NHS at 75 | A workforce crisis

Top management have celebrated the 75th anniversary of the NHS by publishing a workforce plan

I realise that workforce planning is boring, but the NHS is in existential danger due to problems with staffing. The NHS only exists because staff believe in it, not because of politicians or plucky campaigners sharing memes. Senior managers seems to be belatedly realising this

There is plenty of good stuff in it to praise.

Medical school places will rise each year from 7,500 now to 15,000 by 2031, focused on areas where there are too few doctors.

There will be a big expansion in adult nursing training places, taking the total number each year to nearly 38,000 by 2031-32. This is part of a broader plan to increase the number of nursing and midwifery training places to about 58,000 by 2031-32.

There will also be the NHS’s biggest expansion of apprenticeships, including new doctor apprenticeships, with a goal that 20% of all clinical training will be done through these, up from 7% at present. Five-year medical degrees may be shortened by a year.

There are plans to expand dentistry training places by 40% so that there are more than 1,100 annual places by 2031-32, and possibly to introduce a tie-in period requiring dentists to commit to working for several years for the NHS after graduation. This latter point may sound good, but will make dentistry less attractive for people whose parents aren’t already dentists.

Training more NHS staff domestically is intended to reduce reliance on international recruitment from nearly a quarter of staff at present to about 10% of the workforce.

The plan also aims to retain 130,000 more staff in the NHS over the next 15 years through pensions reform, which will make it easier to partially retire or to return to work, and cultural change to address staff concerns about overwork and bullying. Neurotic controlling, micro managers take their lead from neurotic, controlling, micro managing ministers, and achieving this will mean political change not just managerial.

The NHS will get an £2.45bn extra a year for 5 years to fund this, with claims that another £10bn can be saved over the same period by staffing efficiencies. This latter number is nonsense.

There are however some enormous problems with this. Most strikingly – pay.

The BMA has voted for 2 days of industrial action for the first time in 50 years. Hospital consultants will strike for two days, from 7am on 20 July. Junior Doctors have already taken strike action.

The reason for the strike is straight forward. Since 2010 real wages for hospital doctors have fallen by 15%, with the current cost of living crisis by the next election real wages could be 20% lower. Junior Doctors have lost more. No surprise that half of all Consultant Physician posts advertised in 2022 went unfilled.

But something else has happened to the NHS Consultant workforce since 2010. Historically hospital doctors were white and male. Over the last decade increasingly the medical workforce has become more female and less white. Women are still not a majority, however the majority of medical students are and we are probably only a decade away from medicine being a female majority profession.

In basic terms – as hospital medicine had become less male and less white it’s wages have fallen.

I think most people acknowledge that there has historically been a gender and a race gap in the UK. White men got paid more. There is however a widely held assumption that this is a historical problem and that we are going in the right direction, albeit more slowly than we would like.

What we can see here is the opposite. A decline in wages corresponding to an increasingly female and diverse workforce.

This isn’t a historical problem. This is something happening in front of our eyes.

Without addressing these issues fixing NHS workforce isn’t going to succeed, no matter how many medical school places we open.

The NHS also has an enormous problem with waiting lists and waiting times. By the next GE 20% of the population of England will be on an NHS waiting list.

This creates 2 huge problems:

  1. current NHS capacity isn’t big enough to treat all of the patients who need treatment – this requires a long term investment, not just in people, but also in operating theatres, A&E departments, clinics, diagnostics, you name it.
  2. But also additional capacity is needed over and above the long term capacity to castch up on the waiting list

Apologies for the rather scruffy graph, but it illustrates the capacity problem

In 1997 New Labour faced the same problem and dealt with it by using private hospitals and Independent Sector Treatment Centres. Already plenty of the left are signing petitions to stop the Government using the private sector to reduce waiting lists, with plenty of memes to be shared on social media.

Frankly if you are would rather patients waited in pain for an operation just to satisfy your ideological obsessions you’re not a socialist. You’re an idiot.

Proposals in the workforce plan to change pension rules might help bring back recently retired consultants, but they can’t be in 2 places at once- they can’t be working for the NHS to build long term capacity as well as doing waiting list work in private hospitals as well

This means that the NHS has 4 huge demands on budgets:

  1. it needs to expand capacity in workforce and all of the things which go with that- more operating theatres, beds, clinics, etc.
  2. it needs to sort out it’s pay problem, getting consultant real wages back where they were in 2010 and fixing the gender and race divide
  3. it needs a temporary boost in capacity over and above long term demands to meet the backlog
  4. It needs to cope with massive inflationary pressures – inflation in healthcare typically runs a couple of percent above general inflation

And all of this doesn’t address the crisis in social care. Council budgets for social care have lost £6bn in real terms since 2010. Labours plans for a National Care Service would remove the means tests on social care for richer households, and would cost billions more.

Fixing this cannot be achieved with current budgets + £2.4bn pa for 5 years. The NHS needs an increase in NHS spending equal to the Blair years. New Labour were able to achieve a huge increase in NHS spending because the economy was growing quickly, inflation was stable, and the benefit bill was falling have a long period of high unemployment. Right now the economy isn’t growing at all, inflation is rampant, and the benefit bill is soaring due to unfunded commitments to pensions, and increased poverty

Blair is often called a warmonger by those who felt he wasn’t worthy of political success, however he was the first post cold war PM and he was able to cut defence spending to fund healthcare.

None of those options are open to the next PM.

The one good thing financially is that the forecasts for an increasing ageing population look to be miles out. 13 years of NHS cuts and a pandemic mean that life expectancy in the UK is not going to increase the way we thought a few years ago. Some parts of the UK are now seeing a declining life expectancy. But this is cold comfort to politicians working out how to find the money to save the NHS.

Because right now it is in the darkest place it has been in my lifetime.



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