Workforce plan: what does in mean for general practice?

NHS England has set out a comprehensive, long-term workforce strategy for the NHS, for the first time in its 75-year history. Practice Nurse has scrutinised the plan (so you don’t have to) to pick out the salient points

NHS England has published its long awaited, long overdue, long term workforce plan in a bid to ensure it has the right number of people with the right skills and support in place to deliver ‘the kind of care people want’.

It describes the plan as a ‘once-in-a-generation opportunity to put staffing on a sustainable footing and improve patient care’ and aims to do this through significant increases in training and education, retention – ensuring that the NHS keeps the staff it has, and reform – improving productivity by working in different ways, with broader teams with flexible skills and greater use of new technology to free up clinicians’ time.

The plan aims to predict workforce demand for the next 15 years, and detail the action that will be taken to address the current and continuing staffing shortfalls. It shows that, without concerted and immediate action, the NHS will face a workforce gap of more than 260,000–360,000 staff by 2036/37.

Since 2010, NHS staffing has increased by 263,000 full-time equivalent (FTE) staff, including 42,000 more doctors and 55,000 more nurses, health visitors and midwives, with an estimated increase of 4,600 doctors and 2,400 nurses in general practice. However, healthcare need has also been growing significantly, driven by ageing and increasing morbidity, and outstripping the growth in workforce FTEs.

Over the next 15 years, the population of England is projected to increase by 4.2%, but the number of people aged over 85 will grow by 55%. Patients’ needs are changing with increasing levels of multimorbidity and frailty leading to increasing complexity of service delivery. By 2037, two-thirds of those over 65 will have multiple health conditions and a third of those people will also have mental health needs.

NHSE says: ‘We know the NHS is facing clear and pressing workforce challenges. While the workforce has grown by 25% since 2010, the number of staff trained has not kept pace with demand for NHS services. To fill service gaps and ensure safe staffing levels, the NHS is reliant on temporary staffing and international recruitment. Of the doctors who joined the UK workforce in 2021, 50% were international medical graduates. And, in 2022/23, about half of new nursing registrants in England were trained overseas. There were over 112,000 vacancies across the NHS workforce in March 2023.

The workforce shortfall across NHS organisations will grow to 260,000–360,000 FTEs by 2036/37.

• The shortfall in qualified GPs is projected to be 15,000 FTEs by 2036/37
• By 2036/37 the FTE shortfall in community nurses will be at least 37,000; it was 6,500 in 2021/22

The government will invest more than £2.4 billion to fund the 27% expansion in training places by 2028/29. This will enable more than half a million trainees to begin clinical training over the next six years, an addition of nearly 60,000 compared with maintaining current training levels. This is the first step to increasing education and training by 64% by 2031/32, and the aims include:

• Doubling the number of medical school places, taking the total number of places to 15,000 by 2031/32.
• Increasing the number of GP specialty training places by 50% to 6,000 by 2031/32. To support this ambition, GP specialty training places will initially grow by 500 places by 2025/26, increasing to 1,000 additional places (5,000 overall) by 2027/28.
• Increasing adult nursing training places by 92%, taking the total number of places to nearly 38,000 by 2031/32. The increased will be phased in over the next six years, so that in 2028/29, at least 8,000 more adult nurses will start training compared to current levels.
• Increasing training places by 38% for mental health nursing and 46% for learning disability nursing, so that by 2028/29, there will be a total of 40,000 nursing places funded. This will put us on the path to increase nursing training places by 80% to over 53,500 by 2031/32.
• Expanding advanced practice training by 46%, so that 5,000 clinicians are starting advanced practice pathways each year.

These actions build on the steps that NHSE is already taking to grow and train the NHS workforce. Investment in education and training is planned to increase from £5.5 billion to £6.1 billion over the next two years, and actions are underway to:

• Train 5,000 nursing associates (NAs) and around 1,300 physician associates (PAs) in 2023/24 and 2024/25. This Plan emphasises the need to target more PA roles towards primary care and mental health services.
• Ensure at least 3,000 clinicians start advanced practice pathways in both 2023/24 and 2024/25, tailored to support service demand.

There has already been growth in GP specialty training places (with over 4,000 doctors accepting GP specialty training places in 2022, compared with 2,671 in 2014), which is beginning to increase frontline capacity.

As reported in Practice Nurse (June-July 2023) investment in additional direct patient care staff in primary care, has resulted in more than 29,000 FTE staff in post now compared with March 2019. However, there are currently 427 fewer FTE fully qualified GPs than in May 2022. The total number of GPNs is also lower (by 163) than this time last year.

With full implementation of the plan over the longer term, the NHS total workforce would grow by around 2.6–2.9% a year, with an expansion of the NHS permanent workforce from 1.4 million in 2021/22 to 2.2–2.3 million in 2036/37, including an extra:

• 60,000–74,000 doctors
• 170,000–190,000 nurses
• 71,000–76,000 allied health professionals (AHPs), and
• 210,000–240,000 support workers alongside the expansion of new roles such as physician associates and nursing associates, and greater use of apprenticeships.

If the plan is fully implemented, by 2036/37, this will be equivalent to the number of nurses per 1,000 population growing to around 9.5, and the number of doctors per 1,000 population growing to around 4.3, in the NHS in England.

To help facilitate an optimised skills mix, NHSE says it will train more nursing associates (NAs), with 5,000 NAs due to start training in 2023/24 and 2024/25. This Plan estimates a need to incrementally increase that number to 10,000-10,500 per year from 2031/32.

In general practice, NHSE will seek to extend the success of the Additional Roles Reimbursement Scheme (ARRS), which has delivered an additional 29,000 multiprofessional roles in primary care. This would build extra capacity and free up available appointments by increasing the number of non-GP direct patient care staff by around 15,000 and primary care nurses by more than 5,000 by 2036/37.

It is estimated that one in five people who go to their GP do so with concerns that cannot be addressed with medical treatment. Therefore, there will be potential expansion of posts by 2036/37 for:

• Care coordinators (from 4,000 to 12,000)
• Health and wellbeing coaches (from 1,000 to 6,000)
• Social prescribing link workers (from 3,000 to 9,000)

Beyond core terms and conditions, which are outside the scope of the plan, the NHSE says it will need government to support the plan by providing the necessary continued and sustained investment in infrastructure, reforming education funding and strengthening social care provision.

• Infrastructure – Significant training expansion and workforce growth are only possible if there is sufficient physical capacity for staff to be trained in and work in. Continued and sustained investment in NHS estate and equipment, including in primary care, will be critical to achieving the labour productivity ambitions in this Plan. It also requires sustained investment in technology and digital innovation to modernise the environment NHS staff work in.
• Education funding – NHS England and the Department of Health and Social Care (DHSC) are working together to reform the funding of healthcare education and training
• Social care provision – Health and care services are interdependent, and if efforts in this Plan to tackle the current challenges in the NHS are to yield success, then capacity needs to increase across both

The current NHS workforce largely concentrates on responding to care and health needs rather than prevention. The NHS Long Term Plan identified the service changes needed to deliver an NHS fit for the 21st century. These include boosting primary and community care, focusing on population health, integration and prevention, investing in mental healthcare, diagnosing cancer earlier and making sure everyone with cancer has access to a clinical nurse specialist or other support worker, and having an efficient NHS focused on outcomes. However, according to OECD data, in the UK, more healthcare spending is allocated to hospital services than its peers, and less to preventative medicine, residential and outpatient care. For example, the number of full-time equivalent (FTE) nurses working in adult hospital nursing grew by almost 4.6% in the year to February 2023, while the number working in community nursing grew by 2.7%.

RETENTION

While training more staff is critical, if the NHS does not improve staff retention, then NHS workforce shortfalls will continue to persist. Various factors influence why people leave the NHS workforce. In 2022, where people have chosen to leave, some of the most common reasons were pay and reward, work-life balance, progression and continuing professional development (CPD), as well as health and wellbeing.

NHSE says: ‘Currently, staff across the country are working in hugely pressured environments. We must recognise the influence that staff shortages have on organisational culture, and an individual’s experience at work and their decision to leave. In addition to the actions set out here, increased workforce supply will help achieve the retention ambitions in this plan.’

• Everyone working in the NHS should be recognised and rewarded fairly to help ensure we attract and retain the staff we need to provide the best possible care for patients.
• Every staff member should be given the opportunity for regular conversations to discuss their wellbeing and what will keep them in work
• Looking after the health and wellbeing of NHS staff is paramount: monthly NHS staff sickness absence rates peaked in January 2022 at 6.7% and are now declining, although rates remain higher than those observed pre- pandemic. Anxiety, stress, depression and other mental health illnesses remain the most commonly recorded reason for sickness absence. ICSs need to develop and implement plans to invest in occupational health and wellbeing services
• Reforming the system of regulation for healthcare professionals, making it faster, fairer, more flexible and less adversarial
• NHS staff need to be supported to meet their full potential. A continuous approach to the development of staff skills, knowledge and expertise is vital to the provision of high quality care, supporting, delivering and leading high quality research, maintaining professional registration and ensuring staff have rewarding careers. Ensuring staff have access to continuing development, supportive supervision and protected time for training is a core responsibility for all employers. From 2020, employers began receiving national funding equivalent to £1,000 per person over three years to support the personal learning and development of all nurses, midwives and AHPs working in trusts and in general practice
• Flexible working – Expectations of work and work-life balance are changing. Across the NHS, staff want opportunities to work more flexibly and this is key to attracting and retaining talent. Recognising some professions, such as nursing, have a high proportion of women who are likely to have parental and/or caring responsibilities, flexible working is critical
• Career framework – In 2023/24, NHS England will work with partners to develop a national, multiprofession, integrated community and primary care core capability and career framework to support workforce development. This framework will inform flexible career pathways and support staff retention

REFORM

Growing the NHS workforce, on its own, is not enough to ensure the NHS can meet the changing needs of patients. We need staff to work in different ways, including with each other and with patients, and for clinicians to be able to spend more time with patients providing high quality care.

To meet the changing healthcare needs of the population in a cost-effective way, the NHS workforce will need to take full advantage of digital and technological innovations, including artificial intelligence (AI) that can be used to provide:

• Diagnostic support
• Administrative automation: Some studies have shown that over 70% of a clinician’s working time is spent on administrative tasks and 44% of all administrative work in general practice can be mostly or fully automated. A number of general practices have already begun to use speech recognition technology to record clinical documentation, minimising manual record keeping and improving the quality of data input. This could save an estimated one minute per patient consultation, which equates to approximately 5.7 million hours of GP/GPN consultation time
• Remote monitoring: Bringing diagnostics and monitoring closer to the patient across primary, community and acute services provides up-to-date intelligence to support care decisions, relieve pressure on the workforce and empower patients to self-manage conditions, and facilitates earlier detection of escalation of conditions.

NEXT STEPS

The plan recommends actions at every level of the NHS, and NHSE has committed to refreshing the plan at least every 2 years to ensure it remains accurate and up to date.

Working with ICBs, NHSE intends to deliver 10 outcomes-based functions:

• Supporting the health and wellbeing of all staff
• Growing the workforce for the future and enabling adequate workforce supply
• Supporting inclusion and belonging for all, and creating a great experience for staff
• Valuing and supporting leadership at all levels, and lifelong learning
• Leading workforce transformation and new ways of working
• Educating, training and developing people, and managing talent
• Driving and supporting broader social and economic development
• Transforming people services and supporting the people profession
• Leading co-ordinated workforce planning using analysis and intelligence
• Supporting system design and development.

REACTION

RCGP chair Professor Kamila Hawthorne said: ‘The NHS relies on its people, not least GPs and our teams who make the vast majority of patient contacts, in the community where patients want care most, and in doing so alleviate pressures across the rest of the service. For 75 years, the NHS has delivered care at the point of need for anyone who needs it – but it is under considerable, and growing, pressure, and has been in dire need of a long-term workforce plan to ensure it not only exists but is thriving in years to come.

‘This has never more apparent than in general practice. GPs and our teams are working incredibly hard to deliver millions more appointments every month than before the pandemic, with almost half of these on the day of booking. But we are doing this with 930 fewer fully qualified, full-time-equivalent GPs than in 2019.’

The plan includes some ‘encouraging proposals, particularly in terms of training more medical students, increasing capacity in GP training, and a renewed focus on retaining existing staff.

‘We already have more GPs in training than ever before, and we hope this plan means this trajectory will continue. But more GPs are leaving the profession than entering it – often earlier than planned, and citing stress and burnout as reasons. The College has been clear that any workforce plan must include initiatives to retain experienced GPs in the profession, as well as recruiting more – we particularly look forward to seeing the details of this part of the plan.

‘Looking to the future and having ambitious, long-term aspirations is important. Indeed, it’s vital, and the fact this plan is the first of its kind is historic. But we can't ignore the intense pressures GPs and our teams - indeed, colleagues across the NHS – are working under in the here and now. GPs and our teams will continue to need significant support and resource in the short term, so that we can deliver the safe, timely and appropriate care our patients need, without working ourselves into the ground.

‘The publication of this plan is undoubtedly a positive step, and one that has been a long time coming. We have been assured that this is just the beginning of a huge piece of work to ensure the NHS remains sustainable, with enough people to deliver care to patients, with increasing and changing health needs, in years to come. We need to see work begin to ensure this plan becomes a reality as a matter of urgency – and the College looks forward to working with NHS England, and the Department of Health to both retain GPs of the present, as well as train the GPs of the future.’

Doctors speaking at the recent BMA annual representative meeting described the plan as ‘trying to fill a leaking bucket’. BMA Council chair Professor Philip Banfield said the plan ‘ignores that the crisis is now, the crunch is today. Who will train the workforce, who will teach medicine when there are no medics and academics left? Investing in medical school places while refusing to reverse years of pay erosion is illogical.’

Jon Czul, Head of Consultancy and Research at Skills for Health, commented: ‘It is no secret that the NHS has been experiencing chronic skills and labour shortages for some time now. Throughout the most difficult period in its history, NHS staff have, as ever, remained resolute in their determination to keep the wheels turning and continue to deliver excellent patient care.

‘The immense pressures and strain that the workforce is experiencing, however, is clearly unsustainable, and a yawning 10% vacancy rate is a clarion call for government to take swift and decisive action.

‘As proponents of skills and workforce development, we are pleased to see a firm commitment from government to delivering a long-term and sustainable workforce plan for the NHS.

‘The intention to train more frontline staff, while ramping up efforts to upskill and retain experienced staff, should help to alleviate some pressures on the service and will therefore be welcomed by patients and NHS organisations alike.

‘As ever, the devil is in the detail and recognising that while this is only a starting point, it at least sets out an ambition (if not a fixed roadmap) to begin to tackle the NHS’s workforce challenges.’