Written evidence submitted by The King’s Fund (RTR0099)

Introduction

1. The King’s Fund is an independent charitable organisation working to improve health and care in England. Our vision is that the best possible health and care is available to all. We aim to be a catalyst for change and to inspire improvements in health and care by:

• generating and sharing ideas and evidence
• offering rigorous analysis and independent challenge
• bringing people together to discuss, share and learn
• supporting and developing people, teams and organisations
• helping people to make sense of the health and care system.

Summary and key messages

2. The 2019 Conservative Party manifesto included pledges to deliver 50,000 more nurses, 6,000 GPs and 6,000 other primary care professionals. Two years on, no plan to address workforce shortages has been published, funding for the training and development of staff was conspicuous by its absence from the Spending Review and the measures in the Bill relating to workforce remain weak.

-          The Covid-19 pandemic has exacerbated an existing workforce crisis in the NHS and social care. Significant workforce shortages and rates of turnover pose a grave risk to the recovery of services and quality of care, as well as the health and wellbeing of staff. Many staff will emerge from the pandemic in need of time and support to recover.

-          High levels of staff vacancies, sickness absence, turnover and work-related stress are having a damaging impact on staff. There is an urgent need to develop and sustain compassionate and inclusive workplace cultures that protect staff wellbeing and attract, retain, and sustain staff in their vocation to provide high-quality care.

-          The NHS People Plan was the latest in a series of stop gap measures that have failed to address the NHS workforce crisis. The case for a fully funded, multi-year health and social care workforce plan is overwhelming.

-          The Health and Care Bill provides an opportunity to require the publication of regular, independently verified workforce projections to enable better workforce planning.

-          Manifesto pledges to recruit more GPs and primary care professionals are unlikely to be met. The key to addressing staff shortages in primary care is to move to a new model of general practice in which multidisciplinary teams draw on a range of health care professionals alongside GPs. This requires investment in capacity and leadership to support change.

-          Addressing workforce shortages in the NHS must not come at the expense of other parts of the system, including social care. Comprehensive reforms are needed to improve pay, terms and conditions in social care in order to overcome the current social care workforce crisis.

What are the main steps that must be taken to recruit the extra staff that are needed across the health and social care sectors in the short, medium and long-term?

3. The King’s Fund, along with the Nuffield Trust and Health Foundation, jointly outlined the actions necessary to address significant workforce shortages in health and social care in our ‘Closing the Gap’ report in March 2019 (Beech et al 2019). Recognising that there are no ‘silver bullets’, we set out several high-impact policy actions to create a sustainable model for general practice and to eliminate nursing shortages if properly funded.
4. Based on trends at that time, it was predicted that the NHS would have a shortfall of 108,000 full-time equivalent nurses by 2029 – a gap so large, and so urgent, that we saw no alternative but to ethically recruit an additional 5,000 nurses per year from overseas for five years, while domestic capacity to train more nurses could be built up.
5. At the same time, we concluded that more ‘home grown’ capacity must be built up by reducing the drop-out rate during training and encouraging more nurses to join the NHS once they qualify. We called on the government to significantly increase the financial support to nursing students to tackle attrition during training. We therefore welcomed the announcement in December 2019 that nursing, midwifery and many allied health students would receive a £5,000 payment a year, with a further £3,000 available for eligible students to come into effect from September 2020 (Department of Health and Social Care 2019). Early figures show there was an increase in numbers of student nurses between 2019 and 2020, although this is likely to be driven by a range of factors as well as the reinstatement of the bursary (Maguire 2021).
6. General practice is in crisis because of difficulties in recruiting and retaining GPs alongside a growing and increasingly complex workload. While we welcome the manifesto commitment to recruit 6,000 new GPs, we note the Secretary of State’s recent admission that, like the previous target to increase the number of GPs by 5,000 by 2020, the pledge is not on track and is therefore unlikely to be met (House of Commons Health and Social Care Committee 2021a).
7. The key to addressing the shortages in general practice, is to make substantial progress towards a new model of general practice with an expanded multidisciplinary team drawing on the skills of a range of health care professionals alongside GPs (Beech et al 2019). The NHS has committed to funding 26,000 of these roles, such as clinical pharmacists, community link workers, musculoskeletal first-contact physiotherapists and primary care paramedics. However, this target is unlikely to be achieved by 2023/24.
8. Other roles are also key to underpinning effective teams in general practice, such as managers, administrators, data analysts, prescribing clerks and receptionists. Our work on integrating additional roles into primary care networks highlights the importance not only of funding new roles, but of investing in capacity and leadership skills to support changes in how primary care teams work, time for supervision of staff, improvements in career development, training and induction, as well as improving estates (Baird et al forthcoming).
9. There are interdependencies between the NHS and social care and addressing workforce shortages in the NHS must not come at the expense of an already stretched social care workforce (Beech et al 2019). We have made recommendations to improve recruitment and retention in social care, specifically: creating a sector-specific route for international migration that works for social care post-Brexit and a comprehensive reform of adult social care to improve pay, terms and conditions. We welcome the government’s acceptance of the Migration Advisory Committees advice to add the role of care-worker to the Shortage Occupation List for twelve months, although how effective this is remains to be seen (Department of Health and Social Care and Home Office 2021).
10. Pay is a significant driver in recruiting staff in social care and our recent analysis shows that, although there has been some increase in pay for social care workers since 2014, this has not kept pace with other sectors (The King’s Fund 2021b). For example, people can earn more working in supermarkets and cleaning than as care workers (Bottery and Ward 2021). There is also very little scope for pay progression, with those with several years’ experience receiving on average just 12 pence an hour more than those with less than one year’s experience (The King’s Fund 2021b).
11. Measures to improve the sustainability of the social care workforce should be developed as part of wider reform of the sector, since issues such as pay, status and career progression are linked to fundamental and structural challenges within the sector. The commitments made in the recent adult social white paper are not sufficient to meet the challenge of recruitment and retention in the sector. 

What is the correct balance between domestic and international recruitment of health and social care workers in the short, medium and long term?

12. Neither the NHS nor the adult social sector would be able to function without its overseas workforce, for example the UK continues to have one of the highest rates of overseas trained doctors among developed countries (OECD Library 2021). As set out above, ethical international recruitment will be necessary to tackle workforce shortages in England in the short to medium term. This will require a supportive immigration policy (building on the recently streamlined health and care visa process) and arrangements for mutual recognition of qualifications with other countries (Holmes 2021; The King’s Fund 2021c). International recruitment of staff would also benefit from national and regional programmes that provide economies of scale and packages of support for newly arrived staff (Beech et al 2019).
13. To create a sustainable workforce in the longer term, and to meet the government’s manifesto commitments to recruit more nurses, GPs and other health professionals, more staff need to be trained domestically. The government has re-introduced student bursaries to help with living costs and announced additional investment in training places (Department of Health and Social Care 2019; 2020). These measures should help but sustained long-term investment is needed, accompanied by efforts to reduce student attrition and match investment to areas and professions with the greatest needs.

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?

14. Years of poor planning, weak policy and fragmented responsibilities for the workforce mean have led to staff shortages becoming endemic and a reliance on overseas recruitment to plug gaps in the domestically trained workforce.
15. As this Committee has suggested, the Health and Care Bill presents an opportunity to address this by publishing independently verified workforce projections (House of Commons Health and Social Care Committee 2021c). Alongside more than 80 organisations, The King’s Fund is supporting an amendment to Clause 35 of the Bill which would mandate the regular publication of independently verified projections of current and future workforce needs. Ministers have so far dismissed this on the basis that the forthcoming 15-year strategic framework for workforce planning will contain an update on workforce projections. However, this is inadequate - previous iterations of the framework have not included quantified workforce projections and the Secretary of State was recently unable to confirm that the revised framework will set out the required numbers of staff (The King’s Fund 2021a). With a long and growing list of authoritative voices supporting this amendment, we urge parliament to support it.
16. Regarding ongoing training, until recently, data reported in the NHS Workforce Race Equality Standard (WRES) showed that white staff were more likely to report having access to non-mandatory training and continuing professional development compared to ethnic minority staff, part of an ongoing trend since data collection started in 2015/16 (NHS England 2020). More recently, the WRES data (published in 2021) shows the relative likelihood is no longer falling into the ‘adverse range’ and in some regions, ethnic minority staff are reporting they are more likely to access training than white staff (NHS England 2021). This development suggests there is some learning about making access to training more equitable and thus supporting all staff with their career development and progression and creating a better sense of inclusion.

What are the principal factors driving staff to leave the health and social care sectors and what could be done to address them?

17. There is a considerable rate of turnover amongst health care staff which is a sign of dissatisfaction. According to the NHS staff survey data published in 2021, 26.5 per cent of staff said they often think about leaving their organisation; 19.7 per cent said they will probably look for a job at a new organisation in the next 12 months and 14 per cent said they will leave their organisation as soon as they can find another job (Survey Coordination Centre 2021). This is driven by a number of factors.

• NHS staff are 50 per cent more likely to experience high levels of work-related stress compared with the general working population (West 2020). As well as the impact on individual staff, poor health and wellbeing is associated with poorer care quality, patient satisfaction and financial performance; higher levels of staff absenteeism, turnover and intention to quit; and, in acute hospitals, higher levels of patient mortality. Multiple factors can drive work-related stress and burnout in the NHS including high workload and lack of time for patient care, as well as experiences of discrimination, bullying, harassment and abuse at work. The previous Health and Social Care Committee inquiry on workforce burnout has reported its recommendations to address this (House of Commons Health and Social Care Committee 2021b).
• Research evidence points clearly to chronic excessive workload as the key factor influencing stress, staff shortages, absenteeism, turnover, long working hours, and moral distress (West and Coia 2019; West et al 2020). Put simply, among many staff working in the NHS, work demands consistently exceed their resources to meet those demands.
• Analysis of workforce data in 2017 showed the main reason for staff leaving the NHS was work – life balance (Anandaciva 2017; NHS Digital 2019). In general practice, fewer GPs are choosing to undertake full time patient-facing work, often due the volume and intensity of the workload, while our research shows that only around a quarter of GP trainees hope to be working in full time patient-facing roles a year after they have qualified (Bharmal 2021).
• Latest NHS Staff Survey data show only 36.7 per cent of staff were satisfied with their level of pay and over half of staff reported working additional unpaid hours on a weekly basis (Survey Coordination Centre 2021).

18. To ensure wellbeing and motivation at work, and to minimise workplace stress, research evidence suggests that people have three core needs: autonomy, belonging and contribution. All three must be met for people to flourish and thrive at work. Our recent research on ‘the courage of compassion’ sets out eight key recommendations to meet these needs (West et al 2020):

• Authority, empowerment and influence: mechanisms for nurses and midwives to shape culture and processes in their organisations and influence decisions about how care is structured and delivered
• Justice and fairness: nurture and sustain a culture that is fair, inclusive and provides ‘psychological safety’
• Work conditions and working schedules: introduce minimum standards for facilities and working conditions
• Teamworking: develop and support effective multidisciplinary teamworking
• Culture and leadership: ensure health and care environments have compassionate leadership and nurturing cultures that enable both care and staff support to be high-quality, continually improving and compassionate
• Workload: tackle chronic excessive work demands which exceed nurses’ and midwives’ ability to deliver high-quality, safe care and which damage their health and wellbeing
• Management and supervision: ensure there is effective support, professional reflection, mentorship and supervision needed to help nurses and midwives to thrive in their roles
• Learning, education and development: ensure the right systems and processes are in place for continual learning, education and development. These must also promote fair and equitable outcomes.

19. Black and ethnic minority staff continue to face unacceptable inequalities and discrimination in the NHS. WRES data shows that ethnic minority staff face higher levels of bullying, harassment and abuse, are more likely to experience discrimination at work and are more likely to be subject to a formal disciplinary process than their white colleagues. Addressing these inequalities is essential to make the NHS a better place to work, improve the experience of Black and ethnic minority staff and increase staff retention.

What should be in 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?

20. The recent past is littered with promises of workforce strategies and frameworks that have either not materialised or have failed to deliver the action needed. The NHS People Plan, when it was eventually published, was another stop-gap measure; while it contained some welcome measures to support the health and wellbeing of staff and tackle discrimination, it did not look beyond 2020/21 and did not include an implementation plan or targets for delivering additional staff. In our view, the next iteration of the NHS People Plan should make clear:

• How the NHS will close the gap in its workforce shortages and by when, including transparent data and projections for the next 10-15 years, clarity about how functions will be delegated and how national roles will provide support, and commitments to both adequate resources and reporting on progress. 
• How the NHS will embed a collaborative, inclusive and compassionate culture – particularly aiming to tackle chronic excessive workloads and reduce work-related stress and burnout.
• How ICSs will be supported to develop the necessary capacity and capability for sustainable workforce planning.

21. The lack of a people plan or similar framework to enable workforce planning for adult social care is a significant oversight. As set out above, commitments made in the recent adult social white paper are not sufficient to tackle major social care workforce challenges; comprehensive reforms are needed to improve pay, terms and conditions in the sector if the current crisis is to be overcome.

What is the role of integrated care systems in ensuring that local health and care organisations attract and retain staff with the right mix of skills?

22. Integrated Care Systems (ICSs) are a relatively new part of the health and care infrastructure. While recent guidance from NHS England NHS Improvement describes the NHS’s role in developing ‘one workforce’ for each ICS and looks to support local discussions on the creation of system-wide arrangements (a welcome measure and a step towards more transparency), it is not clear that the capacity or skills exist at ICS or regional levels to take forward a task of this complexity.
23. Furthermore, the national level workforce commitments in the Health and Care Bill fail to address the need for a comprehensive national strategy with accountability for improvement within which ICSs can work.
24. Overall, there is an opportunity for ICSs to move the NHS system away from a centralised, opaque approach to workforce planning, to one that is more dynamic and responsive to local need, and is driven by more transparent and inclusive analysis. Similarly, there is an opportunity to move from an absence of workforce planning in adult social care to at least consider this at a system level. However, achieving this will require adequate resources and an overall national strategy which is clear about the national and ICS level roles and how they should fit together.

The King’s Fund

Jan 2022

References

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