Health PolicySecuring a sustainable and fit-for-purpose UK health and care workforce
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.
References (193)
- et al.
Mapping support policies for informal carers across the European Union
Health Policy
(2014) - et al.
Reframing professional boundaries in healthcare: a systematic review of facilitators and barriers to task reallocation from the domain of medicine to the nursing domain
Health Policy
(2014) Annual report and accounts, 2018–19
- et al.
The NHS workforce in numbers
NHS Scotland workforce
Northern Ireland health and social care (HSC) key facts workforce bulletin
- et al.
Brexit and the health & social care workforce in the UK
Carers Week 2020 research report: the rise in the number of unpaid carers during the coronavirus (COVID-19) outbreak
- et al.
The self-care matrix: a unifying framework for self-care
SelfCare
(2019) Women are well-represented in health and long-term care professions, but often in jobs with poor working conditions
Gender in the NHS
The state of the adult social care sector and workforce in England
Narrowing of NHS gender divide but men still the majority in senior roles
Gender pay report
Ethnicity and national identity in England and Wales: 2011
NHS workforce race equality standard: 2019 data analysis report for NHS Trusts
Workforce race inequalities and inclusion in NHS providers
Beyond the data: understanding the impact of COVID-19 on BAME groups
Policies to sustain the nursing workforce: an international perspective
Int Nurs Rev
The toolkit for a sustainable health workforce in the WHO European Region
Managing mental health challenges faced by healthcare workers during covid-19 pandemic
BMJ
The hidden impact of COVID-19 on patient care in the NHS in England
The future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19
Lancet
A practical guide to curriculum development
Become a nurse: advice on beginning your nursing career
Becoming a doctor in the UK
Medical specialty training
Unit costs of health and social care
Expansion of undergraduate medical education: a consultation on how to maximise the benefits from the increases in medical student numbers
Tuition fee statistics
NHS bursary
NHS bursary reform
Nursing students to receive £5,000 payment a year
2019 end of cycle report
RCN Briefing: Staffing levels in the NHS, Westminster Hall Debate
The nursing workforce: second report of session 2017–19
Facing the facts, shaping the future. A draft health and care workforce strategy for England to 2027
The Cavendish Review: an independent review into healthcare assistants and support workers in the NHS and social care settings
Independent report: report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
The talent for care: a national strategic framework to develop the healthcare support workforce
The adult social care workforce in England
Caregiver education in Parkinson's disease: formative evaluation of a standardized program in seven European countries
Qual Life Res
Rising pressure: the NHS workforce challenge
Discover the adult social care workforce data set
Health workforce planning in OECD countries: a review of 26 projection models from 18 countries
Time for a new approach to medical workforce planning
Med J Aust
Operational workforce planning: a self-assessment tool
Community pharmacy in Great Britain 2016: a fragmented market
Securing a cancer workforce for the best outcomes: the future demand for cancer workforce in England
Focus on physicians: census of consultant physicians and higher specialty trainees, 2017–18
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