Staff shortages in the NHS and social care sectors

On 15 December 2022, the House of Lords is scheduled to debate the following question for short debate:

Lord Allan of Hallam to ask His Majesty’s Government what steps they are taking to support public sector workers in the NHS and the social care sectors, given reports of staff shortages and the effects of inflation on NHS and care budgets.

1. What is the scale of the problem?

Although there have been recent increases in the number of doctors and nurses working in the NHS, the number of vacancies has also increased. Similarly, the number of vacancies in the adult social care sector has increased in recent years, as detailed below.

1.1 NHS workforce

The latest NHS workforce statistics, published in June 2021, found that the number of NHS doctors and nurses had increased over the previous 12-month period. The number of hospital and community health service doctors increased by 2.4% from 128,695 in June 2020 to 131,817 in June 2021. Similarly, the number of nurses and health visitors increased by 2.7% from 337,604 in June 2020 to 346,802 in June 2021.

Despite these increases, however, the number of vacancies in the medical and nursing sectors of the NHS had also increased. The latest NHS vacancy statistics found that the total number of vacancies in September 2022 was 133,446, a vacancy rate of 9.7%. This represented an increase from the previous year, when the number of vacancies was 103,809 and the vacancy rate 7.9%.

Of the 133,446 vacancies in September 2022, 9,053 (6.2%) were for medical posts and 47,496 (11.9%) were in nursing. Both sectors have seen increases in the number of vacancies from the previous year, in which there were 7,855 (5.6%) vacancies in medical posts and 39,931 (10.5%) in nursing.

The data also revealed that, although the number of medical vacancies fell slightly between September 2018 and September 2022 (from 9,743 to 9,053), the number of overall and nursing vacancies had increased (from 105,838 to 133,446 and 42,679 to 47,496 respectively).

Chart 1: Medical, nursing and overall NHS vacancies, September 2018 to September 2022

(NHS Digital, ‘NHS vacancy statistics England April 2015–June 2022 experimental statistics’, 1 September 2022)

In June 2022, the House of Commons Health and Social Care Committee reported the findings of its inquiry on the health and social care workforce. It revealed that staff shortages in the NHS have not been limited to doctors and nurses. The committee also reported that almost every healthcare profession was facing shortages. This included dentistry, emergency medicine, intensive care, oncology, radiology, and speech and language therapy.

1.2 Adult social care sector

The number of vacancies has also increased in the adult social care sector. In October 2022, the strategic workforce development and planning body for adult social care in England, Skills for Care, published its latest analysis of the adult social care workforce in England. It revealed that the number of posts in the sector had increased by 0.3% to 1.79mn in 2021/22. However, it also found that fewer posts had been filled (decreasing by 3% or 50,000 to 1.62mn) and more existing posts were vacant (increasing by 52% or 55,000 to 165,000) since 2020/21. Skills for Care suggested that the decrease in filled posts was due to recruitment and retention difficulties in the sector rather than a decrease in demand, with employers not being able to recruit and keep all the staff they need.

In its report from June 2022 on the health and social care workforce, the House of Commons Health and Social Care Committee reported that an extra 475,000 jobs would be needed in health and 490,000 jobs would be needed in social care by the early part of the 2030s.

2. What has caused these shortages?

Several commentators have attributed staff shortages in health and social care to multiple factors. This includes: a lack of long-term workforce planning by the government and the NHS; Brexit leading to a loss of staff coming from the EU; concerns over pay; and job pressures due to increasing staff shortages.

In November 2022, the King’s Fund published a report examining NHS staffing shortages. It stated that these shortages existed because of three groups of challenges “which politicians find hard to overcome”:

• Firstly, the organisation identified that there are difficulties in workforce forecasting due to numerous issues. This includes the length of time it takes to train a health care professional—namely, three years for a nurse; 10 years for a general practitioner (GP); and approximately 15 years for a consultant). As a result, the King’s Fund contend that “by the time those in training enter the workforce, the world will look very different” from the one that workforce planners had prepared for.
• Secondly, the King’s Fund argued that the UK “fail[s] to train enough staff”. It highlighted that for HM Treasury it costs more than £60,000 to train a nurse and more than £500,000 to train a consultant, and said that getting these decisions wrong “generates real fiscal danger”, particularly if the government should overestimate. Indeed, the King’s Fund said it was arguably better for HM Treasury to “assume a high level of productivity from the future workforce in calculating our future needs and thus to run the risk of delivering an undersupply of staff rather than an oversupply”.
• Thirdly, the King’s Fund criticised successive governments for migration policy not being set with the “NHS’s interests in mind”.

In the same month, the Nuffield Trust published the results of its study into whether Brexit had affected the UK’s medical workforce. The study examined four specialities—anaesthesia, cardio-thoracic surgery, paediatrics and psychology—with “ongoing recruitment and retention issues”, in which data showed a “proportionately high” number of staff from the EU and from the European Free Trade Association (EFTA) countries that were subject to free movement before Brexit. The results revealed that if trends had continued at the rate before Brexit, there would be 4,000 more doctors in the UK from the EU and EFTA. Discussing the findings, the organisation contended that “while not definitive, the campaign and result of the EU referendum is the obvious reason for a change in trend around 2015 and 2016”.

Amid cost of living pressures, many NHS staff are also leaving the sector for better paid jobs in other areas. In September 2022, NHS Providers published the results of its survey of NHS trusts, which found that 68% of trusts reported a significant or severe impact from staff leaving the trust for other sectors, such as hospitality or retail. The survey also found that staff were struggling to afford to go to work, with 71% of trust managers surveyed describing this as having a “significant or severe impact” on their trust.

Workplace pressures are also reportedly taking a toll on the existing workforce. In its inquiry on the health and social care workforce in July 2022 (section 3.2), the House of Commons Health and Social Care Committee reported that the NHS had lost two million full-time equivalent days to sickness in August 2021. These included more than 560,000 days to anxiety, stress, depression or another psychiatric illness. The committee argued that this had resulted in “many in an already exhausted workforce […] considering leaving”, which would place further pressure on their colleagues.

3. What action has government taken to tackle staff shortages?

In recent years, successive governments have proposed and introduced measures to tackle shortages in the NHS and adult social care sectors. These measures have included: commissioning NHS England to develop a long-term workforce plan; publishing a white paper on reforming adult social care; and approving pay increases for NHS staff. These measures have been the subject of criticism, however, including for not going far enough to address the issues, as examined below.

3.1 NHS England’s long-term workforce plan

In July 2021, the Department of Health and Social Care (DHSC) commissioned Health Education England (HEE)—a non-departmental public body of DHSC— to review long-term strategic trends for the health and social care workforce and to update the existing long-term strategic framework for the NHS, ‘Framework-15’. HEE stated that the review—known as the ‘Long-term strategic framework for health and social care workforce planning’—would examine the “key drivers” of workforce demand and supply over the longer term. Additionally, it would set out how those drivers “may impact upon the required shape of the future workforce, to help identify the main strategic choices”. The findings of this review are yet to be published.

In January 2022, the DHSC also commissioned NHS England and NHS Improvement to develop a long-term workforce plan to supplement the NHS People Plan (published in July 2020). The NHS People Plan set out a range of actions, including how the NHS intended to increase the size of its workforce:

• expanding shortage specialties: HEE investing in an extra 250 foundation year 2 posts, to enable the doctors filling them to “grow the pipeline” into psychiatry, general practice and other priority areas, such as cancer
• increasing undergraduate places: HEE working with universities to support an increase of over 5,000 undergraduate places from September 2020 in nursing, midwifery, allied health professions, dental therapy and hygienist courses
• expanding the primary care workforce: calling on primary care networks, supported by systems and clinical commissioning groups, to take “immediate action” to recruit additional roles funded by the additional roles reimbursement scheme, which would fund 26,000 extra staff until 2023/24

In June 2022, the government stated that it anticipated that the updated framework would be published in summer 2022.

In the 2022 autumn statement on 17 November 2022, the chancellor of the exchequer, Jeremy Hunt, announced that the workforce plan would be published next year. In his statement, Mr Hunt also said:

The DHSC and the NHS will publish an independently verified plan for the number of doctors, nurses and other professionals we will need in 5, 10 and 15 years’ time taking full account of the need for better retention and productivity improvements.

3.2 Strategy for reforming adult social care

In December 2021, the Boris Johnson government published its strategy for reforming adult social care, ‘People at the heart of care: Adult social care reform’. In the strategy, the government set out its 10-year vision for adult social care. This included providing information on proposals that it said it would implement in the next three years. The government stated that these proposals would be backed by £5.4bn of funding from the health and social care levy. The levy, which was announced in September 2021, would be based on an increase of 1.25 percentage points in the main classes of national insurance contributions (NICs). However, in September 2022, the Liz Truss government announced that the 1.25 percentage points NICs rise would be reversed from 6 November 2022. Additionally, it said that the levy would be cancelled. This took place in October 2022, following the Health and Social Care Levy (Repeal) Act 2022 gaining royal assent.

In the strategy, the government committed to investing at least £500mn to support and develop the social care workforce through several policies. These included:

• working with the adult social care sector to co-develop a universal knowledge and skills framework and career structure for the social care workforce
• investing in social worker training routes
• introducing initiatives to provide wellbeing and mental health support and to improve access to occupational health

The government argued that these policies would aim to create a workforce that is: healthy and supported; sustainable and recognised; and well-trained and developed.

In response to the white paper’s publication, the Association of Directors of Adult Social Services (ADASS) welcomed the government’s vision and principles. However, ADASS argued that many of the proposed reforms in the white paper were “contingent” on action being taken on pay. Therefore, it called for the publication of a national workforce strategy for social care. This national strategy would consider the conditions associated with working in adult social care, to ensure that the overall pay and support package was “appealing”. For example, ADASS called for staff to have better contracts which were not zero-hours based and did not exclude travel time.

Also responding to the white paper’s publication, Simon Bottery, a senior fellow at the King’s Fund, criticised the plan for failing to include information on “securing the staff needed” and for having “nothing to say about pay”. He also argued that “without this detail, the idea that the white paper will make any real difference to the recruitment crisis in the sector is fanciful”.

3.3 Pay increases for NHS staff

In July 2022, the government announced that it had accepted recommendations in full from independent NHS pay review bodies to approve a pay increase for NHS staff under the remit of the 2022 pay review. The government said that this would result in over 1 million NHS staff—including, midwives, paramedics and nurses—receiving a pay rise of at least £1,400 (equal to a 4% uplift). In addition, the lowest earners—such as porters and cleaners—would receive pay rises of up to 9.3%, whilst eligible dentists and doctors would receive a pay rise of 4.5%.

The government argued that this settlement struck a “careful balance between recognising the vital importance of public sector workers whilst minimising inflationary pressures and managing the country’s debt”.

However, with healthcare workers facing cost of living pressures, several trade unions and organisations representing these workers have balloted their members over industrial action. On 9 November 2022, the Royal College of Nursing (RCN) announced that its members had voted for industrial action at the majority of NHS employers across the UK unless they received a pay rise of 5% above RPI inflation. The RCN said that strike action would take place until May 2023. Responding, the secretary of state for health and social care, Steve Barclay, said that industrial action was in “nobody’s best interest” and that the government had given nurses a “proportionate, balanced pay increase”. On 25 November 2022, the RCN announced that its members would stage its first ever national strikes on 15 and 20 December 2022.

In addition, on 6 December 2022, the GMB, Unison and Unite trade unions announced that thousands of ambulance workers and other NHS staff would be striking across England and Wales on 21 and 28 December 2022. Speaking to the Guardian, GMB National Secretary Rachel Harrison criticised the government’s inaction, stating:

Steve Barclay needs to listen and engage with us about pay. If he can’t talk to us about this most basic workforce issue, what on earth is he health secretary for? The government could stop this strike in a heartbeat—but they need to wake up and start negotiating on pay.

3.4 ‘Our plan for patients’

In September 2022, the Liz Truss government published its strategy, ‘Our plan for patients’, to help the NHS and social care “perform at their best” for patients. It aimed to do this by focusing on ambulances, backlogs, care, doctors and dentists. Some of the measures proposed in the plan included:

• ambulances: increasing the number of call handlers to 4,800 in NHS 111 and 2,500 in 999 by December 2022
• backlog: creating additional capacity in hospitals by recruiting 50,000 more nurses by 2024
• care: creating a £500mn fund to support discharging patients from hospital into the community and “bolster” the social care workforce, which would also free up beds for patients who need them
• doctors: expanding the range of services provided by community pharmacies, which would free up time for GPs to focus on the “more complex needs of patients”
• dentists: opening up the NHS dental system from November 2022, to make it easier for patients to see information on the NHS website as to whether practices would treat new patients

In a statement in the House of Commons on the plan, the then health secretary, Therese Coffey, said that the plan would:

inform patients and empower them to live healthier lives; place an intensive focus on primary care, the gateway to the NHS for most people; use prevention to strengthen resilience and the health of the nation; and improve performance and productivity.

Responding to the strategy’s publication, the shadow health secretary, Wes Streeting, criticised the government for its lack of workforce strategy in the plan. He argued that “without a plan to tackle the staffing crisis, she [the then health secretary] does not have a plan for the NHS”.

Similarly, despite describing the plan’s ambitions as “good”, the Patients Association stated that it remained concerned with how these ambitions would be realised “without the healthcare and social care staff to deliver them and the funds to pay for them”.

The current government led by Rishi Sunak has outlined its intention to keep the commitments made in the plan. This included making it a legal requirement for dentists to update their information on the NHS website at least every 90 days to improve information available to patients.

3.5 Other measures on staff shortages

In addition, successive governments have introduced other measures which they argued would help tackle staff shortages in the sectors.

In March 2021, the then government announced that several health and care roles, including senior care workers and nursing assistants, had been added to the shortage occupation list. As part of the points-based immigration system, people applying to come to the UK through the skilled worker route must reach 70 points to be eligible for a visa. The government noted that a role on the shortage occupation list was worth 20 points. It stated that, combined with the mandatory criteria (having an “acceptable standard” of English), an offer from a licensed sponsor and the required skill level were worth 50 points. The government said that this would ensure people in these roles reached the 70 points necessary for eligibility.

Additionally, in July 2021 the government introduced the Health and Care Bill 2021–22 in the House of Commons. The bill included a duty on the health secretary to publish a document once every five years setting out the roles and responsibilities of health and care workforce planning and supply in England. However, several organisations called for the bill to mandate HEE to publish annual, independently verified projections of the future supply of the health and care workforce in England for a 15-year period. Similarly, multiple amendments were tabled against the bill to this effect during its progression through Parliament but were defeated. In April 2022, the bill gained royal assent to become the Health and Care Act 2022.

4. What has been said about the impact of shortages in health and social care?

Parliamentary committees, health organisations and other stakeholders have warned of the impact of staff shortages on the NHS and adult social care sectors.

4.1 Review by the Care Quality Commission into health care and adult social care in England

In October 2022, the independent regulator of health and social care in England, the Care Quality Commission (CQC), published its latest annual assessment of health and social care in England. In its assessment, the CQC warned that the system was in “gridlock” and this was having a “huge negative impact” on people’s experience of care. It also reported that:

• people in need of urgent care were at increased risk of harm due to long delays in ambulance response times, waiting in ambulances outside hospitals and long waiting times for triage in emergency departments
• large numbers of people were stuck in hospital longer than they needed to be due to a lack of available social care
• people’s inability to access primary care services was “exacerbating the high pressure” on urgent and emergency care services.

The CQC attributed these issues to staff shortages and the “struggles” to recruit and retain staff across health and care.

The CQC said that the funding announced by the government to help retain and recruit more care workers was welcome but said that there needed to be more focus on long-term planning and investment. Therefore, it called on the government to provide funding and support to integrated care systems so that they could “own and deliver a properly funded workforce plan” that offered staff “better pay, rewards and training linked to career progression”.

4.2 House of Commons Health and Social Care Committee inquiry into the health and social care workforce

In November 2021, the House of Commons Health and Social Care Committee launched its inquiry into the health and social care workforce. In particular, the committee sought to examine the reasons behind staff leaving the health and social care sectors.

The committee reported in July 2022. In that report, the committee argued that the health and social care sectors were “facing the greatest workforce crisis in their history”. Discussing evidence that it had gathered whilst carrying out its inquiry, the committee said that evidence submitted by the Nuffield Trust in June 2022 suggested that the NHS in England could be short of 12,000 hospital doctors and over 50,000 nurses and midwives.

The committee also criticised the government for a “refusal to do proper workforce planning”, which it said risked the NHS’s principal objective of tackling the backlog caused by the Covid-19 pandemic. It also warned that “persistent understaffing” of the NHS posed a “serious risk to staff and patient safety both for routine and emergency care”.

Therefore, it made several recommendations to the government that centred around workforce recruitment and retention. These included calling for the development of formal re-entry programmes for secondary care doctors wishing to return to work after a long break and offering all international medical graduate GP trainees leave to remain in the UK upon successful completion of GP speciality training.

Responding to the findings detailed in the report, Wes Streeting accused the government of having “utterly failed” to address the issue. Additionally, Unison’s general secretary, Christina McAnea, argued that the government “had years to improve the workforce situation but had done little”.

However, a spokesperson at the DHSC stated that the government was tackling the issue:

As we continue to deliver on our commitment to recruit 50,000 more nurses by 2024, we are also running a £95mn recruitment drive for maternity services and providing £500mn to develop our valued social care workforce, including through training opportunities and new career pathways. We have commissioned NHS England to develop a long-term workforce plan to recruit and support NHS staff while they deliver high quality, safe care to patients and help to bust the Covid backlogs.

4.3 House of Commons Health and Social Care Committee inquiry into workforce burnout and resilience in the NHS and social care

In July 2020, the House of Commons Health and Social Care Committee launched an inquiry examining workforce burnout across the NHS and social care. As part of the inquiry, it considered the increased pressures brought by the Covid-19 pandemic and the resilience of the sectors to cope with high levels of staff stress.

In its report, published in June 2021, the committee found that burnout was a “widespread reality” in the NHS and had negative consequences for the mental health of individual staff, which impacted their colleagues and the patients that they cared for. It said that although there were many causes of burnout, “chronic excessive workload” was a “key driver”. In particular, it highlighted evidence from NHS Providers which revealed that 92% of NHS trusts had concerns about staff wellbeing, stress and burnout following the Covid-19 pandemic.

Noting this and other evidence, the committee said that workforce burnout had become an “emergency” which would not be resolved unless there was a “total overhaul” of workforce planning by the NHS. It also stated that understanding the scale and impact of workforce burnout could only be achieved with a metric for staff mental health and wellbeing that covered the NHS and social care sector. Therefore, it recommended that the DHSC extend the NHS staff survey to cover the care sector. Additionally, it recommended that the NHS staff survey and any equivalent social care survey included an overall staff wellbeing measure. The committee argued that this would help employers and national bodies to better understand staff wellbeing and help them to act based on that understanding.

The government published its response to the committee in February 2022. The government said that it agreed that monitoring staff wellbeing was essential to understand the factors that impact wellbeing. However, it argued that the structure of the adult social care sector differed “substantially” from the NHS and said that it did not consider an extension of the NHS staff survey to social care to be the most suitable measure. Instead, it committed to increasing engagement with the workforce and to working with employers, sector representatives and local government to explore options for national or local surveys with the sector.

4.4 Commentary from other health organisations and stakeholders

Several health organisations and stakeholders have warned of the challenges facing the NHS and adult social care sectors resulting from staff shortages.

In the paper published by the King’s Fund in November 2022 cited above, the organisation said that these shortages were having “manifold” impact, and that with a limited number of staff, the overall capacity of the NHS to “deliver the quality and quantity of care that people expect becomes limited”. Therefore, it argued that with NHS England having a waiting list of almost 7 million people, it had become “plain to see” that a precondition of being able to turn the situation around was having enough staff.

The King’s Fund also examined the impact of staff shortages on the health of the workforce itself. It said that with health care already a stressful profession, demanding that NHS workers coped with staff shortages:

• harms their wellbeing
• increases sickness absences (with sickness rates growing from 4.37% in 2020 to 5.20% in 2022)
• “exacerbates” the challenges of staff retention

The King’s Fund argued that “chronic” staff shortages constrained the NHS’s capacity and impeded reform, resulting in insufficiently sensitive employment contracts and demoralising existing staff, “who then exit into an agency staffing sector, or leave the NHS entirely”.

To tackle staff shortages and the resulting problems it causes, the King’s Fund made several recommendations for the government. These included:

• developing a UK-wide workforce forecast and placing an obligation on all four governments of the UK to publish these forecasts, set out in law, provided they all consented to it
• establishing an independent workforce-planning organisation tasked with predicting the likely level of demand for health care services, and undertaking human resources planning to meet such demands
• accepting that the NHS had a reliance on international recruitment and “transparently encouraging migration if we foresee an emerging staff shortage”

Additionally, in June 2022, the British Medical Association (BMA) warned in a report on the social care sector in England that the sector was in “dire need of reform”. To improve the sector in the long term, the BMA made several suggestions to the then government, including:

• increasing long-term funding
• abolishing means testing and making social care that is free at the point of need
• ensuring social care workers were paid the real living wage (which is £11.95 per hour in London and £10.90 per hour across the UK)

5. Read more

5.1 Parliamentary briefings

• House of Commons Library, ‘NHS staffing levels’, 18 November 2022
• House of Lords Library, ‘The nursing workforce: Royal College of Nursing report’, 10 June 2022

5.2 Parliamentary debates

• Debate on ‘NHS workforce’, HC Hansard, 6 December 2022, cols 214–70 and 272–76
• Debate on ‘Public sector pay: Proposed strike action’, HC Hansard, 1 November 2022, cols 306–29WH
• Debate on ‘Nursing: Staffing’, HL Hansard, 16 June 2022, cols 1731–46

5.3 Parliamentary questions

• Oral question on ‘Social care sector: Staff shortages’, HL Hansard, 21 November 2022, cols 1167–69
• House of Commons, ‘Written question: NHS: Staff’, 3 November 2022, 68594
• House of Commons, ‘Written question: Health professions: Vacancies’, 7 September 2022, 45052
• House of Commons, ‘Written question: Care workers: Recruitment’, 18 January 2022, 102666
• House of Commons, ‘Written question: NHS and Social services: Staff’, 14 January 2022, 98216

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