Elsevier

The Lancet

Volume 397, Issue 10288, 22–28 May 2021, Pages 1992-2011
The Lancet

Health Policy
Securing a sustainable and fit-for-purpose UK health and care workforce

https://doi.org/10.1016/S0140-6736(21)00231-2Get rights and content

Summary

Approximately 13% of the total UK workforce is employed in the health and care sector. Despite substantial workforce planning efforts, the effectiveness of this planning has been criticised. Education, training, and workforce plans have typically considered each health-care profession in isolation and have not adequately responded to changing health and care needs. The results are persistent vacancies, poor morale, and low retention. Areas of particular concern highlighted in this Health Policy paper include primary care, mental health, nursing, clinical and non-clinical support, and social care. Responses to workforce shortfalls have included a high reliance on foreign and temporary staff, small-scale changes in skill mix, and enhanced recruitment drives. Impending challenges for the UK health and care workforce include growing multimorbidity, an increasing shortfall in the supply of unpaid carers, and the relative decline of the attractiveness of the National Health Service (NHS) as an employer internationally. We argue that to secure a sustainable and fit-for-purpose health and care workforce, integrated workforce approaches need to be developed alongside reforms to education and training that reflect changes in roles and skill mix, as well as the trend towards multidisciplinary working. Enhancing career development opportunities, promoting staff wellbeing, and tackling discrimination in the NHS are all needed to improve recruitment, retention, and morale of staff. An urgent priority is to offer sufficient aftercare and support to staff who have been exposed to high-risk situations and traumatic experiences during the COVID-19 pandemic. In response to growing calls to recognise and reward health and care staff, growth in pay must at least keep pace with projected rises in average earnings, which in turn will require linking future NHS funding allocations to rises in pay. Through illustrative projections, we show that, to sustain annual growth in the workforce at approximately 2·4%, increases in NHS expenditure of 4% annually in real terms will be required. Above all, a radical long-term strategic vision is needed to ensure that the future NHS workforce is fit for purpose.

Introduction

Health and care is a heavily service-oriented sector, with staff costs accounting for around 60% of NHS provider spending.1 The NHS in England is the world's fifth-largest employer, with around 1·5 million employees.2 The NHS employs around 164 000 staff in Scotland,3 around 95 000 in Wales, and around 67 000 in Northern Ireland.4 A further 2 million people in the UK are employed to deliver social care services,5 defined as the provision of personal care for children, young people, and adults in need or at risk. Together, the health and care labour market accounts for approximately 13% of the UK workforce. In addition, around 9·1 million people in the UK, notably family members, are unpaid (so-called informal) carers.6 During the COVID-19 pandemic, this number has increased to more than 13·6 million people.6 Increasingly, members of the public are being encouraged to take greater responsibility for their health and to self-care.7

As with most other countries in the Organisation for Economic Co-operation and Development (OECD), the health and social care workforce in the UK is overwhelmingly female.8 77% of the NHS workforce9 and 82% of the adult social care workforce are women.10 However, there are wide disparities in the gender distribution of roles. In 2018, only 37% of senior roles in the NHS were held by women (from 31% in 2009);11 in social care, despite men only comprising 18% of the overall workforce, they occupy 33% of senior management positions.10 A substantial gender pay gap exists in the NHS, with the average hourly salary for women being 19% less than that for men.12 One factor that contributes is that women make up 80% of those employed on the lowest Agenda for Change pay bands (bands 1–4).12 The health and social care workforces are ethnically and culturally diverse; as of the last census, people from minority ethnic groups made up 14% of the population in England and Wales and 40% of the population in London,13 while, as of 2019, these people made up approximately 20% of the NHS workforce and almost half of all NHS staff in London.14 Minority ethnic staff are concentrated in lower pay grades in the NHS, with only 6·5% of very senior managers and 8·4% of board members at NHS Trusts being from minority ethnic backgrounds.14 Minority ethnic staff are less likely to be promoted or appointed to jobs they apply for and more likely to experience discrimination, bullying, and harassment from both NHS colleagues and patients.15 The recent COVID-19 pandemic has seen a disproportionate number of deaths in staff from minority ethnic backgrounds, which has increased debate around the role of discrimination and racism in the NHS as a factor contributing to persistent health inequalities between different ethnic groups.16

The effectiveness of health and care workforce planning has significant implications for the NHS, social care, and the health and wellbeing of the UK population. A sustainable health and care workforce is one that will be able to meet the needs of the population in the immediate term and for the foreseeable future. To deliver a sustainable and appropriately skilled health and care workforce, a long-term workforce strategy is needed. This strategy should be informed by workforce planning models that consider the necessary mix of skills required to meet changing health and care needs and should aspire towards developing a self-sufficient supply of staff, rather than an ongoing reliance on foreign-trained staff.17, 18 Such a strategy will also need to take account of technological developments that have the potential to improve quality of care and productivity. It should also promote life-long learning, facilitate effective substitution of skills between health-care professions, and prioritise the health and wellbeing of the workforce itself to improve recruitment and retention.

COVID-19 has exposed weaknesses in the workforce, and the UK has experienced one of the highest rates of excess mortality attributable to the pandemic. The health and care workforce was placed under unprecedented pressure and frequently exposed to high-risk and traumatic situations.19 The health and care workforce will continue to be put under considerable strain as the NHS seeks to address a growing backlog of unmet need for health-care services caused by the cancellation or postponement of many elective procedures and routine care.20 Now, as the UK seeks to rebuild its health and care service and improve resilience against future health-care shocks, we discuss how to develop, support, and sustain the current and future health and care workforce.

In this Health Policy paper, we start by outlining, in brief, the current approach to developing the health and care workforce and the consequences of this approach, highlighting areas where major staff shortfalls exist. We then describe the current strategic response to these shortfalls and lay out future challenges and suggested reforms to ensure the future workforce is sustainable and fit for purpose. The scope of this paper is the UK health and care workforce and, where possible, we refer to UK-wide data. However, when these do not exist, we refer to the best available data, which, in many cases, are from England. We have found the inconsistency of data collection between England, Scotland, Wales, and Northern Ireland particularly challenging; the standardisation of health and care data collection across the UK is recommended within the main LSE–Lancet Commission report.21

Section snippets

Education and training

Workforce planning in the NHS begins with recruitment to higher education programmes in medicine, nursing, pharmacy, and many other health and care professions. The numbers of publicly funded places on such programmes, apart from a small number associated with private university entry, are determined by bodies such as Health Education England, NHS Education for Scotland, Health Education and Improvement Wales, and the Northern Ireland Medical & Dental Training Agency. Regulatory standards are

Consequences of the current approach to developing the health and care workforce

The UK has fewer practising registered nurses and physicians than many other high-income countries (figure 1). This fact is partly explained by relatively low numbers of nursing graduates each year, whereas the number of UK medical graduates each year compares more favourably with other high-income countries. The UK also has comparatively low numbers of other clinical staff, such as dentists, physiotherapists, and pharmacists. The relatively low numbers of pharmacists might reflect the nature

Reliance on foreign staff

The NHS has for a long time relied on foreign staff to a further extent than health services in many other high-income countries (panel 1). The percentage of foreign-trained physicians and nurses working in the UK has consistently remained at around 30% and 15%, respectively.90 Similarly, for social care, there is an ongoing reliance on foreign staff: in England, 16% of the adult social care workforce had a non-UK nationality in 2020.10 There is also considerable regional variation. In the NHS,

Increasing multimorbidity

Demand for health and care will rise in the future not only because the population is ageing but because people are living longer with multiple long-term conditions. The population in the UK with complex multimorbidity (ie, more than four diseases or conditions) is set to double by 2035.134 Patients with multimorbidity are more likely to have unplanned and preventable admissions to hospital,135 and an increased risk of clinical errors is more probable in this situation.136 To be effective,

Integrated workforce planning

Workforce planning in the UK, while highly fragmented, has been dominated by supply-side rather than demand-side considerations and controlled centrally by a mix of governmental and professional bodies. At the same time, the recruitment and retention of staff is managed by individual health and care providers. This situation has led to a mismatch between the determination of workforce levels through centralised supply-side forecasts and the actual employment of the workforce by individual

Conclusion

To supply a sustainable, skilled, and fit-for-purpose health and care workforce for the UK, a radical, integrated, and long-term strategic vision is needed. To date, this vision has been lacking. Roles and responsibilities for different components of the workforce strategy have been distributed between various national and local stakeholders with no overall ownership or oversight. Workforce planning has been inconsistent and often undertaken in professional silos. The result is fewer health and

Declaration of interests

MF is Chair of NHS Wales Shared Services Partnership Committee. MW was a non-executive director of NHS Lothian between February, 2015, to February, 2021. All other authors declare no competing interests.

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