ANALYSIS
THE BMJ COMMISSION ON THE FUTURE OF THE NHS The future of the NHS depends on its workforce The future of the NHS depends on the people who work in it, so workforce stewardship should be a key priority Mary Dixon-Woods, 1 Charlotte Summers, 2 Matt Morgan, 3, 4, 5 Kiran Patel 6
1 THIS Institute, Cambridge, UK 2 University of Cambridge, Cambridge, UK 3 University Hospital of Wales and Cardiff University, Cardiff, UK 4 Curtin University, Australia 5 TheBMJ 6 University Hospitals Birmingham and University of Warwick, UK Correspondence to: M Dixon-Woods mary.dixon- woods@thisinstitute.cam.ac.uk Cite this as: BMJ 2024;384:e079474 http://dx.doi.org/10.1136/bmj-2024-079474 Published: 27 March 2024
to inequalities, leaving some areas, including those most disadvantaged, under served, affirming the persistence of the inverse care law. 5 The strategy of shoring up workforce shortages through overseas recruitment is unsustainable, especially as attention is drawn to its moral and ethical problems. So too is the increasing reliance on temporary staff, which is not only expensive — the annual cost of using locum, agency, and bank staff in the English NHS rose to £10.4bn in 2023 6 — but also introduces other risks, 7 such as those linked to lack of familiarity with local policies and environments and disruption of team bonds, and might not be positive for patient experience or outcomes. 8 The NHS Long Term Workforce Plan , 9 published in June 2023, offers some welcome commitments to workforce planning and development. But it does not fully tackle the range of problems — including, for example, those relating to the capacity of educational institutions, the availability of suitably trained educators, quality of training, availability of clinical and educational placements, research leadership, and training and support. It also does not adequately tackle the important challenges of retaining and developing existing staff. Its implementation (including scale and pace) is currently uncertain, as is its economic viability. 10 Given that the plan is intended to represent a fundamental reshaping of the NHS, its workforce, and its operations, it must be subject to sound evaluation to assess its risks and opportunities and benefits and harms. Role diversification Role diversification has become an increasingly prominent feature of the NHS in recent years, with primary care providing an important example. Although the number of fully qualified and permanent full time equivalent (FTE) general practitioners is declining and stood at 27 487 in December 2023, 11 the number of FTE staff in primary care who provide direct patient care but are not GPs — such as nurses, paramedics, social prescribers, and physician associates — increased by 34 380 between March 2019 and September 2023. 12 The number of staff providing direct patient care now stands at 45 701, with the recent increases largely driven by the Additional Roles Reimbursement Scheme. 12 Some roles, such as advanced nurse practitioners, have already been operating successfully as key members of multiprofessional teams in primary, secondary, and community care for many years. Some
Achieving a high quality, sustainable NHS is currently challenged by major workforce problems. Staff are the most significant element of NHS expenditure 1 and its most important asset in providing care for NHS patients, but stewardship of the workforce is not optimised at policy or service level. Based on knowledge of the field, the literature, and listening to patients and staff, we identify three key interlinked areas in which action is urgently needed: configuring the workforce, improving conditions and working environments, and enhancing career and training pathways. We propose what might be done to tackle the current challenges, emphasising that workforce stewardship needs to be highly intentional about diversity, inclusion, and equity and needs to be done collaboratively with staff, patients, and the public. Configuring the workforce for the future of theNHS Staff shortages The future of the NHS depends on having the right numbers of staff in the right roles, at the right times, and in the right locations. At present, the NHS simply does not have enough staff to deliver on its goals and commitments: it has fewer doctors, nurses, and managers than peer countries. By June 2023, there were over 125 500 vacancies in hospital and community health services in England. 2 Over 1 in10 nursing posts were unfilled, with mental health and community nursing especially affected. 2 Although the overall number of doctors in hospital and community services has increased to 134 000, representing an additional 39 000 medical staff since 2010, 2 the NHS is currently short of nearly 11 000 doctors (a 7.2% vacancy rate). The vacancy rate in clinical professional roles is compounded by difficulties in recruiting and retaining high quality staff in other roles, including administrative, managerial, scientific, and technical staff, as well as estates and ancillary staff. These groups make up nearly half of the workforce and are essential to the NHS but receive much less recognition than their clinical counterparts. Despite the essential nature of their work, some are disparaged in policy and media discourses as somehow not “ frontline. ” Staff shortages directly affect quality and safety of care, patient experience, and staff experience of work. 3 Less than a third (32.4%) of respondents to the most recent (2023) NHS staff survey said that there were enough staff at their organisation for them to do their job properly. 4 The unequal distribution of vacancies across geographical locations contributes
the bmj |BMJ 2024;384:e079474 | doi: 10.1136/bmj-2024-079474
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