The NHS has turned 75. To coincide with that anniversary, the government published the health service’s long-term workforce plan last week. It’s both an early and late birthday present: the government initially planned for it to be released this time last year.
With £2.4bn of new funding, the plan aims to vastly increase the number of medical professionals in the NHS, as it struggles to cope with workforce shortages and an ageing population. Medical school training places will double; GP training places will rise by 50 per cent; and the amount of nurse and midwifery student placements will double to 24,000 – all by 2031.
The government described the 15-year plan as “a once in a generation opportunity to put staffing on a sustainable footing”. But the strategy’s practicality, financial worries and political uncertainty have many within the health sector worried about the plan’s sustainability.
Vacancies in the NHS stand at over 112,000. A new generation of medical workers will help reduce that figure, but they will take years to train. Therefore, the plan must also compel existing NHS staff – who have taken frequent strike action in the past year because of a decade of dwindling real-terms pay – to stop leaving in record numbers.
But there is nothing tangible in the plan – no new funding or financial incentives, for example – to incentivise the existing workforce to stay. Despite the government labelling training and retention as the two key facets of the strategy, the entirety of the plan’s £2.4bn funding will exclusively be spent on training staff.
Many doubt a striking workforce can be retained on a budget of £0. “If it’s going to be £2.4bn… just for the training,” the Tory MP Mark Francois asked Amanda Pritchard, the head of NHS England, in an unconvinced tone at a Public Accounts Committee session on 3 July, “are you saying that all the other initiatives in this plan… are ultimately going to be revenue neutral? Is that what you’re telling us?”
Pritchard replied that this was “absolutely the basis of the calculations” of the NHS’s negotiations with the government over the plan’s financing. She pointed to other government interventions, outside of the workforce plan’s remit, to entice NHS staff to stay. Pritchard said the abolishment of the lifetime tax-free pension allowance cap, announced last year, is hoped to convince consultants to stay and perform outpatient appointments, as opposed to leaving or retiring early. But this would likely have a limited effect: according to the government’s own figures, only 105 doctors left the NHS due to early retirement in 2021-22.
The plan promises a “renewed focus” on retention, “better opportunities” for career development, and more flexible working options. What that actually means remains to be seen. The first stumbling block on retention is “obviously pay”, Matthew Taylor, the chief executive of the NHS Confederation, told Spotlight. The confederation represents various healthcare groups. It’s important to note, he added, that “staff have accepted their [2022-23] pay settlement”. But, if inflation continues to remain high throughout the rest of the year, then healthcare staff could face another real-terms pay cut.
It’s “quite obvious”, Taylor added, that money being a big factor behind the depleted workforce’s ability to cut waiting lists. That means two of the Prime Minister’s five pledges – halving inflation and reducing the NHS waiting list – “are in tension”. The British Medical Association said the lack of plan to address pay in the strategy to retain staff was “illogical and uneconomical”, and wouldn’t stop the exodus of doctors from the NHS.
There’s another existential financial consideration surrounding the workforce plan that the NHS, and the next government – whatever colour – will have to contend with: future funding in an uncertain economic context.
Despite it being a 15-year plan, there is no reference in the strategy to how it will be funded after the initial five-year period the current government has committed to. “The point is, if there’s a plan that’s going to be delivered over 15 years… [but] there’s a [future] decision not to fund it any further, then the plan would not deliver,” hypothesised Meg Hillier, the chair of the Public Accounts Committee, during the 3 July session with Pritchard. There is also ambiguity over how the extra £2.4bn is being financed: Steve Barclay, the Health Secretary, refused several times on a recent Sky News appearance to confirm whether the cash injection would be financed by tax rises, cuts to other public services or borrowing.
“To make any kind of [government] commitment for five years is as good as you’re going to get,” said Taylor, acknowledging the future volatility of the plan’s finances. What would it mean for the scheme’s future funding if Labour – which recently diluted its £28bn green capital spending pledge – forms the next government, considering its tight rules on fiscal discipline? “Because there’s a 15-year commitment,” said Taylor, “if Labour wasn’t to continue with it, they’d have to explain why. And that’s why we wanted a long-term plan – because we wanted some accountability over the medium-to-long-term.”
The NHS workforce plan has been six years in the making, with stakeholders such as the Department of Health and Social Care, the Treasury, NHS England, unions and other health groups, covering various disciplines, involved in shaping the strategy.
Inevitably, each group has its own wins, concessions and compromises in the final product. A universal concern is that productivity targets will not be met without sufficient capital investment in NHS infrastructure. But there’s also factional tensions across different health bodies. The NHS Confederation is, Taylor said, “in favour” of the plan’s ambition to potentially shorten medical degrees and train more staff through apprenticeships. However, there is some trepidation from the royal colleges that represent different health disciplines about the viability of the proposals: the Royal College of Anaesthetists, for example, said that it requires a “robust evidence base” to determine whether it can be “implemented… [and] not negatively impact on quality and consequently on patient safety and NHS productivity”.
Amir Khan, an NHS doctor and author, labelled the idea of an apprenticeship scheme for doctors as “ludicrous”. He added: “Patients need quality care, they need to trust their clinician has had the appropriate training to treat them safely.”
The government has committed to refresh the workforce plan every two years to “help meet future requirements”. Both the political and economic context of those future refreshers will have an impact on how the full 15-year plan is implemented. “This plan is a very useful document,” said Taylor, “partly because of the quality of the modelling that went into this; it’s not just a set of opinions and ideology – there’s some really deep thinking.
“We fully support the plan – but there are a number of things which could mean that it has less impact than one would hope it would.”