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Staff shortages ‘a greater threat to services’ than finance pressures

Pressures on the NHS workforce – including a high degree of uncertainty around staffing going forward – are as great, if not a greater, threat to the future sustainability of services as the current pressures on finances, the Nuffield Trust has argued.

In written evidence to the House of Lords NHS Sustainability Committee, the think tank’s director of policy, Candace Imison, outlined a series of pressing issues in the NHS workforce, primarily including its “serious and growing gaps, both in numbers and skills”.

She argued that a “striking feature” of these gaps in the clinical workforce is their concentration mostly in areas where needs are the greatest, or where new models of care require workforce expansion – thus undermining these ambitions.

“Despite planned expansions in training numbers, a wide range of factors could magnify the current gaps in the clinical workforce, in particular, the pressures on the workforce created by the current productivity challenge,” she wrote. “The falling morale in many staff groups and subsequent loss of skilled and experienced staff will not be easy to repair.”

While the NHS has invested billions in training doctors and other clinical staff, it focused very little in the necessary skills and capacity to plan and manage a skilled workforce, Imison added.

“Despite a huge productivity challenge, this position has not changed, in fact it has deteriorated, with raids both on training and continuing professional development budgets,” she emphasised.

With regards to long-term demand, the director stated that England has placed “significant reliance” on provider plans for its workforce planning assumptions, meaning that financial pressures will therefore “moderate trusts’ workforce plans”.

Because of the changing demand for healthcare and the limitations in forecasting, there is now a “high degree of uncertainty” in the estimates of future workforce pressures, leaving the NHS largely in the dark.

“For example, Health Education England’s (HEE’s) previous analysis suggested that the difference between supply and demand for adult nurses in 2015 could range from a shortfall of 63,700 to an oversupply of 7,900 depending on different scenarios,” Imison said.

“The National Audit Office pointed out that HEE has not undertaken a comprehensive investigation into the level of uncertainty, including the relative risks and implications of over- or undersupply. It is therefore unclear how the uncertainty is feeding into risk management across the health system.”

Another major uncertainty in what the future holds is the role of technology, with the Nuffield Trust having argued recently that the NHS is either heading towards ‘technology heaven’ or ‘technology hell’. The first would see healthcare transform “the messy, inefficient world it is today, with much that is clinically uncertain and variable, to a glorious nirvana of streamlined efficiency”. The second would result in a “bleak world where clinicians are tied to computers, trying to interpret a set of data, while patients are overburdened with self-management tasks and anxiety about health”.

But despite the leftover uncertainties around workforce planning, the Nuffield Trust stressed that not all is lost, adding that “change is vital, but will not be easy”.

Potential solutions to the challenges include improving staff retention in training and work; introducing more flexible training pathways and continuing professional development; tackling the skills mix challenge by growing the support workforce and extending the skills of registered healthcare professionals; and taking advantage of the opportunities of advance roles, which can be developed “relatively rapidly” in around three years.

Workforce issues in the NHS are nothing new, with both staff vacancies and skills barriers featuring in the news frequently. Most recently, for example, the General Medical Council warned that medical training is being “eroded” by high workloads, and an NHS Providers report pointed to workforce levels as one of the culprits for a “much higher level of risk” in the NHS than it can actually sustain.