Intended for healthcare professionals


A preliminary workforce plan for the NHS

BMJ 2019; 365 doi: (Published 11 June 2019) Cite this as: BMJ 2019;365:l4144
  1. Nigel Edwards, chief executive1,
  2. Billy Palmer, senior fellow1
  1. 1Nuffield Trust, London, UK
  1. Correspondence to: N Edwards nigel.edwards{at}

Useful in parts, but long overdue

After some years of being eclipsed by concerns about money and targets, the growing and serious problem with the NHS workforce has finally hit home. The result is an interim plan1 to tackle some of the most pressing problems and deal with some of the shortcomings in workforce planning arrangements. The plan signals a more substantial document to come, and therefore lacks some detail, but is a generally useful if aspirational publication.

Recognising there will be a wait for the envisaged new staff to come through, the plan focuses on retaining current staff and ensuring that staff who do train remain with the NHS. So it has quite a lot to say about the NHS as a place to work, and how to improve culture and leadership. Although these are encouraging words, this issue has been a recurring theme. The test will be whether the style of top-down performance management that has contributed to some of the more dysfunctional aspects of NHS culture can be reined in.

The plan notes that boards of NHS organisations have paid relatively little attention to the workforce beyond data on nurse staffing, sickness absence, and pay costs. But the NHS England should be mindful that this may reflect its own signals about what was important. The proposal for a compact with staff—setting out the “give and the get” in the relationship with the NHS—is interesting, if not new.2

However, the NHS is too large, and its centre too distant from the front line, for this to be sufficient. To be really effective, workforce plans will need to be developed locally between people who work with each other every day. A national version might be helpful if it acts as a constraint on unhelpful behaviours at national level such as overbearing performance management and intervention in local organisations.

In the past, attempts to improve leadership have often focused too much on top leaders. The plan recognises the importance of people in leadership positions at different levels of the NHS—in particular, the role of middle managers, many of whom are also clinicians. Evidence suggests that their contribution—in setting the tone, solving problems, and improving quality—is underestimated.345

Unsurprisingly, there is a chapter devoted to nursing shortages, with some sensible proposals. But the plan does not recognise the financial burden on frontline services of the proposal to expand clinical placements for student nurses, and there is more optimism than seemingly justified about the effectiveness of the “return to practice” programme, given that annual numbers completing the programme are in the hundreds, whereas shortfalls are in the thousands.6

The plan has a lot to say about developing the existing workforce. It promises more continuing professional development, which has been substantially cut in recent years, compounding problems with retention of nurses.7 There is also a welcome recognition of the need for more generalist skills in medicine—an area with a substantial shortage.8

The plan proposes more investment in new roles, such as nurse associates, as well as improved career progression for medical staff. It suggests reopening and reforming the associate specialist grade, while also signalling support for greater use of, and progression between, the wide variety of grades within professions.

These are all sensible ideas, but thought will be needed on how these roles are integrated into the existing workforces and teams. For example, integrating a pharmacist into a general practice can work well but is not straightforward and requires changes in how the practice works.9

The creation of a more multidisciplinary primary care team is welcome and should reduce the stresses on general practice in the medium term, but time, staff, and resources will be required to make it happen.

The plan is critical of currently fragmented and complex arrangements for planning the NHS workforce while making a tacit admission that one size does not fit all, as shown by the proposal to address the particular needs of rural and coastal communities.

Although elements of workforce planning should be devolved locally, history in this area is not encouraging and suggests the need for better staff training in planning services and the workforce. One of the causes of workforce shortages has been overconfidence in the success of measures to reduce hospital activity. The predicted reductions often failed to materialise, and staff shortages resulted. The need to deal with the growing workforce problem has been apparent for some time, but it has taken the emergence of a full blown crisis to generate action. These new proposals, though reasonable, are long overdue. The wait for tangible improvements in the workforce will be longer still.


  • Competing interests: We have read and understood BMJ policy on declaration of interests and have no interests to declare.

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