Intended for healthcare professionals

Opinion

NHS workforce plan—less operational, more a blueprint for the future

BMJ 2023; 381 doi: https://doi.org/10.1136/bmj.p1515 (Published 30 June 2023) Cite this as: BMJ 2023;381:p1515
  1. Alison Leary, professor of healthcare and workforce modelling1
  1. 1London South Bank University
  1. Twitter @alisonleary1

Resolving NHS workforce issues requires the NHS to see workers as an asset, not simply a resource, writes Alison Leary

The long awaited workforce plan is finally with us. It’s hefty, at 151 pages long, and less of an operational plan and more of a blueprint for the future.

It's good to see a more modernised approach to workforce planning. For many years the NHS has had to rely on demand and capacity modelling—a workforce based on activity not actual demand for labour. The labour deficit is manifest in all the unpaid overtime that has become a normalised part of working practice. We estimate 1.2 million hours unpaid overtime for district nurses in England alone.1 It’s been an entrenched approach. As I watched other industries—particularly safety critical ones—modernise and move to humanistic workforce planning, the NHS stayed firmly in the era of new management of the 1970s and 80s, thinking of the NHS as a factory that was or was not productive, using activity as a proxy for outcomes, and its workers as consumable widgets. This plan shifts the dial on that somewhat. It acknowledges that demand is growing, and the workforce is human. The plan gives a nod to demand based on populations, acknowledges that the focus needs to be as much on retention as supply, and that workforce planning is iterative. The plans to “boost” the number of people in the workforce with a particular reliance on the workplace as an educator in the apprenticeship model relies on staff retention, which is currently the hole in the leaky workforce bucket.

It’s promising that the other shift is from focusing on the workforce being more productive to making the environment of the workforce—systems, process, and estates—enablers of work. For too long the inefficiencies caused by the systems, the process, and even the technology have been brushed to one side. Working an already overworked group even harder will not improve effectiveness. It certainly won’t make the system safer and with over 50 years’ worth of inquiries from Ely in 1969 to the recently announced inquiry into two thousand deaths in an Essex mental health trust, we see workforce issues as a tragic, thorny recurring theme.2

The plan acknowledges the need for flexibility—one of the truly untapped talent management strategies in health and social care. Truly flexible working in a predominantly female workforce is essential, but it needs to go further. It needs to deal with issues of inequity, ending practices such as nurses only being able to work part time if they accept a drop in pay banding, for example.3

There are some things that remain entrenched, however. The “Christmas tree” model where a few professionals supervise lots of other lower paid workers who deliver care that the regulated workers are still accountable for, is still the foundation of this workforce plan. This model causes stress and retention problems. We see this in recent data on the numbers of people leaving the NHS. This was first articulated by Isabel Mezies-Lyth in the 1960s, but still NHS workforce planners see this model of working as a solution rather than an issue to be tackled in itself, with robust workload redistribution, using a different mix of skilled workers.4 The other issue is that the plan proposes introducing even more new roles. It suggests increasing the proportion of new roles from 1% of the workforce in 2022 to 5% by 2036/37.

New roles that meet specific demand can be powerful, but often new roles in healthcare are never modelled on demand and just seem to paper over the cracks of an established and declining workforce without tackling the underlying issues. In some areas like general practice, new roles have not decreased the workloads of existing general practitioners.5

And of course, the plan doesn’t go far enough on social care. With over 165 000 vacancies, lower rates of pay than the NHS and a competitive labour market, it really needs robust immediate action as well as a longer term plan.6

The issues with the NHS workforce are long standing and need money, time, and attention to resolve. They also need a contemporary view of workers as an asset not simply a resource, a position which this plan does not quite reach. The time for action on the NHS workforce was 10 years ago. The second best time is now.

Footnotes

  • Alison Leary is a professor of healthcare and workforce modelling at London South Bank University. She researches the relationship between the workforce and safety.

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.

  • Provenance and peer review: commissioned, not peer reviewed.

References