Despite a growing workforce, NHS staff are under real pressure. The number and complexity of the patients they care for continues to increase. Some geographies and types of job are hard to recruit to. Further challenge arises from ongoing pay restraint and uncertainty for our international staff.
Perhaps surprisingly, given these well understood pressures, frontline NHS staff say their experience at work continues to improve, with overall employee engagement scores now at a five-year high (58). But there’s still much to be done to ensure all staff – including nurses, therapists, doctors in training, support staff, midwives, health visitors and scientists – are properly supported. This chapter of the Plan summarises some of the key actions we will be taking.
What’s been achieved in England over the past three years?
- More staff, including 8000 more doctors and nurses and the highest number of GPs in training ever (59).
- New roles, including 2000 Nursing Associates in training to create both a new role and a career ladder from healthcare assistant to registered nurse, 650 new physician associates in training, and 500 new clinical pharmacists working alongside GPs.
- New routes into the NHS, including new on-the-job apprenticeship route to becoming a registered graduate nurse and over 2000 nurses completing HEE’s return to practice programme.
- Frontline staff report improved working conditions. The annual NHS staff survey (60) published in March 2017 shows another year of improvements, with NHS staff engagement scores at their highest level in five years. And across 32 key measures, over 80% were more positive than last year.
- Action taken on workplace culture and employee support. The percentage of staff witnessing potentially harmful incidents is at its lowest in five years, at the same time as the percentage of staff able to report those concerns is at its highest in five years (61). The new NHS Workforce Race Equality Standard is holding a mirror up to individual employers’ practices in supporting Black and Minority Ethnic nurses and other staff.
- The Care Certificate, introduced in 2015 for new healthcare assistants and social care support workers, sets out 15 standards that describe the fundamental skills, knowledge and behaviours that are required to provide safe, effective and compassionate care.
- 90% of NHS staff report their organisation takes positive action on staff health and well-being. Feeling unwell as a result of work-related stress is at its lowest reported level in five years, but still stands at 37%. So a new national ‘CQUIN’ incentive scheme is promoting workplace health, including musculoskeletal, mental wellbeing, and weight management. 130,000 more NHS staff got flu jabs this winter compared to last, a record high.
Key improvements for 2017/18 and 2018/19
The NHS in 2020 is going to be looking after more patients, better funded and larger than the NHS of today. We are therefore going to need to continue to improve productivity and grow our frontline workforce, especially in priority areas such as nursing, mental health, urgent and primary care. Achieving this will require more training, more recruitment, better retention and greater return to practice after time out of the workforce. It will also require flexibility as roles and places of work evolve in line with changes to the practice of medicine and the shape of health care.
More people are training to join the NHS every year than are leaving it. Health Education England forecasts at least 25,000 to 50,000 net additional clinical staff could be available for NHS employment by 2020, partly depending on the NHS holding onto the staff it already has. This will enable the NHS to reduce its dependence on agency and locum staff.
The NHS will need more registered nurses in 2020 than today, as will the social care system. HEE forecasts growth of at least 6,000 extra nurses but this could be considerably higher if the NHS successfully focuses on:
- Education and training. The number of newly qualified nurses available to be employed will increase by up to 2,200 more per year in 2019, as a result of expansion in nurse training places commissioned by HEE between 2013 and 2016.
- Retention. Improving retention to the level of two years ago would mean around 4000 more whole time equivalent nurses per year. A new nurse retention collaborative run by NHS Improvement and NHS Employers will support 30 trusts with the highest turnover.
- Return to practice. There are over 50,000 registered nurses in England not currently working for the NHS. It takes three years and £50-70,000 to train a nurse, but only £2000 and three to twelve months to retrain a returning nurse. We will target a further 1500-2000 nurses to be supported to return to work over the next two years.
- New fast track ‘Nurse First’ programme. We will consult on creating a Nurse First route to nursing, similar to the Teach First programme. It will provide financial support for graduates from other related disciplines to undertake a fast track ‘top up’ programme to become a graduate registered nurse – in the first instance targeting mental health and learning disability nursing.
- Support new Advanced Clinical Practice (ACP) nurse roles. These senior nurse roles are valuable in their own right, and also have been shown sometimes to offer a better alternative to medical locums and unstable Tier 1 hospital rotas. Training is typically service-based alongside an accredited university programme. HEE and NHS Improvement will publish a new national ACP framework, and deploy ACPs in trusts in the first instance where they can make a demonstrable impact in high priority areas such as A&E, cancer care, elective services or reducing locum costs by converting medical posts.
- Use e-rostering and effective job planning to ensure right staffing at the right time. Building on successful pilot projects for nurses and healthcare support workers in 2016/17, NHS Improvement will publish guidance on electronic rostering to ensure high quality effective care at the bedside (measured by number of care hours delivered per patient according to their clinical needs). This will help further reduce agency spend through more effective deployment of substantive staff, and will make rostering more staff-friendly through use of technology. The benefits of e-rostering and job planning will be promoted for all other staff groups, particularly allied health professionals and pharmacists, to deliver similar benefits for hospitals and their staff. NHS Improvement will focus during 2017/18 on supporting trusts in getting best value from electronic tools to support better job planning for hospital doctors, and implementing newly-issued job planning guidance. The focus will be on maximising direct clinical care time, eliminating unwarranted variation in the number of patients treated per clinic and per theatre list, and reducing extra-duty payments.
In terms of the medical workforce, while we still have fewer practicing doctors than the European average (as we also do for nurses), we have seen a 50% increase since 2000(62), and the number of consultants and GPs available to work in the NHS by 2020 is forecast to rise further.
- Undergraduate medical school places will grow by 25% adding an extra 1500 places, starting with 500 extra places in 2018 and a further 1000 from 2019. These will be mainly geared to producing more of the doctors the NHS needs such as GPs and psychiatrists. This expansion is currently being consulted upon.
- Expand GPs numbers. HEE will train over 15,000 GPs between 2015 and 2020, GP trainee numbers have gone up 10% year on year since 2015, and HEE will target a further 231 places in 2017/18 to ensure the target is met of 3,250 GP trainees per year. The initial round of applications for 2017/18 is 5% up on the equivalent stage last year. (See Chapter Three for more detail on primary care workforce expansion.)
- Tackle pressures on doctors in training. Junior doctors are a crucial part of the NHS workforce, and the NHS needs to do a better job of engaging with the senior doctors of the future. HEE, NHS Improvement, NHS Employers and their partners are committing to tackle head on non-contractual pressures confronting junior doctors. Following consultation with junior doctors over recent months, action to improve working conditions will include these first steps:
- Ensure doctors receive their proposed rota a minimum of eight weeks and final rota by six weeks before they start new rotations, as specified in the code of practice agreed by HEE, NHS Employers and the BMA. From October 2017, NHS Improvement will monitor trusts’ adherence to the six week standard monthly, with a review after six months. HEE will ensure trusts have trainee details 12 weeks before rotations begin.
- From this year, provide Specialty Training applicants with an online ‘Swap Shop’ allowing applicants to swap with others in their cohort or into vacant places, alongside an improved process for trainees wanting to move regions. Also a guaranteed training location for doctors who need to be in a particular region because of ill health or disability, or because they care for someone who is unwell or disabled.
- From April 2017, streamline the process for doctors moving between trusts to reduce the duplication of pre-employment checks, mandatory and induction training, starting at a regional level.
- Introduce, in 2017/18, a new programme making £10 million available for HEE to implement new plans with the Colleges to improve support for doctors returning to training after maternity leave and other approved time out.
- Improve engagement with senior clinicians. Guardians of safe working hours and directors of medical education will set up a junior doctors’ forum in each trust. From June 2017, NHS Improvement will make new information resources available to facilitate engagement, and work with HEE and the GMC to ensure adequate engagement is taking place.
- We commit to continuing to engage with junior doctors locally and nationally, and to taking forward proposals outlined in HEE’s recent progress report.
Action will be taken to address specific staff shortages, including:
- Emergency Medicine: HEE is running an expanded intake of the run- through ACCSEM course, and will add an extra year of 75 additional training posts.
- Endoscopists: HEE will operate an accelerated programme to train non-medical endoscopists, with the first 40 staff completing their training in 2016 and another 160 by the end of 2018.
- Ultrasonography: We will train 200 healthcare professionals in sonography by 2019/20 to support maternity services.
- Radiology: expanded training to build imaging capacity, growing the number of new CCT holders from the current average annual output of approximately 170 to 230 by 2021/22.
The NHS will continue to develop new professional roles, including doubling the number of Nursing Associates to 2000 this year, continuing to grow the Physician Associate workforce, and expanding clinical pharmacists and mental health therapists embedded in primary care as set out in Chapter Three.
Action on NHS staff health and wellbeing will be extended (63). In 2017/18 all trusts will have a plan in place to improve the health and wellbeing of their workforce. By 2018/19, the CQUIN incentive payment will be paid to NHS providers that improve the health and wellbeing of their staff by 5% (on a 2015/16 baseline), as measured by the staff survey. We are introducing the new NHS GP Health Service, to support doctors suffering from mental ill-health and addiction.
The NHS will become a better and more inclusive employer by making full use of the talents of its diverse staff and the communities it serves. On workforce race equality, over the next two years trusts are expected to show year-on-year improvements in closing the gap between white and BME staff being appointed from shortlisting, and reduce the level of BME staff being bullied by colleagues. The programme to improve the employment opportunities for people with learning disabilities will be expanded. And in 2018/19 over four-fifths of trusts, CCGs and national NHS leadership bodies will have set their baseline measurement for the new Workforce Disability Equality Standard and set out their first year action plan. The NHS will work actively with Government to safeguard and secure the contribution made by international nurses, doctors and other staff as the Brexit negotiations proceed.
Leading STPs and ACSs (see Chapter Six) will work with their staff and trade unions on ways of encouraging flexible working and ‘de-risking’ service change from the point of view of individual staff. This could take the form of an NHS staff ‘passport’ to enable, for example, nurses to work in both primary care and in hospital, helping support team-based working. Since only 52% of staff are currently satisfied with the current opportunities for flexible working, it might also mean discussing with staff side representatives and unions new options to encourage individuals who are currently choosing agency or locum work back in to substantive NHS employment. The practicability of term time contracts, seasonal hours, and annualised hours contracting will also be tested.
The national leadership bodies will take action to implement the next steps of the ‘Developing People, Improving Care’ framework for improving leadership and improvement capabilities across the health and care system, with a particular focus on systems working, building improvement skills for staff at all levels, and compassionate inclusive leadership. The framework set out a number of immediate actions in 2017/18, including making available support for systems leadership development to each STP footprint, developing the role of local leadership academies, launching a system-wide programme to address discrimination against staff with protected characteristics, supporting organisations to improve talent management, and establishing a national support function for senior leaders. We are also developing specific improvement capability programmes for boards and executive teams and for primary care practitioners, and CQC and NHS Improvement are jointly creating a single ‘Well-Led’ Framework.
Refreshed workforce planning will now confirm these estimates and requirements. HEE will publish its annual Workforce Plan in April. Local Workforce Action Boards will support their STPs in revising, updating and delivering their workforce plans.
- NHS Hospital & Community Health Service (HCHS) monthly workforce statistics – Provisional Statistics, calculated for November 2014 to November 2016 https://digital.nhs.uk/data-and-information/publications/statistical/monthly-nhs-hospital-and-community-health-service-hchs-workforce-statistics
- The annual NHS staff survey took place during September to December 2016 across 316 NHS organisations. It received 423,000 individual staff responses, 124,000 more than last year. It covers a third of the NHS workforce and is the biggest response achieved in the survey’s 14-year history.
- OECD (November 2016). Health at a Glance: Europe 2016. Shows 2.8 practising doctors per 1000 population in the UK, versus 3.5 doctors as the EU28 average.