The National Health Service (NHS) in England, a truly vast organization and one of the world’s largest employers with 1.7 million people directly on its books (equivalent to 1.5 million full-time staff), is currently grappling with significant staffing difficulties.
This workforce is fundamental to the service’s operation, making up around two-thirds of the expenditure for NHS providers. The NHS has a recurring gap between the number of employees it has and the number it requires, notwithstanding its enormous size.
The Scale of the NHS Workforce Challenge
Unfilled positions remain a major concern. There were 125,572 open positions in the NHS in England between March and June 2023, which accounted for 9% of the total workforce.
Importantly, although the NHS often recruits more individuals than leave annually, the total number of necessary roles has expanded faster than recruitment and retention combined, causing vacancy numbers to climb, reflecting high attrition combined with insufficient recruitment.
This goes beyond simple statistics; inadequate staffing levels directly impact the delivery of services and the quality of patient care nationwide. Looking ahead, projections within the NHS Long-Term Workforce Plan indicate a potential personnel gap ranging from 260,000 to 360,000 full-time equivalent staff by 2036/37 if existing patterns are not altered.
Consequently, this substantial projected shortfall underscores the critical necessity for strategic and decisive action.
A Look Back: Historical Trends in NHS Staffing
Understanding the current predicament requires looking at historical trends. Pinpointing precise historical figures can be challenging due to shifts in data collection methods over time.
However, the evidence that is now available indicates that throughout NHS history, staff growth has differed across different professions. Growth in hospital doctor numbers, for instance, appears to have been particularly dramatic and consistent over many decades
Conversely, the number of general practitioners relative to the population seems to have remained relatively unchanged over extended periods. Similarly, nursing levels appeared static for some time before recent initiatives aimed at boosting numbers.
Trends in NHS Staffing by Professional Group
The staff of the NHS is notably multifaceted and varied. As of June 2023, approximately half of all employees were clinically qualified professionals. Doctors totaled 188,000, and nurses and midwives combined numbered around 423,000.
It is noteworthy, however, that these two large groups constitute only about a third (37%) of the total workforce, emphasizing the vital contributions made by allied health professionals, support staff, and many other essential roles.
For instance, hospital and community services experienced a 29% increase in overall staff numbers. Within this group, doctors grew faster (28%) than nurses (20%) over the same period.
The Crisis in Specific Roles: GPs, Community Nurses, and More
Certain professions within the NHS face particularly acute pressures. In England, there were 848 fewer fully qualified, permanent general practitioners between June 2019 and June 2023.
Simultaneously, the average number of patients per GP has risen considerably. Similarly, community health nursing roles have seen concerning declines since 2010; for example, the number of NHS community matrons and district nurses fell by almost half, school nurses decreased by 35%, and health visitors by 29%.
Mental health nurses also saw a slight reduction (-2%) between 2010 and 2023, even though demand for mental health services is predicted to grow at a high rate (4.4% annually).
While other groups like clinical support staff (+40% since 2010) and scientific, therapeutic, & technical staff (+36% since 2010) have grown, variations exist even within these broad categories; for instance, podiatry staff numbers fell by 19% since 2010.
The Domestic Training Pipeline: Bottlenecks and Opportunities
A primary contributor to staffing shortfalls is the insufficient number of staff trained domestically. This has been particularly true for nurses following a decline in the number of training starters in the early 2000s.
More recently, there was a 20% decrease (-4,620) in placed applicants onto nursing university courses in the 2023/24 academic year compared to the peak in 2021/22.
Estimates suggest a notable attrition rate in the training pipeline; for every five university nursing places, only about three full-time equivalent nurses eventually enter the NHS workforce. This contributes to overall employee attrition before staff even fully join.
Furthermore, the number of UK-national nurses joining NHS hospital and community services at Band 5 fell by 32% in the year to March 2022 compared to 2019/20 and remains below pre-pandemic levels.
Challenges also persist in the doctor training pathway; fewer than three in five doctors (56%) in ‘core training’ remained in NHS hospital and community services eight years later. For GPs specifically, it is estimated that nearly two training posts are needed to yield one fully qualified full-time equivalent GP joiner.
Boosting Homegrown Talent: Training Targets and Strategies
To counter these pipeline issues, the NHS Long Term Workforce Plan proposes a significant expansion of domestic education and training, supported by over £2.4 billion in initial government investment.
Key targets include doubling medical school places to 15,000 per year by 2031/32 and increasing GP training places by 50% to 6,000 by 2031/32. Adult nursing places are planned to increase by 92% to nearly 38,000 by 2031/32.
A major expansion of apprenticeship routes is also planned, aiming for 20% of registered nurses and 20-22% of clinical training places overall by 2031/32. These strategies aim to increase the overall supply of domestically trained healthcare professionals.
However, delivering this scale of training requires finding sufficient academic and clinical educators and supervisors from the currently strained workforce.
The Push for Apprenticeships: Expanding Routes into the NHS
Apprenticeship pathways are undergoing significant expansion. This approach is considered an effective way to broaden participation in the workforce and may also lead to improved staff retention, helping to reduce attrition.
Specific competency and career development frameworks are being created for various support worker roles, establishing clear progression routes, often leading to regulated professional positions.
Consequently, this method aims to utilize a wider talent pool and address specific workforce needs from within the organization.
Recruitment Challenges: Attracting Staff in a Competitive Market
Beyond increasing training numbers, attracting staff remains difficult in a competitive labour market. The NHS is implementing strategies to enhance recruitment processes, aiming for quicker completion of pre-employment checks.
Moreover, the plan acknowledges the need to address disparities in recruitment experiences reported by staff from ethnic minority backgrounds and staff with disabilities, as highlighted by the Workforce Disability Equality Standard (WDES) and Workforce Race Equality Standard (WRES) statistics.
The Role of International Recruitment: Reliance and Future Plans
Insufficient domestic supply has historically resulted in a significant reliance on international recruitment. 16.5% of employees in hospitals and community health services were not British nationals as of June 2022.
The fact that over half of the nurses and midwives who joined the professional registry in March 2023 had training outside of the United Kingdom is noteworthy. While recognizing the invaluable contribution of internationally recruited staff, the plan aims to reduce reliance on this source to 9-10.5% of new joiners across the NHS (excluding dentistry and community pharmacy) by 2036/37 as domestic training numbers increase, managing the impact on overall employee turnover.
Nevertheless, considerable reliance is expected to continue in the short to medium term.
The Retention Crisis: Why NHS Staff Are Leaving
Existing employees must be retained by the NHS. Reducing employee attrition is absolutely vital for keeping staff within the NHS. The attrition rate for hospital and community health services staff was 11.2% in the year ending in June 2023, indicating significant employee turnover.
Reasons for leaving are complex and varied. Although pay is a prominent issue, especially in the context of recent industrial disputes and real-terms decreases in average basic pay for both doctors and nurses in 2023, stress and understaffing are frequently cited ahead of pay as reasons for departure in staff surveys.
Reasons related to work-life balance and health have also increased significantly over the past decade, representing further factors in employee attrition.
Attrition Factors: Stress, Burnout, Pay, and Discrimination
High workloads contribute substantially to stress and burnout among staff. Data indicates that significant proportions of medical and dental staff experience work-related stress and feel burnt out. Meeting screening criteria for depression, anxiety, and PTSD is strongly associated with intentions to leave.
Furthermore, experiencing discrimination and not feeling valued by the government or employer are major factors driving attrition. Addressing these issues through better support, improved working conditions, and fostering a positive and inclusive culture is critical for reducing attrition.
While the plan emphasizes cultural improvements and flexible working options, commentary notes that it contains fewer immediate, concrete actions regarding pay and addressing current workplace pressures, which impact attrition.
Diversity in the NHS: Progress Made, Inequalities Remain
The NHS workforce exhibits notable diversity, with one quarter (25%) of staff reporting a minority ethnic background, significantly higher than the UK working-age population average.
However, the proportion varies by staff group (e.g., 39% of nursing staff vs 7% of ambulance staff). Despite progress in some areas (like representation at very senior management levels), inequalities persist.
Staff from minority ethnic backgrounds are less represented in senior roles, report worse day-to-day working experiences (including higher rates of harassment and bullying), and face greater challenges in career advancement.
A New Path for the NHS Long-Term Workforce Plan
The Long-Term Workforce Plan represents a crucial shift towards a comprehensive, long-term workforce strategy. It acknowledges previous shortcomings in planning and proposes actions across the Train, Retain, and Reform pillars to address the projected staff shortfall and adapt the workforce for future healthcare needs, including managing attrition.
The plan is intended to guide actions at local (Integrated Care Systems – ICSs), regional, and national levels.
Reforming How the NHS Works: Skill Mix and New Roles
Reform focuses on improving productivity, understanding that this is not about increasing staff effort but about changing how work is organized and delivered. This involves shifting care delivery towards community settings and optimizing the skills mix within multidisciplinary teams (MDTs).
The plan proposes expanding roles like advanced practitioners and consultant practitioners, increasing non-GP staff roles in primary care via initiatives like the Additional Roles Reimbursement Scheme (ARRS), and enhancing the deployment of support workers and administrative staff (such as doctor’s assistants) to free up clinician time.
Developing core skills for personalized care and public health is also a priority across the wider workforce.
The Role of Technology in NHS Workforce Reform
Technology is identified as a fundamental enabler of reform and productivity gains. The plan highlights leveraging artificial intelligence (AI) for tasks such as diagnostics support and administrative automation, implementing Robotic Process Automation (RPA) to reduce administrative burden, expanding remote monitoring, and developing robotic-assisted surgery.
These technologies are anticipated to free up staff time and enhance efficiency, although their successful adoption requires sustained investment in digital infrastructure and adequate staff training and support.
Implementing the Plan: Funding, Capacity, and Dependencies
The plan’s delivery is a challenging task that calls for cooperation from several entities. Initial funding specifically supports training expansion up to 2028/29 (£2.4bn), but funding beyond this period remains uncertain, being contingent on future government spending reviews.
Furthermore, realizing ambitious productivity improvements relies heavily on substantial, sustained capital investment in physical infrastructure and digital technology, which is also not fully guaranteed long-term.
The plan also acknowledges a critical dependency on the social care sector; improvements in social care capacity are essential for reducing demand on the NHS by supporting timely patient discharge and enhancing preventative care, yet the plan does not cover the social care workforce itself, which faces its considerable vacancy crisis (152,000 vacancies reported), exacerbating attrition in the wider health and care system.
The plan is designed to be iterative and will be refreshed at least every two years to adapt to changing circumstances and incorporate new data and insights.
Expert Commentary: Opportunities and Criticisms of the Plan
The plan has been widely welcomed as the most comprehensive and transparent long-term workforce strategy in recent memory, particularly for its detailed focus on training expansion and its acknowledgment of the scale of the problem.
However, expert commentary also identifies significant risks and criticisms. Concerns include the uncertainty of funding beyond the initial period, questions about the feasibility of the scale of training expansion and ambitious productivity targets, and a perceived lack of urgent, concrete actions on immediate retention drivers, especially pay, which impacts attrition.
The omission of a strategy for the social care workforce, despite its direct impact on the NHS, is also a major point of concern.
What the Plan Doesn’t Directly Address
Crucially, the Long Term Workforce Plan does not directly address NHS workforce pay. While it acknowledges that reward packages, terms, and conditions influence retention and were central to recent industrial disputes, decisions on these matters rest with the government and fall outside the plan’s direct scope.
Furthermore, as noted, the plan does not include a strategy for the social care workforce, despite its critical interdependence with the NHS and its significant vacancy levels, which also impact attrition across the care continuum.
Comparing the NHS Workforce Internationally
Caution must be exercised when making comparisons with healthcare workforces in other countries due to variations in system design, geography, and data collection.
However, data suggests the UK appears to have relatively fewer doctors and nurses per capita compared to other developed countries, although it may employ a higher number of support staff per head.
This comparison underscores the scale of the challenge in increasing key clinical staff numbers to match international benchmarks.
The Outlook for the Future: Risks and the Path Ahead
Despite overall increases in staff numbers, the NHS workforce crisis persists, and resolving it presents complex challenges that require long-term commitment. The Long-Term Workforce Plan sets out a necessary and ambitious path forward.
Its ultimate success, however, is contingent on securing consistent, long-term funding; effectively implementing reforms and technology adoption; significantly improving retention by addressing staff concerns, including pay and working conditions; ensuring sufficient educators are available for increased training; navigating regulatory changes for new roles, and seeing parallel action to strengthen the social care sector.
The plan is designed to be iterative and will require regular review and adaptation to meet the evolving needs of the service and the population, significantly improving retention and reducing attrition.
Conclusion
The NHS faces a profound and multifaceted workforce crisis characterized by high vacancies, significant projected shortfalls, and deep-seated challenges in training and retaining staff.
Effectively managing attrition and tackling the retention challenge is paramount. The Long-Term Workforce Plan represents a vital strategic step, providing a comprehensive framework and ambitious targets for expanding the workforce and reforming practices over the next 15 years.
Nevertheless, its successful implementation is far from guaranteed. Key dependencies on sustained funding beyond the initial period, substantial investment in infrastructure and technology, and effectively addressing the intertwined crisis in social care are critical.
Furthermore, tackling the retention challenge necessitates concrete actions on issues such as pay, working conditions, and fostering a supportive culture. While the plan establishes a crucial direction, collaborative effort across all levels of the health and care system, ongoing adaptation, and a commitment to addressing both immediate pressures and long-term goals will be essential to build a sustainable NHS workforce capable of meeting future patient needs and providing high-quality care.
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