Can the UK's largest employer solve acute staffing shortages in all sectors? Jeremy Davies reports

To an outsider, the placing of human resources issues at centre stage in a health service that employs nearly a million staff might seem an obvious move. But it is one the government has only fairly recently made.

For the first time, ministers have decided the NHS is not the only employer in the world, and that if it is to attract the staff it needs to modernise and sustain the service into the new century, it must make an effort to find and keep them.

'Until a few years ago, finance was the push in the NHS, ' explains Tracey Myhill, personnel director at Gwent Healthcare trust and president-elect of the Association of Healthcare Human Resources Management. 'Everything was about budgets. Now it's all quality and clinical governance, which means putting the people who do the caring at the centre of things. Suddenly HR is 'sexy', which is really good news. But there's a massive challenge there, too.'

Paradoxically, recruitment problems have hit the headlines in recent months, largely because of heavy government investment in the NHS. The NHS plan, published in July on the back of unprecedented new money for the health service in the March Budget, promises 20,000 more nurses, 7,500 more consultants and 2,000 more GPs by 2004.More detailed targets for this year are included in the recent human resources performance framework (see box 1).

To achieve such expansion, the government will be relying on human resources teams and other managers with employment responsibilities throughout the service to implement a whole raft of new approaches. HR departments could be forgiven for feeling daunted by the task.

Medical vacancy rates - the percentage of vacancies still unfilled after three months - in some hospital-based specialties are already running as high as 7 per cent. Eleven per cent of GP vacancies take more than six months to fill; and 4 per cent lie vacant for more than a year.

Evidence on early retirement among doctors is scant, but many trusts claim it is increasingly common. Milton Keynes General Hospital trust surveyed its consultants last year and found that 50 per cent planned to retire early.

1Ingeneral practice, two-thirds of the wave of south Asian doctors 'imported' to the UK in the 1960s - many of whom work as GPs in deprived urban communities - will have retired by 2007. Some health authorities could lose as much as 25 per cent of their GP workforce in the process.

The extent of the nursing recruitment crisis is, if anything, even bigger. The Royal College of Nursing claims there are 20,000 nursing vacancies across the UK, with 9,900 of them unfilled for three months or more. The RCN points out that the NHS spent£344m on employing agency staff in 1999 - enough money to pay for the appointment of 10,000 fulltime nurses. It also estimates that bank nurses cover the equivalent of 10,000 nursing jobs at any given moment.

An ageing workforce profile is also storing up nursing recruitment problems for the future. Ten years ago, 26 per cent of all nurses on the UK Central Council register were aged under 30, but by 1998-99 this age group had halved, to just 13 per cent of the total. And recruitment problems are by no means confined to doctors and nurses. Vacancy rates highlight particular difficulties for several other groups within the professions allied to medicine category, which encompasses staff such as pharmacists and therapeutic radiographers (see table 1).

Sandra Meadows wrote last year's highly influential nursing report The Last Straw as visiting fellow at the King's Fund and is currently HR adviser to several NHS organisations in north-east London. She suggests one big factor is that the people who have traditionally trained as PAMs - white, middle class women - now have more alternative careers open to them.

2'They can choose other jobs entirely or go to employers who pay better. We haven't caught up by changing what we offer, or improving recruitment among men and ethnic minorities, ' she suggests.

Detailed figures on recruitment and retention of NHS managers are hard to come by, although the Institute of Employment Studies is due to publish research on the subject soon. NHS Confederation human resources chair Andrew Foster suggests that spending on middle management is being squeezed through a desire to cut red tape, with the effect of pushing increasing numbers of managers into consultancy - a trend backed by news that the Institute of Healthcare Management is set to launch a register of managers available for project work.

Many trusts report problems recruiting and retaining ancillary staff, as shown by relatively high turnover rates (see table 2).

More generally, there is a sense that public service recruiters as a whole are on the ropes. An Audit Commission report published last month found turnover rates of 26 per cent among residential homecare workers, and 63 per cent of local authorities reported shortages of social workers, for example.

King's Fund chief executive Rabbi Julia Neuberger has argued forcibly that ministers' challenge is to build a new vision of public service 'that harnesses the values of equity and altruism, as well as chiming in with the personal goals of the kinds of people the state needs to get to work for it'.

The NHS is dated, she says: 'Ambitious young people leaving schools and universities no longer see public service as the height of personal achievement. Instead it is associated with ponderous bureaucracy, political manipulation, poor opportunities and low pay.'

4So what is the government doing to tackle the problems?

In medicine, the Department of Health has pledged to increase the total medical student population to 7,000 students by 2005 - a rise of 40 per cent from current levels. Chances are there will be no problem filling the extra places - there are now 1.8 applicants per place, with successful candidates still producing the highest average A-level scores of any university subject - 28.8 points as compared to the overall average of 19.4.

But it will take several years before trusts even find bigger numbers of junior doctors banging on their doors, let alone experience any stepchange in qualified specialists.

Before the NHS plan, the government was committed to training 45,000 nurses, midwives and health visitors between now and 2004, along with 13,000 therapists and other health professionals. The NHS plan promises a further 5,500 nurses, midwives and health visitors each year, and a total of 4,450 more therapists.

The DoH ran a high-profile recruitment campaign last year to attract both new nurses and returners to the service, and is running a similar one this winter. So far, through extensive collaboration between employers and education consortia, a total of 4,600 nurses have returned to the NHS since 1999, and applications to pre-registration diploma courses rose by 73 per cent over the year.

The NHS plan also announced a 'market forces supplement' to allow trusts in areas of particular difficulty to attract recruits by boosting pay.

The government is all too aware that throwing money at recruitment will not be enough, however.

One NHS Executive survey found that the main factors in nurse returners' decision to rejoin the service were the availability of part-time or flexible working (35 per cent), the availability of refresher courses (22 per cent) and help with childcare (12 per cent). Only 5 per cent of respondents said better pay was the key factor.

5Improving Working Lives is a set of guidelines on introducing and implementing flexible working in NHS organisations. It was launched in 1999 by the NHS recruitment and retention unit (see box 2). It is central to government policy on NHS recruitment and retention, regardless of job function or title.

All NHS employers were told in October that as part of the human resources performance framework they must sign up to Improving Working Lives as a basic requirement by April 2001 and monitor progress against a range of other targets.

Many trusts are already pursuing a flexible working philosophy with enthusiasm. London's King's Healthcare trust recently won the title 'employer of the year' in a scheme organised by Parents at Work and sponsored by the Department of Education and Employment and Lloyds TSB, for example. The trust's 'KingsFlex' scheme, open to all of its 4,200 staff, includes options such as staggered working hours, career breaks and the chance to trade salary for time off or vice versa.

The second major policy thrust is towards overseas recruitment. This is fairly well-established practice in nursing these days, albeit on a smaller scale than currently envisaged. Several trusts, especially larger ones, have taken on batches of foreign recruits since the summer (see panel above).

DoH head of employment David Amos, who has spearheaded visits to various countries, including China and Spain, to negotiate recruitment deals, is expected to appoint a head of international recruitment for this reason.

'We want to co-ordinate trusts' efforts, rather than have people trooping off separately and paying commission to agencies, ' he says. 'It's better to be able to say to countries, 'Here are a group of employers and these are their needs - how can we work together?'.'

Overseas recruitment is considered more problematic in medicine. Shadow health secretary Dr Liam Fox caused controversy earlier this year by suggesting foreign-trained doctors might endanger patients' health because of poor language skills.

More generally, the confederation's Andrew Foster says there are concerns about the appropriateness of non-UK medical training for the workload found in most of our hospitals: 'Most people worry about taking on EU-trained doctors, because their training just doesn't chime in with the kind of jobs we have here.'

Trusts' best hope of patching over doctor shortages until the new medical school intakes pass through the system is probably to get better use out of the doctors already here. The British Medical Asociation's non-consultant career grade doctors' sub-committee is pushing for trusts to provide a clearer career pathway and better training for its constituents. Refugee doctors have also been established as a source of untapped talent.

In general practice the gradual expansion of the personal medical services contract could be key to both the introduction of more flexible working, and to cooling down recruitment hotspots by establishing more salaried posts.

Other centrally led initiatives include Flexing Retirement, the NHS Executive's guidance, issued in July, aimed at stemming the tide of early retirements from the service, which could help to enable employers to hang on to professionals' wealth of experience for longer, and an NHS pension modernisation review.

The government's national job evaluation project, which is examining objectively what different professionals in the NHS actually do and therefore how their pay should compare, may help raise the prospects of laboratory workers, scientists, technicians, pharmacists and the like, many of whose skills are currently lost to much more highly paid jobs in the private sector.

The NHS Executive's strategic human resources intelligence network (SHRINE), launched in 1999, allows HR professionals to share best practice and benchmark performance. SHRINE now encompasses 16 local and regional networks, and activity plans cover areas such as recruitment and retention, diversity, Improving Working Lives and medical workforce issues.

A SHRINE website is planned, as is an NHS recruitment website accessible by the general public, due to launch in April 2001.

In the meantime, HR departments continue the complex task of monitoring vacancy, turnover and wastage rates, hoping to unpick underlying trends and innovate accordingly.

Sandra Meadows explains that keeping tabs on the statistics, department by department and grade by grade, is essential.

'The devil really is in the detail, ' she says. 'When I was HR director at London's University College Hospitals trust, for example, we had a very stable nursing workforce at G and H grade, but beneath that, at D and E grades, the turnover was phenomenal.

'When we sat down with the line managers and examined what was happening we found there were major problems with nursing accommodation - all we could offer was single-room accommodation, and people were getting dissatisfied and leaving.

'By working with local housing associations we were able to improve what we offered and hold on to people much longer.'

In terms of less qualified staff - often ignored at national and regional level - several NHS organisations are trying interesting new approaches, with a view to creating new career pathways and recruiting more effectively from hitherto untapped sections of the community (see panel, right).

Others are concentrating on the basics, like improving the administration of the recruitment process itself (see box 3).

Dorset Community Healthcare trust's 'HR Direct' programme, for example, has introduced much less formal induction processes for hotel services and ancillary staff, after finding it was losing out to employers who allowed new staff to start work immediately - a big factor for low-wage earners.

But many HR professionals, even if they feel better equipped as recruiters than five years ago, still feel there is a mountain to climb. An NHS Confederation survey found that only 27 per ccent of NHS employers felt the nursing recruitment situation would improve over the year to April 2001, for example.

6Tracey Myhill, whose trust employs 11,500 people and currently has 200 long-term nurse vacancies, is sanguine: 'The will to make the NHS a better employer is certainly there, but we're talking about a big cultural change - it's all about embracing diversity, and saying, 'We'll look at how we as an organisation can accommodate our employees' diverse needs', ' she says. 'We've already come a long way, but it can take a long time to change people's mindsets.'

David Amos is also confident: 'Recruitment is partly about us at the centre directing things but partly about networks developing organically, which is where SHRINE fits in.

'We're getting cash out to the regions to allow them to move things forward. It's a big operation.

'I'd say we know the size of the current gaps and long-term vacancies, and have made judgements on how the return to work initiatives will work. What's left is what we'll fill through international recruitment.'

REFERENCES

1 Pearson C. The True Extent of Early Retirement. Employing Medical and Dental Staff; September 1999: 10-13.

2 Meadows S. The Last Straw. King's Fund 2000.

3 Jones D. People Need People. Audit Commission, October 2000.

4 Neuberger J. The Jobs That Nobody Wants. Guardian Society, 27 September: 7.

5 Return to Nursing. NHS Executive survey, 1998. Quoted in NHS Confederation nursing pay review body evidence (see below).

6 NHS Confederation Survey on Nurse Recruitment, quoted in Employers' Evidence to the Pay Review Body for the Remuneration of Nurses, Midwives, Health Visitors and Professions Allied to Medicine for 2001/2. NHS Confederation. September 2000.