Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Act on workforce gaps, or the NHS will never recover

BMJ 2022; 376 doi: (Published 05 January 2022) Cite this as: BMJ 2022;376:n3139
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

As we start 2022, the NHS workforce is under more pressure than ever. Its inadequate numbers of staff face unmanageable workloads, unrealistic expectations, burnout, and moral distress, compounded by the effects of covid-19.1234 Without enough clinical staff the health service won’t recover, let alone thrive.

There’s also an urgent need to tackle social care provision, preventable ill health, and health inequalities. But failings in workforce recruitment, retention, and planning are the biggest existential threat to the NHS. Professional leaders, health policy experts, and parliamentarians have been saying this ever more urgently for a decade. But these SOS calls have met with platitudes, promises, and vague ambitions—or just been ignored. Where’s the rescue plan for the stricken and slowly sinking NHS ship, battling increasingly hostile conditions as its crew evacuate?

The NHS operating plan for 2022-23 claims to make workforce a key priority but states that “Health Education England and NHSEI [NHS England and NHS Improvement] will work with systems to develop workforce plans.” After all this, is that all there is?4 In every sector of health and social care, workforce gaps abound.5 The NHS and social care each have over 100 000 unfilled vacancies.67 The UK is low down in the Organisation for Economic Co-operation and Development’s league table for numbers of doctors and nurses per capita.8 Whole time equivalent GPs are fewer now than in 2015, despite government promises to increase GP numbers.9 One in 10 NHS nursing vacancies is unfilled,10 and district nursing numbers have declined sharply.11

Brexit and new “points based immigration rules” have harmed recruitment of staff from overseas.121314 This year the Care Quality Commission’s State of Health Care and Adult Social Care in England15 and the General Medical Council’s State of Medical Education and Practice in the UK16 have both highlighted workforce recruitment, retention, and workload as major problems for practitioners and patient care.

In 2019, just before the pandemic struck, the Closing the Gap report from the Nuffield Trust, the Health Foundation, and the King’s Fund made a series of recommendations for action.17 Themes included “supply of new staff,” “pay and reward,” “a good employer,” “workforce redesign,” “international recruitment,” and “social care recruitment and retention.”

National NHS bodies have been promising a comprehensive workforce strategy since at least 2017.18 The publication of anything but short term fixes has repeatedly been pushed down the road, and we’re still waiting. In August 2021 NHS England promised its “first ever national inventory of medical workforce gaps,”19 the results of which have so far not seen the light of day despite freedom of information requests by me and others. Perhaps a long or even medium term workforce strategy is too big an ambition ever to be realised, and certainly not as we reorganise NHS structures through a Health and Social Care Bill20 and oversee recovery in services that are still affected by the pandemic. Is it perhaps serially delayed because it’s unachievable?

With a backdrop of ever rising demand, no additional capacity, and longer wait times accelerated and compounded by the pandemic, exhausted staff will face higher rates of attrition. Workforce gaps beget unmanageable workloads, which beget departures, reduced hours, or disengagement and fatigue. Real terms NHS pay has fallen significantly over the past decade for clinical staff groups, and pension tax relief changes have deterred senior medics from taking on extra work or staying in employment.2122

We need to train more staff, allow more to come here from overseas, and reward and treat them better so that we can retain them, removing any work not essential to patient care. Among those holding the purse strings and levers of power in government or its arm’s length bodies, nowhere do I see any sense of urgency about the scale of this crisis, or the threat to the viability of NHS services and patient care, in a service that’s increasingly struggling to stay afloat.



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