FINAL GOVERNMENT RESPONSE
It is important to recognise the great strain the pandemic has placed on the health and social care workforce, and the exceptional response of those working in health and social care throughout this period.
The Government, working together with NHS England and Improvement (NHSEI), Health Education England (HEE) and partners across the health and care system is undertaking a large programme of work to train and grow the workforce, recruit internationally and retain and support the current workforce. It is also working to set out the future drivers of demand and help support the workforce to meet new models of care.
The Department for Health and Social Care (DHSC) works through its arm’s length bodies and sector delivery partners, including Skills for Care, on the delivery and implementation of workforce policy. In conjunction with the Department, NHSEI is responsible for setting the priorities and direction of the NHS workforce and encouraging and informing the national debate to improve healthcare. As part of this work NHSEI is responsible for delivering the NHS People Plan.
Education and training of the regulated health workforce in health and social care is the core function of HEE and, subject to parliamentary passage of the requisite powers within the Health and Care Bill, will be merged with NHSEI. The merger will help ensure that this workforce is placed at the forefront of the national NHS agenda as it will integrate service, workforce and finance planning in one place, reflecting its importance to NHS delivery. It will also simplify the national system for leading the NHS, ensuring a common purpose and strategic direction. To support this joint strategic direction the department for Health and Social Care has recently commissioned NHSEI to develop a workforce strategy, including long term supply projections, and will set out the key conclusion of that work in due course.
NHSEI and HEE have responsibility for shorter term health workforce planning and the deployment of the health workforce to meet service need. Subject to the passage of the Bill, each Integrated Care System (ICS) will have a role in planning workforce requirements for its own service. We touch on these responsibilities later in our evidence.
We recognise that Adult Social Care (ASC) employers are struggling to recruit and retain the right number of staff and that there are high rates of staff turnover (34% for care workers and 21% for registered managers). Challenges in the sector include the absence of opportunities to train, progress and be rewarded for doing so, as well as burnout and lack of health and wellbeing support from providers and authorities. These challenges are long-term but have been exacerbated by the COVID-19 pandemic.
Our vision is for an adult social care workforce where people can experience a rewarding career, where they are recognised for the vital work they do and feel their wellbeing is prioritised, with opportunities to develop and progress now and in the future. Our White Paper, People at the Heart of Care is backed up by at least £500 million to help us achieve that vision by developing and supporting the ASC workforce over the next three years.
We have also made available two rounds of the Workforce Recruitment and Retention fund, totalling £462.5 million, to support local authorities and care providers recruit and retain care staff through this winter.
The ASC sector is primarily a private and independent sector with over 18,000 separate employers. It is our ambition to provide targeted investment to enable the sector and its employers to maintain a healthy and sustainable workforce. We recognise the crucial role of the sector in driving change.
The Health and Social Care Leadership Review, announced in October 2021, continues to make great progress in considering the best ways to strengthen leadership and management across health and with its key interfaces with social care in England. The review is led by former Vice Chief of the Defence Staff General Sir Gordon Messenger and will report back to Secretary of State for Health and Social Care in early 2022.
The Department retains strategic oversight for the health and care workforce and is delivering longer term strategic workforce planning. This includes working closely with NHSEI on the plan for elective recovery, which will emphasise the importance of workforce in any recovery.
Training and Growing the Workforce
The monthly workforce statistics for October 2021 show that there are record numbers of staff working in the NHS, with over 1.2 million Full-Time Equivalent (FTE) staff (which is over 1.3 million in headcount). This includes record numbers of doctors and nurses.
Since October 2020, there are now almost 20,500 (3.3%) more professionally qualified clinical staff working in NHS trusts and CCGs, including over 4,800 (3.9%) more doctors and over 10,900 (3.6%) more nurses. In total there are over 44,700 (3.8%) more Hospital and Community Health Service staff compared to October 2020.
We continue to introduce measures to expand the workforce. The Government has funded an additional 1,500 undergraduate medical school places each year for domestic students in England - a 25% increase over three years. This expansion was completed in September 2020 and has delivered five new medical schools in England. In addition, the Government lifted the cap on medical and dental school places for students who completed A-levels in 2020 and 2021 and who had an offer from a university in England to study medicine or dentistry, subject to their grades. As a result of this action, there are record numbers of medical students.
The Government has committed to deliver 50,000 more nurses by the end of this Parliament. This will achieve through a combination of investing in and diversifying the training pipeline, recruiting, and retaining more nurses in the NHS. There are already nurses working in the NHS as the result of the work of the nurse 50k programme.
To support both the 50k Programme and recruitment in general, since September 2020 Government have offered non-repayable grants of at least £5,000 per academic year to eligible students studying pre-registration programmes across nursing, midwifery, and allied health professions. A further £3,000 per year is available to students with child dependents and students studying specialist subjects.
Over 30,000 nurses and midwives accepted places to study nursing and midwifery at English universities in the 2021 recruitment cycle. This is a 28% increase compared to the 2019 application cycle. There are currently over 60,000 people training to be nurses, around 10,000 people training to be midwives and nearly 30,000 training to become Allied Health Professionals.
The Government remains committed to growing the GP workforce and number of doctors in general practice and is determined to deliver this as soon as possible. There were 1,841 more Full Time Equivalent doctors in general practice in September 2021 compared to September 2019.
DHSC is working with NHSEI, HEE and the profession to increase the general practice workforce in England. This includes measures to boost recruitment, address the reasons why doctors leave the profession, and encourage them to return to practice. The updated GP Contract Framework announced a number of new retention schemes alongside continued support for existing schemes for the general practice workforce. To boost recruitment, we have increased the number of GP training places. In 2021/22, the highest ever number of doctors accepted a place on GP training - a record 4,000 trainees, up from 2,671 in 2014.
Encouraging Staff to Return to Practice
Emergency registers for former healthcare professionals that were set up in March 2020 by the General Medical Council, the Nursing and Midwifery Council, the Health and Care Professions Council and the General Pharmaceutical Council also remain in place.
Return to practice initiatives have seen thousands of people commence training to return to practice in nursing and other professions – working in acute, community and primary care settings across England. The national scheme for nurses has been run by HEE since 2014 and provides experienced nurses with training and a route back into the NHS. The programme has supported 7,978 nurse returners since its inception in 2014.
In addition, NHS England has piloted an NHS Reserve Programme in eight areas of England. Reservists are paid, supplementary, NHS staff. They include clinical and non-clinical staff and can be deployed regularly during times of high demand. Around 17,000 reservists have signed up to the pilots. From April, these will be extended to a national scheme based in each ICS area.
We are continuing to commission and fund a range of training opportunities and programmes to help recruit people into the sector and develop career pathways. These include the Workforce Development Fund (WDF) which distributes around £12 million a year (2020/21) through which employers can bid for funding to pay for their staff to gain training and qualifications at all levels.
DHSC also fund the £27 million Think Ahead two year fast-track high-calibre graduate programme to train new mental health social workers. We also support a range of training programmes to bring more high-potential graduates into children and family social work. We are committed to ensuring maintaining a sufficient supply of social workers with the right skills, knowledge, and values to support vulnerable adults, children, and families.
The White Paper People at the Heart of Care includes our longer-term strategy for the social care workforce. It sets out three key aims that over the next three years, backed up by an investment of at least £500 million to build:
These reforms are the first steps on the journey towards our vision for adult social care. Our programmes include a Knowledge and Skills Framework, careers pathways and linked investment in learning and development and will ensure staff feel recognised, rewarded, equipped with the rights skills and knowledge and have their health and wellbeing supported. This investment will enable a five-fold increase in public spending on the skills and training of our direct care workers and registered managers.
Alongside this, we will develop a new care workforce hub as a central digital platform for the workforce that will allow staff to easily identify themselves as working in care and signpost the new support available for the workforce. We will also develop new policies to identify and support best recruitment practices locally.
We also believe offering funded learning and development opportunities whilst creating pathways for progression within role and into new roles will make ASC a more attractive place to work. Workers who receive structured learning and development opportunities feel valued and supported and therefore are more likely to remain in their posts (State of Adult Social Care, SfC, 2019).
Initial training is essential for ensuring a baseline level of skills and knowledge, which in turn underpins quality of care. That is why the recent white paper set out our plans to invest in a Care Certificate. We will ensure Care Certificate training is high-quality and portable, so that care workers can carry it with them throughout their careers. Longer term, we want it to be a requirement for all care workers to have reached this baseline standard, and we will explore options for how to achieve that.
Recognising the pivotal role of Registered Managers in developing a skilled workforce, we want to support this cadre by funding Level 5 diplomas for those without relevant qualifications in addition to creating a bespoke support programme for new registered managers where turnover is particularly high.
The White Paper, also provides detail on our intention to develop an enhanced assurance framework for adult social care. Our aim is to support improved outcomes and a better experience of care for people and their families. There will be a new duty for the Care Quality Commission to assess local authorities’ delivery of their adult social care duties, including relating to workforce.
The Government has taken steps to make the process of recruiting overseas less costly and more attractive through implementation of the Health and Social Care Visa and an exemption from Immigration Health Surcharge (IHS) for health and social care staff who come to work in the UK.
The Government is clear that international recruitment of health and care staff must be managed in accordance with high ethical standards. We published a revised Code of Practice for International Recruitment on 25 February 2021 to guarantee the most stringent ethical standards when recruiting health and social care staff from overseas. The code aligns with the latest advice from the World Health Organisation (WHO) in preventing active recruitment from 47 countries with the most pressing health and social care workforce challenges.
It also sets out how the UK can work collaboratively with governments from around the world, forming partnerships to benefit health and social care workers, their country of origin and the UK.
In the last year we have signed Government to Government agreements which set out a mutually agreed framework to ensure recruitment of healthcare workers is ethical, sustainable and mutually beneficial with the Philippines, Malaysia and Kenya. We also have a Taskforce on health workforce migration with India, as a key partner and supplier of healthcare workers.
There is no correct balance between domestic and international recruitment of the health and care workforce. Internationally trained staff have always been part of the National Health Service (NHS) and we value their contribution to delivering world-class care day-in day-out.
As set out above, the Government is putting in place interventions to ensure a sustainable domestic pipeline of health and care staff, as referenced earlier, including driving substantial increases in doctors and nurses. In the medium and long term, ethical international recruitment will remain an important part of our workforce planning, provided flexibility in increasing workforce supply as the domestic pipeline matures.
For social care, as a medium-term intervention, we are expanding the Health and Care Visa to include Care Workers and Home Carers, to be reviewed at the end of a 12-month period. These roles will be added to the Shortage Occupation List (SOL), which providers lower visa fees and a reduced salary threshold of £20,480, in addition to senior care worker roles, registered managers and registered nurses which have been on the SOL since April 2021 (nurses since January 2021). This will make it quicker, cheaper, and easier for social care employers to recruit eligible workers from overseas, helping to fill thousands of vital vacancies.
Our long-term ambition is to sustain the ASC workforce through domestic supply. As shapers of their local care market, it will be imperative for employers, local ICSs, and local authorities to ensure jobs in social care are attractive to local people with clear routes for progression.
In parallel we are working closely with counterparts across government – in Department for Work and Pension (DWP) and Department for Levelling Up, Housing and Communities (DLUCH) – to help ensure we bring enough people with the right skills and values to work in the ASC sector.
The health and social care workforces have been severely tested by the pandemic. As we move into service recovery alongside the ongoing pandemic response, it’s important that the workforce is supported over the coming months.
We know that NHS staff have worked tirelessly to provide excellent care throughout the pandemic and looking after the wellbeing of staff is crucial. The four themes of the People Plan – Looking After Our People, Belonging in the NHS, New Ways of Working and Growing for the Future – provide a common framework and clear direction for the system to develop its workforce plans and priorities.
Delivery of the People Plan will continue to be overseen by NHSEI’s People Plan Delivery Board (PPDB) which brings together national People Plan leads, DHSC representatives, Regional People Board Chairs, system, Trust and Primary Care Network representatives.
The plan prioritises the wellbeing of the NHS workforce, both an end in itself and to support workforce retention. It set out a comprehensive range of actions including a dedicated health and care staff support service including confidential support via phone and text message, the implementation of a wellbeing guardian role, and 40 mental health hubs. Every member of the NHS should have a health and wellbeing conversation with their line manager or a peer, and Wellbeing Guardians have been established to ensure board level scrutiny of staff health and wellbeing.
The published leaving rate for all staff working in NHS trusts and clinical commissioning groups for the year to September 2021 is 10.5%. This includes people moving to different parts of the health and social care sector as well as people going on maternity leave. This is an increase from 9.6% for the year to September 2020. The rate is now returning to pre-pandemic levels.
The NHS has established a People Recovery Task Force to ensure there is a framework and a set of interventions which will ensure that all NHS staff – including students and trainees – are kept safe during the pandemic. This includes:
The people priorities for 2021/22 and 2022/23 are set out in the NHS national planning guidance. This builds on the framework set out in the NHS People Plan and is informed by learning from the pandemic.
The People Plan aims to retain people more effectively by strengthening support for flexible working within organisations, so all NHS staff in the future can have the chance to work flexibly, regardless of role, grade, reason or circumstance.
Flexible working can support employers in attracting, recruiting and retaining a diverse workforce across a range of roles, levels and across a range of characteristics. This enables NHS workplaces to become more inclusive by attracting talent from a range of backgrounds (including carers) who feel more engaged and supported, which in turns helps to improve staff engagement and the standard of care for patients.
‘We work flexibly’ is one element of the People Promise, which the NHS is committed to delivering for staff by 2024/25. It is important to many NHS staff to have the opportunity to work flexibly, regardless of role, team, organisation, grade, or reason.
From September 2021, contractual changes took effect for employees covered by the NHS Terms & Conditions of Service Handbook to have the right to request flexible working from day one without the need to provide a justification. NHS employers are expected to promote flexibility options at the point of recruitment and should cover flexible working in standard induction conversations for new starters and in one-to-ones, health and wellbeing conversations, and annual appraisals as appropriate.
As models of care change to meet the needs of local populations, we will need to ensure that workforce redesign and transformation continues to take account of the needs of staff. We know that NHS staff who are engaged in their work and empowered to make changes to the benefit of patients are more likely to stay in work.
Improving retention is a crucial response to the supply challenge we face in supporting elective recovery and is a key component in achieving all our People Plan goals and embedding the People Promise. NHSEI will continue to take a multi-dimensional approach to retaining staff through a range of interventions at organisational and system level to improve the experience of our people.
NHSEI plans for recruitment and retention are supported by quality improvement methodologies and robust data analysis and insights. They elicit feedback through focus groups, stakeholder engagement activities and the latest evidence. This offers insights and intelligence gathered on where they can provide support, both nationally and regionally to have the greatest impact.
The People Plan commits NHS employers to “overhaul recruitment and promotion practices to ensure the workforce reflects the diversity of communities, and regional and national labour markets”. To improve diversity, employers should consider:
Alongside this, the NHS Retention Programme continues its work to understand why staff are leaving, resulting in targeted interventions to support staff to stay whilst keeping them well. While much is being done, we are not complacent and both the Department and NHSEI will continue to seek to understand what further action will help support staff in keeping well and feeling supported while doing the difficult jobs that they do.
We know from our own data, and reports from Skills for Care, that common challenges to recruitment and retention include pay and wider terms and conditions outside the care sector, vaccination hesitancy, stress and burnout, distance travelled to work and lack of training and qualification opportunities.
In addition to the reforms summarised above and set out in detail in the adult social care White Paper, the Government is implementing a range of interventions which aim address these challenges.
Firstly, we are providing support for local authorities who can work with care providers to determine a fair rate of pay based on local market conditions. Local authorities can make use of over £1 billion of additional resource specifically for social care in 2022/23. This includes the increase in Social Care Grant and the improved Better Care Fund, a 1% ASC precept and deferred flexibilities from last year's settlement.
This funding is designed to ensure key pressures in the system are met, including National Living Wage and National Minimum Wage. An increase in the rate of the National Living Wage means many of the lowest paid care workers will have benefited from at least a 2.2% pay rise effective from April 1st.
To support the wellbeing of the care workforce, we have worked alongside the NHSEI and other organisations to provide a package of emotional, psychological and practical resources for the workforce, including publishing wellbeing guidance on gov.uk aimed at both workers and their employers. This package includes support helplines, guidance, bereavement resources and a bespoke package of support for registered managers. We are also working with the sector to ensure that wellbeing resources and best practice advice are streamlined and easier to navigate.
Planning for the Future
The announcement of the Government’s intention to integrate HEE and NHSEI is a major step towards unifying workforce planning across the health system so that we are better able to ensure that we train and recruit the right mix of staff to maximise the return on our investment.
This integration will help ensure that service, workforce and finance planning are integrated in one place at a national and local level. It will also simplify the national system for leading the NHS, ensuring a common purpose and strategic direction.
Subject to parliamentary approval, it is our intention to formalise the integration of HEE and NHSEI using the transfer of functions powers contained in the Health and Care Bill. Ahead of the exercise of these legal powers, HEE and NHSEI will begin to integrate their structures and work. This two-stage process will help smooth the transition and ensure that we start to the see the benefits of the integrated organisations more quickly.
HEE has been commissioned to review long term strategic trends for the health and regulated social care workforce and update the existing long term strategic framework for the health workforce.
This will help underpin actions which will ensure the system has the right numbers, skills, values and behaviours to deliver world leading clinical services and continued high standards of patient care. For the first time ever, the framework will also include regulated professionals working in social care, like nurses and occupational therapists.
This work will look at the key drivers of workforce demand and supply over the longer term and will set out how they may impact upon the required shape of the future workforce, to help identify the main strategic choices.
Further, the Department commission Care Policy Evaluation Centre (CPEC)1 to produce projections of the long-term demand on ASC services under the current system. These include projections over a 20-year period of:
CPEC projections account for trends in the key drivers of demand and costs of providing different care services.
Integrated Care Boards
ICSs are partnerships of health and care organisations that come together to plan and deliver joined up services and to improve the health of people who live and work in their area, including working to ensure the system is retaining, recruiting and, where required, growing its workforce to meet future need.
As we respond to the challenges that the pandemic has placed upon the health and care system, Integrated Care Boards (ICBs) will have a critical role to play in growing, developing, retaining and supporting the entire health and care workforce locally. To support them in fulfilling this role, in August 2021 NHSEI published draft guidance for ICBs, including specific guidance on the ICS People function (Building strong integrated care systems everywhere: guidance on the ICS people function).
Once established, and subject to Parliamentary approval, ICBs will have specific responsibilities for delivering against the themes and actions set out in the NHS People Plan, as well as new people requirements outlined in guidance. These include a role for ICBs in growing the workforce for the future and enabling adequate workforce supply, through strategic planning and collaboration across the system to ensure that current and future population, service, and workforce needs are met. In addition to this, the draft ICS people function guidance further sets out the expectation that ICBs will work with partners within the ICB area to develop system workforce plans for the entire health and care workforce – based on population health needs and taking an integrated planning approach across workforce, finance and activity. The draft guidance also asks ICBs to work with regional and national workforce teams to support aggregated workforce planning and to inform prioritisation of workforce initiatives.
In addition to this, the draft guidance also has a focus on the training and development of the current workforce. ICBs are expected to enable staff to learn and work together, as well as flexibly across different parts of the system, whilst developing a consistent system approach to managing talent, supporting social mobility and the potential for lifelong careers across health and care. ICBs will also have a responsibility in ensuring there is accountability for delivering the health and wellbeing agenda across the ICS, including strengthening staff engagement, experience and wellbeing to build workforce resilience across the system.
NHSEI will, including through its regional teams, have a role in supporting ICBs to deliver these priorities and responsibilities.
Integration requires a workforce equipped with the skills and opportunities to move across the health, public health and social care family, supported by holistic workforce planning to ensure there are the right people deliver the best outcomes for service users and populations. The Integration White Paper will set out our intention to accelerate workforce integration by removing barriers to collaborative planning and working.
Integration will happen at a local level – central government’s role is in facilitating and supporting that, ensuring the right structures, accountability and leadership are in place to enable workforce integration locally.
New Models of Care in Adult Social Care
New models of care, including housing-with-care, have a vital role in delivering more personalised care, promoting prevention and enabling people to live independently, with the necessary care and support available. As we deliver our reforms to support the development of workforce, we need to ensure that we understand the implications of emerging models for the people and skills we need to deliver care.
In the White Paper, we announced we will launch a £30 million Innovative Models of Care Programme to support local systems and providers to build the culture and capability to embed into the mainstream innovative models of care that will work for a changing population, with more options for people that suit their needs and circumstances.
We will work with the sector to agree the priorities for the programme, and we expect some are likely to focus on developing workforce skills and capability. Many examples nationally and internationally focus on equipping the workforce with new skills as part of these models. For example, the Buurtzorg model, founded in 2006 in the Netherlands, involves small, autonomous, neighbourhood-based teams that provide a range of care and support services to people in their homes. The opportunity for care professionals to work with greater freedom and responsibility can result in better outcomes for the individual and better working lives for the healthcare professionals.