Accountability for workforce supply and retention

Establishing integrated care systems' responsibility for meeting the workforce needs of the health service in England

Why it matters

The population’s health and care needs are growing. People are living longer and are more likely to have multiple long-term conditions.

Meanwhile, the health and care system in England is facing a significant shortfall of registered nurses and nursing support staff. There are high numbers of vacant posts and not enough staff entering the workforce.

This causes problems for nursing staff and care quality, including:

working additional hours to meet high workloads
longer treatment waiting times
missed interventions and lost opportunities to avoid complications
poorer quality, unsafe care
compromised staff health and wellbeing

Three people in suits looking at documentation on a clipboard

How we collected evidence

We reviewed legislation, guidance and plans at a national level to identify where roles and responsibilities have been allocated and clarified. We'll continue to monitor these documents to identify any significant changes.

What we learnt

The Health and Care Act (2022) requires the government to publish a report at least every 5 years describing the system in place for assessing and meeting the workforce needs of the health service in England. They have not yet clarified these roles and responsibilities since the Act became law in 2022.

The NHS Long Term Workforce Plan didn’t set clear roles and responsibilities for workforce decision-makers or include any measurable objectives, outcomes or success indicators. Without clear roles and parameters, it’s hard to conceptualise how this plan will be delivered. We continue to make the case for clear roles, responsibilities and delivery plans.

Our position on this issue

Workforce plans throughout the system are uncosted, lacking in detail and not grounded in evidence

Neither government or ICS leaders have set out how they will:

increase nursing staff numbers through undergraduate and postgraduate routes
resolve the financial pressures on students (including the cost of living)
incentivise more people to join the profession when working conditions are so challenging, and when nursing pay, terms and conditions remain unresolved

We’re concerned that this level of ambition cannot be delivered unless significant capacity issues are identified, understood and resolved. This includes challenges with clinical placements, the capacity of the educator workforce and the availability of existing staff to support nursing students on placement.

A focus on expanding the support workforce, without considering the impact on registered nursing

There’s heavy emphasis on growing the number of nursing associates to 64,000 by 2036. We also see this in local recruitment campaigns and workforce plans. There’s no reference to understanding the scope of the role, or how (or whether) this has been considered in parallel to projections for registered nurses. Registered nurses should not be substituted with support staff – evidence shows that patient safety can only be upheld when there are enough registered nurses.

We’re concerned that increasing the number of nursing associates will have significant implications for social care and could risk inappropriate substitution of registered nurses across the entire workforce. This is unsafe for patients and for nursing associates. Employers should provide additional detail and assurances that the workforce is protected from inappropriate substitution.

What local health and care leaders should do to address this issue

Integrated Care System leaders should:

Provide clear roles, responsibilities and commitments for workforce planning and supply within their Integrated Care System (ICS), to ensure transparency and accountability for workforce decision-making.
Champion the need for national decision-makers to set clear roles and responsibilities for workforce plan delivery, so that ICS leaders can be clear on what actions fall within their remit.
Make sure there is a nurse at executive level within their governance structure to provide professional, strategic and operational guidance to corporate boards and commissioners on nurse staffing (see the RCN Workforce Standards).

Services providers should:

Use the RCN Workforce Standards to support a safe and effective nursing workforce, and ensure nurse leaders are involved in workforce planning, setting staffing establishments and developing individuals within their workforce.