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Views And Reviews Acute Perspective

David Oliver: Solutions for the workforce crisis exist, so let’s act now

BMJ 2022; 376 doi: (Published 12 January 2022) Cite this as: BMJ 2022;376:o23
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter @mancunianmedic

The serious and growing workforce crisis in the NHS and social care is the biggest, most pressing threat to the viability of services for people who need them.1 Covid-19, Brexit, and points based immigration rules have accelerated issues around recruitment, retention, workload, and wellbeing that were already affecting the workforce even before the pandemic.

We’ve had several false dawns where major workforce plans have been promised, with deadlines announced, and then lapsed. Here we are, in January 2022, and the NHS Operating Framework for 2022-23 merely says that NHS England and NHS Improvement “will work with systems to develop workforce plans.”2 This is six years on from an initial pledge from the same bodies.

Yet in 2019 there were already some very concrete proposals from the Health Foundation, the King’s Fund, and the Nuffield Trust. Their report, Closing the gap: Key Areas for Action on the Health and Care Workforce,3 set out sensible recommendations that remain very relevant today. They included at least 5000 more nurses to start training each year by 2021, with greater financial support for living costs and tuition fees and with funded, high quality clinical placements, and at least 5000 more internationally recruited nurses each year until at least 2023-24.

They also advised concerted action to tackle the growing shortfall of GPs, with more support for their role and workload by expanding the numbers of pharmacists, allied health professionals, and nurses in team based primary care. The think tanks were clear that current implementation was too slow and that the GP contract and financial investment were key factors. The report added that the NHS needed to become a far better place to work, with a clear “universal offer” to staff—around wellbeing, work-life balance, and support but also personal development, career opportunities, tackling discrimination, and more inclusive leadership.

Better financial terms and contracts were explicitly mentioned. Pay would have to continue to rise in real terms, given the real terms reductions in NHS pay over the past decade. The damaging impact of pension tax rules for more highly paid staff would have to be tackled to avoid losing senior clinicians. The NHS training and development budget should increase fourfold, it advised.

In social care, which faces workforce gaps and threats to its viability at least as bad as those facing the NHS, the report highlighted the need for “sector specific immigration routes” after Brexit and the impact of new “points based” immigration rules that don’t apply just to potential employees from the European Union. The failure to plan for this has already hit the social work force even harder than it has the NHS workforce.45

Although the government has belatedly announced that care workers, home care workers, and care assistants can now be granted 12 month work visas,6 the poor remuneration for such work is still a problem when other industries also have big vacancy rates. Social care experts had long warned that immigration policy would worsen workforce gaps. Closing the Gap was also explicit about the need for meaningful solutions to social care funding, which could in turn allow employers to stay in business and improve terms and conditions.

Now, of course, the government is under no obligation to do any of this. And any policy action would need funding, risk assessment, and potential new secondary legislation or regulations. But at least the proposals from 2019 represent a coherent, thought through, well evidenced set of actions. If three health policy think tanks employing many former senior civil servants, NHS managers, or clinicians can devise them, so could the government, with the collective will.

Many of these levers can be pulled only at national level because they require central funding, planning and permissions, legislative or regulatory changes, or changes in national terms and conditions. They simply cannot be left to local integrated care systems with nebulous pledges from NHS England to “work with” or “support” them.

We don’t need more pledges or rhetoric, nor more analysis and consultation. We need a relentless focus on implementing solutions, resourcing them properly, and reporting progress.


  • Competing interests: See David Oliver is an unpaid trustee of the Nuffield Trust and an unpaid visiting fellow at the King’s Fund.

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


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