The NHS workforce plan: the Godot of public policy?

Workforce shortages and an end to free lateral flow testing are just some of the issues giving our health columnist a headache
Waiting for Godot theatre sign

By Andy Cowper

22 Mar 2022

The NHS workforce plan is the Godot of public policy. As discussed last month, we have the elective (electoral, as health secretary Sajid “The Saj” Javid keeps calling it) recovery plan, and the new integration white paper. A new white paper is quite the thing at this point, while the current health bill is still not passed (more on that shortly). But the workforce plan – a 15-year framework, we are promised – remains a mystery. (F15 is the inevitable abbreviation – perhaps not a great sign, given that F15 is also the brand of a well-known US combat jet.) This is not just a free-standing mystery, of course: it’s also a source of big, real problems.

Cutting through

NHS workforce shortages have cut through to register in public opinion, as a recent Ipsos MORI poll for the Health Foundation proved. That makes it a political problem for the government.

The internal War of the Briefings that we saw between The Saj and chancellor Rishi “The Brand” Sunak over funding for the “electoral” recovery plan and NHS targets is as nothing to what is likely coming over the resource implications of F15 being anything that’s of practical value.

The Treasury’s clever stupidity over workforce training

The Treasury’s approach to NHS workforce spending is a bit: “A-ha! If we don’t fund the NHS workforce training, then we won’t have to pay the salaries! Clever, eh?”

Nope. Very stupid: a bit like aiming to save money on public transport by not commuting to work, but then not earning your salary as a result. In reality, as opposed to Treasuryland, NHS workforce shortages drive a) low care quality and safety, which is expensive; b) high use of agency and bank staff, which is expensive; c) poor retention of existing staff, which is expensive; d) massive backlogs, which are expensive.

Then there’s the big problem of workforce shortages being obviously an issue for the existing NHS staff we do have, as YouGov polling shows. The workforce is knackered from two years of battling Covid. Many are leaving early, as recent data show.

We’re very used to hearing that there are 100,000 full-time equivalent vacancies in the NHS. We need to come up to date: NHS Digital’s latest figures show this has now passed 110,000. In the NHS in England, one in 10 full-time nursing posts are vacant; likewise, one in 17 doctors’ posts.

I’ve been pointing out for well over a year that the no-longer-that-newly-announced community diagnostic centres will need staff and people to read the resulting tests and scans: this has now been picked up in a fairly decent piece in the Guardian entitled “NHS lacks 6,000 staff needed to run testing centres in England”.

It covers health minister Edward Argar’s written answer to a parliamentary question, which reveals that the 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, who are senior nurses.
So there’s another few thousand staff shortages to add to the vacancies pile. And this pile is being exacerbated by about 400 NHS staff quitting every week for reasons related to work-life balance and burnout, according to new research by former DHSC strategy director John Hall for Engage Britain, shared with the Observer.

Oh, and on pay and conditions...

The DHSC’s submission to the Pay Review Body was spotted by Health Service Journal, which reports that the department favours holding down pay to catch up on the backlog and on “lost” efficiency from the pandemic. In a clearly Treasury-inspired move, DHSC’s submission argues “NHS financial sustainability is key to its post-pandemic recovery with increasing productivity crucial to restoring the performance of the NHS… There is an expectation that the NHS can catch up on some of the lost efficiency and make productivity savings in 2022 to 2023 in order to return to financial balance...

“Any pay recommendation needs to be absorbed within existing budgets. To put this into context, each additional 1% of pay for the workforce costs around £6m per year allowing for the full system costs. This equates to around 100 full-time nurses or 3,500 procedures. For the [hospital and community health service] workforce as a whole, an additional 1% of pay costs around £900m, which is equivalent to around 16,000 full-time nurses or 500,000 procedures.”

In a gorgeous piece of symmetry here, 16,000 nurses maps near-perfectly onto the 18,500 sub-figure used within the government’s manifesto-promised 50,000 more nurses to describe those who would have quit, but will now decide to stay. The irony is mordant.

Hunting transparency on workforce plans

These workforce issues are behind Health Select Committee chair (and erstwhile health secretary) Jeremy Hunt’s proposed amendment that NHS workforce projections and trajectories towards achieving them should be independently and regularly published. 

Although this was rejected on second reading in the Commons, the idea is being re-moved in the Lords Report stage of the Bill Committee.

The bill for the workforce

Speaking in favour of Hunt’s proposed amendment on 3 March, resurrected by Baroness Cumberledge, former NHS England boss Lord Stevens of Birmingham noted that “as of 10am this morning, Health Education England still does not have its workforce operating budget from 2022-23. We need to look beyond our nose.” It’s worth reading his speech in full.

Ministerial reassurances that “key conclusions” of the F15 workforce would be “set out” were rightly ignored by the Lords Spiritual And Temporal, who roundly supported the workforce publication amendment by 171 to 119. 

Lords vote for no “more Matt Hancock”

The Lords also supported restrictions to the proposed powers for the secretary of state (what I call the “more Matt Hancock”)’ amendment by 145-122. Those kinds of numbers usually get a boxing match stopped. This, and the other “dog” area of increased SOS interference powers (the “more Matt Hancock” stuff), will leave the government – having already accepted both of the Stevens amendments on publishing mental-health spending and on net zero – facing a quandary when the bill goes back to the green benches.

Assuming that Lord Stevens’s political coalition-building holds effective (against which one wouldn’t wisely bet), then Commons-Lords “ping-pong” on these topics – neither of which were not manifesto commitments, so the Salisbury Convention doesn’t apply – risks seeing the bill run out of time in this session of parliament.

The PM announces “Living With Covid”

The PM announced the much-trailed end of Covid-19 precautions and mitigations to the Commons. Thank goodness that the hell of free Covid-19 tests and mandatory self-isolation will both soon be things of the past.

From the aptly-chosen date of 1 April, lateral flow tests will become free market commodities, as trailed. The free market worked absolutely brilliantly for overseas travel testing. It surely gives us all huge faith in this move.

The PM claimed that “we should be proud that the UK has established the biggest testing programme per person of any large country in the world”. No. We should be proud of the bits of test and trace that worked, but given its cost and declared “world-beating” intentions, it was rightly judged a costly failure.

“It is time we got our confidence back” was a genuinely pathetic line from the PM. It’s time we got competence back, but this government wouldn’t recognise competence if it bit them on the Big Dog.

Responding to Labour leader Keir Starmer’s statement, the PM’s point that “week after week, month after month, I have listened to the Labour party complaining about NHS Test and Trace, denouncing the cost” was an absurdity. Test and trace was a costly failure at its own declared aims, as the Public Accounts Committee report made amply clear. 

Known unknowns

The PM’s statement overall was surreally absurd, as The Times’ Chris Smyth pointed out on Twitter: “Remarkably little detail in living with Covid plan. Unresolved points include age at which you will get free tests after April; what advice on isolation will be after March; size of stockpile of LFTs/PCR capacity; scale of ongoing NHS and social care testing.” It’s equally worth reading the Twitter thread by Imperial College Health Partners boss Axel Heitmueller, formerly of NHS Test and Trace, on the implications of the announcements for a wider Covid-19 strategy.

In an excruciating Downing Street briefing that evening, the PM’s boosterism stood in marked contrast to the words of the chief scientific adviser and chief medical officer.

Patrick Vallance said “This virus feeds off inequality and drives inequality... I’d like the rate of infections to be lower”; Chris Whitty added that “the Omicron wave is still high, still between one in 20 and one in 25, according to the ONS survey... this is still a very common infection... we all expect there to be new variants.”

The PM suggested that the UK should be more like Germany, where workers don’t have a “habit of going into work when not well”. Mmmmm. It’s worth noting that statutory sick pay in Germany is 50% pay for 84 weeks; in the UK, it is £96.35 per week for 28 weeks. Mr Johnson also announced that who is eligible for free testing from 1 April will be decided “in March”. Yes, I’m reassured too.

The price of LFTs

I’m intrigued by suggestion that a box of seven LFTs will retail here for around £20, or £2.85 each. Wholesale, a pack of seven costs £1.85 bought in bulk in the UK. In a major French supermarket chain, a pack of five LFTs costs €6.20 – the equivalent of about £5.20, or just over £1 per test. That’s quite a disparity. Given the disgraceful price-gouging we saw on travel testing, and the incompetence of delivery, this should be a concern.

Last August, a large number of travel test providers were warned by the government over misleading prices. The Competition and Markets Authority is investigating a number of those providers. 

I’m becoming very curious as to what the Department for Health But Social Care is paying for a pack of LFTs.

It’s also worth noting that while DHBSC recently set up a procurement framework for LFTs, they then completely ignored it by awarding a £62m LFT supply contract via direct award to MedCo Solutions (the Plymouth Bretheren-linked newly-incorporated company also awarded £84m worth of PPE contracts). Likewise, Innova just picked up another LFT supply contract worth £143.7m. 

Andy Cowper is the editor of Health Policy Insight. This column was first published in CSW's March 2022 issue, which you can read in full here

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