Staff Shortages
Shortages of staff are widespread within the NHS and exist across all disciplines. The NHS has too few nurses, midwives, GPs, hospital doctors and mental health workers. Staff are leaving the service due to low pay, work-related stress and reduced job satisfaction, whilst recruitment and retention continues to be a growing problem.
Recent evidence for staff shortages
In July 2022, the health and select committee within Parliament confirmed what everyone working in the NHS has known for several years, the NHS has a major staffing crisis.
The committee heard that almost every healthcare profession is facing shortages, with at least 105,000 vacancies. The situation is worse in social care, where according to a Skills for Care report, one in three care workers left their job in 2020–21, making continuity of care extremely difficult. In December 2021, Care England reported that 95% of care providers were struggling to recruit staff, and 75% were struggling to retain their existing staff.
Staff shortages affect the safety and quality of care and details are discussed below for separate areas, but lack of staff also leads to increased costs due to spend on agency staff.
In 2018/19 NHS trusts spent £5.8bn on temporary staff. This cost represents 80% of nurse vacancies and 90% of doctor vacancies being filled by more expensive agency or bank staff. Due to the pandemic this cost rose to over £6.2bn in 2019/20.
Since the pandemic, the NHS continues to increasingly rely on agency staff. In 2021/22, the NHS paid out £9.2bn on additional staff, of which £3bn was on agency staff, up 20% on the previous year. Accounts data published by NHS England in late 2023 shows this outlay increased to £3.5bn in 2022-23.
What is the government doing?
In June 2023, the Conservative government finally published a long-term workforce plan. Although initially welcomed by the Royal Colleges and NHS organisations, it soon became clear that there were problems with the plan and many are sceptical about whether it will lead to sufficient increase in staff numbers. More details of the plan can be found here and criticisms of the plan can be found here.
The 151 page workforce plan document sets out how the NHS is going to train thousands more doctors, nurses, and other healthcare workers to fill the current vacancies in the NHS (currently around 112,000) and to provide staff for the predicted increase in demand over the next 14 years.
The government projections are for the number of people over the age of 85 to grow by 55% by 2037, and this risks a shortfall of NHS staff of between 260,000 and 360,000 by 2036-37.
If the plan is successful, the government believes the NHS will have 300,000 extra doctors, nurses and other health professionals by 2037. The key to achieving this is, according to the government plan, training, retention and reform.
Criticisms of the plan include over the planned reduction in length of medical degree courses (5-6 years to 4 years) and the general vagueness around who will train the expansion in medical students. There is also uncertainty over funding, particularly after the first 5 years of the 14 year plan.
The most striking thing about the plan is the total absence of any mention of pay and its importance in retention. The NHS is currently experiencing a wave of strikes over pay involving a broad spectrum of clinical staff, the latest being consultants and radiographers, yet the plan makes no mention of pay whatsoever.
Pay is “the elephant in the room” according to the Hospital Consultants and Specialists Association, and the BMA noted that:
“Training new doctors will be to no avail if they don’t stay in the workforce, so the focus on retention is important – but doctors need to be valued fairly for their work and expertise or they will leave for better-paid jobs elsewhere. This plan is set up to fail if doctors’ pay continues to be eroded, the pay review process continues to be interfered with and pay disparities across the public health system persist.”
In October 2023, the cross-party Public Accounts Committee heavily criticised the workforce plan in a report, in particular the lack of funding estimates and it has “serious doubts” on how the plan will be achieved.
The committee notes that the “unfunded and uncosted” workforce plan, which promises to train thousands more GPs and double medical school places, risks placing the NHS under ‘unsustainable financial pressure’ in the future.
Dame Meg Hillier MP, chair of the committee, said: “The government and health system need to be alert to the serious doubts our report lays out around the workforce crisis, both the approach to tackling it now and the additional costs funding it in the future.”
This plan has been a long time appearing. In July 2022, the Parliamentary committee noted that the Government has shown “a marked reluctance to act decisively.” The workforce plan promised in the Spring had not yet been published.
Pressure from organisations within the NHS for a funded workforce plan increased. In November 2022, a coalition of over 100 health and care organisations, including the Royal College of Physicians (RCP), signed a letter to the Chancellor in support of publishing the NHS long-term workforce plan in full, including assessments of how many staff will be needed to keep pace with demand.
As well as not producing a workforce plan, they voted against an amendment to the recent Health & Social Care Bill that would have required the government to publish independently verified forecasts of the workforce numbers needed across the NHS to ensure that services are safely staffed.
To protect the patients the NHS must have the right number and mix of staff, with the right level of education, qualification and experience. Numerous studies show that low nurse staffing levels were associated with higher rates of falls and deaths and major safety issues in midwifery. These include The Keogh review, the Berwick review, and most recently the Ockenden review of midwifery.
The parliamentary committee’s report noted:
“The persistent understaffing of the NHS now poses a serious risk to staff and patient safety both for routine and emergency care. It also costs more as patients present later with more serious illness.”
Latest vacancy data
The latest NHS Digital vacancy statistics show 112,498 vacancies across England at 31 March 2023. For the Registered Nursing staff group alone there was a vacancy rate of 9.9% or 40,096 vacancies.
Why is there a shortage of staff?
There are a number of factors behind this shortage of staff:
- lack of long-term planning by the government, which means not enough staff being trained over the past decade or more;
- removal of the nursing and other bursaries (now partially reversed);
- low pay and for some staff a pay cut;
- brexit leading to a loss of staff from the EU and a reduction in staff coming from EU countries;
- job pressure and high workload made worse due to a lack of staff meaning working conditions for many are untenable and staff leave.
Things were difficult prior to the pandemic, but the Covid pandemic and now the cost of living crisis has escalated the pressure on staff and consequently the difficulty of retaining staff.
Recent research published in Nursing Notes found that 16% of health and social care workers are looking to totally leave the industry, while nearly half (43%) are actively looking for a new job. The study also found that almost a third of healthcare workers (28%) admit to feeling overwhelmed at least once a week, with 17% feeling burnt out every day. Half of the health and social care workers surveyed cited not having enough staff as the biggest pressure they face, followed by low pay (39%) and high workload (35%). A staggering 97% believe the cost-of-living crisis has caused further stress or burnout among healthcare professionals.
NHS trusts are now giving their staff hardship grants, low-cost meals and money to buy their children’s school uniforms to help them cope with the deepening cost of living crisis. Others have set up food banks, are subsidising public transport fares and advising hard-up frontline personnel how to access supermarket vouchers to help feed their families.
When nothing is done about staff shortages there is a spiral of events that leads to ever greater pressure on staff. The health and social care committee report noted:
“In August 2021 alone, the NHS lost two million full-time equivalent days to sickness, including more than 560,000 days to anxiety, stress, depression, or another psychiatric illness. The result is that many in an exhausted workforce are considering leaving—and if they do pressure will increase still further on their colleagues.”
Too few nurses
Issues with both recruitment and retention
There is a major issue with nurse recruitment and retention. The overall number of nurses employed has increased, but this doesn't meet the increased demand. NHS Digital statistics reveal there were almost 40,096 nursing vacancies in health and care settings in England in March 2023.
Although this increased demand for nurses was widely predicted, government policy over the past decade has hampered the NHS's ability to cope with it.
The accumulative effect of government policies has led to a significant shortfall in the number of nursing staff.
The Health and Social Care committee in parliament was told of one NHS Acute Trust, where a senior nurse said his department is missing 30% of their nursing staff, and as such, they are reliant on agency staff who are paid double or triple what his permanent staff are paid.
Removal of nursing bursary
In 2015, the nursing bursary was removed by the Conservative government, which led to a drop in applications to nursing. The Royal College of Nursing (RCN) said the policy has been very damaging and was a key reason why the number of unfilled vacancies in nursing in the NHS in England rose to 43,000 by 2019.
In 2019 the government under pressure partially reversed the policy and reinstated a maintenance grant, plus those who plan to work in areas with severe shortages of nurses, or in one of the areas of care where the lack of nurses is acute – such as mental health or learning disability care – will receive another £3,000. However, students still have to pay the £9,000 per year tuition fees, and although the RCN welcomed the grants, it wanted a return of full packages of financial support for training nurses, including paying tuition fees for student nurses.
The impact of Brexit
The Brexit vote in 2016 led to a substantial drop in nurses and midwifes coming to the UK from EU countries, down 87% from 6,400 in 2016/17 to 800 in 2017/18.
The impact of the pandemic
The coronavirus pandemic significantly increased the strain on frontline nurses. The RCN is concerned that the extra responsibility and pressure placed on nurses could increase the rate of staff “burnout”. This comes amid successive waves of Covid patients, the annual pressures that accompany the winter and the inevitable struggle to clear the growing backlog of cancelled appointments from 2020.
High international recruitment enables target to be met
In its 2019 manifesto the government set a target of recruiting 50,000 additional FTE registered nurses in the NHS HCHS and general practice in England by the end of the current parliament.
In December 2023, NHS England’s chief nursing officer revealed that 93 per cent of the 51,245 nurses who have joined the NHS in the last four years have been recruited from overseas.
The original intention was that international recruitment would make up just a quarter of the 50,000 target, with the remainder of the total coming from domestic recruitment and retention
In November 2023, a new analysis from the Royal College of Nursing (RCN) showed the “inadequacy” of the government’s political target to recruit 50,000 nurses.
The report highlighted that official statistics show there has been a 16% increase in nursing staff, but patient waiting lists have grown 70% since the target was set.
The official number nurse vacancies has fallen by little over 100 in the four years since the pledge was made – with 43,339 roles still unfilled in England’s registered nurse workforce compared to 43,452 at the time of the pledge.
There is also a problem of international recruitment and the RCN has warned that large-scale international recruitment is “expensive, unsustainable, and unethical” given global nursing workforce shortages.
See also The Lowdown article on international recruitment and why it's not the answer to the nurse shortage.
Two few midwives
Warnings on midwife numbers issues time and time again
The July 2022 parliamentary committee report notes a serious shortage of midwives and the pressures on maternity services.
A year previous in July 2021, the committee said that NHSE needed an additional 2,000 midwives and 500 obstetricians to operate at a level that the staffing tool Birthrate Plus considered safe. This recommendation was supported by the Ockenden report and accepted by the Government. However, despite this, the NHS in England lost 552 midwives between March 2021 and March 2022.
Ockenden report highlighted staff shortages
The final Ockenden report into the failings in maternity care at Shrewsbury and Telford NHS Trust published in March 2022 identified midwifery staffing shortages across the service, resulting in unmanageable workloads, a lack of support for junior midwives and doctors, and delays in the appropriate review and management of care for women and babies.
The report called on the Government to ensure there is sufficient funding to deliver safe staffing levels, to enable staff to deliver safe care. This is something the RCM has been telling successive Health Secretaries for over a decade.
In April 2022, the Royal College of Midwives (RCM) noted that due to over a decade of underfunding some NHS trusts and boards have to base midwifery staffing levels on what they can afford, not women and baby’s needs.
The number of midwives continues to fall
An RCM State of Maternity Services report released in July 2023 noted that the impact of staffing shortages on women is ‘stark and sobering’ and highlights historical failures to invest appropriately in maternity services.
According to the report’s findings, if the number of NHS midwives in England had risen at the same pace as the overall health service workforce since the last general election, there would be no midwife shortage. Indeed, there would be 3,100 more midwives in the NHS, rather than having a shortfall of 2,500 full-time midwives.
England has a chronic shortage of over 2000 midwives and the situation is deteriorating with midwife numbers falling month on month, worsened further by pandemic related staff sickness and absences. Data for April 2022 show the number of midwives has dropped by 600 compared to April 2021 and the fall is accelerating particularly in the north of England. The RCM says these figures are “alarming”.
According to the latest survey by the Royal College of Midwives (RCM), 57% are considering leaving their role as a midwife or MSW. Concerns over staffing levels and the ability to deliver safe care are the top reasons midwives are leaving or have considered leaving the profession, with 84% were not happy with staffing levels and 67% not satisfied with the quality of care able to deliver.
Almost all surveyed said that being a midwife or MSW is not valued by the government or ‘said they did not feel valued by the current Government’. The survey shows retention could be a serious issue for maternity services.
The RCM’s General Secretary and Chief Executive, Gill Walton, said;
“Every midwife and maternity support worker goes to work to provide safe, quality care. That so many feel that understaffing means they are unable to do so is deeply worrying. What these numbers suggest is a midwife exodus, which will leave already-struggling services on their knees. Quite rightly, there is a strong focus on improving maternity safety, but there is a risk that the Government is ignoring the essential ingredient to that: having the right staff, in the right place.”
An ever decreasing number of GPs
Promises on GP numbers will not be met
There are widespread problems with both the training and recruitment of new GPs and the retention of current GPs. In 2015 the Government promised 5,000 extra GPs by 2020, then extended to 2021. In 2016 and 2017, the pledge was repeated. In the 2019 general election campaign, Boris Johnson announced a new commitment to increase the number of GPs in England by 6,000 by 2024. However, Sajid Javid, the then health secretary, admitted in November 2021 that this pledge was unlikely to be met because so many family doctors were retiring early.
GP numbers continue to fall
In reality, the number of GPs in England has fallen every year since 2015. There were 29,364 full-time-equivalent GPs in post in September 2015, but by October 2023, there were 27,368 full-time fully qualified GPs.
From October 2022 to October 2023 in FTE terms of 37.5 hours per week, the NHS lost the equivalent of 254 fully qualified full-time GPs.
England has around 7.8 (headcount) GPs per 10,000 people, compared to the OECD average of 10.8. England would need an additional 16,700 GPs to be on equal footing with the OECD average.
A high rate of GPs taking retirement is often cited as the reason behind the falling numbers, but organisations representing GPs, such as the BMA, also say heavy workloads, rising expectations among patients, excess bureaucracy, a lack of other health professionals working alongside them in surgeries, and concern that overwork may lead to them making mistakes are also leading to GPs quitting in order to improve their mental health and work-life balance.
Source: The Nuffield Trust (November 2023)
High number of practice closures
Over recent years, the GP sector has seen high numbers of practice closures. Pulse began investigating the issue in 2013, when just 18 practices shut their doors. Pulse's latest investigation published in August 2022 shows that 474 GP surgeries across England have closed in the past nine years without being replaced, with small practices on lower funding in more deprived areas most likely to be affected. This leaves 1.5 m patients having to find a new GP, many of them will have to travel a number of miles to a new surgery.
Beccy Baird, senior fellow at independent think tank the King’s Fund, said:
“Practices can’t recruit enough GPs, nurses or other professionals to meet the rising levels of need, because in many cases those staff simply don’t exist. There has been a failure of successive governments to adequately plan and invest in the future NHS workforce, a failure that has left GPs and patients to pick up the pieces.”
Regional inequality in GP numbers
In addition to staffing concerns nationally within general practice, there are serious inequalities regionally. Analysis by the Health Foundation in 2020 found that people living in the most-deprived communities are less likely to have a GP appointment, with nurses substituting doctors in some areas. Doctors working in these communities are responsible for an average of 10% more patients than GPs in more affluent areas.
Too few hospital doctors
Short of 12,000 hospital doctors
Recent research by the Nuffield Trust submitted to the Health and Social Care Parliamentary committee suggests that the NHS in England could be short right now of 12,000 hospital doctors.
Previous research by the Nuffield Trust found that two in five consultants and nearly two-thirds of senior trainee doctors said there were daily or weekly gaps in hospital cover in 2019. Gaps in rotas can mean there are not sufficient senior medical staff to ensure quality and safety of training. This can result in junior doctors withdrawing from hospitals, exacerbating staffing issues.
Record number of jobs unfilled
The latest Royal College of Physicians (RCP) census found a record number of physician jobs unfilled; more than half (52%) of advertised consultant physician posts in England and Wales went unfilled in 2021. This was up from 43% before the pandemic and 48% in 2020 and the highest rate since records began in 2008. Of the 52%, nearly three quarters (74%) were unfilled due to a lack of any applicants at all.
England ranks 19th out of 20 OECD EU countries for the number of physicians with 2.7 per 1,000 population. Additionally, in England there remain over 8,000 full-time equivalent job vacancies for doctors.
Emergency medicine continues to be regularly listed on the Government's occupation shortage list. As NHS England entered the pandemic in 2020, the was a 17% shortfall of emergency medicine consultants and a 9% shortfall of respiratory medicine consultants.
BMA says pay is an issue
According to the latest BMA pay review, declines in doctors pay has had a damaging impact on the morale of frontline NHS staff. This has contributed to a workforce crisis in the NHS and has had a detrimental effect on its ability to recruit and retain doctors.
A study by the Institute of Economic Affairs suggests that importing doctors from abroad will be “essential” over the next decade. However, this could be complicated due to Brexit and the predicted increase in competition internationally for doctors.
Mental health services lack staff
Shortages causing a crisis in services
Mental health services are experiencing staff shortages across the board - nurses, therapists and psychiatrists. Despite many commitments to bolster the workforce, any increase has not been sufficient. The result is very long waiting times and increased visits to A&E for patients in crisis, with a major knock-on effects on services for those with physical illnesses.
Patients already on wards are not having one-to-one therapy sessions, not receiving medication on time, and activities are being cancelled due to insufficient staffing. Staffing issues also impact on community services, where a lack of qualified staff leads to long waits and difficulties providing safe care.
Prior to the Covid pandemic, demand rose year on year, but in early 2021 The Royal College of Psychiatrists warned that England is now “in the grip of a mental health crisis” as a result of the Covid pandemic.
Between 2009 and 2020 there was a 12% drop in the number of mental health nursing posts. Both psychiatry clinicians and psychologists are listed on the Migration Advisory Committee’s list of occupations experiencing staff shortages.
In recent years, staffing levels have failed to keep up with the rise in prevalence of mental health disorders. A survey released by NHS England in November 2023, found one in five children and young people in England aged eight to 25 have a probable mental disorder, with large rises in the last few years in the number with eating disorders.
But data from NHS England shows that these children and young people are struggling to get access to care, with over 24,000 waiting almost two years to receive any help.
The analysis also shows 19,000 adults with a serious mental illness waiting for longer than 18 months for a second contact with community mental health services. In total, almost 240,000 children and young people were waiting for treatment from community mental health services in August 2023, as well as more than 192,000 adults.
One of the most recent analyses of the NHS situation by the King’s Fund published in February 2024, found that the current numbers of mental health beds (17,836) are at their lowest level since data collection began in 2010/11. Bed occupancy was consistently over the recommended level of 85% , which is the point at which quality of care is at risk of being compromised.
The knock-on effect of dwindling bed numbers and staff is that A&E visits have increased, with waits of up to 80 hours for some mental health patients. Patients are not found suitable care, instead they are admitted into inappropriate acute hospital beds meant for physically ill patients.
The latest mental health services dataset released by NHS Digital in July showed that active out-of-area placements were at 805, the second highest level in five years, despite many promises over the years to phase such placements out, as they are known to be detrimental to a patient’s ability to recover.
Posts going unfilled
The Royal College of Psychiatrists’ 2021 census has revealed that at least 1.5 million people in England are waiting for treatment but a tenth of consultant psychiatrist posts (568 out of 5,317) are not filled. Consultant vacancy rates vary dramatically across England. The North West and Trent (East Midlands) have a vacancy rate of 15% - significantly higher than the national average of 10.68% - followed closely by the West Midlands and South West at 14%.
Official NHS workforce data shows that there are 4,500 full-time consultant psychiatrists for 56.5 million people, one consultant per 12,567. Addictions, eating disorders and child and adolescent psychiatry have the highest vacancy rates, even though the numbers of those needing support from these specialties are overwhelmingly high. The RCP notes that vacant posts mean an unmet need and that work is likely to be reallocated within a medical team, potentially leading to burnout and low morale or gaps in service provision.
A survey published at the beginning of 2020 revealed the shortage of mental health professionals was leaving the service at ‘breaking point’. 52% of respondents said they were too busy to provide the care they would like. 65% said that on their last shift or day worked, there was a shortage of one or more nursing staff.
Although the mental health workforce has expanded since 2017, according to the King’s Fund analysis, this is not enough to meet current demand and any planned expansion of services. The sector has high vacancy rates and the push for recruitment has resulted in many more newly qualified staff and a change in skill mix of staff, for example less registered nursing staff and more support staff, which is having a direct impact on staff morale and patient care.
An analysis of CQC inspection reports shows that staffing problems are a factor in all those services rated as ‘requiring improvement’ or ‘inadequate’. This impacts on patient safety, and wider patient wellbeing.
Overall, in September 2023, there were 28,600 vacancies (19% of the total workforce) in mental health services, including 1,700 medical and 13,300 nursing vacancies. In every region of England, vacancy rates in mental health services are higher than the overall NHS vacancy rate.
Vacancies vary by service and setting. The challenges posed by some settings such as inpatient care can also create difficulties in recruiting staff to these posts, and in some cases there is an increasing reliance on bank or agency staff. Retention is also a problem, with a 19% turnover rate in the overall workforce in the year to September 2023.
Lack of staff causing health issues for staff
Worryingly, the number of NHS mental health staff who have had to take sick leave because of their own mental health issues has risen by 22% in the five years up to 2017.
The King's Fund reported in February 2024 that the latest NHS Staff Survey (2022) shows that, overall, staff in providers of mental health care report more positive experiences of the workplace than the NHS average. However, there was a decline in several markers of staff satisfaction. Some of this fall in satisfaction is due to staff shortages. An analysis of CQC inspection reports found that in inpatient services, staff regularly work extra hours or additional shifts. Some staff felt they were put in a position where they had to help other wards, but this meant they were working in environments (and with patients) they were unfamiliar with. In community services staff reported feeling worn out and finding work frustrating and stressful as a result of low staffing levels.
Shortage of radiologists
Shortage leads to treatment delays
A UK wide shortage of radiologists is a continuing issue, contributing to treatment delays for patients in cancer care and other medical care.
Data submitted by the Royal College of Radiologists to the Health and Social Care parliamentary committee in 2022, showed that the RCR estimate there is a shortage of 1,939 whole-time equivalent consultant radiologists for the UK – this equates to a 33% shortage. For consultant oncologists, this figure stands at 189 WTE consultants (a 17% shortfall). If current trends in demand and workforce entries and exits continued to 2030, there would be shortages of close to 6,000 consultant radiologists and 700 consultant oncologists.
New community diagnostic hubs take key staff
The government has an ambitious plan to set up over 100 community diagnostic hubs, however these centres will need an extra 3,500 radiographers to carry out diagnostics tests and 2,000 radiologists to interpret the results, as well as 500 advanced practitioners. The drive to recruit the staff needed at the community diagnostic hubs (CDHs) in England risks already-understaffed hospitals losing key staff to work there.
Shortage has been known for some time
Reports in 2020 revealed that the consultant radiologist workforce in England is 35% short-staffed. Scotland (31%), Wales (37%) and Northern Ireland (27%) have similarly high shortages. In order to keep up with demand and safe staffing quotas, NHS England needs at least an extra 1,613 full-time equivalent consultants.
The Royal College of Radiologists have reported that NHS hospitals are increasingly having to pay for staff to do overtime or outsource the analysis of complex scans to private companies to cover the shortfall.
The work of radiologists is a central component to a lot what the NHS does and so these staff shortages can have a substantial impact on the NHS by prolonging waiting times.
Too few anaesthetists being trained
In February 2022 the Royal College of Anaesthetists published the report - The Anaesthetic Workforce: UK State of the Nation Report - that warned that more than eight million operations per year will be cancelled or delayed by 2040 unless anaesthetic workforce shortages are addressed.
The report noted that already there is a shortage of 1,400 anaesthetists, which means that 1 million operations can not be carried out. The shortage will only get worse, with 8.25 cancelled operations each year by 2040 and a shortage of 11,000 anaesthetic staff. The situation is due to a combination of a weary workforce, burnout and staff sickness, plus a lack of training places to train staff to replace those due to retire.
The report shows that without investment in training posts for anaesthetists the situation will only worsen. The report pressurised Health Education England to fund more training places, unfortunately this was only an increase in 100, 70 anaesthetists and 30 intensivists.
