The publication of the first-ever NHS long-term workforce plan in June 2023 received a mixed reception. There was relief that a workforce plan had at last been published after so many years of false reports of its imminent appearance. Now commentators are analysing the plan in more detail, however and criticism is emerging. 

The plan is badly needed if the NHS is going to be able to cope with the predicted increase in demand for its services over the coming years. The NHS currently has around 112,000 vacancies and the government’s prediction is that if nothing changes then it could have a shortfall of staff of 260,000 to 360,000 by 2036/37, as the number of 85 year olds increases by 55%.

The announcement by PM Rishi Sunak, like so many other important announcements in recent times, was made first by press release that contained limited information, rather than to the House of Commons. The full plan was published the next day.

The initial response from the medical colleges, based on the government press release, was relief that the plan had finally been published and a welcome for the increase in training places.

This is an important first step towards a sustainably resourced NHS,” said Sarah Clarke, president of the Royal College of Physicians (RCP), adding that the announcement of 15,000 extra medical school places with a focus on areas of greatest need was “particularly welcome”.

The RCP also welcomed the £2.4bn in funding and the commitment to review the figures in the plan every two years.

The major healthcare think-tanks, The Health Foundation, the King’s Fund and the Nuffield Trust, all published responses welcoming the plan and its commitment to train more staff. 

With the Health Foundation noting that ‘The headline commitment to train more doctors, nurses and other medical staff is a huge step forward.’ and the King’s Fund noting that it was a ‘landmark moment’ and an ‘essential first step to overcome the current workforce crisis’.

However, many organisations noted that little assessment of the plan could be made due to the lack of detail on measures to retain staff, improve the culture and how exactly funding will be provided. The BMA noted that:

“As ever, the devil will be in the detail – especially when it comes to funding – and we await the full publication to make a proper assessment.”

The 151-page document is now being analysed by the Royal Colleges and other organisations to really get to grips with what exactly the plan contains and how it will be implemented.

The government believes that the plan will provide for around 300,000 more doctors, nurses, and other healthcare staff by 2037 achieved by increased training, staff retention and reform. 

Criticism of the plan is already beginning to emerge, however, in particular with the funding and timing of training. Whilst welcoming the expansion of training places, the need for sustained funding was noted by several of the Royal Colleges’ responses to the plan, including the Royal College of General Practitioners (RCGP) and the RCP. The £2.4bn is only for five years.

Furthermore, the expansion of places is not set to begin until September 2025 for university medical school places and GP training places and the Department of Health and Social Care did not respond to a request from the Guardian as to when universities would begin educating the 10,000 extra student nurses a year.

Another issue noted by the HCSA is that there is already “a bottleneck of trainees unable to progress into specialisms because of a lack of consultants and placements to train them, and the plan was “worryingly vague” on how it would address this.” 

The HCSA and BMA are concerned about the plan to cram the already packed five year curriculum of medical degrees into four years in an attempt to get doctors onto the wards quicker and to introduce medical apprenticeships.

They say that this risks producing future generations of doctors who do not have the same skills as today’s medics, notably the ability to build a rapport with patients and talk to them in terms they understood.

Prof David Strain, the chair of the BMA’s medical academic staff committee, said: 

“There would also be concerns as to what could be omitted from an already crammed course. A broad understanding of the diagnostics and interventions is clearly essential, therefore we would be concerned that the ‘softer skills’, such as communication skills, research and education, could be disadvantaged.”

The most striking thing about the plan is the total absence of any mention of pay and its importance in retention. The NHS is currently experiencing a wave of strikes over pay involving a broad spectrum of clinical staff, the latest being consultants and radiographers, yet the plan makes no mention of pay whatsoever. 

Pay is “the elephant in the room” according to the Hospital Consultants and Specialists Association, and the BMA noted that:

“Training new doctors will be to no avail if they don’t stay in the workforce, so the focus on retention is important – but doctors need to be valued fairly for their work and expertise or they will leave for better-paid jobs elsewhere. This plan is set up to fail if doctors’ pay continues to be eroded, the pay review process continues to be interfered with and pay disparities across the public health system persist.”

A recent analysis of NHS workforce statistics by the Observer found that a record number of nearly 170,000 workers left their jobs in the NHS in England last year. This includes more than 41,000 nurses that left NHS hospitals and community health services, the highest leaving rate for at least a decade. 

The plan’s section on retention mentions flexible working and health and wellbeing support. It notes that every staff member should be given the opportunity for regular conversations to discuss their wellbeing and what will keep them in work.

However, HSJ has also just reported that NHS England will not provide enough funding to run staff mental health and wellbeing hubs this year. The money allocated is way below current running costs, and HSJ notes that this “appears to confirm fears that many of the 40 hubs will need to be shut, if they are not funded locally.”

Recent reports have highlighted racism and bullying within the NHS. The most recent GMC annual national training survey found more than a quarter (28%) of trainees saying they had heard insults, stereotyping or jokes relating to their or another person’s protected characteristics in their post. This shows how much work needs to be done to make the NHS a safe and supportive place to work for everyone. 

The outgoing president of the Royal College of Psychiatrists, Dr Adrian James, warned a few days ago that racism is “a stain on the NHS” and tackling it is key to recruiting and retaining staff. 

Finally, how do the funding plans stack up?  The £2.4bn for increased training covers just five years and further funding will be dependent on political decisions from 2028 onwards. There is no specific funding for the retention part of the plan, as Amanda Pritchard, CEO of NHS England, admitted to the Public Accounts Committee (PAC) session on urgent and emergency care earlier this month. 

With no funding except for the £2.4bn, the plan is relying on assumptions of a 1.5-2% productivity increase, which the plan notes is “ambitious”, plus the power of AI and other technological advances to deliver care outside hospitals in cheaper locations. 

There has been some scepticism about whether this productivity figure is possible and whether AI can really save money.

David Oliver, NHS consultant, writing in the HSJ, noted that the plan “makes magical assumptions about productivity increases and the power of digital technology, including AI, to transform service delivery. But we cannot currently know this and will be proven to be true, and recent experiences with NHS IT aren’t encouraging.”

Although desperately needed, it is clear that many things will hamper the plan’s execution, including funding and the fact that it ignores pay. Furthermore, the NHS will continue to be affected by the growing crisis in social care. 

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