New proposals to solve staffing shortages in the NHS focus on training more staff and retaining those already working in surgeries, clinics and hospitals. But the plan may be insufficiently ambitious; and it requires more effective processes to evaluate the outcomes.
The long-awaited NHS national long-term workforce plan was unveiled on 30 June 2023. The report comes at a pivotal moment in NHS history, coinciding with July’s celebrations of the organisation’s 75th birthday, but also with a point of crisis.
The NHS is beset by strikes, a high level of staff vacancies (with 10% of nursing posts vacant), long waiting times and fewer people being treated than before the Covid-19 pandemic. All this means that more patients than ever before are waiting for treatment.
Of the challenges faced by the NHS – and discussed in the workforce plan – the current crisis of workforce retention is the least tractable.
While the plan sets out to solve this issue, unfortunately, the proposals lack novelty. Comparing them with similar past efforts to improve NHS retention indicates that while the plan is focused on the right issues, it is unlikely to deliver the stated target of preventing up to 130,000 workers leaving the NHS over the next 15 years.
Missing the retention target raises fundamental questions about the overall achievability of the plan’s objective, namely to close the gap between healthcare demand and supply in the context of an ageing population.
What are the main proposals?
The plan is organised around three pillars: train, retain and reform. Proposals under the 'train’ pillar captured headlines. The plan sets out to double medical school places by 2031 and shorten medical degrees by one year. GP training places will increase by 50%.
There will also be a large rise in nurses and midwives trained and an expansion of apprenticeships across the NHS, including in new more generalist roles. Many health leaders have welcomed the focus on long-term workforce needs, an area on which the NHS has historically been weak.
But if newly trained workers cannot be kept in their roles, then increasing training places will be a waste of money and do little to resolve the workforce crisis. A hospital consultant writing in the BMJ (published by the British Medical Association) notes that ‘you can’t recruit yourself out of a retention crisis’. And the NHS is certainly in a retention crisis: a record 170,000 workers left their NHS jobs last year.
The plan states that by improving culture, leadership and wellbeing, rates of workers leaving the NHS will be reduced from 9.1% to between 7.4% and 8.2%, saving 55,000-128,000 full-time workers over the plan’s 15-year horizon.
The goal is to reverse the post-pandemic spike in staff quits, and to return to rates that were in the low to average range observed between 2015 and 2019. That would be an improvement of between 0.9 and 1.7 percentage points. But how realistic is this goal?
What does evidence from economic research tell us?
Between 2017 and 2020, NHS Improvement – the hospital care supervisory body now merged into NHS England – oversaw the Retention Direct Support Programme (RDSP). This policy provided information to NHS trusts and supported them in carrying out actions that would best address their own retention challenges. The goal was simply to improve trusts’ retention rates.
A careful evaluation of this policy shows that participation in the RDSP programme for more than 12 months reduces the NHS leaver rate by 0.5-0.6 percentage points (Sayli et al, 2022).
Many of the actions taken by trusts in the RDSP correspond to themes referred to in the workforce plan. The ability of the new plan to deliver even larger changes than the RDSP crucially depends on the extent to which the proposed activity differs from ‘business as usual’.
Given that most NHS trusts looked at their retention through a similar lens in 2017-19, it is questionable how many new lessons there are to learn. Much of the language used in the 2023 plan comes directly from the 2020/21 NHS People Promise.
On the other hand, the pandemic was hugely disruptive, suggesting that trusts may now face new workforce problems that were not addressed in the previous policy. The lesson from the RDSP is that encouraging employers to assess and react to their own workforce issues is effective.
But on balance it seems questionable whether the retention focus of the new workforce plan will be able to shift the dial on retention more than the original RDSP did. If we assume that the retention policies will have comparable effects to the RDSP, the 0.6 percentage point improvement that would result is clearly short of the 0.9-1.7 goal expressed in the plan.
Broader evidence confirms that working conditions matter for healthcare workers. The plan mentions the importance of promoting ‘autonomy, belonging and contribution’, factors highlighted by recent economics research as being key to generating meaningful work (Cassar and Meier, 2018).
Meaningful work is valued by workers and encourages them to remain in employment (Mas and Pallais, 2017; Gallus, 2017; Hoffman and Taledis, 2021). The plan assumes that NHS productivity grows by 1.5-2% per annum as a result of policies outlined in the ‘reform’ section. Evidence (including updated results from the evaluation of the RDSP intervention) suggests that improving working conditions also benefits health outcomes.
The plan stresses the importance of staff engagement for retention and the need to monitor engagement through the NHS staff survey. Related research demonstrates that nurse engagement is an important predictor of nurse retention within trusts (Moscelli et al, 2022), a result confirmed in a report from the Institute for Fiscal Studies (IFS) (Kelly et al, 2022).
But this is not the end of the story, as retention of experienced nurses is highly predictive of hospital consultant retention (Moscelli et al, 2022). The new plan emphasises the importance of taking a holistic rather than a piecemeal approach to improving workplace culture and retention, which is in line with the interrelationships observed in research.
Despite the new plan being published against a backdrop of strikes over pay, there is little said about the role of remuneration in attracting and keeping NHS workers. Most previous research suggests that healthcare workers have relatively muted labour supply reactions to pay (Crawford et al, 2015; Lee et al, 2019). This has been interpreted as indicating that healthcare workers have strong ‘pro-social’ motivations – they are not just in it for the money.
Nevertheless, a study analysing variations in the relative value of centrally set NHS salaries across areas finds that relatively low pay worsens hospital quality, leading to more deaths from heart attacks (Propper and Van Reenen, 2010).
This suggests that healthcare workers do react to pay in some dimension, and it raises questions about whether the workforce plan’s objectives are achievable if NHS pay rises continue to lag behind the private sector.
How relevant is the evidence?
The recent evaluation of the RDSP provides a good guide to the likely effects of the 2023 plan on retention because the actions proposed, in so far as we can tell, are similar. But reading across from the 2017-19 RDSP does not take account of the substantial shock caused to the NHS and its workers by the pandemic.
Further, the plan provides insufficient detail on exactly which activities will be conducted to improve retention, generating considerable uncertainty about its likely effects.
As mentioned above, low relative pay may undermine efforts to increase staffing and productivity in the NHS. The macroeconomic and political context that will underpin NHS pay settlements in the next 15 years is unknown.
Even if earnings trends could be predicted, there is little good evidence on how NHS staff will react. There is only one study based on variation in wages, based on data from the period 1997-2006 and focused on the effect of nurses’ pay on a heart attack deaths (Propper and Van Reenen, 2010). There is also limited evidence on broader labour supply reactions to variations in pay.
In the next 15 years, the number of people over 85 in the UK is predicted to rise by 55%, making the healthcare demand predictions in the workforce plan grim reading. The proposals should be praised for taking steps to think creatively about how new training and work approaches can help to equip the NHS to meet these challenges.
But the evidence on what works in the healthcare workforce is still scant. The NHS already has detailed administrative data, which are being increasingly used for research. But there are inherent difficulties in identifying causal effects in a national healthcare system where policy changes are made across the board.
Consideration should therefore be given to designing policies with a careful eye on how their success can be evaluated. Medical trials are common of course, and this form of analysis has been extended to education through the work of the Education Endowment Foundation.
More consideration should be given to how the evaluation of experiments can be used to understand how best to use NHS human resources, the organisation’s most important asset.
Where can I find out more?
- NHS long-term workforce plan: Proposals published 30 June 2023.
- Staff engagement, job complementarity and labour supply: evidence from the English NHS hospital workforce: Institute of Labor Economics paper by Giuseppe Moscelli, Melisa Sayli and Marco Mello.
- Medical labour supply and the production of healthcare: IFS report.
- Factors associated with staff retention in the NHS acute sector: IFS report.
Who are experts on this question?
- Jo Blanden
- Elaine Kelly
- Marco Mello
- Giuseppe Moscelli
- Carol Propper
- Melisa Sayli