The NHS workforce plan

Missing pieces

First, it is unclear whether the vision is funded. Projecting that the NHS will employ over 900 000 more staff over 15 years—representing a two thirds increase—is bold. That said, as our history of training too few people has shown us, when it comes to the supply of staff, it is best to err on the side of caution and minimise the risk of staff shortages, which are more costly than an oversupply.3 But without an accompanying long term commitment to increase the NHS budget to employ such numbers, we have to consider the plan—as yet—unfunded. Even the £2.4bn pledged for additional training is not due until 2025, after the next general election.

Second, the consequences of ramping up training are largely untested. Despite signalling a reduction in the clinical placement hours required for some courses and increased use of simulation, the plan does not explain how sufficient numbers of academic and clinical educators and supervisors can be found from a current NHS clinical workforce that is often already under too much pressure. The plan is also silent on the effect of lowering thresholds for accepting people onto clinical courses, which seems an inevitable consequence of substantially increasing numbers in training. We have only the vaguest idea about what effect that could have,45 leaving the professional regulators with some of the trickiest parts of the puzzle to solve, including providing assurances around shorter and more diverse educational routes.

Third, the plan does not fully join the dots between increasing training capacity and getting more clinicians working in public services. Admittedly, there are interesting proposals for clinical staff to complete their clinical education earlier and take up paid internships (for doctors) and employment (for nurses). These are certainly worth trialling and evaluating given that internships are used in, for example, Ireland and Australia.67 The plan suggests exploring a tie-in period to encourage graduates to spend a minimum proportion of their time delivering NHS care, but this proposal is limited to dentistry, where the modelling points to a huge increase in participation in NHS commissioned services being required to have any chance of staffing levels matching demand for care.

Trying to secure a return on the substantial public investment in education and training is prudent. But given the current industrial relations and the need to make the profession more appealing if the additional training places are to be filled effectively, policies to promote participation rather than restrict leaving should also be explored. A carrot rather than stick approach might be best—for example, creating policies around forgiving or delaying student loan repayments to incentivise participation in public services.8

Fourth, it is not clear what delivery mechanisms will be put in place to secure better outcomes than obtained for previous iterations of similar policies. General practitioner training places will apparently be increased by half again by 2031-32, but previous increases did not seem to yield more fully qualified GP joiners in subsequent years, as that pipeline just became leakier. Important lessons should also be learnt from, for example, both previous well intended policy to reduce costs for agency staff,9 and current general practice policy in relation to incorporating new roles and changing skills mix.10 Such policies rarely prove pain free. More broadly, the general lack of proved policy proposals in the plan suggests that the entire health workforce research ecosystem—connecting those delivering, evaluating, and designing policies—is not working in sync.

Another important uncertainty concerns how to deliver the assumed productivity improvements—worth up to 2% annually (equivalent to over 170 000 fulltime staff after 15 years). The prime minister seems confident on this,11 but the real costs of recruiting and integrating so many new staff and in different roles are poorly established. Frontline clinical leadership and skills in service redesign will presumably be key to delivering the productivity and the cultural changes needed, but there is little to incentivise and support improvements in that area. The struggling social care sector and the floundering pay review process are other obvious missing pieces of the puzzle.

Potential benefits

Despite these caveats, the principle of a more sustainable supply of homegrown clinicians is commendable; the plan commits to investment allowing a larger and more inclusive cohort of students to learn valuable clinical skills and knowledge and be able to benefit from varied and (at least potentially) rewarding career opportunities. This could, in turn, reduce reliance on some of the less ethical overseas recruitment practices. Ramping up training also means that the additional places can be distributed in otherwise underserved areas of the country, which could also benefit from the push for more generalist staff.

NHS national leaders probably intended the plan to, first and foremost, make central government commit to an adequate clinical workforce, with sustainable supply of staff. To that end, it could be seen as a success. But that alone will not get the NHS out of its workforce crisis. A huge amount of endeavour has clearly gone into producing this plan but it risks joining the pile of previous redundant modelling exercises unless the initiative is taken soon for filling in the remaining policy gaps and delivering the changes needed. As for any complex puzzle, a systematic, strategic, and persistent approach is needed for success.