Though this may be a generalisation, until recently I am sure most people working in health and social care would have agreed that their biggest challenge was money, given the impact of sustained austerity on public services in general and on the NHS and social care in particular. However, by 2017, for many people workforce issues have caught up with – and sometimes overtaken – financial pressures as the key challenge facing both services. Most pressing are the staff shortages and high turnover now experienced in many services (nursing, general practice and much of social care to name but three) although long-term questions of self-sufficiency in workforce and skill-mix are also important, particularly as we look further into the future, post-Brexit.
In this context, announcing that there would be a 10-year workforce strategy for health and care was welcomed by many, even if creating such a strategy is a daunting task given the current pressures in the NHS and the ongoing evolution of new service models (which should partly determine the shape of the future workforce). The consultation document, Facing the facts, shaping the future, published in December 2017 will be followed by the strategy itself due around the NHS 70th birthday in the summer.
As part of the process to shape the strategy The King’s Fund came together with the Health Foundation and the Nuffield Trust and offered Health Education England (which leads on the strategy for the national NHS bodies) a roundtable event to discuss the underlying workforce modelling and ways to take it forward. On a fairly short timescale, we brought together a group of academics, representatives from national NHS bodies (both statutory and membership organisations) and some experts on forecasting and modelling. Health Education England then led into the discussion by talking through its approach to modelling the future workforce.
What were some of the key messages from the discussion? I’d pick out four (a purely personal choice). First, though the consultation document did pick up the importance of the NHS being a good employer, there is still much more than can be done here. Given the time it takes to train new health care staff, reducing the current number of people leaving health care professions, early retirements and turnover within the current workforce is likely to provide benefits to everyone and makes sense whatever we conclude about the shape and size of the future workforce. Easy to say, not so easy to do as it requires action at all levels in the NHS.
Second, we know social care faces its own workforce challenges. In some cases (notably in nursing), there is a big overlap with health and it is important to recognise that – there is little long-term benefit in health cannibalising parts of the social care workforce or vice versa. However, for the greater part of the social care workforce the dynamics are quite different. Much of the workforce is low paid, unregistered and employed in small private sector organisations. Behind this sits an equally important (if not more so) army of informal carers. While social care employers compete for staff with the health service, they also face competition from other sectors of the economy – retail, for example. Some of the current shortages in this part of the social care workforce will reflect the drive by local authorities to stretch their straitened social care budgets as far as they can by keeping costs low with the consequent effect on the wages that social care employers can pay their staff rather than any fundamental shortage of slow-to-train staff.
Third, many parts of the health and care system are currently engaged in re-thinking pathways of care to create a more integrated and joined-up system. This includes better preventive and supportive care in out-of-hospital settings, better links between mental health and physical health, better support to people living in care homes. So, whatever the state of the current workforce, what should the future workforce look like? This is intrinsically hard to answer as the models themselves are still evolving but clearly has to be thought through, both in terms of what staff we train in the future but also how continuing professional development and re-training can allow greater flexibility once people are trained, recognising that many of the 2027 NHS workforce are already employed in the NHS today.
Finally, at a more philosophical level, the workforce approach to the health care workforce in England has often been based on a ‘train-who-you-mean-to-employ’ basis. Arguably, we may have been too risk averse to any suggestion of ’over-supply’. This tendency to err on too few, rather than too many, has probably contributed to the recurrent workforce shortages experienced by the NHS over at least fifty years and it may be time to reconsider. This is truer than ever, given that Brexit and migration policy are currently making the traditional get-out-of-jail-free card (international recruitment) work rather less well.
Since the intention to publish a 10-year workforce strategy was announced, the Prime Minister has also committed to a long-term funding plan for the NHS on top of the expected Green Paper on social care. As most of both the health and care budget gets spent on staff, there is clearly a link between overall funding and the size of the affordable workforce. Rather than being an additional complicating factor we should welcome the recognition of the importance of long-term planning both for spending and for workforce. As national NHS bodies turn their minds to making the most of these opportunities (not least to ensure any strategy is continually refreshed given the current uncertainties) the enthusiasm to engage shown by the roundtable attendees bodes well for any future engagement as indeed, does Health Education England’s willingness to share its thinking with a wider external group.