500 FTE GPs by 2028/29.

• Even assuming ambitious policy intervention, our projections suggest that there will be only an extra 650 FTE GPs working in general practice by 2023/24 and an additional 3,500 FTE GPs by 2028/29. This is largely due to long lead times in GP training and no anticipated improvement in the rate at which GPs leave their training or choose to join the NHS following their training. Policy will therefore need to look to alternative solutions to the substantial shortage of GPs. Closing the gap in demand will require ambitious changes to the workforce composition in primary care and leveraging the skills of a wider team. Our projections estimate that by 2023/24, 3,100 more FTE pharmacists would need to be working in general practice and by 2028/29 6,000 more FTE physiotherapists, as well as increases in administrative and clinical support staff.

February 2021