Recruitment without retention won’t save the NHS

It would be easy to be cynical about the publication, on 30 June 2023, of the NHS England’s Long Term Workforce Plan. For a start, it was commissioned by the government and its publication date had long been delayed. Has it finally been published by a government not expecting to win the next election and therefore not expecting to be held accountable for any of its targets?

On top of that, what on earth can be expected of a workforce plan which cannot address a major factor in the haemorrhaging of existing staff –pay?

And there are other problems, notably that it is an England-only plan when the NHS workforce clearly needs a Britain-wide plan. It is too narrow on other issues too: for example, it only looks at NHS staff – even though the plan acknowledges that improving nursing staff recruitment to the NHS could deplete the social care workforce, which then impacts health care outside the NHS.  

Downhill

Nor is it the NHS’s first long-term plan. The last one was published in 2019, and since then the situation has gone downhill. As the Health Foundation showed in April, the proportion of NHS staff leaving leapt from 9.6 per cent in 2020 to 12.5 per cent in the year to September 2022.

So a plan is a plan, not a promise or a guarantee. But for all that, a workforce plan is something that the NHS needs. Whatever its limitations, it is something workers must understand and use to their advantage. It is, after all, a plan with new funding attached, and unless we as workers are planning a future, we have given up.   

The plan was devised in conjunction with sixteen royal colleges, professional bodies, trade unions, patients’ organisations, education providers and regulators. What matters now is how they choose to use it. Workers controlling entry to their profession and caring for new entrants is a concrete example of workers running a part of society, and always has revolutionary potential.

The plan contains useful baseline data showing that Britain sits below the OECD average for the number of practising doctors as a proportion of the population and we have fewer GPs per 1,000 population than most other OECD countries.

It also shows that Britain has (per 1,000 population) fewer than half the number of practising nurses of Norway and Switzerland, while countries like Germany and Australia have 39 and 41 per cent more nurses respectively

NHS data shows a reliance on temporary staffing in the NHS in 2021–22, which is estimated to have been approximately 150,000 full time equivalent staff. The plan uses this as its starting point to argue that domestic education and training will need to increase between 50 and 65 per cent from 2022 to 2030–31. That is an indication of the scale of the problem.

There are also a number of taboos broken, with statements that highlight how relying on overseas recruitment is a weakness in the NHS and an admission that many well qualified home-grown applicants are denied places at medical schools.

Unethical

The plan falls short of saying that recruitment of overseas staff to the NHS is unethical given the worldwide shortage of healthcare staff. But – finally – here is an official document that admits that the NHS is “particularly reliant” on overseas staff, with the total proportion of NHS workers having non-British nationality (across all professions) now over 17 per cent.   

But it does accept that overseas recruitment cannot be the solution. Covid-19, it acknowledges, demonstrated that “A heavy reliance on overseas staff leaves the NHS exposed to future global shocks and fluctuations.” Quite.

‘An admission: the NHS is “particularly reliant” on foreign staff…’

For each profession, the plan sets out a bespoke approach to optimise domestic supply by detailing expansions to entry routes and increasing training and education to meet demand. This marks a significant departure from the government cap on home medical student numbers.

Remember, in 2022 the government re-imposed its cap on the number of British medical students it would support after lifting it in 2020 and 2021 in the wake of the pandemic.

As Workers reported in January this year, a new medical school, Three Counties, based in Worcester, had been told by the Department for Health and Social Care that no British students would be supported, although it could recruit overseas students. This followed similar limitations on home students at Brunel and Chester universities.

At the time cancer specialist Karel Sikora told The Times, “It is heartbreaking that we are having to turn away bright British students with straight As who want to be doctors.”

The plan estimates that medical school places need to be increased by 60 to 100 per cent, providing 12,000–15,000 places by 2030–31 to address the NHS shortfall. It argues that this can be delivered by expanding existing medical schools and establishing new ones, and by introducing medical degree apprenticeships.

Ambitious

The scale of expansion set out will require close working with medical schools, higher education institutes and the further education sector. This is a hugely ambitious target and if the funding is not secured for home students by an incoming government, then universities will be only too happy to revert to current practice and use the new facilities for more lucrative overseas students.

Commenting on the training plan the British Medical Association, representing doctors, said, “Too many lofty plans from previous governments have ended up just being aspirations, and we cannot allow this to happen again.”

Each section on training new staff does have a corresponding section on what can be done to retain existing staff but the difficulty here is that the question of pay was not allowed to be part of the remit of the workforce plan. The elephant in the room.

As the British Medical Association says, “Training new doctors will be to no avail if they don’t stay in the workforce…This plan is set up to fail if doctors’ pay continues to be eroded…”

Equally ambitious targets are set with a plan to increase nursing training places, increasing the number of nursing graduates by more than a third over the next five years, accompanied by a 40 per cent rise in nursing associate training places over the same period. 

But it won’t be easy. Unlike medicine, where significant numbers of well qualified students don’t get an opportunity to study, many applicants for nursing degrees do not meet the qualification requirements. So the nursing target may prove elusive even if funding for training is available, and will require investment in further education funding to help applicants achieve skills in maths and English.

Interlinked

As with medicine, the problems of training and recruitment are interlinked – the current shortage of qualified nurses means there is already a shortage of those supervising students in the practice element of their course.

Interestingly, the document does dare to suggest that Britain should break away from the European model of nurse education as specified in an EU directive whereby all EU nursing programmes must entail 2,300 academic hours and 2,300 practice hours. For years, nurse educators and students have been arguing that it is the quality of the learning rather than the hours spent that matter.

Many countries around the world achieve as good or better outcomes without adherence to the EU directive formula. One of these is the Philippines, and the irony is that the NHS has been happy to employ many Filipino nurses.  

The plan states that NHS England will work with the Nursing and Midwifery Council “on its welcomed commitment to explore the potential for further changes to nursing degrees. To train staff more flexibly, taking into account the opportunities presented by EU exit…” and notes that this will “reduce pressure on our learners while significantly increasing placement capacity across the NHS.”

The reality is that NMC changes tend to come about very slowly, and it will be a miracle if this change is in place by September 2026. So the frustration here is another example of a Brexit benefit which may not be realised until a full ten years after our EU exit.

Retention

As in medicine the challenge for all the NHS professions whether staff can be retained. For nursing the lack of financial and other support means nearly one in four do not even complete training.

Sara Gorton, Head of Health at Unison, spoke for many: “At long last there is a plan. Now everyone committed to making the NHS thrive again can focus on the challenge of filling the huge gaps in the workforce.” Her suggestion for step one was that “Action on retention is key… pay must lie at the heart of any solution.”