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This briefing discusses the NHS workforce in England, focusing on the clinical professions, including doctors and nurses. It gives an overview of workforce demographics and workforce policy and planning since 2019. It also looks at turnover and vacancy rates, the use of temporary staffing and how safe staffing levels are decided.

It considers trends in domestic and international recruitment and factors affecting both recruitment and retention, including staff wellbeing, pay and pensions, and bullying, harassment and discrimination.

NHS Workforce policy and planning

In June 2023, NHS England published the NHS Long Term Workforce Plan, as commissioned by the Government. Actions in the plan are backed by £2.4 billion in Government funding up to 2028/29.

According to the plan, if fully implemented, the permanent NHS workforce would increase from 1.4 million in 2021/22 to between 2.2 and 2.3 million in 2036/37. Alongside the expansion of associate roles, this would include an additional:

  • 60,000 to 74,000 doctors
  • 170,000 to 190,000 nurses
  • 71,000 to 76,000 allied health professionals
  • 210,000 to 240,000 support workers.

Features of the plan include the increasing training places, measures to retain more staff and increasing labour productivity by 1.5-2%.

The plan was broadly welcomed by stakeholders but questions have been raised about the feasibility of the training commitments and the “stretching” productivity targets involved. Some stakeholders have also criticised the strength of actions in the plan to improve retention.

The Institute for Fiscal Studies has said the implications of the planned workforce expansion for the NHS pay bill will mean “difficult fiscal decisions at future Spending Reviews”.

Reforming professional regulation

Regulatory bodies set standards for education and training, as well as clinical skills and fitness to practice. Each regulator maintains a register of people who meet the standards. There are nine statutory professional regulatory bodies in the health and care sector in the UK.

The Government plans to reform the legislation underpinning the regulation of healthcare professionals by giving regulators greater autonomy over their own regulatory procedures without the approval of Parliament or the Privy Council. The programme of reform will begin with the General Medical Council (GMC) and the Health and Care Professions Council.

Legislation providing for the regulation of physician associates and anaesthesia associates by the GMC has been approved by both Houses of Parliament. The GMC expects to begin regulation from the end of 2024.

NHS staffing levels

Over the past decade, NHS turnover figures for England tend to show more people joining than leaving the NHS. Despite this, the level of vacancies in the NHS in England has increased in recent years, because the total number of roles has grown.

In September 2023, a total of 121,070 vacancies were recorded across the NHS in England. Of these, around 42,300 were nursing vacancies (10% of the nursing) workforce and around 8,850 were doctors (6% of the medical workforce)

The NHS uses internal “banks” of staff and external agencies to fill vacancies. Since 2015, there have been caps on the hourly rates paid for all agency staff in the English NHS, designed to ensure that agency pay is in line with equivalent, directly employed NHS staff. The rules include a “break glass” provision which allows the caps to be overridden on patient safety grounds.

Despite these measures, between 2018/19 and 2021/22, spending on bank staff and agency staff increased by 51% to £5.2 billion and by 23% to £2.96 billion respectively.

In 2022/23, NHS providers spent £3.46 billion on agency staff. The NHS workforce plan aims to lower agency spending by increasing capacity and making greater use of bank staff to fill vacancies.

Safe staffing levels

Health and care providers have a legal duty to deploy enough suitably qualified staff to meet the needs of those using the service.

There is no set formula or ratio for deciding safe, or minimum staffing, although there are tools and guidance available.

The Royal College of Nursing and the British Medical Association have warned staffing levels are not meeting patient demand and this is putting patient safety at risk. The UK has a low number of both doctors and nurses per person compared to its peer countries.

The Strikes (Minimum Service Levels) Act 2023 established powers for the Government to make regulations setting minimum service levels (MSLs) in specified services within key sectors, including healthcare. The Government must consult before bringing forward regulations.

Where MSLs have been set, the Act allows employers to issue work notices requiring individuals to work through strike action to ensure the minimum service level is met. Unions must take reasonable steps, as set out in the Code of Practice, to ensure compliance with such notices.

In December 2023, the Government introduced the Strikes (Minimum Service Levels: NHS Ambulance Services and the NHS Patient Transport Service) Regulations 2023.

Domestic education and training

The number of medical school places is capped. The NHS Long Term Workforce Plan sets out a plan to double medical school places to 15,000 per year by 2031/32.

The number of nursing students accepted onto courses is not limited, but universities must work within their capacity to provide practice-based learning. Consistently, more students apply to nursing and medicine courses than there are places available. The NHS workforce plan includes plans to increase nursing training places by 80% by 2031/32. It also sets out how placement capacity will be increased to enable this expansion.

Trends in healthcare student numbers are explored in the Commons Library briefing on Medical, dental, and healthcare students: UK numbers and student support arrangements.

In March 2023, Health Education England (now merged into NHS England) published an Educator Workforce Strategy. The strategy sets out actions on the capacity and quality of the educator workforce, to facilitate the planned growth in the healthcare workforce.

NHS England plans to reduce the proportion of nursing students who leave training from 16% in 2019 to 14% by 2024. Nursing students report financial challenges and poor support as reasons for leaving. Trainee doctors report feeling burnt out.

International recruitment in the NHS

The NHS Long Term Workforce Plan says the NHS is “particularly reliant” on international recruitment compared to healthcare systems in other countries such as the USA and Canada. If the ambitions set out in the plan are met, NHS England foresees there will be a material decrease in international recruitment of adult nurses from 2030. Until then, international recruitment would need to remain “at least around current levels”.

In 2022/23, one in five nursing professionals on the Nursing and Midwifery Council (NMC) register trained overseas. Four in five of those were educated outside Europe.

The General Medical Council’s (GMC) annual workforce report 2023 said in 2022, international medical graduates made up the majority (52%) of joiners.

Professionals on the NMC and GMC registers might not work for the NHS or currently be practising. The Commons Library briefing on NHS staff from overseas: statistics examines trends in staff from overseas.

The Code of practice for the international recruitment of health and social care personnel in England sets out best practice for health and social care employers and recruitment agencies undertaking international recruitment. It includes a ‘red list’ of countries from which no active recruitment is permitted. Individuals from those countries may still apply directly to health and social care employers in the UK of their own accord.

Concerns have been raised about a rise in recruitment from red-list countries and the treatment of internationally recruited healthcare workers in the UK.

Workforce retention in the NHS

The NHS Long Term Workforce Plan sets out how NHS England and the Department of Health and Social Care intend to retain NHS staff over the next 15 years to reduce the leaver rate from 9.1% in 2022 to between 7.4% and 8.2%.

Information on reasons for workers leaving the NHS is limited. Data on leavers in NHS hospital and community services is published as an aggregate across all staff groups. It includes staff moving within the NHS as well as leaving the NHS. Across all staff, the most common reason for leaving is retirement and the second most common reason is work-life balance. The numbers leaving for health reasons have nearly quadrupled in the last decade.

Issues highlighted as factors in NHS workforce retention include work-related sickness and burnout, bullying, harassment and discrimination, and pay.

Pay in the NHS

Data for the year ending September 2023, shows that basic pay for both full time equivalent (FTE) doctors and nurses has fallen in real terms (adjusted for inflation).

The average basic pay of FTE doctors in September 2023 was £75,300, representing a real-terms decrease of:

  • 1% since September 2022 (£76,900)
  • 0% since September 2013 (£79,200)

The average annual basic pay of FTE nurses was £37,900 in March 2023, a real terms reduction of: 

  • 1% since September 2022 (£38,700)
  • 7% since September 2013 (£40,600)

The NHS has sets of pay bands or “pay spines”. Each pay spine has a different body that makes recommendations to the Government on pay. The NHS Pay Review Body reviews the pay of all NHS staff on Agenda for Change terms and conditions (excludes doctors, dentists and senior managers). The Review Body on Doctor’s and Dentist’s Remuneration reviews the pay of medical and dental staff.

The pay review bodies are independent of Government and review evidence from relevant organisations. Final decisions on the implementation of recommendations made by the bodies are the remit of the Prime Minister and relevant health ministers.

The Government’s 2022/23 pay offer was widely rejected by healthcare worker unions, prompting industrial action through 2023 and into 2024.

A summary of which unions have been on strike and the different pay offers can be found in the Library briefing on NHS strike action in England.

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