Getting into shape:
Delivering a workforce
for integrated care
Getting into shape:
Delivering a workforce
for integrated care
The authors would like to thank the 37 individuals who participated in semi-structured
interviews for the paper. We are extremely grateful to Professor Val Wass (Chair of
Advisory Assessment Board, General Medical Council), Dr Charles Alessi (Senior Advisor,
Public Health England), Robbie Turner (Director of England, Royal Pharmaceutical
Society) and Claire Warnes (Partner, KPMG) for helpful comments on an earlier draft of
this paper. The arguments and any errors that remain are the authors’ and the authors’
Reform is an independent, non-party think tank whose mission is to set out a better way
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Reform is a registered charity, the Reform Research Trust, charity no.1103739. This
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Executive summary 4
1 A new NHS workforce policy to support integrated care
and reform 10
1.1 The shape of the workforce 11
1.2 The case for integrated care 13
1.3 Barriers to integration 14
2 Invigorating the medical labour market 17
2.1 Pharmacy 18
2.2 Nurses/Allied Health Professionals 19
2.3 Doctors 20
2.3.1 The cost of training 20
2.3.2 Training excess doctors within the
current framework 22
3 Devolved workforce planning and pay 25
3.1 The current system 26
3.1.1 Going against integrated care 27
3.2 Implementation 27
3.2.1 One-system one-budget 27
3.2.2 Devolve training 28
3.2.3 Devolve pay 31
4 Overcoming professional boundaries 33
4.1 Deregulation 34
4.2 Continuing professional development 36
4.2.1 State of play 36
4.2.2 A Skills Pass 38
4.2.3 Performance management 40
A new NHS workforce policy to support integrated care and
The Government is rightly committed to a radical reshaping of NHS delivery, based on a
shift to new care models and treatment in the community. Its management of the NHS
workforce, however, has not delivered with nearly three times more doctors, and four
times more nurses in the acute sector than in the community.1 Since 2009, the number of
consultants has risen by nearly a third, whilst the number of GPs has fallen.2 Freedom of
Information requests made for this report found that, across 61 acute trusts, only 6 per
cent of consultants work in the community for at least one session per week.
As the Government and the NHS leadership have repeatedly said, the priority for the NHS
is to increase its speed of innovation.3 To do this, the NHS is rightly seeking to devolve
decision-making and to deregulate. For the workforce, however, policy remains highly
centralised and tightly regulated. This paper shows how to bring the same reform ideas to
the workforce as the NHS is applying to other areas.
A number of practical and cultural barriers need to be overcome if this imbalance is to be
redressed. The funding model of the NHS continues to drive activity, and resources,
towards the acute sector.4 Medical training is based on specialisation and gives little
recognition to inter-specialty transferable skills.5 Interviewees for this paper concluded that
this approach creates a workforce of “super-specialists” based predominately in the acute
sector rather than an integrated team built around patient needs. The vast majority of clinical
training placements are weighted towards the acute sector.6 Interviewees also reported a
“snobbish” attitude that places primary care at a lower status than secondary care.7
This paper follows a previous Reform report, Work in Progress, which showed how better
use of technology and a better culture of employment can increase efficiency in the whole
public-sector workforce.8 The paper focuses on the structural barriers to delivering
Invigorating the medical labour market
Removing the cap on training places for doctors
The deregulation of the NHS workforce begins with the removal of the national cap on
doctors’ training places, set by the Department of Health. The aim of the cap has been to
control costs by limiting the number of doctors in training. The result, however, has been
an inadequate pool of labour, difficult working conditions and a powerful staff body, many
of whom choose to work for expensive agencies.9
There is a worldwide shortage of healthcare professionals and yet the NHS imports 26 per
cent of its doctors, many from poorer countries struggling to afford the drain on their
workforce.10 OECD statistics show the UK as the sixth biggest importer of foreign trained
1 NHS Digital, NHS Workforce Statistics - February 2017, Provisional Statistics, 2017.
3 Jeremy Hunt, ‘Innovation and Efficiency’, Speech, (13 November 2014). NHS England, Health service embracing
innovation as NHS England announces major trials to improve patient care (2016).
4 Kate Laycock and Elaine Fischer, Saving STPs. Achieving Meaningful Health and Social Care (Reform, 2017).
5 General Medical Council, Adapting for the Future: A Plan for Improving the Flexibility of UK Postgraduate Medical
6 Professor Val Wass, Professor Simon Gregory, and Katie Petty-Saphon, By Choice – Not by Chance (Health Education
8 Alexander Hitchcock, Kate Laycock, and Emilie Sundorph, Work in Progress: Towards a Leaner, Smarter Public-Sector
Workforce (Reform, 2017).
9 National Audit Office, Managing the Supply of NHS Clinical Staff in England, 2016.
10 Jeremy Hunt, ‘Speech to Conservative Party Conference 2016’, October 2016; Carl Baker, NHS Staff from Overseas:
Statistics, HC 7783 (London: House of Commons Library, 2017). World Health Organization, “New global alliance seeks
to address worldwide shortage of doctors, nurses and other health workers”, Press Release, (25 May 2006).
doctors.11 Talented individuals are being turned away from medicine. In 2017, 19,210
applicants applied for just under 6,000 places.12 The NHS should uncap training places
for doctors following successful removal of caps for pharmacists whilst learning lessons
from the removal of bursaries for nurses and allied health professionals.
By removing the cap on training places, the NHS could produce a sufficient or excess
number of trained individuals that it could employ. Greater number of trainees should give
managers more flexibility in shaping the workforce in accordance with population demand
rather than workforce supply. It should aim to create a more conventional labour market,
as seen in other sectors.
Reduced bill for agency staff
High vacancy rates have resulted in excessive agency spend. In 2015/16, the NHS spent
£1.3 billion on agency doctors.13 This is the same amount it spent on training student
Accurate costing of medical education
This report proposes a review of the true cost of medical training. At present, there is a
wide variation between institutions, with some hospitals paid tens of thousands of pounds
more per student by HEE than others.15 Buckingham University provides training for
doctors at a total cost of £162,000,16 compared with the Department’s own target of
£230,000.17 This suggests that there are great efficiencies to be made. The report
estimates that a doubling in the annual output of trained doctors, to 12,000, could cost
an additional £140 million per year.
New funding arrangements for student doctors
Ministers should require trained doctors to pay back the taxpayer-funded costs of medical
training should they decide not to work in the NHS. This report suggests that students
should pay back £11,700 per year, for a maximum of ten years, for each year spent
working for a non-NHS employer or locum agency. In other professions, such as
accountancy, it is normal for employers to pay for the cost for training, but for trainees to
take on that cost should they leave the firm during training.
Devolved workforce planning and pay
The NHS is right to seek to devolve decisions on the future pattern of services to the local
level, in the form of Sustainability and Transformation Partnerships (STPs). Local health
economies are best placed to decide how to reform health and social care in their areas.
Decision-making over the workforce, however, remains highly centralised, with the key
actor being the Department of Health, working through the arms-length body Health
New powers for STPs to innovate
STPs should take control of the training budget in the same way as they should take
responsibility for the whole health and social care budget in their areas. Different STPs have
different priorities and require different workforces. An STP in an area with a large elderly
population, for example, could invest in community nurses and geriatricians capable of
11 OECD, “Health at a glance”, Web Page, (4 November 2015).
12 UCAS, Deadline Applicant Statistics: October, 2016.
13 NHS Improvement, ‘Reducing Reliance on Medical Locums: A Practical Guide for Medical Directors’, Web Page, (2016).
14 Department of Health, Expansion of Undergra