The Competence Test

Most people become politicians because they want to change something, to make the world a better place. The fun part of being a minister – and there can’t be many – is devising and announcing new policies. But in the Westminster bubble, seeing the steady stream of new announcements, it’s easy to forget that nothing actually happens when you announce a policy.  Getting the implementation right is the much duller part of governing, but much good intent has fallen at the hurdle of poor implementation.

Competence – the ability to devise coherent policy and then to implement it well – is crucial to the reputation of government, and voters punish politicians who fall short.

Over the next few months, it’s reasonable to bet that the competence lens will be focused on how well the government can steward the NHS through what is widely expected to be one of the toughest winters in recent history. Much will depend on the weather and the virulence of this year’s flu strain. But there is no doubt that the NHS is in a fragile state going into winter as a result of widespread capacity problems. There simply aren’t enough nurses in hospitals or in the community, to meet demand and social care and primary care are bucking under the strain.
The causes of the capacity problems are long-term and complex but a very large contributor is the fundamental and systemic fault line in the planning and management of the workforce – a failure of workforce policy competence.  

Brexit didn’t create the NHS’s staffing problem but it brings it into even sharper relief. The NHS has always tended to train fewer doctors and nurses than needed and then rely on overseas recruitment. But analysis by the Health Foundation found a 96% drop in the number of EU nurses registering to work in the UK since last summer. Relying on international recruitment to bail the NHS out of workforce policy and planning failures has become high stakes poker. With the ongoing decline in GP numbers the government is looking overseas again for family doctors, aiming to entice 600 GPs from abroad to join the NHS by next April, and 2,000 in total over the next three years. An impressive sounding announcement. But just 38 GPs were recruited from overseas in the first six months of this year, which shows how challenging this policy will be to implement.

The overall size of the NHS workforce increased over the last year, with more senior doctors and managers – but the numbers of nurses and GPs fell. Official estimates are that the NHS is short 30,000 nurses – equivalent to one in 10 posts. Announcements of ambitions to remedy this are coming thick and fast: the government plans to grow the mental health workforce by 21,000, increase nurse training places by 25% and recruit 5,000 more GPs.  

The problem is, the gap between national rhetoric and reality for the NHS workforce is growing. One example is the abolition of bursaries for nursing. Until this Autumn nurses paid no tuition fees and received help with living costs. But in recent years nursing courses have been substantially over-subscribed, but places were capped due to cost. So from this year nurses’ degree training is funded by the standard student loan scheme, to remove this financial cap on the number of places. The rationale for this policy makes sense, but there were obvious risks – lots of nursing students are older than typical undergraduates, and loans schemes tend to impact older students and part-time students more. Nursing involves lots of work experience in clinical placements in hospitals, so another risk was that hospitals wouldn’t be given the support needed to take on more students.

As expected the shift to loans seems to have had little impact on young people straight out of school or college: 6% more 18 and 19 year olds are starting a nursing degree this autumn. But the signs are this growth is not enough to expand overall numbers as there are around 10% fewer people aged 20 and over starting a nursing degree. Overall the number of nurses applying from England starting training is down by 1,220. Funding announcements to support more clinical placements were hugely delayed and the issues for mature students not fully addressed. The obvious risks were ignored – another well intentioned policy hampered by poor implementation.

NHS staffing issues are now receiving long overdue policy attention. This is a step in the right direction but there is a long way to go to a workforce policy that inspires real confidence that the NHS will have the doctors and nurses it needs. These workforce issues are at the heart of the risks facing the NHS, but as we gear up for winter there is little chance that the government’s policies can have much impact in the short term. Once more we will be relying on luck and some great skill from those who currently work in our hospitals and GP practices – but they and everyone who uses the NHS deserve better.