Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: NHS workforce policy is not joined-up government

BMJ 2018; 363 doi: (Published 23 October 2018) Cite this as: BMJ 2018;363:k4417
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}

In 1997 the prime minister, Tony Blair, coined the phrase “joined-up government.”1 When policy problems didn’t fit neatly into departmental and ministerial boundaries the idea was to collaborate on and coordinate aligned approaches and messaging.2

Unfortunately, the recent response to the NHS workforce crisis is the antithesis of this, across departments and a confusing array of national NHS arm’s length bodies created by the 2012 Health and Social Care Act.3 Let me take you on a quick tour.

NHS England’s new chair, David Prior, stated on arrival that the three biggest challenges facing the NHS over the next 10 years were “prevention,” “integration,” and “technology.”4 He has long experience in ministerial, regulatory, and NHS board roles. Yet, bizarrely, he didn’t mention the growing gaps in the clinical workforce or the looming threat of worsening recruitment and retention.

Without adequate staffing in clinical roles NHS performance will decline, and services will become unsustainable. Morale will worsen, and staff will leave or choose to do less—a vicious circle. The workforce is surely the most pressing existential threat.

Don’t take my word for it. When NHS Providers surveyed organisational leaders they cited workforce gaps as their biggest challenge.5 This aligns with numerous surveys of frontline clinical staff who cited workload, workforce, and rota gaps as their main causes of stress and the biggest threats to patient safety.678 Those same organisations reporting to NHS Providers found around one in 10 consultant, nursing, and allied health professional posts unfilled—and more in busy acute specialties and some regions.5

Within a month of Prior’s comments Dido Harding, NHS Improvement chair, said that “The NHS’s biggest problem is that not enough people want to work in it.”9 This realism is consistent with NHS Digital’s recent workforce report, which reported gaps just as big as NHS Providers did.10 My worry is that NHS England and NHS Improvement are now meant to be working in ever closer alignment,11 yet here their chairs don’t seem to be in the same book, let alone on the same page.

Morale will worsen, and NHS staff will leave or choose to do less—a vicious circle

To be fair, last year Health Education England produced the first attempt at a transparent national workforce plan for the NHS in its 70 year history.12 Since it went out to consultation I’d say it’s pretty light on tackling gaps in secondary and tertiary care, it’s silent on social care and public health, and it says little useful about allied health professions.

I’m not especially confident that the strategy will be fully funded or implemented. Nor do I see solutions to many issues in junior doctors’ working lives, which they’ve clearly told system leaders about.1314 They’re leaving training programmes in growing numbers at every grade, and we don’t know how many will return.15

The House of Commons’ own briefing reported that 12.7% of NHS staff are not British nationals and 5.7% are EU nationals.16 Continuing uncertainty over Brexit means that those from EU countries are less inclined to come or stay.17 The home secretary, Sajid Javid, having made visa exemptions for doctors from non-EU countries, has now said that this was only temporary, probably under pressure on immigration policy.18 Meanwhile, despite the Care Quality Commission’s State of Care report19 having found short staffing a major issue in its inspections, England’s health secretary, Matt Hancock, spoke last week about a “crackdown on agency staff.” How will this help when there aren’t enough permanent staff?20

From my tour bus window, the view of NHS workforce planning shows lots of fragments and not many joins.



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