As the UK healthcare system appears collapses under pressure of patient numbers, Tony Hockley explains how Treasury driven manpower planning is at the heart of the problem.
The pandemic has tested the historic weaknesses of UK health and care system to near destruction; the prioritisation of treatment over prevention, of institutions over community services, and of grand projects over workforce. The result of skewed planning is a system that is poorly staffed and systematically inequitable. Scarce (but growing) resources continue to be badly directed. Whilst health ministers usually take the blame, in truth all they do is manage the effects of the dead hand of the Treasury. As a ‘spending department’ the Treasury is in charge.
Nowhere is this more evident than in the stringent control of the workforce. There is a long dark shadow of disastrous workforce planning hanging over the care system. Two dangerous traits underpin the approach. Firstly, the Treasury is gripped by overconfidence in a regime of rigid centralised planning, such as is rarely seen outside countries that are either communist or dictatorships. Secondly, its decisions over the number of training places funded shows a deep aversion to producing “too many” clinical professionals. These fears were realised in 2007, when the worst episode ever of the Treasury’s boom-bust cycle of NHS funding led to tabloid headlines of jobless doctors and nurses.
On top of this endemic tendency to planning failure, it was the Treasury again who imposed a lifetime cap on pensions with no regard to the impact on NHS professionals, although this was immediately obvious to anyone familiar with NHS incomes. It still seems extraordinary that an exception was later made for the judiciary, but not for medicine. Is this a symptom of a wish to turn a blind eye to the huge disparity within NHS salaries groups between the best and worst paid, or of a misguided desire to rid the system of some of the highest-paid? The logic is elusive to say the least.
This type of rigid central workforce planning may have worked 50 years ago, but it is ill-suited to the modern health and care workforce, changing care capabilities and needs. It is tantamount to using an abacus to resolve an extraordinarily complex problem. As a personal aside, I will never forget when, as a new special adviser in the Department of Health, I decided to sit in on a meeting of one of our medical workforce advisory groups. As an undergraduate economist I had been fascinated by the history of failed workforce planning for the teaching profession. If something that seemed relatively simple failed repeatedly, then how could it succeed amidst the complexity of medicine? At the advisory group each professional specialty made the case for its calculation of trainee number. The total, if my memory is correct, came to 3200 medical profession training places needed. A quick ministerial discussion with the Treasury produced an announcement of 1600 places. Whilst the advisory system has changed since these times, the decision making seems to be as rough as it ever was. The lack of a worldview or appreciation of behavioural complexities is incredible.
Health and care today is a team effort. Decisions in relation to one profession directly affect the others. Newly qualified clinical professionals face a plethora of life choices against which the NHS must compete, not just at home but worldwide. Is it really a problem if the UK trains “too many” nurses, health visitors, physios or doctors? Does it really matter if they pursue part or all of their careers delivering care in brilliant health charities, in private practice, or in other countries? Why is it only acceptable for other countries to export professionals to the UK?
If anything, the Treasury approach to the workforce seems to have deteriorated over time rather than adapt to the complexities of the modern environment. The pretence of an academic basis to decisions appears to have been abandoned; not to be upgraded to something smarter but downgraded to ‘ad hoc’ decisions forced by dire need alone. The contrast with ministerial excitement around the latest “Life Sciences Vision”. Yet the most elementary basis for health policy must recognise is that the clinical workforce is the primary component of any health system. Why is there a “mission-led approach” for life sciences but no mission-led approach for the workforce to deliver this care?
It seems that the Treasury has thrown the baby out with the bathwater when it comes to workforce needs. Confidence in centralised planning certainly needed a huge shake of modern reality. But rather than simply abandon any forward planning it needs to learn from a critical assessment of past failures. The need for a mission-led workforce vision is urgent, followed by a creative and flexible delivery strategy.
There is no simple solution to the very predictable crisis precipitated by Covid. But a much smarter and more honest workforce policy will be at the heart of any effective recovery.