Faced with heavy reliance on agency workers and overseas recruitment, the NHS is at a critical crossroads when it comes to its workforce. As the government and NHS leaders have repeatedly said, the priority for the health service is to increase the speed of its innovation. But in contrast to the devolution of its decision making powers to the UK’s 44 sustainability and transformation plan (STP) regions, the Department of Health’s approach to its workforce remains highly centralised and tightly regulated.
In a new report, the thinktank Reform has found this approach has not delivered the workforce needed to suit the demands of an ageing population. There are nearly three times more doctors, and four times more nurses in the acute sector than in the community. On average, just 6% of consultants work in the community for one or more sessions per week.
The same arguments for devolution apply as much to staff as they do patient care. In order for STPs to deliver care that best suits the local population, they must be able to train and retain the workforce they need.
A truly devolved health reform policy would see STPs take over the work and budget of Health Education England and scrap the national cap on doctors’ training places, set by the Department of Health. Such caps have created an inadequate pool of labour, difficult working conditions and a powerful staff body, some of whom choose to work for agencies. The £1.3bn it costs to train medical students (pdf) is the same amount the NHS spends on agency doctors annually. And according to the Organisation for Economic Co-operation and Development, the UK is the sixth biggest importer of foreign trained doctors, who make up 26% of its current cohort.
This statistic could be improved if the caps were lifted. In 2017, 19,210 applicants applied for just under 6,000 medical school places. Increasing this to 12,000 places a year, for instance, would cost £140m per cohort per year, over a 10-year period. The move could be cost neutral for the NHS, when balanced by a fall in spend on agency staff, reductions in the cost of individual training places and repayments of training costs by some doctors, if they choose to work for locum agencies or a non-NHS employer. Shorter courses and more flexible training opportunities could also attract more candidates. Some universities, such as Buckingham, are also able to provide training for doctors for £162,000, compared with the Department of Health’s own target of £230,000.
There has been some success with this approach elsewhere in the healthcare profession. Pharmacy training has been uncapped for many years and, broadly speaking, has delivered sufficient numbers of pharmacists. Uncapping numbers has also seen the development of a diverse pharmaceutical labour market. More than half (53%) of pharmacists are aged 39 or younger and 39% are non-white. Pharmacists work more flexibly than other areas of the care system, with 32% working part time, 11% working across more than one sector (community, hospital, primary care, industry and academia), and 17% holding more than one job.
Earlier this year, the government also removed the cap on the number of nurses in training. While the removal of bursaries has led to some concern applications will decrease, providing local areas with greater flexibility should empower them to find innovative solutions to attract and retain staff. Hospitals and universities have partnered to provide fee-paying students with nursing degrees in exchange for a guaranteed job following graduation at the trust. In Manchester, Andy Burnham pledged during his mayoral campaign to introduce a system of education funding in which bursaries are provided if nurses agree to work in the NHS for at least five years following qualification.
The final step in a devolved workforce strategy is local control of pay and conditions. Employers should not be restricted by rigid pay scales or government-imposed caps. Instead, they should be able to use all the tools available to design contracts that promote working across boundaries while suiting staff needs. Flexible and alternative routes into the workforce must also not be underestimated. A programme for 1,000 new degree-level nursing apprenticeships was recently launched by the government, as part of its plans to create 100,000 NHS apprenticeships by 2020.
Such programmes are laudable. But workforce planning – including training and pay – must be done locally. The success of NHS reform lies in the steady development of local areas. Let them consider how many doctors and nurses they should train, and at what cost.
Kate Laycock is a senior researcher at Reform
Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.
If you’re looking for a healthcare job or need to recruit staff, visit Guardian Jobs.
