It sounds intuitive that having a good model of the NHS workforce would be useful for solving many observable problems in the current NHS. But there are reasons to assume any such model would not be as useful as expected and could even be harmful. More importantly, the starting point suggested for the model is wrong in multiple ways that almost certainly guarantees the model would fail to solve the real problems.
When I first heard that a coalition of Labour MPs and the ex-NHS SoS Jeremy Hunt were proposing an amendment to the Health Bill to insist on regular publication of a workforce model for the NHS, I thought the idea was a good one. Better, transparent information about the staffing needs of the future NHS sound like a useful idea to test against government policy.
But, when I reflected on some of the issues I have seen in the past when Strategic Health Authorities did workforce plans I started to have doubts. Then, after some further conversations and cogitation, those doubts grew. Considered alongside my analysis of what the biggest challenges are for the NHS (in short, the front line workforces is far from the biggest problem), my skepticism strengthened.
So, I'm going to argue that, while a good workforce plan might help, the one we are likely to get is likely to be somewhere between useless and harmful. It is starting in the wrong place, has unclear goals that will likely make it far less useful than expected and has some risk of making things worse.
That's a big claim. Let me walk through the potential issues I see step by step.
Where the workforce model might go wrong
It doesn't start by considering productivity
The starting assumption in the debate is the almost universal belief that the problem is a shortage of front line staff. Commentators observe busy A&Es, overwhelmed GPs risking staff burnout, hospitals where waiting lists are growing not falling, and leap to the conclusion that the only way to address these is more medical staff.
But the problem framed this way distracts from any analysis that concludes anything other than "more staff" can influence the amount of work done. Concluding that only more staff matters rules out many known interventions that should be part of the debate, especially those that improve productivity..
Here is a simple example. NHS A&Es are currently catastrophically crowded and patients are getting treatment so slow it is killing them. But we know from analysis that has existed since the 4hr target was introduced that the number of A&E doctors has very little influence on the speed (for a fun review of the evidence on this and how little appetite the system has to listen to it read this BMJ piece and the replies). The dominant cause of long waits in the last decade has been slow access to free beds for admitted patients. The problem isn't even inside the A&E, so adding more A&E staff won't fix it. To be fair, the workload needs in A&E do increase sharply with the length of the queue. But they don't help to make the queue shorter. So any workforce model that ignores the external factors causing the queue will end up recommending far more A&E staff than needed if the external bottleneck causing the queue is ever solved.
Another example shows that not thinking more widely about the mix of staff required is a major problem in planning. A Royal College of Surgeons blog reported in 2017 that the productivity of surgeons had declined sharply as their numbers rose because numbers of support staff and nurses had not risen. It reports "Between 2010 and 2016, consultant numbers rose by 22%, compared to just 1% for nurses and 2% for all staff." It Also pointed out that "... consultants in hospitals that invested more in infrastructure and building … are more productive". (it is worth reading the original analysis by the Health Foundation as well for much more detail). So, is a workforce model is built to forecast the number of surgeons required, but ignores the number of nurses and support staff or the capital required to create a productive theatre, it will vastly overestimate the number needed.
The point is that productivity depends on the mix of staff and other factors like equipment. Driving higher output across the NHS requires a good understanding of where the bottlenecks to productivity are so the right mix of capital and people can be deployed. Adding more of the most visible front line staff is often not that effective. But it is what a "more resources to the front line" workforce model is likely to achieve.
It is unclear what decisions a long term workforce model is intended to support
The only point of any model is to support better decisions. If you are vague about what decisions, then the model is likely to be unhelpful and even misleading.
So what decisions could a long term workforce model support? So far the discussion has tended to focus on the need for a model to inform the NHS about its workforce need in 5, 10 or 15 years.
What decisions could such a model influence? Not many. If we know we need more nurses in 5 years time the NHS might just have enough time to increase the number of training places to increase the numbers qualifying in 5 years time. But it is unclear whether increasing the number of doctors in training right now would lead to higher available numbers in a decade's time.
If the NHS is short of particular skills right now, it is unclear how a long term model can possibly help. What the system needs most urgently is some idea of what the options are today.
If the model focuses–as much of the discussion about it has–on front line staffing need, then it also misses critical groups that contribute to the productivity of the front line (see the section on productivity for why this is important). The question that desperately needs an answer is what different mix of staff, equipment, buildings and new clinical processes would give the biggest increase in the number and quality of treatments delivered. Many of those questions are not workforce questions at all and even a workforce-only model needs a good understanding of how different staff interact to make the front line more productive. That understanding will only come from a significant piece of careful analysis that doesn't seem to exist.
What the NHS needs right now is that analysis. It needs to know where the bottlenecks to higher activity are. It needs to know what mix of capital spending, front line staff, support staff and managers would lead to the largest improvement. Without that a workforce plan will be about as useful as a one-legged trapeze artist with an itchy bum.
A workforce model designed to tell the system how many staff it needs to put into training now will get the wrong answer because it ignores all the interactions and other factors that matter and, even if that wasn't true, could not influence any decision that will have an effect for 5-10 years at best.
Major factors that influence the workforce today are likely not part of the model
The NHS has a workforce problem right now. And many of the factors causing problems are not relevant to the long term supply of qualified staff. Or anything else likely to appear in the proposed workforce model.
Right now the biggest factors influencing staffing gaps are recruitment problems and high turnover (plus illness, if temporary pandemic-specific problems count). These problems don't just affect the front line staff groups but are common in the other groups where a lack of staff has a lot of leverage over front line productivity.
There are many causes of recruitment problems and high turnover. In some groups NHS pay is inadequate compared to other jobs the same staff can do. This is a big issue for nurses but a huge problem for support staff like data scientists. It is also a bigger problem in some geographies like London where the cost of living is much higher and there are more alternative well-paid jobs. But the NHS finds it almost impossible to flex salaries to retain the people it needs both because the pay scales are national and because some groups are vastly undervalued in AfC grading compared to the market.
Working conditions are also a huge factor for recruitment and turnover. If the space is badly adapted to the work being done (~14% of buildings predate the NHS!) then the environment will be poor. Badly maintained buildings add to this (the maintenance backlog is about £10bn). Old, shonky equipment is slower and harder to use than modern equipment. IT systems are often slow and not seamlessly integrated so staff waste time waiting to log on or logging in to a dozen separate systems to complete a clinical task. Front line staff end up spending too much time doing tasks that should be done by support staff or managers (where staffing levels have been cut to "put more staff on the front line") instead of caring for patients.
Too much of the people management in the NHS is bad. Staff are treated badly and insensitively by managers but also by senior doctors and nurses (the Ockenden report didn't just blame "staff shortages", it clearly blamed senior staff of all professions for ignoring clear signals about problems and even suppressing whistleblowers).
Very few, if any, of the factors that discourage recruitment and drive high turnover are part of any proposed workforce model.
So the model won't tell the NHS whether a big increase in capital spending, creating better buildings, equipment and IT systems, would yield rapid gains in a better working environment. Nor will it conclude that recruiting more support staff to enable the front line to focus on treating, rather than admin paperwork, would improve their job satisfaction. And nobody in NHSE would allow the model to conclude that salary flexibility might yield immediate benefits in both lower turnover and higher recruitment rates.
That means that the model is likely to have nothing to say about the major factors that could impact the workforce any time in the next 5 years. What was the point of it again?
A long term workforce model risks fossilising current mistakes and practices
More than a decade ago I was part of a team auditing some workforce models for SHAs (when they still existed). One of the problems the team spotted was that complex models with very large amounts of detail tended to be very hard to audit properly and often contained errors in their code. That's bad when you rely on their outputs.
But that complexity also had a side effect that is, though not an error, worse: they fossilised current assumptions about the mix of the workforce. In particular, they made assumptions about the need for very small specialist subgroups of staff (humorously like the number of orthopaedic surgeons specialising in only left hands). The problem is that practices often change faster than the model. So, if the model spits out the demand for some small highly specialised group in a decade's time, it may have been overtaken by major changes in the way that specialty works. Once upon a time, for example, most cataract operations were done under general anaesthetic. Then it became obvious that local anaesthesia was faster and safer and the mix of activity changed rapidly. Any model built before that change was obvious would forecast a completely incorrect mix of staff or number of staff.
When you build complicated models there is always a big risk that the assumptions in the model persist long after the change as many models are even harder to update than clinical practice. Or the modellers just don't notice the changes and the NHS keeps relying on their model as the users of the model don't understand it well enough to understand the assumptions it makes.
In another case I studied a model built for NICE on staffing in A&E departments (see my commentary). The original report gained a lot of credibility when NHSE allegedly suppressed it. But it was leaked alongside the full documentation on a simulation model built by external consultants that had been a major evidence source for their recommendations. I read the documentation. I wept. The assumptions about how an A&E worked had almost no relationship to reality and ignored very clear, well-known, data about actual performance. It looked like it had been built by someone who had never visited a real A&E or mapped a real world operational process. I suspect that most people who read the report didn't understand the model or that it was a major part of the evidence behind the recommendations. But bad models make bad recommendations. Worse, complex models make those mistakes harder to spot.
Even when a model works it may fail to influence the right decisions
The debate about the need for an NHS workforce model seems to assume that models have a magical ability to change the decisions people make. Decision scientists know this isn't true.
Many analyses and models completely fail to influence actual decisions even when they are reliable and the data behind them is correct. For example, the NHS has reported on the hospital maintenance backlog for years, including an estimate of the need for urgent action to limit the immediate risk to patients. Yet decision makers have repeatedly chosen to spend far too little on capital (the budget has been about half that of peer health systems for most of the last two decades). And the high risk maintenance budget backlog grows every year. Maybe bad decision making is very resistant to modelling or analytical data.
Models work best not when they give a highly specific and precise answer but when they help decision makers to understand the core issues behind the decisions they have to make. A complex and detailed model of the NHS front line workforce is unlikely to achieve this. Not least because, if its focus is just the front line, it will fail to help decision makers to understand the tradeoffs involved in between different decisions they could make today.
What if, for example, a small increment in the number of managers greatly improved the productivity and quality of the work done in hospitals? How would that choice interact with the future needs for front line staff? We already know that more managers do have significant effects (see this summary from the NHS Confederation) but the idea that a workforce model should think about them is entirely absent from the current discussion on workforce modelling.
Also missing in the discussion on workforce modelling is any hint of how capital spending on better buildings, equipment or IT could contribute to productivity. But decision makers have to make tradeoffs today about how to split the budget among front line staff, support staff (including managers) and capital spending. And for most of the last decade that choice has skewed towards the front line leaving the NHS with a chronic deficit of support staff, managers and adequate modern buildings and IT (for some data see my analysis here). Those choices have led to declining front line productivity, a much worse working environment and, arguably, contributed to recruitment problems and higher staff turnover. A model focussed just on the long term needs for front line workforce numbers will encourage continued neglect of those other factors which directly impacts the immediate workforce.
Conclusion: a long term workforce model is a distraction not a solution
It seems obvious that the NHS has a serious shortage of front line staff. But that observation is very deceptive. It is a symptom of widespread problems of productivity and blocked flow of patients. As with many medical conditions, there is a strong temptation to treat the symptom and assume that this cures the disease. In NHS language, focussing on the front line workforce assumes that investment in the front line workforce cures the problem. But, like trying to cure headaches caused by a brain tumour with stronger painkillers, treating the symptom doesn't solve the underlying problem.
A model that assumes that frontline overload is cured purely by adding more staff distracts attention from all the other factors causing overload of front line staff. So attention will be distracted from inadequate buildings, obsolete equipment, slow and badly designed IT, admin overload caused by a lack of support staff and managers, and poorly designed clinical pathways. And "more staff" doesn't fix problems where the issue is having the wrong mix of staff.
Some of those problems might be fixed, in principle. We could, perhaps, build a model that takes into account the staff mix, not just the overall number of staff. It could even highlight the areas where extra staff would most improve overall productivity (eg, to fix A&E overload, invest in staff who can improve the flow through beds). Unfortunately the first step would be to develop an analysis of how the whole system fits together and therefore identify which incremental investments would most improve the productivity of the system. There is no such analysis, though there are plenty of hints that workforce isn't the biggest problem.
The workforce model as currently discussed seems likely to further distract the NHS from other major problems. A focus on the front line risks distracting from even bigger staff shortages behind the front line. And from a long term neglect of capital spending (leading to major issues with buildings, equipment, and IT). Furthermore there is a big risk that a long term workforce model could ignore the short term decisions that might help the immediate problems with workforce and could encourage the NHS to build in false assumptions that fossilise bad current choices.
That's a lot of risks for an unclear outcome. Whatever the intuitive attraction of a transparent model of workforce needs, it is far from obvious that the NHS would get anything useful.
We need a more informed debate about what holds back NHS productivity, not a model focussed on the front line workforce.
