Managing the supply of NHS clinical staff in England Contents

1Staffing shortages

1.On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department), Health Education England, NHS England and NHS Improvement1, on managing the supply of NHS clinical staff in England.2

2.In 2014, some 824,000 full-time equivalent clinical staff were employed in the NHS in England, providing hospital care, ambulance services, community health services, mental health services and primary care. Clinical staff make up over two-thirds of the total NHS workforce, and include some 141,000 doctors and 329,000 nurses, midwives and health visitors. Clinical staff are needed to treat and care for patients, and may have other responsibilities such as supervising more junior staff, managing teams and contributing to organisational leadership.3

3.New staff need to be supplied to replace those who leave, to meet changing demand for services and to cover shortfalls. The supply of staff can involve, for example, training new staff, recruiting from overseas, or using temporary staffing. The total number of NHS clinical staff increased by 1.4% per year on average between 2004 and 2014.4

4.The Department is ultimately accountable for securing value for money from spending on health services, including on training and employing clinical staff. Health Education England is responsible for providing leadership and oversight of workforce planning, education and training. It and its 13 local education and training boards develop national and regional plans and commission the training of new clinical staff. It spent £4.3 billion on training places in 2014–15, and around 140,000 students are in clinical training at any one time.5

5.Healthcare providers, including NHS trusts and NHS foundation trusts, are responsible for employing staff and supporting clinical placements. The cost of employing enough staff to meet the demand for healthcare has a significant impact on providers’ financial position and sustainability. Clinical staff cost around £43 million each year to employ and account for around half of healthcare providers’ costs, so the need to manage the supply of these staff effectively is particularly important given the financial pressures that the NHS is currently facing.6

6.Ensuring there are enough clinical staff with the right skills to meet the demand for high-quality, safe healthcare is essential to the operation of the NHS. However, the staffing gaps in the NHS indicate that the supply of staff is not currently meeting demand. In 2014, there was a reported overall staffing shortfall of around 5.9%. This equated to a gap of around 50,000 clinical staff, with shortfalls varying between different staff groups and regions. This undersupply of staff could lead to longer waiting times for treatment and shortcomings in the quality of care and patients’ experience.7

7.NHS bodies should prioritise retaining existing clinical staff as this is cheaper than training new staff. The limited available data suggest that the proportion of all staff (including non-clinical) leaving the NHS increased from 7.9% in 2010–11 to 9.0% in 2014–15; and, within NHS hospital and community healthcare services, the proportion of nurses leaving increased from 6.8% in 2010–11 to 9.2% in 2014–15.8 The Department told us that there is no simple answer to who is responsible for managing the staff they employ. NHS Improvement said that it aimed to support trusts in terms of staff satisfaction, productivity and retention. The Department accepted that there was no enough data on why clinical staff leave the NHS and where they go when they leave, and that a more systematic approach was needed to obtaining feedback and doing exit interviews when people leave trusts.9

Efficiency targets and safe staffing

8.Each year trusts submit local workforce plans to Health Education England and financial plans to the NHS Trust Development Authority or Monitor. NHS Improvement told us that the link between financial plans and workforce plans had historically been poor, and that trusts were challenged when plans were inconsistent. The National Audit Office reported that trusts’ workforce plans were determined to a large degree by financial considerations.10

9.In recent years trusts have been under pressure to make efficiency savings. The Department and more recently Monitor and NHS England set trusts efficiency targets of 4% in real terms each year from 2012–13 to 2014–15, and expected trusts to submit financial plans and workforce plans that would meet these challenging targets. Trusts had forecast that significant efficiencies would come from staff costs, which account for around two-thirds of their costs. Each year acute hospital trusts planned for around £1 billion in recurrent pay savings, although in practice they achieved less than two-thirds of these efficiencies.11

10.NHS Improvement said that the efficiency targets created downward pressure on trusts’ workforce plans. Trusts typically understated how many staff they would need in order to align their financial plans and workforce plans. NHS Improvement accepted that the 4% efficiency target in 2014–15 was unrealistic.12 We also concluded in our recent report on the sustainability and financial performance of acute hospital trusts that the efficiency targets for providers set by NHS England and Monitor were too optimistic. The 4% efficiency target was driven by the shortage of resources available across the NHS overall, and historically the NHS has only been able to achieve efficiency savings of 1%–2%.13

11.At the same time as trusts were under pressure to meet efficiency targets, a greater focus on care quality led them to increase their demand for nurses in particular.14 Reports in 2013 on the failings at Mid Staffordshire NHS Foundation Trust had highlighted the importance of staffing to the quality of care. Subsequent safe staffing guidance published by the National Institute for Health and Care Excellence (NICE) in July 2014 had noted there was increased risk of harm associated with a registered nurse caring for more than eight patients during daytime shifts.15

12.The Department told us that many trusts had interpreted the ratio of one nurse to eight patients as a requirement, when it was not intended to be. NHS Improvement said that trusts felt under particular pressure to commit to additional staffing before or after an inspection, and the Department noted that trusts’ perception of what the Care Quality Commission expected led them to feel that quality was more important than managing cost. Health Education England said that trusts could not recruit as many permanent nursing staff as they considered they needed and so filled the gaps, in part, with bank, locum and agency staff. NHS Improvement explained that trusts’ perception of the inspection regime and that they needed to meet NICE safe staffing guidelines had been the main driver of cost increases.16

13.The Department told us that decisions about the staffing needed to provide high-quality care had to be taken within each trust. NHS Improvement said that trust boards needed to exercise judgement when setting staffing levels and that in recent years boards may have been too risk averse.17 The Department told us that trusts should be aiming to achieve “sustainable quality”. It accepted that it should have questioned how aligned workforce plans and financial plans were, but steps were now being taken to consider finance and quality together. NHS Improvement and the Care Quality Commission had written to trusts about the need to achieve quality in a sustainable way within the resources available.18

14.The Department also told us that Lord Carter’s review of productivity in the NHS had highlighted huge variation in the way trusts approached staffing.19 NHS Improvement said that it was building stronger regional teams to support trusts, and suggested closer working was required to understand what level of savings was reasonable.20

Supply of nurses

15.The number of new nurses being trained has not been sufficient to meet increased demand. In light of the economic downturn and predictions about reduced demand, the Department cut the number of nurse training places in four consecutive years; 11,500 places were commissioned in 2012–13 compared with nearly 14,900 in 2008–09.21 However, by 2014, trusts’ needed 24,000 more nurses than they had forecast two years earlier in 2012. Therefore, as it takes three years to train a nurse, fewer nurses were qualifying as demand was increasing.22

16.Health Education England increased the number of training places from 2013–14 onwards. It told us that these nurses would soon start to enter the system, with 800 more newly qualified nurses in 2016.23 However, it predicted that until 2019–20 there would be a gap between the demand for additional nurses and those finishing their training.24

17.The supply of nurses has also been affected by reductions in the numbers returning to practice and being recruited from overseas. The National Audit Office found that there is limited regional or national coordination of overseas recruitment or return-to-practice initiatives, despite the fact that providers may be competing for the same staff.25

18.Recruitment from outside the UK has been an important source of clinical staff for the NHS. However, the National Audit Office found that the number of nurses newly registered from outside the European Economic Area fell from 11,359 in 2004–05 to just 699 in 2014–15, a drop of 94%.26 The Department highlighted that, in October 2015, it had agreed with the Home Office and the Migration Advisory Committee a temporary measure to put nurses on the shortage occupation list. This should make it easier for trusts to recruit from overseas as it allows them to employ nurses from outside the European Economic Area without first needing to show that there are no settled UK workers who could fill the role, and allows applicants to be prioritised a visa. However, the Department was unclear what the long-term solution to this issue would be.27

19.The National Audit Office also reported that relatively little use is currently made of return-to-practice schemes: 4,800 former nurses and midwives completed return-to-practice courses between 2010 and 2014, compared with 18,500 between 1999 and 2004.28 The Department told us that Health Education England had taken action on return-to-practice, which was a much cheaper route for getting nurses into employment than training new staff. Health Education England also said that it was consulting on creating a new post of ‘nurse associate’ to provide more support to the nursing workforce.29 Subject to the consultation, it intended to start training the first 1,000 nurse associates later in 2016.30

20.Health Education England told us that staffing shortages were not evenly spread across the country and the rate of vacancies was specialty-specific and profession-specific. For nurses, the highest vacancy rate was about 15% in North, Central and East London. In London, the workforce tended to be younger, more diverse and more transient, and this higher turnover made London more susceptible to staffing shortages. In contrast, Health Education England also highlighted that, by and large, it had been more difficult to fill GP training places in the north and east of the country, while 100% of these places had been filled in London, Kent, Surrey and Sussex.31

Use of agency staff

21.The use of temporary staff, including from agencies, can provide trusts with flexibility to respond to short-term fluctuations in demand or in the availability of their existing workforce. However, the demand for temporary staff has risen significantly, and spending on agency staff increased from £2.2 billion in 2009–10 to £3.3 billion in 2014–15.32

22.At our evidence session on the sustainability and financial performance of acute hospital trusts in January 2016, the witnesses gave the impression that the rise in agency spending was mainly due to increased hourly rates, and blamed the agencies for charging excessive commission. NHS England said that agencies were taking advantage of the situation to charge “rip-off” fees, and the Department argued that no one had foreseen the scale of “exploitation” by agencies.33 NHS Improvement repeated this view in our session on managing the supply of clinical staff, saying there had been “abuse of the system” with “extortionate rates” charged. However, the National Audit Office reported that the rise in spending was mostly the result of trusts needing to use more agency staff, often to cover vacancies. Its analysis suggested that three-quarters of the increased spending on temporary nurses from 2012–13 to 2014–15 resulted from greater use and the rest was due to higher average hourly rates. NHS Improvement accepted that the biggest benefit would come from reducing the use of agency staff.34

23.In 2015, the Department and NHS Improvement introduced new rules aimed at controlling spending on agency staff, including new arrangements for procuring temporary staff and caps on how much trusts can pay per shift. The caps mean that an agency worker should not be rewarded more than exiting permanent staff at that grade.35 The Department aims to save the NHS £1 billion by March 2018 through the price caps, although NHS Improvement raised doubts as to whether this amount could be achieved within that timeframe. NHS Improvement told us that nine in ten organisations had breached the cap at some point, but around three-quarters of locum and agency shifts were paid within the cap. It also said that from 2016–17 providers would be mandated to use framework suppliers, who would have to pay NHS rates.36

Affordable homes

24.We asked what was being done to ensure that the lack of affordable homes was not impeding the supply of permanent key workers in the NHS, particularly in parts of London and other areas where it is expensive to rent and buy property. The Department told us that there were no specific housing bursaries for particular workers within the NHS, but that trusts could pay staff recruitment and retention premiums and high-cost area supplements. In our report on the sustainability and financial performance of acute hospital trusts in March 2016, we concluded that ultimately, until the NHS solves its workforce planning issues, including the lack of affordable homes for NHS staff, it will not solve the problem of reliance on agency staff. We also noted that the Department was looking to generate £2 billion from disposing of surplus estate during this parliament, but there was little detail on how this would be realised.37 NHS Improvement told us in our session on managing the supply of clinical staff that the NHS estates rationalisation plan required some land to be sold for homes for nurses and other healthcare staff, although the plan was still being developed.38

1 NHS Improvement brings together the NHS Trust Development Authority and Monitor.

2 C&AG’s Report, Managing the supply of NHS clinical staff in England, Session 2015–16, HC 736, 5 February 2016

3 C&AG’s Report, paras 1.2–1.3

4 C&AG’s Report, paras 1.4–1.6, 1.8

5 C&AG’s Report, paras 1.13–1.15, 1.17, 3.7

6 C&AG’s Report, paras 7, 1.3, 1.14

7 C&AG’s Report, paras 5–6, 1.9

8 C&AG’s Report, paras 3, 1.4

9 Qq 8–10

10 Qq 27–28, 36; C&AG’s Report, paras 2.3, 2.11

11 C&AG’s Report, paras 2.14–2.15

12 Qq 30, 35, 45; C&AG’s Report, paras 13, 2.11, 2.18