Closing The Gap - Ideas That Change Health And Care
Closing the gapKey areas for action on the healthand care workforceJake Beech, Simon Bottery, Anita Charlesworth,Harry Evans, Ben Gershlick, Nina Hemmings,Candace Imison, Pinchas Kahtan, Helen McKenna,Richard Murray and Billy Palmer
Closing the gapKey areas for action on the healthand care workforceJake Beech, Simon Bottery, Anita Charlesworth,Harry Evans, Ben Gershlick, Nina Hemmings,Candace Imison, Pinchas Kahtan, Helen McKenna,Richard Murray and Billy Palmer
Contents1. IntroductionScope of this report3Approach and methodology42. Supply of new staff: education and training6Key messages6Introduction8Commissioning and funding training9Commissioning of nurse and allied health professional training13Location of training17Delivering value from training18Attrition during nurse training19Converting medical school places to senior doctors20Participation in NHS services on qualifying23Apprenticeships23Conclusion263. Pay and reward: ensuring pay policy supportsrecruitment and retentionii128Key messages28Introduction29Role of pay as an incentive30Recent trends in pay30After the pay deal32Importance of pay for the lowest-paid staff33Pay flexibility and other financial incentives33Progression and pay gaps34Pay harmonisation across sectors35Conclusion36Closing the gap
4. A good employer: making the NHS a better place to workand build a careerKey messages38Introduction40The scale of the retention challenge42Equal opportunities and diversity43Work–life balance44Support for staff at the beginning and end of their career46Support for recently qualified staff47Pensions policy47Leadership49The NHS offer to staff50Opportunities to improve retention51Return to practice52Conclusion545. Workforce redesign: the right teams with the right skillsand technological support 56Key messages56Introduction58Technology and the workforce59Safe staffing61How the workforce is changing63General practice and primary care66Barriers and enablers to workforce redesign77Challenges for expanding teams in primary care79Conclusion826. Supply of new staff: international recruitmentiii3884Key messages84Introduction85International recruitment86Past history86
Current position87How does the NHS currently do international recruitment?88Challenges to international recruitment91Challenges to international recruitment in the longer termand ethical considerations97Conclusion98Costings of recommendations7. Closing the gap: modelling the impact of reform and fundingon nursing and GP shortages102Nurses in NHS trusts103Reducing the nursing gap105The outlook for GPs110Implications for the HEE Budget in Spending Review 2019113Conclusion1158. Social care: pay, recruitment and retention117Key messages117Pay119Recruitment and retention121International recruitment and Brexit122Conclusion1259. Next steps and conclusion12610. Full table of sing the gap129133
123456789101. IntroductionWhen the National Health Service (NHS) was first established in 1948, it was supportedby a workforce of around 144,000 people. Now, 70 years later, the NHS is the largestemployer in England, with around 1.1 million full-time equivalent (FTE) staff in hospitaland community services (NHS Digital 2018b).1 These people are the health system'sgreatest asset. Without its many different staff – including doctors, nurses, scientists,porters, clerks and therapists – there would be no health service.And yet right now, the NHS workforce is struggling to cope. In November 2018, The HealthFoundation, The King's Fund and the Nuffield Trust jointly published a briefing in advanceof The NHS Long Term Plan (NHS England 2019c), highlighting the scale of workforcechallenges facing the health service and the threat they pose to the delivery and qualityof care over the next 10 years (Health Foundation et al 2018). In it we showed that NHShospitals and mental health and community providers are currently reporting a shortageof more than 100,000 FTE staff (representing one in eleven posts) (NHS Improvement2018b), severely affecting some key groups. One of the greatest challenges lies in nursing,with 41,000 nurse vacancies2 (one in eight posts) (NHS Improvement 2018b), but there arealso problems in medicine, particularly in some specialties – eg, core psychiatry training isnow on the Migration Advisory Committee's list of occupations experiencing a shortage ofstaff – and geographical areas, as well as some allied health professions. These pressuresalso extend beyond NHS trusts, with serious staffing issues in general practice.The adult social care sector is also under pressure and facing many of the same issuesas the NHS. There are 1.1 million FTE jobs in adult social care (Skills for Care 2018a),and vacancies are rising, currently totalling 110,000, with around one in ten social workerand one in eleven care worker roles being vacant (Skills for Care 2018a). There is alsoa registered nurse vacancy rate of 12 per cent in adult social care, implying around 5,000nursing vacancies in this sector as well (Skills for Care 2018a).The current level of vacancies looks set to worsen. Concerns about Brexit appear to havecreated additional risks in both the short and medium term. Already a net inflow of nursesfrom the European Union (EU) into the NHS has turned into a net outflow; between July2017 and July 2018, 1,584 more EU nurses and health visitors left their roles in the NHSthan joined (NHS Digital 2018d). Further, the government's efforts to increase the number1 These figures exclude staff working in primary care or the voluntary and independent sectors.2 Our November 2018 briefing referenced more than 36,000 nurse vacancies based on data published byNHS Improvement. In our modelling for this report we refer to 32,500 nurse vacancies. This figure comesfrom applying the nursing vacancy rate from NHS Improvement data to the nursing establishment datapublished separately by NHS Digital. We have used NHS Digital data on the nursing establishment becausethese are classed as official statistics and are consistent with other sources whereas the staff numberscollected by NHS Improvement are reported as management information.1Introduction
12345678910of nurses and allied health professionals in training by up to 10,000 (by removing the NHSbursary for students starting courses from August 2017 – see Chapter 2 for more detail)(Health Education England 2017a) have so far not been successful; in fact, the numberof placed English applicants for nurse undergraduate training in 2018 was 4 per centlower than in 2016 (UCAS 2017, 2018a).3In addition to these vacancies, staff in post face other challenges. The 2018 NHSStaff Survey showed that 12.8 per cent of staff reported experiencing discriminationat work during the previous 12 months and around one in six did not believe that theirorganisation provided equal opportunities for career progression or promotion (NHSEngland 2019c). And in terms of progression, while the NHS has made progressin addressing unwarranted inequalities, there is evidence that disparities still exist,resulting in pay gaps. For example, the estimated median basic FTE pay gap betweenmen and women in 2017 was 8.6 per cent in favour of men and was significantly worsefor women in some ethnic groups.Workforce challenges are currently the biggest threat facing the health service andare already having significant consequences for both patients and staff. As the CareQuality Commission (CQC) stated in its recent report on the state of health and socialcare in England: 'Workforce problems have a direct impact on people's care' (CareQuality Commission 2018). The latest GP Patient Survey shows clearly that patientshave problems accessing general practice, with more than a third of patients strugglingto get an appointment when they need one (NHS England and Ipsos MORI 2018). Forservices provided by NHS trusts, performance against key waiting times standards hasbeen in decline since 2012/13, with patients experiencing longer waits for both A&E andplanned care. Mental health services are also under pressure – for example, national datapublished in November 2018 found that 675 patients in acute need were admitted to mentalhealth units outside their local area (NHS Digital 2019b), a practice that the governmenthas committed to eliminate by 2020/21. In the longer term, if substantial staff shortagescontinue, we could see waiting lists continue to grow and a further deterioration in carequality, potentially undermining the future sustainability of services.As we set out in our November 2018 briefing, the scale of the workforce challengescurrently facing the health service pose a threat to the delivery and quality of careover the next 10 years. We also urged national leaders to use the long-term plan asan opportunity to address these issue. The long-term plan was published in January,setting out far-reaching commitments to improve health outcomes and quality of care.The plan rightly recognises that the NHS can only achieve these outcomes if it hasenough staff with the right skills and they are given adequate support to work effectively.However, it acknowledges that conditions currently fall far short of this, with 'our staff feeling the strain' (NHS England 2019c).3 This figure is based on applicants permanently living in England, accepting a place at any university withinthe UK, using the latest available data for comparison (UCAS 2017, 2018a).2Closing the gap
12345678910To address this, the plan outlines a number of measures, including proposals to increasestaff numbers through training and recruitment. It also proposes to make the NHS a betterplace to work, so that more staff stay and feel able to make better use of their skills andexperience. It sets out some immediate actions, to be overseen by NHS Improvement anda newly established, cross-sector national workforce group, with membership from acrossthe health sector, including representatives from our three organisations. The group willexplore other actions, to be set out in an 'interim' workforce implementation plan in April2019 and finalised in a 'full' plan following the Spending Review later this year. Widerchanges are deferred until after the 2019 Spending Review, when the budget for training,education and continuing professional development (CPD) is set, alongside decisions oncapital investment, public health and social care funding over the rest of this parliament.The plan has already been followed by ambitious goals in the new GP contract, which plansfor many more physiotherapists and pharmacists to be brought in, and in the Topol Reviewon training staff to use new digital technologies (Health Education England 2019d).Scope of this reportOur report lays out a set of high-impact interventions that, if put into action now, could helpto ameliorate the current workforce crisis. We focus on the areas where severe nationalproblems are having an immediate impact – in particular, nursing and general practice.Our recommendations do not amount to a full workforce strategy for the future or a planfor the NHS; this would be an enormous task, taking several years and that is the job ofsystem leaders. In relation to the NHS, we focus on five main opportunities: training new staff, specifically nursespayhelping the NHS become an employer of choice for health care workers, improvingthe career offer and ensuring that staff from all backgrounds are treated fairlythe right teams with the right skillsinternational recruitment.In order to assess how many health care workers the NHS can secure through theseactions and whether it will be enough, we project the potential demand for staff in thefuture. This is based on estimates of the size and age of the population, the rising burdenof chronic disease, and ambitions for the quality and range of services which are in linewith planned growth in spending. We then model the impact of our recommendations onthe gap between supply and demand for nurses in NHS hospitals, mental health providers,community trusts and GPs.The NHS long-term plan and associated workforce implementation plan are concernedwith the NHS, and so this is our focus. However, the NHS has a close inter-relationshipwith social care and there are strong connections between the two workforces, witha flow of workers between the two sectors and day-to-day, side-by-side collaborationin care. While the fundamental structural differences between the two sectors mean3Introduction
12345678910they cannot currently be treated as one sector, the deep links between them necessitateworkforce strategies that cover both. We therefore also, albeit in less detail, look atmeasures needed to improve recruitment and retention in social care.Approach and methodologyThe report itself is structured along the five 'opportunity' areas we outlined earlier.These are: training new staff; pay; the NHS as a good employer; the right teams with theright skills; and international recruitment. In addition, we set out our modelling analysisin Chapter 7 and in the final chapter we look at the implications of the interrelationsbetween health care and social care in terms of staffing.The report has been produced as a collection of policy analyses by experts from thethree think tanks. Each analysis has named authors and although they are inter-linked(for example, they all draw on our modelling exercise), each can be read asa standalone document.The purpose of this report is to make policy-level recommendations for national bodiesthat are designed to support progress towards the objectives that have been set for theNHS over the next 5–10 years in The NHS Long Term Plan. The recommendations will,however, also be of interest to those leading on workforce issues at local and regionallevels. In each chapter, we have estimated cost implications of our recommendationsfor HEE budget which will be set as part of the 2019 Spending Review.In developing our recommenda
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