Intended for healthcare professionals


New proposals for reorganisation of healthcare staff in England

BMJ 2011; 342 doi: (Published 22 March 2011) Cite this as: BMJ 2011;342:d1839
  1. Jennifer Dixon, director
  1. 1Nuffield Trust, London W1G 7LP, UK
  1. jennifer.dixon{at}

Extensive, rapid, and risky

Last year’s white paper Equity and Excellence: Liberating the NHS proposed extensive reform of the NHS.1 Away from the current parliamentary debates on the resulting Health and Social Care Bill, the Department of Health is still seeking responses to proposals in some key areas. One of these is how the healthcare workforce might be developed in the future.2

The workforce is central to the current NHS—1.4 million people are employed in 300 roles and cost more than 60% of the £107bn (€123bn; $174bn) NHS budget. How intelligently the supply of staff, their education, training, and development are planned and managed is crucial for the future viability of the NHS. Previous experience suggests substantial room for improvement. The Health Select Committee in 2007 noted the shortage of skills and data on which to plan supply, lack of coordination in planning across professional silos, poor engagement from local NHS organisations for whom these matters were a secondary consideration, lack of integration with financial planning and plans for future service development, and the lack of a long term view.3

The new proposals cover both planning the supply of and the education, training, and future development of healthcare staff in England, except for public health staff (for which there will be a separate consultation). The rationale for change includes the points made by the select committee, but also that planning has been too “top-down,” siloed by profession, inflexible, and not driven enough by local employers. It argues that this has resulted in persistent shortages (the agency bill is apparently £1.9bn) and unaccountable variations between strategic health authorities in the costs of running the system. Furthermore, non-NHS providers do not contribute to the funding of professional education and training (central investment this year is about £4.8bn) but may benefit from hiring NHS trained staff. It suggests that such funding could be allocated in a way that is more transparent, fair, and increases the quality of training.

Like other areas of the NHS reform programme, extensive and rapid changes are proposed. The overall objectives are to ensure a secure supply of staff; flexibility and responsiveness to patient needs; high quality education and training that supports good quality care; value for money; and fair opportunities for all, free from discrimination. Although top-down planning is eschewed, the consultation document is clear that just relying on market signals from providers (without planning) would not secure the right long term supply of staff. Instead, the main change is to shift responsibility for developing the workforce from the Department of Health and strategic health authorities to local employers, with oversight from a national body, Health Education England, accountable to the secretary of state (but “free from day to day political interference”).

The main proposals are that local healthcare providers form “local skills networks” (new legal entities) to plan the short to medium term and long term supply of staff and education and training needs, and take on the functions of the postgraduate medical and dental deaneries, which currently reside in strategic health authorities. These plans will be assessed by Health Education England, which will provide national leadership on planning and developing the workforce; be the ultimate arbiter of priorities; allocate resources to local skills networks to commission education and training; and act as a forum for the interests of relevant national stakeholders, local healthcare providers, staff, and patients. Health Education England will also commission some education and training in highly specialised areas where a national perspective is needed.

It is proposed that the £4.8bn multi-professional education and training budget (which currently funds central investment in the workforce—half of which goes on clinical placements for students and trainees) will be distributed to local skills networks for commissioning and will be confined to funding the next generation of clinical staff only. At present this budget is “top sliced” centrally, but in future a levy on providers of healthcare (possibly all providers whether providing NHS funded care or not) is proposed. Healthcare providers will fund the educational development of their existing workforce. Professional bodies, such as the royal colleges and societies, will retain their current responsibilities, as will the General Medical Council, which as the regulator has statutory responsibility for assuring the quality and outcomes of undergraduate and postgraduate medical training.

Much of the direction of travel seems sensible: potentially more flexible bottom-up planning that reflects local needs; a levy on all healthcare providers rather than a top slice from the NHS budget to fund education and training (important if there will be more non-NHS providers in future); and more cross professional planning—locally through the skills networks and nationally through Health Education England. But big questions remain, and much of the detail is still to be fleshed out.

Firstly, will healthcare providers play ball in the local networks and have the skills to take on the intended role? The white paper and bill champion competition in the delivery of clinical care yet suggest collaboration in developing the workforce. There is considerable scope for conflicts of interest among providers within a network (for example, primary care versus hospitals)—who will arbitrate on these and how will the adequacy of governance (and financial probity) arrangements be assessed? Provider networks will have duties to collaborate in planning both the workforce and the provision of local education and training, provide relevant information, and consult on workforce plans. They will also then be responsible for commissioning nearly £5bn worth of workforce development. Which bodies will be accountable for which duties? With substantial budget cutbacks and with providers wholly responsible for funding continuing professional development, what will be the role of the GMC and possibly the Care Quality Commission in assessing its adequacy? The GMC has already questioned the potential conflict of interest if the same bodies are responsible locally for the quality of education and for immediate service requirements.4

Secondly, one of the important proposals for medical training is the transfer of the functions of postgraduate deaneries to local skills networks. The deaneries have done good work over the years by helping to improve specialty training through credible medical leadership and strengthening links with the medical royal colleges and GMC. If this proposal stands, it will be important that all the deaneries’ functions are identified and continued by the local skills networks. It will take time for the networks to develop the expert skills needed, so there is a case for retaining a regional entity until then to maintain stability in the system. Other important questions are whether the local skills networks will be big enough to plan training in highly specialised areas of medicine, and how the GMC and royal colleges will be able to interact with numerous smaller entities; again, a regional entity may be needed.

Thirdly, the timescale is tight, the strategic health authorities are due to be abolished in April 2012 and local skills networks set up by that date. This is unrealistic—it could adversely affect the quality of education and training and destabilise the £5bn funding streams to providers. This deadline should therefore be extended. In 2007 the select committee noted the detrimental effect of persistent structural reorganisation on workforce planning. We risk this happening again.


Cite this as: BMJ 2011;342:d1839


  • Competing interests: The author has completed the Unified Competing Interest form at (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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