Can the Long Term Workforce Plan work without International Recruitment?

In 2022, Sky News reported that ‘record numbers of doctors are resigning – with twice as many leaving … than a decade ago’. Since then, frequent reports of the NHS’s ‘historic’ workforce crisis have surfaced, with vacancies peaking at 130,000 in December of 2022. There are currently over 112,000 vacancies in the NHS, despite the best efforts of the NHS and the Government. The NHS is currently facing several other challenges, not least the 6-million strong elective backlog, the increasingly aging population of the UK and years of underfunding. The recently published the Long Term Workforce Plan sets out to increase recruitment and training while improving retention to significantly increase the size, skills and improve productivity in the NHS over the next 15 years.

Six months since the plan was published, how realistic are the targets?

The Long Term Workforce Plan in Brief

Published last June, the Long Term Workforce Plan (LTWP) sets out three main strategies to meet increased demand – ‘train, retain, reform’. More specifically, it aims to double medical places for doctors, increase plans for trainee nurses and midwives by 24,000 and introduce more routes into medicine – while reducing international recruitment to 9-10% of the workforce by 2038. Alongside strategies to increase retention, the plan projects an extra 17,000 nurses and an extra 60,000 doctors to be working in the service by 2036/7 on top of current levels.

The focus on retention has been met with enthusiasm by NHS leaders, providers and staff, though the recent industrial action borne from chronic staff dissatisfaction with both pay and working conditions suggests improving retention will be a difficult feat. Changes to current medical training, such as plans to reduce the number of years doctors spend in medical school from 5 to 4, are hoped to bring clinicians into the workforce earlier – though concerns over the implications of reducing training time and the increased stress this may put on students undertaking medical degrees have been raised. Diversifying and increasing routes into medicine by introducing apprenticeship-style degrees, has also been proposed, but it is not clear if this is logistically possible. Medical students are already struggling to find placements, so training a whole cohort of doctors via apprenticeships seems ambitious.

The Government aimed to reach 50,000 new nursing recruits by mid-2024 – figures show that an additional 51,245 had been recruited by September 2023, 6 months early. While it is heartening to see targets being reached early, the previous year saw 41,000 nurses leave the service – the highest leaving rate for at least a decade. The current workforce crisis is as much a result of chronic staff turnover as it is of under-recruitment. The plans focus on retention measures, as well as creating a pipeline of new joiners, is positive – it is impossible to recruit out of a retention crisis, and these figures certainly suggest the service is facing a severe retention crisis. However, with no mention of strategies to resolve the current industrial action, or making the NHS a more attractive and competitive employer, the retention and recruitment aims of the plan seem increasingly unrealistic.

The Covid-19 pandemic years saw an increase in applicants for nursing degrees. However, UCAS figures from September 2023 show a decrease in nursing applications across the board – just two years ahead of the LTWP’s aims to increase nursing student places by more than a third over the next five years. If there is not the appetite to begin a career in medicine in the domestic population of the UK – which evidently there is not, against the backdrop of the last 12 months of industrial action – what position does that leave the LTWP in, and how will we measure its success?

Measuring Success

While it is hard to measure the success of a ‘Long Term’ plan 6 months after its publication, there have been some indicators of its potential.

As previously mentioned, the Government’s aim of recruiting 50,000 additional nurses into the NHS by early 2024 was hit early, in September 2023. This is a promising indication of the global appetite to work in the NHS – however, 93% of the new recruits came from overseas, further emphasizing the lack of desire to work in the NHS felt by the domestic population. The plan originally aimed for no more than one quarter of these nursing recruits to be recruited from overseas. The immense discrepancy between target and reality here does not bode well for the LTWPs wider target to reduce international recruitment across the board to just 9% by 2038. If this can be achieved remains to be seen.

The Government’s pledge to double numbers of medical students by 2036 already seems in danger, with cuts already being made to funding for additional places. News broke this week that only 350 additional places will be funded in 2025-6, less than a quarter of the annual number widely anticipated. There is no guarantee that even this level of resource will be repeated – though with UCAS having reported a decline in applicants for medical courses in 2023, increasing medical school places will be redundant if there are no students to fill them.

The LTWP’s staffing model relies on students taking up the increased number of places available on medical degrees – but this is not where the focus should be, nor is it looking likely.

The LTWP’s success also depends on the retention of clinicians currently in the service. The failure of the Government to successfully negotiate a pay deal with the BMA, and the failure to address the increasingly uncompetitive salaries in an increasingly globalised market and working conditions the NHS offers, is unlikely to help retention. While the plan does suggest some retention measures, it does not specify a timeline or budget for the most pressing grievance among existing staff – pay reward. Worryingly, an increasing proportion of early years clinicians are leaving the service, with one in four doctors now leaving within two years of completing foundation year training.

Beyond addressing staffing difficulties, the LTWP needs to form part of a larger conversation about improving the health of the nation at large. While the plan aims to expand the specialist public health workforce by providing 13% more training places than when published, there is no targeted drive to increase interest in these careers. A move from reactive healthcare – treating patients when they present with critical health needs – to more preventative healthcare, assessing and treating patients before their conditions escalate, will be crucial in managing patient demand.

The already astronomical elective recovery list, now estimated at 7.6 million, is thought to be an underestimation as patients on ‘hidden’ waiting lists have not been counted in official figures. The pressure of the waiting list is unsustainable – and unless we find a way to address care needs, via primary or community care, the backlog will continue to grow.

International Recruitment and the Long Term Workforce Plan

Taking into consideration the apparent lack of domestic interest in medical degrees, the increasingly aging UK population, and the mounting dissatisfaction of the current NHS workforce, the LTWP seems slightly out of touch. While the plan proposes practical measures, such as increasing medical training places, it lacks the ‘how’ – how do we get students to pursue medical careers? How do we ensure there are enough placements for students on these courses? How do we ensure apprentices can be properly trained when medics are already stretched almost beyond capacity? How can we achieve the desired 9% international recruitment when 93% of nurses recruited as part of the LTWP were internationally educated? Clearly, we can’t.

The success of the LTWP, and of the NHS as an institution, depends on international recruitment. Without international recruitment improving NHS capacity, there is limited room for apprentices and students on placements to be taught on wards and in hospitals. Without international recruitment, pressures on clinicians remain intolerable and clinicians working in the service will continue to leave for better pay overseas, for the private sector, or leave the medical profession entirely.

While the LTWP brings a welcome focus to the state of the NHS workforce, it is impossible for one document to address all of the needs of the service or to predict and plan for all outcomes. It is essential for the plan to adapt to the changing needs of the population and market conditions – and while it sets out bi-annual reviews, 6 months in it is clear the plan will need some adjustments if the recruitment goals are to be met.

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