Workforce burnout and resilience in the NHS and social care Contents

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5Workforce planning

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”.193

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.194

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”.195 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 2033–34.196

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.197

139.Although the NHS Staff Survey for 2020 showed an overall decrease in the number of staff considering leaving the NHS,198 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,199 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 2019.200

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%).201

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.202

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”;203 while Skills for Care pointed to estimates of approximately 122,000 vacancies at any one time,204 with a turnover rate of 30.8% for directly employed staff working in the adult social care sector in 2018/19.205 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 2035.206 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”.207

Workforce planning and social care

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”.208 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”.209

144.Like a number of others who submitted to the inquiry, such as the Carers Trust210 and the LGA,211 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.212

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”.213 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”.214

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”.215

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.216 She also highlighted that more needed to be done to “align, acknowledge and understand the career pathways between social care and health”.217

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”.218 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.219

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”.220

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 2023–24.221 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.222 It commits the Government to “sustainable improvement of the adult social care system and will bring forward proposals in 2021”.223

The People Plan

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”.224 In July 2020, NHS England and Improvement published We are the NHS: People Plan 2020–21.225 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.’226 DHSC told us that the Plan requires employers across the NHS to:

• Invest in physical health and wellbeing, with:
  • a new wellbeing guardian role ensuring board level scrutiny of health and wellbeing support for staff.
  • continued support for staff to get to work and free car parking.
  • a focus on healthy working environments and safe spaces for staff to rest and recuperate.
  • prioritisation of psychological support and treatment, with resilience hubs working in partnership with occupational health programmes to undertake proactive outreach and assessment, and co-ordinate referrals to appropriate treatment.
  • support to switch off from work, take breaks and annual leave.
• Make flexible working a priority by:
  • aiming for all clinical and non-clinical permanent roles to be offered on a flexible basis.
  • where possible, covering flexible working in standard induction conversations and offer flexible working from day one.
  • board members giving flexible working their focus and support.
  • being supported to implement and make effective use of e-rostering systems.
• Create an inclusive and diverse workplace, with:
  • a focus on ensuring staffing reflects the diversity of the community, and regional and national labour markets.
  • line managers being encouraged to discuss equality, diversity and inclusion as part of the health and wellbeing conversations.
  • every NHS trust, foundation trust and CCG being required to publish progress against the Model Employer goals to ensure that at every level, the workforce is representative of the overall BAME workforce.
  • a target that by the end of 2020 51% of NHS organisations to have eliminated the gap in relative likelihood of entry into the disciplinary process.
• Maximise opportunities for multi-professional working and developing new skills, with:
  • guidance having been provided to employers to on safely redeploying existing staff and deploying returning staff.
  • continued focus on upskilling—developing skills and expanding capabilities - to create more flexibility, boost morale and support career progression.
  • a commitment for Health Education England to work with professional and regulatory bodies to provide a nationally recognised critical care qualification which is open to different professions.
  • a commitment for Health Education England to develop an educational offer for generalist training and work with local systems to develop the leadership and infrastructure required to deliver it.
  • support from Health Education England for the expansion of multi-disciplinary teams in primary care, through the full roll out of primary care training hubs.
  • the learning, training and development of volunteers being supported by The National Learning Hub for Volunteering.227
  • Systems and employers being prompted to review how volunteers can help support recovery and restoration, and develop plans to enable and support volunteers who wish to move on to employment opportunities across the NHS to do so.
  • Systems and employers being encouraged to promote the NHS Ambassadors programme to their people and allow them time to do this valuable outreach work.
• Create time and space for education and training, with:
  • A focus on fully integrating education and training into plans to rebuild and restart clinical services.
  • A prioritisation of continued access to continuing professional development.
  • £15m to increase clinical placements in the NHS and support growth in Nursing, Midwifery, Physiotherapy, Speech and Language Therapy and all the other Allied Health Professions. This represents a 50% increase in the funding previously pledged.
  • further development of e-learning materials, including simulation
  • several universities across England starting a pre-registration blended learning nursing degree programme.

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 2021/22.228

154.As part of the national Looking After Our People retention programme, NHS England and Improvement launched three local pathfinder regions on 1 September 2020.229 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 2020.230 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:

• creating a national support service for critical care staff who research suggests are most vulnerable to severe trauma
• funding nationwide outreach and assessment services, ensuring staff receive rapid access to evidence based mental health services
• developing wellbeing and psychological training, set to be rolled out this winter.231

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.232

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”.233

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”,234 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”.235 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”.236 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.237

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”.238 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,239 while NHS Providers told us that the Government needed to prioritise “a multi-year funding package” in the Spending Review.240

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.241

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.

162.We recommend that the Department published regular, costed updates along with delivery timelines for all of the proposals in the People Plan.

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.

164.We therefore recommend that, as a priority, the Department produces a People Plan for social care that is aligned to the ambitions set out in the NHS People Plan.

165.We have made recommendations to the Department on the reform and funding of social care in previous Reports. We believe that they are worth restating. Those recommendations are as follow:

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)