Written evidence submitted by NHS Professionals (RTR0091)
Below is NHS Professionals’ submission in response to the Call for Evidence. As the largest provider of flexible staff to the NHS we believe we are ideally placed to discuss the current challenges and need for Government-supported change.
In this document we do a number of things:
We would be happy to provide further information or clarification, if helpful, to the Committee.
NHS Professionals is the largest provider of bank workers to NHS Trusts. We are a limited company, wholly owned by the Department for Health and Social Care. Originally formed in 2001, we now manage the staff banks of over 50 client Trusts, provide staffing services to a further 50 Trusts, and have over 180,000 registered health care professionals. We are the largest payroll in the NHS. (Details of all the Trusts to whom we provide Managed Service bank solutions are provided in the Annexe).
Since the start of the pandemic we have responded to requests for recruiting, deploying and training staff to meet a range of urgent requirements including expanding bank supply (recruiting 20,000 people in a matter of weeks through our Rapid Response programme) staffing Nightingale Hospitals (London, Manchester, Harrogate), recruiting and training 12,000 clinical staff for the Test and Trace service, and recruiting, training and making deployment-ready over 16,000 vaccinators and vaccination support staff.
Over the past two years we have, therefore, engaged with more NHS workers (substantive and flexible) and the ‘NHS curious’, than any other organisation. We believe this qualifies us to talk knowledgeably about NHS staffing challenges.
The flexible workforce is made up of a blend of substantive workers undertaking additional shifts and those individuals that choose a ‘flexible’ only working pattern – providing their services at times (and in places) that suit other work or family commitments.
In 2019/20, NHS England Trust spending on flexible workers totalled around £6.1 billion (circa £3.8 billion bank and £2.4 billion agency). This compares against a total paybill of £53b. The contribution of flexible workers to the NHS is, therefore, significant.
Just as important is the contribution that flexible working opportunities make to retention. The interim People Plan suggests that flexible working is one of the top interventions known to have the biggest impact on improving retention. Where contractual inflexibilities exist (such as shift patterns that include weekend or night work that some people find hard to accommodate) – flexible working provides a powerful vehicle for retaining qualified professionals.
NHSPs own persona research (covering Nursing and Midwifery, Doctors and Non-Clinical groups) has consistently revealed that workers are attracted to flexible working by more than just pay: workers talk of gaining control over both the time and place of work in addition to opportunities for new learning and skills development.
Determining the ‘gap’ between supply and demand in the NHS is fraught with difficulty. NHS Digital has been exploring experimental data for some time in an attempt to reconcile differences between the number of jobs advertised (through NHS jobs), vacancy rates reported on ESR, and data collected monthly by NHSE for the Model Healthcare dataset. All three sources provide differing numbers on vacancy rates – the metric typically used as a proxy to quantify the workforce gap. None of these sources, however, reflect the size, scope and contribution of the flexible workforce. As a consequence, they tend to overstate the size of the staffing ‘gap’.
We contend that a more accurate reflection of the gap can be determined by understanding the scale of ‘ward unfilled sessions’ and would urge consistent and accurate collection of this data to help inform the debate (and development of appropriate solutions). Unfilled shifts reflect a Trust’s inability to fill via all staff groups (i.e. substantive workers, bank staff and agency) and therefore provides a much better measure of the true gap in terms of ability to fill staffing demands.
NHSP’s data (Figure 1) shows that the Whole Time Equivalent (WTE) for unfilled shifts (i.e. the number of people working full time that would be needed to fill these shifts) ranges from 4,468 in April 2021 to 10,054 in December 2021 across all NHSP clients. Grossing this up to reflect an approximate national rate (based on NHSP currently delivering to 22.8% of all Trusts), reveals a WTE gap ranging from 19,596 in April to 44,096 in December 2021 – a difference in demand across this period of 24,500. Our data also reveals that, in the December ’21 demand peak, the WTE gap resulting from staff vacancies was 7,275 (suggesting a national vacancy rate for posts required to fill demand of 31,908 – considerably below the 100,000 estimate often quoted).
Figure 1: Whole-time Equivalent Workforce Numbers for Unfilled Shifts [NHSP only]
Data in Figure 2 confirms that the biggest gaps are in clinical professional areas (Doctors, and Nursing and Midwifery) – but also shows the more extreme fluctuations in demand through the year for nursing and midwifery, healthcare support workers and support staff.
Figure 2: Unfilled Shifts by Staff Group (%) [NHSP only]
Figure 3 reveals quite marked differences in rates across different regions – the lowest in London (consistently below 10%) and the highest in the North East and Yorkshire (where the rate has been tracking above 30% since May this year).
Figure 3: Unfilled Shifts by Region (%) NHSP Only]
Looking at the data in this way reveals the need for flexibility in the workforce to cope with differences in demand over a typical annual cycle. It also demonstrates the contribution that flexible workers make to overall workforce supply. In the December peak last year, we estimate that flexible workers contributed the equivalent of 51,979 whole time equivalent staff to the NHS (based on grossed up NHSP data). The fact that this resource can be flexed up during peaks in demand without Trusts having to take on the fixed costs associated with substantive workforce expansion should not be overlooked. Additional benefits are also likely to accrue as staff sharing agreements are extended across Integrated Care Systems (through bank sharing and passporting schemes).
This flexible resource is made up of both bank and agency workers. Providers like NHSP work hard to ensure their clients minimise the amount of shifts that cascade to agency (because they cannot be filled from the bank) through rigorous management of the supply chain and diverting staff to the bank wherever possible. We have some concerns (which we are currently discussing with DHSC) about the inability to flex pay caps within the agency management framework to deal with extreme pressures in supply, such as those being experienced at the moment. This has the potential to push supply ‘off-framework’ and lose the benefit of the price-caps which the frameworks mandate. This is definitely not in the interest of the NHS. Figure 4 shows that there is a case to address in this regard.
Figure 4: Trend in the Sum of Total Hours Filled Off Framework
Market impediments are always easier to deal with in the long-term because structural changes in how supply is managed can be planned and delivered over a more protracted period. To achieve better supply in healthcare we obviously need to increase the number of people we train (through higher education or other routes) – although this isn’t simply a matter of increasing training places at higher education institutions. It requires a fundamental re-think of the profession and how we engage, attract, and manage talent and how we make a career in healthcare an attractive option. It also means we need to align demand with growing workforce needs (rather than being linked to affordability), and consider how we resource and support staff in training so that front-line staff are not over-stretched as a result of increased demands on their time for mentoring and/or pastoral care.
Expanding and developing our flexible workforce should be a central part of this plan. Although building the substantive workforce should always be a priority, ensuring sufficient flexible resource that allows the NHS to flex up and down to reflect peaks and troughs in demand is also important as the data above demonstrates. This means making flexible careers a truly attractive alternative.
As an organisation that provides flexible workforce resources, NHS Professionals are acutely aware of the fact that those who choose a flexible bank career frequently say they feel under-valued and do not have access to the same career opportunities as their substantive counterparts. This needs to change and Trusts need to plan and manage their temporary workforce demand more strategically so that flexible workers are considered a valuable extension of the workforce rather than a separate entity altogether. Below we discuss the importance of giving flexible workers more access to training and development to ensure there is parity in career opportunities with substantive workers.
In the medium-term, continued use of market interventions to attract talent will still be required. Nursing bursaries, for example, should be used to ensure people take-up training places. Longer-term, however, the attraction of the career (and fair reward) should replace this as an incentive.
Similarly, international recruitment will need to be used to balance the medium-term shortfall – although longer term we should be working towards a more self-sustainable model of supply with international recruitment being used more strategically to bring new talent and thinking rather than make up the workforce shortfall.
New pathways of training for mature students and career changers need to be developed, promoted, and financially supported. School leavers may not always be ready to commit to a caring profession; those with more life experience (which may include caring) can be highly attracted by the profession but find it hard to access due to limited pathways and lack of financial support. This is also the case for those seeking opportunities to switch career.
It is also arguable that support should be extended to those that wish to work flexibly. There is a considerable, untapped, supply of part-time workers that may also be interested in career change opportunities that fit with other caring commitments.
New models of employment for flexible workers (including wider access to training and development and a review of contracting terms that offer more security – or simply make it easier for individuals to, for example, negotiate a loan or mortgage) need to be developed. This will mean reconciling differences in perceptions of what flexibility means to employers and employees.
In the short-term there are, arguably, only four ways of increasing the supply of staff:
More is said about international recruitment below. Regarding Returners, our experience of the Landmark programme has highlighted that although people may be willing to step forward in a crisis – their enthusiasm for making a long-term re-commitment to the NHS is limited (only 17% of registered professionals that stepped forward for the national vaccination programme re-engaged with the Landmark programme, less than 10% of non-registered ‘NHS curious’ applicants). This is not helped by the fact that returner pathways (beyond the pandemic) are viewed as onerous, time consuming and costly. It is also clear that skills can date very quickly - even those that had left the profession within the last two years found it hard to return to the front line during the pandemic. Programmes to support the on-going training for leavers (such as the NHS Reserve) therefore have merit.
Creating new roles that involve training people in very specific tasks should also be explored. The National Vaccination programme has demonstrated this with individuals from sectors like the airline industry cross-training to become vaccinators in a very short space of time. Such an approach requires considerable creative thinking and potential policy reform. These things happened at pace during the pandemic but may be harder to realise as the NHS focuses on dealing with the backlog.
Finding solutions to this will, however, be challenging as recruitment market conditions continue to be competitive – although since October 2021 (according to APSCO) there are some signs of levelling off.
Short-Term to Medium-Term
We do not see the challenge as one of determining a ‘correct balance’ – more one of ensuring that international recruitment is used strategically to support the NHS now and in the future. As a result of current market challenges, this inevitably means that international recruitment is a powerful tool for enabling the NHS to meet its staffing requirements. Moving forward, however, the emphasis should be on how international recruitment is used to bring new talent and thinking into the NHS as well as ensuring UK citizens that have elected to study outside the UK can find pathways back into NHS employment through training conversion programmes.
In the short-term, Government should expedite agreements with countries which have a planned[i] surplus of healthcare professionals that the NHS can utilise. Arrangements to encourage overseas workers into the care sector will benefit the NHS significantly, as it will promote the throughflow of patients and enable more creative thinking about strategies for managing people’s conditions (particularly post-hospital discharge) – in their own homes. Exploring national recruitment solutions for this kind of approach should be sought.
More should also be done to understand flows of students out of the UK to study abroad with marketing campaigns being used to attract them back to the NHS through programmes that allow them to train to NHS standards. NHSP’s Doctors’ Gateway programme enabled around 120 UK nationals that trained abroad to engage in top-up training. According to a research article from the University of York, 3-4% of NHS doctors in training are UK doctors who got their degree outside the country. Their research suggests they perform less well in training when they return to work in the NHS making them less attractive to employ. Conversion programmes like that offered by NHSP are a powerful way of both encouraging back to the NHS and providing a way of transitioning them into NHS employment more effectively.
In the long-term we should work towards being self-sustaining in the supply of healthcare workers. However, the NHS should still encourage international knowledge and skills exchange – particularly in nursing where this kind of activity could/should support developments in nursing research – an area that is under-developed (and under-funded) at present. International recruitment in the future should, therefore, become more of a vehicle of skills exchange rather than simply being regarded as a channel to fill vacant posts.
There is also a case to argue that we should consider a model such as that employed in the Philippines of ‘over-supplying’ in the healthcare sector and becoming a net-surplus supplier of healthcare workers to the rest of the world in return for remitted currency.
What changes could be made to the initial and ongoing training of staff in the health and social care sectors in order to help increase the number of staff working in these sectors? In particular:
To what extent is there an adequate system for determining how many doctors, nurses and allied health professionals should be trained to meet long-term need?
Do the curriculums for training doctors, nurses and allied health professionals need updating to ensure that staff have the right mix of skills?
Could the training period for doctors be reduced?
Should the cap on the number of medical places offered to international and domestic students be removed?
The fundamental objective of any changes made to education and training should be to ensure that the UK can boast a world-class standard. Reducing the quality of our educational provision to meet short-term market imperfections in the supply of staff is not considered an option. What is possible, however, is configuring work differently and breaking (some) work down into task-based functions which can be supported with focused training.
It is also possible to consider how ICS’s can begin to focus attention on reducing the number of patients in hospitals by creating new community-based roles that, for example, support people with long-term health conditions and/or those that are discharged from hospitals to limit the number of interactions they need to make with professionals in both the acute and primary sectors. Work we are undertaking with a global expert on integrated care has shown us how system-thinking has led to the proliferation of community-based quasi-clinical roles which can be filled much more quickly than nursing or medical posts thus considerably alleviating pressure on the system. More needs to be done at a national level to support ICSs in the rapid development of these solutions.
What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?
‘Burn-out’ from the pandemic is a very real issue. From a bank supply perspective, we are seeing high bank attrition and high incidences of ‘inactive staff’ that are unable/unwilling to provide the additional discretionary effort we rely on for workers to pick up shifts. We are currently very conscious of the need to carefully balance strategies for encouraging people to undertake additional shifts (through incentive programmes) at the same time as ensuring we are not putting undue pressure on those that are both emotionally and physically exhausted. We have recently shared information with NHSE on the relative success of different incentive schemes for prompting bank shift take-up to support ‘best practice’ across the sector.
Prior to the pandemic we were observing increased attrition due to people leaving the profession to seek better paid employment elsewhere. The long-term impact of below-inflationary pay rises brought about by austerity measures were already taking their toll.
It is also worth noting that the strength of the NHS ‘employer brand’ at the height of the pandemic when the nation came out to ‘clap for carers’ has quickly faded and is likely to worsen as the backlog starts to impact people’s lives. With constant media coverage suggesting a sector under severe pressure in which staff struggle to cope, the ability to attract people to a career in this type of environment will only become more challenging.
Lack of flexibility in working arrangements continues to be an issue. Although it is now a legal requirement to offer NHS staff flexible working opportunities wherever possible – more needs to be done around the development of e-rostering and/or better strategic utilisation of flexible workers. More is said about this below.
In nursing and midwifery there are specific challenges in Adult Acute Nursing, Midwifery, specialist areas such as A&E and Theatres, and Mental Health. There are also challenges in a variety of medical specialist areas, and the national shortage of GPs has been well documented.
In terms of filling bank shifts, some challenges can be attributed to skills gaps rather than people gaps: i.e. we don’t have the right people with the right skills in the right place at the right time. Some of this arises as a consequence of specialisms and the fact that there is limited ability to flow workers across specialist areas. [We note that the concept of ‘credentialing’, discussed in the Draft People plan, was dropped from the final version, which appears short-sighted given the growing importance of improving workforce optimisation]. Some challenges arise because individuals don’t have access to (or don’t have time to engage in) the training they need to upskill them to undertake the shifts that are available. Unfortunately, this type of role-specific training sits outside of formal training pathways that can be supported through the Apprenticeship Levy. Questions therefore should be asked about whether the money that sits, unspent, in Levy pots could be better utilised to support training that will allow workers to move into areas of shortage. While Apprenticeships clearly add considerable value in terms of formal professional career development – they are not agile enough to respond to skills gaps. In addition, the fact that funding is only available for individuals that are ‘employed’ means that NHSP cannot utilise funds to support ‘workers’ on the bank meaning there is no scope to channel bank only workers into Apprenticeship pathways.
In areas of acute skills gaps it is also the case that those that possess in-demand skills can offer their services ‘to the highest bidder’. As workforce shortages become more acute, we expect to see more workers with specialist skills signing up with agencies where they can often earn 50% more as they can on the bank. As economic conditions worsen and standards of living fall (inevitable as we recover from the pandemic) – the incentive to seek out higher paid agency opportunities will only increase.
More remote Trusts (particularly those in rural areas) typically struggle more than their metropolitan counterparts as skilled staff tend to aggregate in areas where they can choose to work for a range of different organisations and consequently are better placed to develop their careers. Support to be able to offer market supplements should be considered to ensure that more remote regions are able to attract the talent they need.
What should be the next iteration of the NHS People Plan and a people plan for the social care sector, to address the recruitment, training and retention of staff?
We need a fully costed workforce plan that aligns training and development to projections for the increase in healthcare demand that also takes full account of expected attrition. In other words, a plan that is properly aligned to need so that workforce supply runs ahead of demand.
Alongside this there needs to be a clear plan for the long-term strategy for positioning healthcare careers in a way that makes them attractive. If staff do not feel adequately rewarded, then they either won’t apply in the first place – or they won’t stay. This is particularly the case in social care. For too long the country relied on low-paid labour from the Eastern Bloc and this disguised the problem of a sector that was failing to offer rewarding employment. This means making a commitment to bring pay and conditions up to a level at which the sector can attract and committing to pay increases at or above inflation. When these things are linked to ‘affordability’ we will continually find ourselves in a situation where there is a shortage in supply which has associated costs linked to attrition, recruitment agency pay rates and agency fees.
Within the strategy we would like to see plans for new ways of working for delivering care – particularly strategies for alleviating pressure on acute and primary care services by wider use of telehealth solutions and/or community care roles. With a clear strategy, organisations such as NHSP can begin to plan more strategically for training, developing and deploying these new workers with the confidence that they will be demanded by Systems as local work re-organisation becomes the norm.
We would also welcome much more attention to integrated workforce planning which takes into account the need to balance substantive and flexible workforce planning and management.
The impact that inflexible working patterns have on staff retention is well documented. Many staff lament the fact that shift patterns that suit employers (e.g., variable patterns which include, for example, some weekend and some night working) simply do not work for individuals with caring commitments for whom the cadence of family life is severely disrupted by these contractual norms. It is often this which serves as the impetus for people to consider a ‘bank only’ career option wherein they can control their own shift patterns.
E-rostering provides a vehicle for much greater flexibility and whilst this is gaining some traction in shift planning for doctors – the complexities of making it work for nursing staff groups mean that its potential has not been fully exploited. It is arguable, however, that distinctions between substantive, bank and agency workers need to be broken down with a ‘one workforce’ approach which looks more creatively at the strategic utilisation of staff regardless of their contractual engagement. Staff could then be rostered around patterns which better suit personal requirements which would positively impact on attraction and retention.
More research and more support is needed to explore the feasibility of developing one workforce solutions – not least because the theoretical opportunity needs to be matched with the reality of delivery – which also includes consideration of team working, continuity of care, and clear line and performance management. This is on the radar of NHSE as it looks to reform the HR profession across the NHS – although additional funding and support to expedite the development of new solutions would help to make an impact now when the workforce is facing such severe challenge.
NHSP are also planning research to better understand the role that flexible workers can / should play in the post-pandemic landscape.
We see there being three critical inter-dependencies here:
Alder Hey Childrens NHS Foundation Trust
Barnsley Hospital NHS Foundation Trust
Berkshire Healthcare NHS Foundation Trust
Buckinghamshire Healthcare NHS Trust
Camden & Islington NHS Foundation Trust
Chesterfield Royal Hospital NHS Foundation Trust
Coventry & Warwickshire Partnership NHS Trust
Croydon Health Services NHS Trust
Doncaster & Bassetlaw Teaching Hospitals NHS FT
East and North Hertfordshire NHS Trust
East Kent Hospitals Uni NHS Foundation Trust
East Suffolk & North Essex NHS Foundation Trust
George Eliot Hospital NHS Trust
Greater Manchester Mental Health NHS FT
Harrogate and District NHS Foundation Trust
Herefordshire and Worcestershire Health Care NHS T
Hertfordshire Community Trust
Kent & Medway NHS & Social Care Partnership Trust
Manchester University NHS Foundation Trust
Mid Yorkshire Hospitals NHS Trust
NHS Blood and Transplant
Norfolk and Suffolk NHS Foundation Trust
North Tees and Hartlepool NHS Foundation Trust
Northern Care Alliance NHS Foundation Trust
Northern Devon Healthcare NHS Trust
Nottingham University Hospitals NHS Trust
Oxford University Hospitals NHS Foundation Trust
Princess Alexandra Hospital NHS Trust
Royal Berkshire NHS Foundation Trust
Sheffield Childrens NHS Foundation Trust
Sheffield teaching Hospitals NHS Foundation Trust
South London & Maudsley NHS Foundation Trust
South Tees Hospitals NHS Foundation Trust
South Tyneside and Sunderland NHS Foundation Trust
Southern Health NHS Foundation Trust
Southport and Ormskirk Hospital NHS Trust
Stockport NHS Foundation Trust
Surrey & Borders Partnership NHS Foundation Trust
Tameside and Glossop Integrated Care NHS FT
The Clatterbridge Cancer Centre
The Pennine Acute Hospitals NHS Trust
The Rotherham NHS Foundation Trust
The Walton Centre NHS Foundation Trust
University Hospital Southampton NHS FT
University Hospitals Plymouth NHS Trust
Warrington & Halton Teaching Hospitals NHS FT
West Hertfordshire Hospitals NHS Trust
Wirral University Teaching Hospital NHS FT
Worcestershire Acute Hospitals NHS Trust
Wrightington Wigan & Leigh NHS Foundation Trust
 NHSI, Annual Workforce Data
 Interim NHS People Plan, NHSE, June 2019
 With similar measures in specialist areas, such as ITU, theatres, etc
 Closing the Gap, The Health Foundation, King’s Fund and Nuffield Health, 2019).