ICSs where staffing has grown by a quarter revealed

Several systems have increased their permanent staff numbers by around 25 per cent since the end of 2019 despite reporting large financial deficits, an analysis of official data suggests.

The analysis comes with health systems facing increasing pressure to constrain further staffing growth, and in some cases launching redundancy programmes to reduce headcounts.

Regulators are likely to pay particular attention to systems which have grown substantially and are falling far short of being able to balance their budgets.

Shropshire, Nottinghamshire and the Black Country were among those reporting an increase in their permanent acute, specialist and community headcounts of around a quarter in the four years to 2023, and deficits of more than £100m for the financial year just ended, the data shows.

Between the end of 2011 and 2015, England’s full-time equivalent NHS workforce in England grew by 3 per cent, to just over 1 million. In the next four-year period, to the end of 2019, it grew by 10 per cent, to 1.12 million.

Between the end of 2019 and December 2023, a period that included the pandemic, it grew by around 18 per cent, reaching around 1.33 million.

Elective activity over the same period increased by around 10 per cent, while emergency attendances were roughly flat, raising concerns over productivity.

Systems able to benchmark well with their activity levels have, over the past two years, been more easily able to fend off scrutiny over their workforce growth, due to concerns around waiting lists. But attentions have more recently turned to whether the growth in staffing can be afforded within local financial allocations.

A spokeswoman for the Lincolnshire system, which had the highest growth, said its staffing baseline from 2019 was not one to emulate. But she said the growth over the past four years had enabled significant reductions in agency spending, while the quality of services had improved to the extent its main provider had been released from special measures. The system reported a deficit of £27m last year.

The Nottinghamshire system, which reported a deficit of £114m for 2023-24, said its staffing growth had matched the “immediate and evolving needs of our population”, and assessments would be made of ongoing need. The Black Country, which has also reported a deficit of more than £100m, said it recently put in place “enhanced workforce controls” along with quality impact processes to support a “safe reduction in our headcount where appropriate”.

The Shropshire system, where the deficit of £130m last year was the largest relative to its size, said: “Our focus includes finding innovative ways of cost reduction through workforce planning such as flexibility, reducing agency, increasing training and harnessing digital and technological innovations.”

HSJ excluded mental health trusts from the analysis of individual systems, as senior national sources have indicated that growth in this area is deemed to have been necessary and will not receive the same level of scrutiny.

Alex Baylis, deputy director of policy at the King’s Fund think-tank, said ICSs face a “potentially impossible balancing act” between balancing their books and delivering the expected levels. He added: “The long-term workforce plan and targets for improving access require increases in staffing, which is the biggest driver of costs for providers. While at the same time the hard realities of financial management require cash savings.

“For years, the NHS has been in a cycle where it is given an impossible or conflicting set of asks, where unrealistic plans can be submitted, and where a lot of management time at both local and national level is spent negotiating the fallout of this. Improving this situation requires a different relationship between policy and delivery, which is more based on reality than hope, and transparency rather than workarounds.”

Other systems in the table above said their workforce had grown according to population needs, which would continue to be monitored.

NHSE said: “We continue to work with systems to set final plans for 2024-25 which deliver the best possible outcomes for patients from the NHS resources available.”

Healthcare Financial Management Association director of policy and research Emma Knowles said: “Our members are clear that workforce growth over recent years is a consequence of other pressures and it’s those pressures that need to be understood and addressed to achieve financial sustainability….

“Each system will have been considering this – and measures to improve productivity – as part of the delayed planning process.”

She added that workforce growth also “needs to be seen in the context of the NHS having 120,000 vacancies, many of which will be filled by less cost-effective temporary staff, and the NHS Long-Term Workforce Plan, which targets a significant increase in staff over the medium and long term”.