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The Ward Round: A plan with uncertainty

Published on: 13 Jul 2023

Staffing is the issue keeping NHS leaders awake at night – and which consumes two-thirds of trusts’ spending. The fortnightly The Ward Round newsletter, this week by HSJ workforce correspondent Nick Kituno, ensures you are tuned in to the daily pressures on staff, and the wider trends and policies shaping the workforce.

If you somehow missed it, the government and NHS England finally unveiled the long-term workforce plan.

Heralded as a “once in a generation opportunity” ahead of the NHS’s 75th birthday, a press release running to nearly 6,000 words rolled out the red carpet for this long-awaited (and long overdue) plan.

Of course, the press trail did not include the actual report itself, which was not published until after the following morning’s media rounds, but it is here now. That is what counts.

Two particular targets in the document gave me pause for thought: increasing labour productivity and reducing reliance on international recruitment.

Let’s take the first one, where the plan’s objectives are based on an “ambitious” productivity assumption of up to 2 per cent per year.

To many staff – tired and overstretched post-covid – hitting a productivity level of up to 2 per cent each year will sound unrelenting and unnerving.

Others would argue that is exactly the point, to get staff working more efficiently (and perhaps even more happily), not to get them doing more work.

It will need a lot of things to come together, and quickly, if it is to be achieved.

For instance, marrying an increase in staff with an improved skill mix to maximise everyone’s abilities and place them in the best environments to excel.

Staff numbers alone do not instantly translate into improved outcomes and the plan will leave some readers wondering how that part of the equation will be achieved.

Retention is another clear priority. While it acknowledges measures such as flexible working, improved work-life balance and continuing professional development, the plan is light on what “total reward package” will be attractive enough to stop people from leaving. Despite landing in the middle on unprecedented industrial action over pay.

There are also question marks about things beyond the NHS’s control, such as social care and pledges to reform the health service when a new government comes in.

The plan’s authors concede sustained capital investment in the NHS’s ageing estates, alongside investment into digital infrastructure will be required, but so far it is nowhere to be seen. Perhaps this will be an ask for this autumn’s government spending round?

Billy Palmer, a senior research fellow at the Nuffield Trust think tank, said there was a “hint of blind optimism” to parts of the plan’s proposals, and that the plan was “silent about many of the possible consequences”.

He told the Ward Round: “In particular, even with shorter training and more diverse clinical placements, staff currently in the service who are already overstretched will have to educate and supervise more trainees.

“Moreover, onboarding of more staff and often in new roles comes at a cost even if necessary in the long-term. There will likely be growing pains for this vision of the NHS workforce to be achieved.”

He also raised an eyebrow at the productivity goal, adding: “In reality, this productivity figure is a balancing number to make the projections of demand and supply add up.

“But for a service already under strain there is huge uncertainty over how to achieve any productivity savings, particularly with current falling trends in productivity not well understood.”

Looming large in media coverage of the workforce plan was a pledge to drive down the NHS’s reliance on international recruitment.

That will sound familiar to some. Similar pledges were made during the early 2000s, before there was a push to recruit more from overseas a decade later, and 20 years on the NHS finds it’s come full circle.

The plan seeks to more than halve this reliance, from 24 per cent to as little as 9 per cent.

There are various questions that must be addressed for this to be reasonable.

For instance, how do you ensure areas where overseas staff are relied upon most are not left wanting, with domestic supply still falling short? 

Allied to that, even within the acute sector, there is significant variation and some trusts will not be able to keep up. Geographical differences play a major role.

Take inner London trusts as an example, who can pay higher rates and can adjust better to shifting efforts to recruiting domestically given their location, the financial resources available to them and proximity to neighbouring organisations.

This becomes more challenging if you are a single acute trust in an area less well-served and unable to attract domestic staff to roles as easily. Not to mention if you are a community or mental health provider.

There are wider uncertainties too.

The plan will receive a “refresh” carried out by the NHS and government every two years. Speaking to the Commons health committee on Tuesday, NHS England leaders admitted that – while they hope such reviews will lead to more ambitious growth – it could also lead to the initial aspirations being watered down.

NHSE medical director Professor Steve Powis also highlighted that the question of the phasing of the first five years’ funding, which could hold back the pace of training expansion, has not yet been resolved in government.

Also TBC – and contingent on future economic developments, as well as political decisions – is whether the NHS will get enough expansion funding to actually give permanent jobs to the larger workforce envisaged in this long-term plan.