The NHS can’t plan tomorrow’s workforce with yesterday’s assumptions

Drawing on his experience as chief nurse at Health Education England and deputy chief nursing officer for England, Professor Mark Radford considers why NHS workforce planning needs greater long-term stability, alongside the intelligence to respond when circumstances change.

There is a premise that workforce planning succeeds or fails according to the accuracy of its forecasts. If too many clinicians qualify, the numbers were wrong. If shortages persist, the numbers were wrong in the opposite direction.

That view is appealing because it suggests workforce planning is primarily a mathematical exercise; but it isn’t.

It is one of the most complex public policy challenges the NHS faces, shaped by economics, politics, demography, education, technology and human behaviour, all moving at different speeds.

The recent debate surrounding graduate nurses being blocked from a third of entry level NHS jobs last month illustrates this.

Hundreds of graduates have completed their training at a time when some NHS organisations have limited opportunities to recruit them. Yet those same organisations continue to describe significant workforce pressures.

Workforce need sits alongside funded establishment, financial pressures, retention and decisions about how services are delivered.

An organisation may know it needs additional capacity while having limited scope to recruit it. A workforce shortage and a shortage of jobs can therefore exist at the same time.

A workforce ‘wicked problem’

Improving one part of the system can also alter the pressures elsewhere. For example, improving retention rates may keep experienced clinicians in the NHS, but it may also change turnover and the number of vacancies available to new entrants.

Changes in productivity or models of care alter future staffing requirements. Decisions taken in response to today’s problem become part of the conditions that shape tomorrow’s.

This is why workforce is better understood as a classic “wicked problem”. There is no fixed set of variables to solve because the variables themselves respond to the decisions being made.

The task for policymakers is to manage a continually changing set of choices and trade-offs.

Planning beyond political cycles

Professor Mark Radford

Those trade-offs extend beyond the health service.

In a predominantly state-funded system, decisions about workforce supply cannot be separated from decisions about public spending.

The number of professionals the NHS needs is only part of the equation. There is also the question of what can be funded, when, and against what other priorities.

This places workforce policy directly in the path of the wider economic and fiscal environment.

Governments may invest in education and training knowing that the return will not be seen for several years.

They inherit the consequences of decisions taken by their predecessors and make choices whose effects will largely be felt by their successors. That tension exists regardless of who is in government.

The NHS needs to think about workforce supply over decades; governments necessarily operate through budgets, spending reviews and electoral cycles.

Perhaps the question is whether those two timescales need to be better reconciled.

There is a case for greater continuity around education, training and workforce supply, while retaining the political accountability that comes with a publicly funded health service.

In many respects, this is what the NHS Long Term Workforce Plan sought to achieve. Its success depends on whether long-term workforce commitments can withstand shorter-term changes in political and economic circumstances.

From workforce data to intelligence

Continuity, however, only deals with one part of the problem. The other is how the NHS responds when reality begins to move away from the plan. This is where workforce intelligence matters.

The NHS has no shortage of workforce data. The harder task is understanding what that data means in context.

Vacancy rates, turnover, sickness and temporary staffing use each tell part of the story. Their value increases when they can be considered alongside operational demand, financial pressures and changes in the way services are being delivered.

National and organisation-wide figures can also conceal considerable variation. A trust may appear broadly on track while a handful of services account for a disproportionate share of its workforce pressure.

Equally, an organisation experiencing difficulties overall may have teams performing well from which others could learn. Knowing where a problem sits, what is driving it and what has worked in comparable settings makes for a different kind of workforce conversation.

It also changes the role of planning. A long-term plan can set the direction without becoming a fixed answer.

Current intelligence can then show where assumptions are starting to diverge from reality and where intervention may be needed.

Artificial intelligence will have a role, but it is unlikely to be the golden ticket some hope for.

Policymakers are increasingly looking to AI to support productivity gains and service redesign to help bend the curve on workforce demand.

As workforce planning becomes focused on productivity, there is also a question about how we describe the people at the centre of it.

We often hear that “our people are our greatest asset”, yet it has become something of a benign management phrase.

An asset is valued for what it produces; people are valued for their professional judgement, commitment and contribution to a shared purpose. The NHS must improve productivity, but the narrative through which it pursues that objective matters.

If staff increasingly hear that their value is measured through efficiency, flexibility and output alone, the moral relationship between the workforce and the organisation risks becoming increasingly transactional.

Productivity should be the consequence of a supported and valued workforce, not the measure of its worth.

We need to become more comfortable with the idea that a long-term plan can be necessary without being definitive.

The aim should be to give the NHS enough stability to plan beyond the immediate political and financial cycle, alongside enough intelligence to know when the plan needs to change.

There will still be difficult decisions about productivity, affordability and long-term workforce supply. That is the nature of a wicked problem.

What matters is that they are made with a clear view of what is happening across the system and what the consequences are likely to be.

About the author

Professor Mark Radford CBE i s an advisor to RLDatix and former Deputy Chief Nursing Officer for England and Chief Nurse of Health Education England.

He has held senior national roles in NHS workforce strategy, education and training, including work on the NHS Long Term Workforce Plan.

Mark has a clinical background in emergency, critical and perioperative care and is a Professor of Nursing. He was awarded a CBE for services to nursing in 2022.