Reading between the lines of the NHS Long Term Workforce Plan 

The NHS’s Long Term Workforce Plan (LTWP), unveiled in June 2023, stands as an impressive, extensive document spanning 151 pages. Yet, in its breadth lies the risk that we don’t see the wood for the trees and that some key issues become overlooked.

So, what are the essential features of the plan, including those the plan plays down, and how might focussing on these areas help systems and providers develop their own plans and take agency for solving local challenges whilst contributing to the national plan?
 

I have highlighted four key issues:-
 

1. ‘All Levers at All Levels’ Approach: The solution to workforce challenges cannot be solved by pulling a single policy lever nor by expecting this to be done through action by national agencies alone.

The nature of workforce demand and supply is shaped by the actions and policies of multiple ‘actors’ at all levels of the system. The LTWP explicitly recognises this, including the need for action on workforce demand and supply.

The LTWP groups these actions into Train, Retain, and Reform, and whilst the £2.4bn investment in an unprecedented expansion in clinical education has dominated the headlines, each of these domains significantly contributes to the overall position, enabling the planned reduction in reliance on international recruitment.

However, a key unstated part of the plan is that assumed service productivity mitigates future demand by 200-300k fte more than historic productivity would account for (and this is, therefore, the single largest action area). Whilst such productivity is supported by the ‘reform’ elements of the plan, it is not seen as one of the plan’s actions, as it is perceived as a ‘service’ rather than a ‘workforce’ action.

2. Diverse Time Frames for Different Levers: The 15-year time frame of the plan does not mean it is a plan for 2037. It is a plan for now, the next five years, and the next fifteen years.

It is important, however, that we collectively recognise that some levers can have an impact now, and some take time to have an effect. The plan likely relies more on retention, recruitment, reform, and service productivity in the earlier phases than the ‘train’ elements.

However, it is disappointing that the model and its assumptions aren’t more transparent in respect of this phasing. At Tricordant, we believe that good PDSA cycles are built on transparency of assumptions and subsequent reporting.

3. The ‘Train’ actions are the most significant investment in domestic supply ever: The proposed expansion of clinical training is the most significant in the history of the NHS. An expansion of 27% by 2028/29 is supported by an explicit investment of £2.4bn. The need to expand training to 64% more than now by 2031/32 is accepted by the government and the NHS but cannot be funded until future spending reviews. This acknowledgement of future needs is an enormous step forward for long-term workforce planning, as traditionally, investment in domestic training has always been a lower priority for politicians due to the time lag to outcomes compared to investment in immediate service delivery. The original MPET levies were designed to ring-fence this investment, but successive Spending Reviews saw this laudable intent denuded over time.

The WHO has reported that countries with secure domestic supply have training volumes between 8-12% of their workforce. This fits with our assessment that new supply needs to a) replace leavers (at 4-5%) and b) meet new demand (at 3-4%). The volume of UK training has consistently lagged behind these indicators with the subsequent reliance on International recruitment. The proposed increases in the LTWP, if fully implemented, would place England in a broadly sustainable position by the 2030s.

4. The plan is integrated with service and financial planning – future demand is ‘owned’ by the government and the NHS. For me, this is the single most important element of the plan and the one the Treasury would like us to highlight least!!

Creating actions on supply or demand requires us to have an assessment of what workforce demand will be far further into the future than traditional service and financial planning exercises allow. Because the NHS is tax-funded, Spending Reviews become the apex of service and financial planning. This does not, however, provide a basis for long-term integrated workforce and service planning. Historically, different agencies have made up long-term scenarios, but critically, these have not been owned or endorsed by the government.

The LTWP explicitly describes that demand, net of ambitious productivity, will run at between 2.6% to 3.0% per annum, which will result in the creation of between 744k and 843k additional posts by 2037. The annual growth figures are reassuring in that they are similar to historic long-term trends.

What is implicit, but not explicit, in the plan is that the gross demand figure is 4.5% per annum, driven by known factors around population drivers.

The plan’s 1.5%-2.0% per annum productivity assumption is between 0.5% and 1.0% higher than that achieved historically (assuming 1%) and, as described above, represents an additional 209k to 308k fte of avoided workforce demand.

The service cost of this net demand is not yet funded. As I’ve already said, we are tied to Spending Review cycles that never exceed 3-5 years, but the reasonableness of these as demand assumptions to support long-term workforce planning is acknowledged for the first time ever by HM Treasury.

Why are HMT nervous? Well, even with the ambitious productivity, the assumption the plan is based on represents up to £70bn in additional service costs, of which £44bn would be the pay bill for the 800k additional posts. The £2.4bn they have found for supply action clearly pales into insignificance. This is why there is so much visible focus on the ‘reform’ actions, even if they are only part of the productivity landscape.

What does this mean for systems and providers?

The key action is to understand which levers are in your control, how do you intend to pull them, and when? Good local system and provider planning is required to underpin these actions.

Critically, the ambitious productivity assumptions can only be delivered by providers/systems. This is being played out in the current debate around staff growth and productivity. The NHS has achieved a 17% increase in substantive staff since 2019 (including 50,000 more nurses), but activity hasn’t increased by a similar factor. Colleagues are now getting conflicting policy messages of maximising workforce supply but achieving financial balance. The assumption that would reconcile these two issues is if new substantive supply had replaced agency staff, but instead, we have both, hence the renewed focus on productivity.

We would also encourage systems/providers to be active in holding other levels of the system to account for their contribution and in the planned ‘refresh’ of the plan. Failure of any part of the ‘all levers’ plan ultimately impacts your ability to deliver services, so it is in your interests to be active in demanding transparency across the whole plan.

Curious to learn more about Strategic Workforce Planning?

Join us on 27th February, from 3 pm to 5 pm, when we will host a FREE webinar titled “Accelerating System Productivity and Efficiency through Strategic Workforce Planning.” During this session, we will share our perspectives on Strategic Workforce Planning and how organisations and ecosystems can develop a business-driven integrated plan. This plan, founded on robust economic analysis, ensures strategic positioning for sustained success.

To register for this FREE webinar, please email office@tricordant.com. Feel free to extend this invitation to colleagues who share an interest in this topic.