135.At the heart of the solution to workforce burnout and resilience is one simple change, without which the situation is unlikely to improve except at the margins - namely the need for better workforce planning. There was a high degree of consensus in the submissions to our inquiry that both the NHS and social care workforce were overstretched and had been for some time. The King’s Fund told us that the current approach to workforce planning was “incoherent” and that funding for education and training was “inadequate” with a “reliance on overseas recruitment”.
136.In its written evidence, the Health Foundation set out the level of the problem:
The NHS workforce gap in 2020–21 was 115,000 FTE. This is projected to double over the next five years and to exceed 475,000 FTE staff by 2033–34 […] This does not account for any potential impacts of the covid-19 pandemic, which will take more time to quantify and understand.
The Health Foundation went on to say that to meet rising expectations for the quality and range of care provided and for services to adopt new technological advances, the NHS in England was likely to require workforce growth of 3.2% a year over the next 15 years; which “implies a requirement of a projected 179,000 additional FTE staff by 2023–24, rising to 639,000 additional FTE staff by 2033/34”. They further projected that the NHS in England faced a shortfall of 108,000 FTE nurses by 2028/29; and a shortfall of 7,000 FTE GPs in 2023/24 rising to 11,500 FTE GPs by 2028/29.
137.Alongside the figures for the NHS, the Health Foundation and the Institute for Fiscal Studies projected that 458,000 additional FTE social care staff would be required in England by 2033–34.
138.Concerns about staff shortages were reflected in NHS Providers’ 2019 survey which indicated that only 29% of Trust leaders that responded were confident that their Trust had the right numbers, quality and mix of staff in place to deliver high quality healthcare to patients and service users. That figure decreased when respondents were asked to look forward to future years, with only 18% saying they were confident of the right numbers, quality and staff mix in two years’ time.
139.Although the NHS Staff Survey for 2020 showed an overall decrease in the number of staff considering leaving the NHS, staff shortages are endemic and not limited to one area of health and social care. The Royal College of Midwives raised concerns about numbers being trained and retained in midwifery, while the Royal College of Nursing (RCN) highlighted that, going into the pandemic, there had been almost 40,000 unfilled nursing vacancies in the NHS in England alone. In July 2020 they reported that a recent survey of approximately 42,000 RCN members in England had shown that 36% were thinking of leaving the profession, up from 27% at the end of 2019.
140.According to the 2020 NHS Staff Survey, the proportion of staff considering leaving their current NHS organisation had decreased by 2% since 2019 (down from 35.8% to 33.8%) and represented an improving trend since 2018 (37.4%). (That figure included all staff considering leaving their current job other than those looking to move to another job within the same organisation.) The proportion of staff who were considering leaving the NHS altogether had decreased by 1% since 2019 (down from 19.6% to 18.2%) which also represented a year on year improvement since 2018 (21.0%).
141.However, staff shortages are not only affected by people leaving. In oral evidence, Dr Chaand Nagpaul told us that a BMA tracker survey from October 2020 indicated that around 50% of doctors said that, once the pandemic was over, they planned to reduce their working hours. In addition, Dr Nagpaul said that: “A fifth plan to retire early. A fifth plan to do a job other than being a doctor” He described that as “a serious situation” to which solutions must be found.
142.This situation is replicated in social care. The King’s Fund told us that the social care workforce was “if anything even more fragile than the NHS”; while Skills for Care pointed to estimates of approximately 122,000 vacancies at any one time, with a turnover rate of 30.8% for directly employed staff working in the adult social care sector in 2018/19. Furthermore, data modelling undertaken by Skills for Care suggested that if the adult social care workforce grows at the same rate as the projected number of people aged 65 and over in the population, then the number of adult social care jobs will increase by 32% (or by 520,000 jobs), to around 2.17 million jobs by 2035. Similarly, Anchor Hanover (a provider of housing, care and support) told us that a further one million care staff would need to be recruited by 2025 “to meet the needs of an ageing society and the implied increase in disabilities”.
143.In our report, Delivering core NHS and care services during the pandemic and beyond, published last year, we concluded that there was “no equivalent of the NHS People Plan for the social care workforce”. The absence of a People Plan for social care was also noted in the Care Quality Commission’s (CQC) latest report, The state of health and care in England. That Report made clear that urgent action was needed to tackle workforce problems in social care. It stated that the longstanding need for reform, investment and workforce planning in social care had been “thrown into stark relief” by the pandemic, and what was needed was “a new deal” for the adult social care workforce that included “clear career progression, secures the right skills for the sector, better recognises and values staff, invests in their training and supports appropriate professionalisation”. The CQC’s report concluded that the legacy of the pandemic was the recognition that “issues around funding, staffing and operational support need to be tackled now—not at some point in the future”.
144.Like a number of others who submitted to the inquiry, such as the Carers Trust and the LGA, the NHS Confederation called for a social care people plan to accompany that for the NHS. This was needed alongside wider social care reforms to “stabilise and secure the sector’s long-term future”, as well as build the ability to recruit from outside the UK into the UK’s new immigration policy.
145.In his oral evidence, Professor Martin Green of Care England also called for a 10-year plan for social care that was “aligned on every level” with the NHS Plan and included workforce issues, skills mix, support for staff and how to ensure that “we retain as well as recruit the right people”. He added that a People Plan for social care should start with “a vision for social care” and what it delivers—together with a shared competency framework across the relatively fragmented employers:
We could identify a very clear skills and competency framework. […] There is a real opportunity to have a very clear skills and competencies escalator. […]
Professor Green also recommended opening out the training and development budget to the whole system so that people from both the NHS and social care could access it. He believed that this would have the benefit of providing both a “lot of skills and training to the social care workforce” and enhancing relationships with a “understanding of what each bit of the system does”.
146.In oral evidence, Anita Charlesworth explained how a skills escalator would work as part of a wider workforce strategy across health and social care:
If you start in one job that might have a relatively low qualification requirement, you can get on-the-job training and the opportunity to progress so that you can acquire your qualifications, move into the next job and up through the system.
147.She told us the evidence was clear that “if you train local, people are more likely to stay,” She described this approach as a “win-win” as it was a benefit to the both the community and the individual. She concluded that it would also “benefit the NHS and social care systems in terms of retention” but cautioned that it should not be “just be a national policy” as there needed to be “good connection locally as well”.
148.Oonagh Smyth of Skills for Care emphasised the possibilities that new ICSs might bring and that a social care plan would facilitate more integrated local strategies. She also highlighted that more needed to be done to “align, acknowledge and understand the career pathways between social care and health”.
149.Although she told us that the NHS’s remit did not extend to social care, Prerana Issar, NHS Chief People Officer agreed that we did need a People Plan for social care: “given that health outcomes depend so much on the interaction between health and social care, we need the same kind of focus for social care”. When he gave evidence to the Public Accounts Committee on 20 July 2020, Sir Chris Wormald, Permanent Secretary, Department of Health and Social Care acknowledged that while the NHS People Plan was developed “to set out what the workforce needs are to deliver the Long Term Plan” for the NHS, he acknowledged that the case could be made for having a people plan that covered both the NHS and social care.
150.In January 2021, Sir Simon Stevens told our joint inquiry with the Science and Technology Committee into Coronavirus: lessons learnt, that he “definitely” thought that the social care system needed a 10-year plan and said that “one fitting legacy” of the pandemic should be to “once and for all to resolve the question about fair funding and reform of adult social care”.
151.In our Report, Social care: funding and workforce, published in October 2020, we called for a 10 year plan for the social care sector, a sustainable funding settlement, and improved financial conditions for workers in social care. The report asked that the starting point for a social care funding increase be an additional £7bn per year by 2023–24. The Government’s response set out the level of funding provided to the social care system during the covid-19 pandemic, along with the funding commitments made at the 2020 Spending Review. It commits the Government to “sustainable improvement of the adult social care system and will bring forward proposals in 2021”.
152.In June 2019, the Government published its Interim NHS People Plan, which set out “our vision for people who work for the NHS to enable them to deliver the NHS Long Term Plan”. In July 2020, NHS England and Improvement published We are the NHS: People Plan 2020–21. The Department of Health and Social Care’s response to the inquiry outlines the commitments made in the People Plan, which ‘focuses on strengthening resilience’ and ‘embedding the positive changes that staff saw during COVID-19.’ DHSC told us that the Plan requires employers across the NHS to:
153.The People Plan also sets out the support which is expected from employers to ensure that staff can switch off from work, in order to decrease work-related stress and burnout. Employers must make sure staff understand that they are expected to take breaks, manage their work demands together and take regular time away from the workplace—with leaders to role model this behaviour. To understand NHS people’s experience through covid-19 and recovery, the 2020 NHS Staff Survey will be adapted, with a new quarterly staff survey to track morale in the first quarter of 2021/22.
154.As part of the national Looking After Our People retention programme, NHS England and Improvement launched three local pathfinder regions on 1 September 2020. These will be used to test assumptions about how best to empower the whole workforce to feel valued, safe, productive and supported, giving regions the opportunity to try new things and share learning about best practice. Metrics to accompany and track the impact of the actions in the Plan would be developed in partnership with systems and stakeholders by the end of September 2020. From September 2020, every member of the NHS should have a health and wellbeing conversation and develop a personalised plan, and from October 2020, employers should ensure that all new starters have a health and wellbeing induction.
155.At our evidence session on 20 October, NHS England and Improvement also announced the launch of a further £15 million funding package to be spent on:
156.Our report, Delivering core NHS and care services during the pandemic and beyond welcomed the ‘important and ambitious measures’ set out to address workforce fatigue and provide mental health support in the People Plan, but called for ‘more substantive action’ to be taken to support the wellbeing of staff, especially before the busy winter period.
157.Equally, many of our witnesses have given qualified support for the People Plan. In his oral evidence, Professor Michael West described the People Plan as “a very smart looking car” but without an “engine” because it did not provide detail on:
How many of the recommendations and prescriptions in the people plan can be implemented by integrated care systems at regional or local level or and how individual trusts will be supported to implement the recommendations.
He concluded that the direction of travel was “excellent”, but more detail was required “particularly around workforce strategy”.
158.The absence of detail on the workforce strategy was a concern for a number of our witnesses. The King’s Fund described the People Plan as “another stop-gap that falls a long way short of the workforce strategy needed”, while the Royal College of Nursing said that “a fully funded, fully costed and modelled workforce strategy” was needed to “ensure that the substantial gaps in the workforce are filled”. The question of funding was also raised by the NHS Confederation who said that “too many investment decisions have been postponed or clarity has not been forthcoming, especially with the longstanding need to address vacancies”. It warned that for an exhausted workforce, “platitudes and promises need to rapidly turn into tangible solutions that are fully resourced in the upcoming spending round” which it described as “the last opportunity to ensure systemic workforce challenges do not enter an acute phase” in the approach towards winter.
159.In a similar vein, the Royal College of Psychiatrists said that “a longer-term and more detailed People Plan” was required after the Spending Review to “further expand the workforce and ensure education and training are fit for the future”. The Royal College of Physicians called for “greater clarity on the scale of plans to expand the workforce” to address the “historic levels” of understaffing in the health service, while NHS Providers told us that the Government needed to prioritise “a multi-year funding package” in the Spending Review.
160.More detail on workforce planning had been expected after the Spending Review that took place last Autumn. However, in answer to a Parliamentary Question on 2 February 2021 asking when the final report of the NHS People Plan would be published, Lord Bethell, Minister for Innovation in the Department for Health and Social Care, gave a broad-brush response:
We are working with NHS England and NHS Improvement, Health Education England and with systems and employers to determine our workforce and people priorities beyond April 2021 to support the recovery of NHS staff and of services. This will include building on many of the positive ways of working that have emerged through the pandemic whilst continuing to support the wellbeing of NHS staff.
161.It is clear from our witnesses that although the People Plan presents comprehensive ambition to address the failings in the culture of the NHS, and address the needs and wellbeing of NHS staff, its delivery will depend on the level of resourcing allocated to these priorities. Without adequate funding the laudable aspirations of the People Plan will not become reality.
163.The absence of a People Plan for social care serves only to widen the disparity in recognition and support for the social care components of health and social care. The Government should rectify this as a matter of urgency in their upcoming work to reform the social care sector; and it is essential that it is included in the social care reforms promised this year. The adult social care workforce has stepped up to the plate during the pandemic. They deserve the same care and attention that the People Plan pledges to NHS colleagues.
166.(a) Alongside […] a long term funding settlement we strongly believe the Government should publish a 10 year plan for the social care sector as it has done for the NHS. The two systems are increasingly linked and it makes no sense to put in place long term plans for one without the other. Failure to do so is also likely to inhibit reform and lead to higher costs as workforce shortages become more pronounced with higher dependency on agency staff. Reducing the 30% turnover rates typical in the sector will also require a long term, strategic approach to social care pay and conditions. (Social care: funding and workforce, Third Report of Session 2019–21, Paragraph 37)
167.(b) The social care sector needs reassurance that both the structural and financial problems it faces will be tackled by the Government in a timely way. For that reason, we recommend that a duty is included in the Bill for the Secretary of State to publish a 10-year plan with detailed costings within six months of the Bill receiving Royal Assent. (The Government’s White Paper proposals for the reform of Health and Social Care, First Report of Session 2021–22, paragraph 65)
193 The King’s Fund ()
194 Anita Charlesworth (Anita Charlesworth at Health Foundation) ()
195 Anita Charlesworth (Anita Charlesworth at Health Foundation) ()
196 Anita Charlesworth (Anita Charlesworth at Health Foundation) ()
197 NHS Providers ()
198 NHS Staff Survey Co-ordination Centre, , accessed 28 April 2021
199 Royal College of Midwives ()
200 Royal College of Nursing, , accessed 27 April 2021
201 NHS Staff Survey Co-ordination Centre, , accessed 28 April 2021
202 , Dr Chaand Nagpaul CBE, Chair, BMA Council
203 The King’s Fund ()
204 Skills for Care ()
205 Skills for Care ()
206 Skills for Care ()
207 Anchor Hanover ()
208 House of Commons Health and Social Care Committee, , HC 320, para 141
209 Care Quality Commission, , accessed 27 April 2021
210 Carers Trust ()
211 LGA ()
212 NHS Confederation ()
213 , Professor Martin Green OBE, Chief Executive, Care England
214 , Professor Martin Green OBE, Chief Executive, Care England
215 , Anita Charlesworth, Director of Research and REAL Centre, The Health Foundation
216 , Oonagh Smyth, Chief Executive Officer, Skills for Care
217 , Oonagh Smyth, Chief Executive Officer, Skills for Care
218 , Prerana Issar, NHS Chief People Officer, NHS England and NHS Improvement
219 Oral evidence taken before the Public Accounts Committee on 20 July 2020, HC (2019–21) 408, [Sir Chris Wormald, Permanent Secretary, Department of Health and Social Care]
220 Oral evidence taken on 26 January 2021, HC (2019–21) 877, [Sir Simon Stevens]
221 House of Commons Health and Social Care Committee, Third Report of Session 2019–21, , HC 206
222 Department of Health and Social Care, , accessed 27 April 2021
223 Department of Health and Social Care, , para 2.10, accessed 27 April 2021
224 NHS England, (June 2019)
225 NHS England, (July 2020)
226 Department of Health and Social Care ()
227 Health Education England, , accessed 26 April 2021
228 NHS England, (July 2020)
229 Department of Health and Social Care ()
230 NHS England, (July 2020)
231 NHS England and Improvement, , accessed 6 May 2021
232 House of Commons Health and Social Care Committee, , HC 320, para 138
233 , Professor Michael West, Senior Visiting Fellow, The King’s Fund
234 The King’s Fund ()
235 Royal College of Nursing ()
236 NHS Confederation ()
237 NHS Confederation ()
238 The Royal College of Psychiatrists ()
239 Royal College of Physicians ()
240 NHS Providers ()
241 [on NHS: staff] 2 February 2021