Changing the workforce

NHS England’s Five Year Forward View (FYFV) calls for substantial changes to the NHS workforce, saying that new care models it wants to introduce won’t be effective unless there is a ‘modern workforce’ with the right numbers, skills, values and behaviours. According to the FYFV, this means that

  • There needs to be local flexibility in the way payment rules, regulatory requirements and other mechanisms are applied;
  • More support should be available for employers to increase productivity and reduce the waste of skills and money: consideration needs to be given to the most appropriate employment arrangements to allow staff to work across organisational and sector boundaries;
  • Health Education England will commission and expand new health and care roles, to ensure a ‘flexible’ workforce;
  • Working patterns and pay and terms and conditions will be looked at, in order to work towards rewarding high performance, supporting job and service redesign and encouraging recruitment and retention of staff across the country.
  • A dramatic increase in the use of volunteers: the new models will “draw on the ‘renewable energy’ of carers, volunteers and patients themselves”.

According to a report by the Nuffield Trust, commissioned by NHS Employers  and published May 2016, in the future,

“care will be supplied predominantly by non- medical staff, with patients playing a much more active role in their own care. Medical staff will act as master diagnosticians and clinical decision-makers. All staff will be supported by increasingly intelligent medical and information technologies”.

It finds evidence that the new and extended healthcare roles that the FYFV suggests could:

  • increase demand
  • cost rather than save
  • threaten the quality of care, and/or
  • fragment care.

There are also potential problems that new roles may not be recognised by professional regulators and those working in new roles in primary care may not have proper indemnity cover.

The report also concludes that the financial context in which the NHS is currently operating makes the aim of radically reshaping the workforce particularly challenging, not least because national and local training budgets are being cut just at the point that they need to be increased.



The proposals for workforce efficiencies depend on disregarding the current, nationally agreed system called Agenda for Change (AfC) that assesses jobs and determines the appropriate pay for most NHS staff. Since 2004, this system has ensured that pay and conditions of employment have been consistent across the NHS and meet the requirements of equal pay law. In contrast, the FVFV proposals support the introduction of local agreements that are likely to drive down pay, and risk pay becoming a source of industrial relations conflict. Local pay agreements may also introduce damaging competition for staff between NHS organisations. The FYFV expects NHS employees to accept new roles, working patterns and skill mixes that will support service ‘redesign’ but that will probably also mean downgrading staff (expecting them to do the same job for less pay); getting less qualified staff to take on nursing and medical work; reducing or ending pay for working unsocial hours (already seen with proposals for junior doctors’ contracts); and reducing the number of staff per patient.

This is a recipe for a poorly paid workforce with low morale. It is highly unlikely that such a workforce will be able to deliver quality patient care.

updated July 2016

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