What needs to be done to address staffing shortages in health and social care?

England’s NHS does not have an adequate workforce strategy. Staffing shortages in health and adult social care are limiting the delivery of services. Adult social care, which is more organisationally heterogeneous than the NHS, also has a staffing crisis. There are over 250 000 vacant posts across both sectors.^1,2 The two systems are symbiotic, and their staffing issues must be addressed together. As the main gateway for patient access to the rest of the NHS, general practice teams hold responsibility for providing care for patients in the community. General practice is hit by the staffing deficit twice over, soaking up additional demand caused by shortfalls in secondary care and social care while grappling with its own staffing crisis. What is the relationship between staff levels, financial cost, and staff and patient welfare across the NHS and social care, and what are the potential solutions?

WHAT DO WE KNOW ABOUT THE STAFFING CRISIS?

Workforce numbers in health and social care only tell one side of the story as demand has increased over time because of demographic change. The total number of patients registered with GPs has increased by around 9% since 2015.³ The number of full-time equivalent GPs per 1000 patients has been falling since 2015,¹ while the number of posts in health and care have increased by almost 450 000 in the past decade to meet the population’s needs.^1,2 NHS workforce data from June 2021 to June 2022 show over 200 000 joiners compared with 170 000 leavers.⁴ It is unclear how many leavers moved to different roles in the NHS or social care and were therefore retained in the health and social care workforce overall.⁵ The most common reasons for leaving include retirement, completion of training, promotion, relocation, and work– life balance, some of which suggest mobility rather than attrition. General practice workforce data are particularly opaque, with some sources reporting on numbers of ‘doctors’ or ‘clinicians’ working in general practice, masking the deficit in full- time equivalent, fully qualified GPs. Social care is made up of around 18 000 different organisations, mainly based in the private sector, around 50% of which have under nine employees.² Almost half of the social care workforce employed in delivering domiciliary care are on zero- hours contracts.² The annual turnover rate in social care is around 30% compared with around 15% in the NHS, but over 60% of staff are recruited to new roles from within the sector.²

Demand that outweighs resource contributes to work-related stress. Data from the NHS staff survey and surveys from other professional bodies suggest a high degree of work-related stress, moral injury, and burnout within the NHS workforce.^6.7 Demand in general practice is challenging to quantify because of the hidden workload of administrative tasks that is not reflected in the appointments data collected and published by NHS Digital. Several royal colleges have highlighted the relationships between reduced staffing numbers and patient safety and mortality.^8,9 Temporary staffing plans are expensive and can lead to poorer patient outcomes.¹⁰ There is also an association between healthcare professionals’ wellbeing and patient safety.¹¹ Research shows continuity of care in general practice is beneficial to staff welfare and patient care; however, continuity is being jeopardised by challenging working conditions that are a barrier to GPs working more sessions and delivering care in practice. Research on these issues within social care is lacking despite workers facing similar challenges and the interconnectedness of staffing shortages across the entire patient journey.

WORKING TOWARDS SOLUTIONS

The first step to solving the staffing crisis will be improving data collection and analysis on staffing movement and attrition in health and social care. We need a clear understanding of why staff are leaving, whether they are moving to other roles within health and social care, and what they say would make them stay. There is a particular dearth of these data in social care. The fragmented makeup of the social care sector, with varying security of relationship between employer and employee, makes it difficult to interrogate reasons for staff movement. Policymakers must take on this challenge for improvements to NHS staffing and services to be impactful. This has been recognised in the UK Government’s response to the Health and Social Care Committee inquiry on burnout, which suggests extending the NHS staff survey from NHS trusts to include social care, and moving to translatable wellbeing scores for organisations.¹² Primary care should be included in this too.

Second, the workforce needs health and wellbeing services. Primary care staff in England need self- or employer funding to access certain occupational health services and can therefore face barriers in accessing support compared with colleagues employed by hospital trusts,¹³ a double standard that needs to be addressed. The impact of this gap in national support has been recognised, with initiatives such as free coaching recently made available for staff in primary care. This is not a substitute for comprehensive support. Meanwhile, the social care workforce is in desperate need of investment. The independent and fragmented nature of the social care sector is a barrier to this. The UK Government should publish workforce plans for both health and social care in parallel,⁸ though how top-down workforce plans will permeate through social care is unclear. Social care workers face similar hazards and risks to healthcare workers but have less access to wellbeing support.¹⁴ Staff mental health and wellbeing hubs established during the pandemic operate across both sectors, but this is the exception. The shortfalls in workforce wellbeing initiatives for NHS staff are acknowledged with a long- term roadmap of growing occupational health and wellbeing resources to meet this need.¹¹ Stakeholders in social care, the NHS, and government must collaborate to extend this to general practice and social care.

Finally, health and social care organisations must invest in understanding what works to recruit and retain staff, and, in the case of general practice, in patient- facing roles delivering care in practice. NHS Employers suggests target areas for focus for employing organisations, such as encouraging flexibility and supporting new starters; however, there is a lack of evidence on what is proven to keep people in post, recently highlighted by the Royal College of Anaesthetists concerned about staffing levels within their own specialty.¹⁵ Financial incentives including pay, taxation, and pensions must be optimised but do not exonerate the need to optimise working conditions. Outcomes of health, wellbeing, and support initiatives such as patient safety, staff turnover, sickness absence, and financial impact should be analysed and shared across organisations. Local and national retention programmes should involve staff, patients, and occupational health. Looking after the workforce in all health and social care settings will improve productivity and staff retention as well as provide safer care.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.