If the workforce plan for the next five years is to squeeze more work out of fewer staff for less money, we’re in trouble. We need a bigger vision, says Richard Taunt

Today’s new NHS workforce census numbers are a reminder of the sheer scale of human enterprise bound up in our healthcare system.

Richard Taunt

Richard Taunt

As one looks closer, some of the longer-term trends for the key professions are discernible. Consultant numbers continue to rise steadily, up 4 per cent, an increase planned years ago and not affected by the ups and downs of current policy and spending reviews.

More doctors means a larger medical consultant pay bill – raising the stakes on the consultant contract negotiations and the future affordability of the medical consultant workforce, whatever the definition of plain time on a Saturday night turns out to be.

But nursing numbers have increased by just under 1 per cent in the last year, and it’s here that we really see the act of juggling safety and the need to balance the books playing out. The National Audit Office has estimated a shortfall of 7 per cent in the supply of nurses. The financial problems which have seen 95 per cent of hospitals go into the red this year are due in part to the need to fill vacancies with agency staff.

Institutions are somewhat tamer than professions and less likely to bite back when pushed about. Workforce policy is tiger country, better kept at a distance. Let sleeping doctors lie

Fundamentally, it’s impossible to escape the conclusion that delivering radical change is mostly about sorting out the policies which impact on NHS staff. People are at the core of whether we get safe, effective and compassionate care; how NHS staff feel about their jobs impacts on how well they do their jobs. From the taxpayer perspective, NHS staff account for the bulk of the money we put into the system: more than two thirds of our overspent hospital budget.

If workforce policy is so important, it is strange then that policy talk so often moves swiftly on to buildings, models of care, commissioning and the new favourite policy thing. The current disturbing breakdown of trust between junior doctors and the system is perhaps one very present clue as to why this is the case.

Institutions are somewhat tamer than professions and less likely to bite back when pushed about. Workforce policy is tiger country, better kept at a distance. Let sleeping doctors lie.

Perhaps as a result, what we get is a workforce policy system that is so labyrinthine. The Health Foundation’s new report Fit for Purpose? is apparently the first time anyone has tried to capture it all in one document. Power is distributed across more than 40 bodies: nine professional regulators, dozens of trades unions and royal colleges, four Whitehall departments, two European Commission directorates, three pay review bodies, and a clutch of Department of Health quangos: you wouldn’t want to start here.

While there is bilateral cooperation on particular issues, there is little evidence of effective strategic leadership of this complex world. Who leads workforce policy in England? Department of Health? Health Education England? NHS England? No one has articulated a nationally compelling vision of which way is north – a workforce policy pole star for England – to guide this jumble of drifting institutions towards a common strategic destination.

The latest staff survey suggests a fair way to go before people working in the NHS rediscover the “joy in work” that Don Berwick has made his rallying call

If most of the real workforce business was sorted locally, this would perhaps matter less. However, workforce policy is highly centralised. Pay, pensions, terms and conditions are a deal between politicians and trades union leaders.

Professional regulation sets central standards and seeks to assure national consistency of training. Workforce planning and education and training are run nationally by HEE. Successive administrations may have sought to encourage local institutional diversity and experimentation, but the workforce system ensures central conformity and standardisation.

This isn’t making anyone very happy. Politicians are frustrated with the pain and glacial speed of change. The latest staff survey suggests a fair way to go before people working in the NHS rediscover the “joy in work” that Don Berwick has made his rallying call.

It doesn’t have to be like this.  So where to start? A good place would be to think beyond financial incentives and penalties and better understand the culture, values and positive intrinsic motivations that guide NHS people every day.

Scrape by

For policy makers that means making policy with people working in the NHS rather than doing it to them. It will mean a longer conversation and it will be a difficult one, in which the various NHS tribes – doctors and managers in particular – will need to walk in each other’s shoes and find the common ground in which to cooperate in the interest of both patients and taxpayers.

If the plan for the next five years is just to scrape through by winning contractual battles – making fewer people work harder for less – then we are in deep trouble.

We need a radically different way of working with a deeply disenchanted workforce. As our report published today recommends, we need to use that new relationship to build a unifying policy vision that can guide our complex system to a better place for patients.

Richard Taunt is director of policy, The Health Foundation.