Paul Cézanne ‘The Three Skulls’ 1898

Empty promises, real threats

James Linney picks apart the NHS workforce plan and warns that Sir Keir’s Labour is committed to exactly the same agenda of privatisation and austerity

So here we are again, looking down the barrel of yet another Tory-sponsored plan for ‘saving the National Health Service’ - this time we are presented with a 15-year plan to solve the current workforce crisis.1

We have seen many such schemes since the Conservatives took the reins of government back in 2010. First came Andrew Lansley’s infamous Health and Social Care Act 2012, when we were promised the cutting of red tape and the handing over of more control to doctors in running the NHS. In reality the act was a Trojan horse: the restructuring overburdened primary care with bewildering layers of bureaucracy and hidden within its belly was the real reason for the reforms - the opening of the door to private health companies.

The NHS has never been free from the influence of private companies, but the HSCA 2012 introduced the requirement of offering service contracts to “any qualified providers”, which further catalysed its marketisation, and since this door has been opened the private sector’s influence has grown exponentially.

Since the HSCA 2012 we have also seen further attempts at making the process of privatisation go more smoothly, through the further fragmenting of care provision (the most recent being the creation of integrated care boards) and the starving of GP surgeries and hospitals of funds. Forcing NHS services to compete for contracts with private providers has predictably seen a race to undercut, to cherry-pick the more profitable sectors and consequently the quality of care has fallen drastically. Meanwhile the NHS’s increasingly scarce funds have had to deal with more GP consultations than ever, the Covid-19 pandemic, disastrous social care services, longer waiting lists than ever before and A&E departments that are on their knees.

All of this has happened in parallel with the freezing of pay across the NHS, leaving staff completely demoralised; many have been forced to retire early, go off with stress or leave for other jobs in order to be able to pay their bills. The process of dismantling and demoralising has effectively left the NHS on the brink of total failure. Presumably the intention all along.

We should instinctively distrust any new publication claiming to save the NHS, such as the ‘Long Term Workforce Plan’. It has been concocted in cahoots with the very same people who manufactured the existential crisis that currently threatens us. Without any irony or mention of how we got into this position, we read in the foreword how the plan is “one of the most seminal moments in [the NHS’s] 75-year history” and a “once-in-a-generation opportunity to put staffing on a sustainable footing and improve patient care”.

We are informed that the NHS currently has a 150,000 staffing shortfall and that without any intervention this is projected to climb as high as 360,000 by 2037, but we are expected to believe that these shortfalls are solely due to an ageing population and setbacks resulting from Covid-19 - nothing here about the sustained attack on the NHS by the same bunch now claiming to be its saviours.

These projected staff shortages are even more scary than they first appear, given that the UK already has significantly fewer doctors per 1,000 population than most nations in the OECD.2 Imagine for a second if, as is perfectly possible, in 2037 another pandemic hits the UK (or Covid-19 mutates again, becoming as deadly as it was in 2020), what will happen if the current rate of disintegration is allowed to continue - a terrifying thought.


So, with this possible disaster in mind, let us turn to look at how exactly NHS England and the government aims to save our health service with their Long Term Workforce Plan. The plan is divided into three parts: ‘Train’, ‘Retain’ and ‘Reform’. The first part, focusing on training more staff, is where we see the main, headline-grabbing ideas and is the only part of the plan that commits to any concrete funding.

We are told that £2.4 billion will boost the training of more nurses and doctors; we are promised a doubling of medical school places, including a 50% increase for general practitioner training and a 92% increase for adult nursing by 2031-32. On the face of it these pledges actually seem quite ambitious and have been welcomed by many leading doctors.

But, of course, it raises the immediate question: if all we had to do was train more clinicians, then why have they waited 13 years, with the NHS on the point of collapse, to come up with it? The obvious answer is that these pledges give the Tories positive headlines and useful slogans for the upcoming general election without them having to commit any funding or action in the near future.

However, even if the extra training targets were met, the new doctors and nurses would not be seen for many more years. We are promised 500 extra medical school places by 2025, but how would this benefit in the short term, for example, primary care, which has recently been haemorrhaging GPs due to stress and burnout? In the meantime, far more GPs would have been forced to leave their jobs due to stress and the reality of the crisis facing the NHS each winter means that even surviving the next 12 months is not certain!

Then there are the other features of the plan: eg, shortening medical school training. Currently this involves a five-year university course, but there is no evidence suggesting that doctors are being overly educated. Speaking personally, when I started my junior doctor years, I felt the opposite was true: I could have done with an extra year or two of education, so that I was not left to try and learn things on the job - often with not so good consequences for the patients.

True, making mistakes on the job can be a valuable way to learn and healthcare workers will always make mistakes just like in any other job, because they are human. But, in healthcare more than in other jobs, every effort must be made to minimise mistakes, or accept them only in controlled situations, where the impact on patients is likely to be minimal.

The proposal to introduce more apprenticeships for doctors and nurses is an even worse idea - it means that by 2031-32 apprenticeships would make up at least 22% of the entire workforce. Apprenticeships in any profession are usually bad for the workers - they essentially enable employers to pay them less (sometimes pay nothing at all for a while) to do their job. Introducing large numbers of apprenticeships, or less well educated doctors, would thus require a large pool of the current, very experienced doctors and nurses to teach and train these less experienced - sadly the exact opposite situation exists in our hospitals and GP surgeries currently. The experienced clinicians do not even have enough time to care safely for their own patients - hence the horror of 12-hour delays in A&E and the 7.47 million people who have been waiting years for treatment.

The plan goes on to describe other ways that “innovative new ways of working” will be established, with greater reliance on, for example, physician and nursing associates (PAs and NAs); by 2036-37 we are promised there will be 64,000 NAs and 10,000 PAs. These are not actually new roles: PAs have been around for several years now and nursing associates sounds very much like the rebranding of healthcare assistants, who have been part of the workforce for decades. We are back to the same issues here as with apprenticeships. What these roles are essentially about is an attempt to get doctors and nurses to do work they have always done for far less pay.

Medical training for PAs would be squeezed into a two-year course - at the end of which they would be expected to do the same job as foundation doctors. But again they are going to be very inexperienced, and employed in workplaces that are more unsafe; they will be overwhelmed with patients and will have little or no time to be fully trained for their roles - a recipe for disaster.


The other two parts of the workforce plan - ‘Retain’ and ‘Reform’, which span 151 pages - are very light on any concrete ideas, but very heavy on vague, meaningless soundbites that from a certain perspective sound reasonable, but are at the same time fully detached from the reality of the extent of crisis in the NHS. They are also aims for which it will be impossible to hold anyone to account. Thus in ‘Retain’ we are told NHS jobs will become more “flexible” and healthworkers will have “access to health and wellbeing support” and “work in a team that is well led”. In other words, generic managerial speak that could have been (and probably was) copied and pasted from any organisation’s occupational health policy.

Perhaps the token mention of supporting the health and wellbeing of NHS staff implies recognition of the terrible problems we face. For example, a recent survey revealed that almost 80% have considering leaving due to stress, anxiety and burnout in the past year.3 But access to a “wellbeing service” is not going to have much impact: it will no doubt involve workers in that service (themselves probably woefully undertrained and overworked) telling stressed staff to work on their self-resilience, whilst all the time ignoring the main cause - an unsafe working environment and inadequate pay.

Pay is, of course, the elephant in the room throughout this plan - predictably, given the recent strikes. It is not mentioned. Why after all would paying someone enough to be able to feed their family and pay their bills be relevant to convincing people not to leave their job or sign up to all these new, shiny and very expensive training courses?

Despite what the government and their media collaborators would have us believe, the recent NHS strikes have not been caused by greedy nurses or junior doctors. The typical starting salary for a band 5 nurse is £28,407 per year, which is about the average wage in the UK currently - and clearly not much more than the bare minimum needed to survive, given the current cost of living. The same situation is true for the vast majority of NHS staff - paramedics, ambulance crew, physiotherapists, etc, etc. Even doctors who have historically been paid more than other staff are now much worse off; as we learnt from junior doctors during their strikes, they are now being paid 26% less in real terms compared to 2008

So it is all very well wanting to double doctors’ training places and increase nursing numbers by 92%, but are people going to be flocking to take university degrees that will make them £100,000-plus in debt for a profession that leaves them barely able to pay their bills and with stress-related illness?

What becomes more clear, the more we analyse the workforce plan, is that it is obviously not a serious attempt to tackle the current funding and staffing issues that are driving the NHS crisis. It is a useful document that allows them to play lip service to the NHS, while continuing to preside over its destruction. If things continue as they are for another decade or so, most likely the NHS will exist in name only.

Some may say that there is a small glimmer of hope in that the chances of the Tories winning the next election are currently looking slim. But, of course, Sir Keir is on a crusade to steer Labour more to the right than even Tony Blair dreamed of. If Starmer and shadow health secretary Wes Streeting have their way, then a Labour win would mean very little in the way of sanctuary for the NHS; hence Streeting’s stated intention to continue to use the private health sector to reduce NHS waiting times and Starmer’s general disdain towards striking NHS workers - not to mention the fact that the Labour leadership is now giving full support to the workforce plan, which they think is so good, they accused the Tories of stealing it from them!

  1. www.england.nhs.uk/long-read/accessible-nhs-long-term-workforce-plan.↩︎

  2. www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/workforce/nhs-medical-staffing-data-analysis.↩︎

  3. www.newstatesman.com/spotlight/healthcare/2023/07/nhs-staff-quitting-strikes-stress-burnout.↩︎