Managing the supply of NHS clinical staff in England Contents

2Informed decision-making

Funding training places

25.Health Education England provides funding to higher education institutions, to providers for clinical placements and to students to cover some tuition fees and living costs. In the 2015 Spending Review, the Government announced plans to reform the funding system for health students by replacing grants with student loans and abolishing the cap on the number of student places for nursing, midwifery and allied health subjects.39 Written submissions to us from a number of royal colleges and other bodies raised concerns that replacing grants with loans would deter many people from applying. In particular, they suggested the change might act as a disincentive to applicants from lower income backgrounds, women, mature students, people with caring responsibilities, and those from black and minority ethnic communities. They also pointed out that people training to become health care professionals had to attend clinical placements, and therefore had less time for part-time or seasonal paid work.40

26.Health Education England told us that it did not know whether the funding changes would deter people from applying, or whether the changes would disproportionately affect certain groups such as mature students or those with children. It said that currently there were about three applicants for every nurse training place and that the introduction of student tuition fees for other courses had not deterred people from applying. It intended to use the £150 million it spent each year on clinical placements for nurses and allied health professionals to incentivise people to work in geographical areas or specialisms that may be less popular.41

27.Trusts also receive funding from Health Education England to cover half of the basic salary costs of junior doctors.42 Health Education England told us it considered it was appropriate to pay a proportion of salary costs to cover the time junior doctors spent training; individual employers paid for the time junior doctors spent providing patient care.43 However, it also highlighted that the amount of time junior doctors had available for patient care varied significantly by specialty and stage of training. For example, a new trainee in anaesthetics could not be left without a more senior doctor supervising them, while an anaesthetic trainee in their last year of training was able to do almost everything that a consultant could do. Health Education England explained that it was conducting a review of the funding arrangements for junior doctors to assess whether the system was fair or whether it should be adjusted to reflect the time different trainees had available for patient care.44

Implications of policy initiatives

28.The need for clinical staff is expected to change in the coming years. New models of care outlined in the NHS Five Year Forward View may involve changes in the number and mix of staff as more care is provided outside of hospitals and closer to people’s homes. In addition, the Department has mandated NHS England to implement 7-day services in the NHS by 2020, which is likely to require more staff.45 The Department explained that the focus of 7-day working within hospitals was on urgent and emergency care and ensuring that senior clinical decision makers were available at weekends.46

29.However, the Department was not able to provide us with an indication of the workforce that would be needed to implement 7-day services. It told us that the workforce implications were complex, and would differ substantially from one local area to another. It was working with eight trusts to assess what the implications would be. It said that, for these reasons, it would be difficult to quantify implications precisely. It could not give us an approximate answer either.47

30.We also asked whether the NHS had the necessary funding to implement 7-day services. The Department told us that the 2015 Spending Review had committed an extra £10 billion for the NHS between 2014–15 and 2020–21, and that this included funding to meet the Government’s objectives for 7-day services as well as delivering the Five Year Forward View.48 The Department told us there is no separate pot set aside for something specifically labelled 7-day services. It said that there was considerable overlap between initiatives and that it had not separated out the money for 7-day services from the funding for the Government’s other objectives.49

Gaps in information

31.The National Audit Office reported that the data used to monitor workforce numbers are not sufficiently reliable or comprehensive to support Health Education England’s decisions. It highlighted a range of limitations in NHS clinical workforce data, including poor information on vacancy rates, course completion rates and leaver rates.50 The Department accepted that there were gaps in the data underpinning workforce planning.51 In particular, there was a lack of data on why clinical staff leave the NHS, where they go when they leave, or why they transfer between trusts, in part because exit interviews were not used to collect feedback in a systematic way.52

32.The Department and Health Education England said they were planning to fill these data gaps, through what the Department called a “workforce information architecture process”.53 For primary care, NHS England explained that it had commissioned a review of the available evidence on why GPs were leaving earlier than their retirement age. It said the review had not been asked to look specifically at the impact of changes to pension arrangements on GPs retiring early, but it had run focus groups to explore the impact of the ‘pension pot’ limit.54

33.The main source of workforce data are electronic staff records systems, which are used by nearly all trusts. However, the National Audit Office reported that there was a lack of detail for some staff and that the processes for checking the accuracy of the data were limited.55 The Carter review of productivity in the NHS found that inaccuracies in the electronic staff record meant that trusts did not have a full picture of where all their staff were and what they were doing.56

34.Health Education England draws on input from a range of experts in developing the national workforce plan. It told us it received many different sources of information and advice, including from the Centre for Workforce Intelligence, medical royal colleges and individual employers. In all, it received over 100 submissions in its annual ‘call for evidence’ in 2014.57 The National Audit Office concluded it was unclear how Health Education England had used the workforce projections submitted by the Centre for Workforce Intelligence in deciding how many training places to commission. For example, the projections showed a large oversupply of infectious disease consultants in the next five to ten years, but Health Education England did not adjust how many training places it commissioned for this speciality.58 Health Education England told us it did not make adjustments based on the advice of single organisations, but instead weighed the balance of opinion and evidence to come to a conclusion.59

39 HM Treasury, Spending Review and Autumn Statement 2015, November 2015

40 Unison, Royal College of Midwives, British Dental Association, Society of Chiropodists and Podiatrists, Royal College of Nursing, Chartered Society of Physiotherapy and the National Union of Students (NSC0004)

41 Qq 149–152

42 C&AG’s Report, para 3.5

43 Q 75

44 Q 77

45 Department of Health, The Government’s mandate to NHS England for 2016–17, January 2016; C&AG’s Report, para 1.7

46 Qq 113–114

47 Qq 106–111, 141–143

48 Q 107; HM Treasury, Spending Review and Autumn Statement 2015, November 2015

49 Qq 109, 136, 140

50 C&AG’s Report, Appendix 3

51 Q 144

52 Qq 10, 126