The long term workforce plan for our NHS wrongly omits off-payroll

The National Health Service has long been the pride of the United Kingdom, providing healthcare to millions of people and, if that doesn’t turn your head, it’s also the largest employer in the UK, writes a former agency contractor for the NHS Jacob Bellas, founder of Contractor Voice.

However, over the last decade, the NHS has faced an ongoing crisis in staffing shortages, leading to a heavy reliance on agency professionals. The government’s recently released long-term workforce plan – the first of its kind, aims to address the vacancies and reduce reliance on agency staff.

NHS agency staff spend is in the billions, but its message to temps may be almost as costly 

It’s a welcome step, but consider where that reduction needs to come down from. According to the plan, over the three years up to 2021/22, expenditure on agency staff has increased by 23% to £2.96billion. The NHS says use of agency staff is expensive and offers poor value for money for the taxpayer. The plan also sends a slightly unpalatable message, speaking of “increasing evidence that use of temporary staffing – particularly agency staff – can negatively impact on patient and staff experience, and continuity of care.”

Despite being engaged by the NHS as an agency worker, I welcome the pledge for the NHS to, in effect, wean itself off non-permanent staff, but it may be too late to completely reverse the trend.

What does the NHS staffing crisis look like?

From what I’ve seen (and I've also worked as an agency contractor for a private hospital), the staffing crisis in the NHS has been evident for at least the last 10 years. It’s a crisis characterised by unfilled positions, an overdependence not just on temporary workers but on international recruits, and a workforce that responds to care and healthcare needs, rather than prevention. 

On nurse vacancies alone, the data shows more than 68,000 job vacancies in just the single month of June 2023, observes Kate Shoesmith, deputy CEO of the Recruitment & Employment Confederation. She also points out that permanent and temporary vacancies in the healthcare sector have risen for 34 months in a row.

My take is that skills shortages, significant reductions to bursaries and pay discrepancies have been key driving factors behind so many openings for medical professionals going unfilled.

Areas such as nursing, primary care, mental health and critical care, have struggled to attract and retain qualified professionals. The result we have today? Increased workloads enough to put off any new qualified professionals, and for existing staff, burnout.

Off-payroll working rules have made a bad staffing situation worse

Reforms to the IR35 legislation introduced on April 6th 2017 (and April 6th 2021 in the private sector) have had significant repercussions on the healthcare sector too, notably its workforce. The changes, aimed at combating tax avoidance by ‘disguised employees,’ shifted the responsibility of determining worker status from the contractors to the agencies and end-hirers themselves.

Unfortunately, many agencies opted for a blanket approach, categorising most contractors as inside IR35, making contracting in the NHS financially less attractive. Consequently, many skilled healthcare professionals were pushed into the private sector (where there is marginally more willingness to navigate the changes) or opted for alternative professions.

In short, IR35 reform has exacerbated our health service’s staffing crisis. I’ve not seen the government respond to that exacerbation whatsoever, with any mitigation measures despite their regularly trotted out rhetoric that ‘the situation will be kept under review.’

Contractors, you're fundamental but overlooked in the NHS staffing plan as IR35 is ignored

Despite the stigma surrounding agency staffing – which IR35 changes have added another layer of stigma to –  contractors have become a fundamental and crucial part of the NHS staffing strategy.

As Seb Maley, CEO of Qdos has described it, “the NHS relies on the skills and flexibility of contractors and locums”, and so “where we would be in recent years without these workers”?

It’s true – agency professionals have filled critical gaps in service delivery, allowing the NHS to maintain necessary levels of patient care. From a contractor’s perspective, the primary reasons we choose to work via an NHS staffing agency is better pay and the freedom to determine working hours (for work-life balance purposes).

So the flexibility contracting offers has been a major draw for skilled professionals seeking better work-life balance and career autonomy, and by extension, contractors have been a major lifeline for the NHS. But a bit mystifyingly, IR35 or “off-payroll” is totally absent from the NHS workforce plan. There is a mention of ‘clinicians being pushed out of the workforce for tax reasons’ but that appears to be a segue to trumpet Spring Budget 2023 making changes to pensions.

As a whole, the NHS’s long-term workforce plan is a step in the right direction, with its priorities of addressing the staffing crisis and reducing reliance on agency staff.

What strategies does the NHS workforce plan contain?

We are a very long way off from seeing the results of the proposed strategy. The plan outlines several key principles, including:

Increasing training and education

The NHS is promised significant investment in training and education, focused on areas with the most severe skill shortages. By nurturing homegrown talent and creating attractive training opportunities, the NHS aims to fill the gaps in the workforce organically.

Retention and wellbeing initiatives

The government’s plan recognises the importance of retaining existing staff and promoting their wellbeing. By addressing the issues that lead to burnout and dissatisfaction, the NHS hopes to reduce the attrition rate and improve morale among healthcare professionals. This is one of the main reasons why professionals opt to engage via an agency and have left their NHS employment, so the initiatives will need to be attractive to entice contractors back into full time employment or to retain existing staff.

Pay and benefits review

The government acknowledges in the plan that pay disparities have been a driving force behind the NHS staffing crisis.

So a comprehensive review of pay and benefits is promised, to ensure that healthcare professionals are fairly compensated for their work. With NHS staffing strikes still ongoing, it is evident that the government is far from delivering fair pay to NHS workers and will need to address this if it is expecting to see applicants flooding toward the high number of existing job vacancies.

Technology and innovation

Embracing technology and innovation is a key aspect of the NHS workforce plan. By implementing modern healthcare solutions, the NHS aims to streamline processes, improve efficiency, and reduce the burden on staff.

Unfortunately, many frontline workers have seen the introduction of several IT systems slow down the service that we provide patients, with multiple different systems used across a variety of trusts without any uniform solution for patient care.

In review…

The NHS has faced a staffing crisis for over a decade, leading to an increasing reliance on agency professionals. While the government’s NHS workforce plan is a positive step towards addressing this, it will be challenging to fully reverse the trend given the deep-rooted nature of the current situation -- skill shortages, pay disparities, and the IR35 reforms have all entrenched the staffing crisis. And, as said, those reforms don’t appear to be even factored into the NHS workforce strategy.

With recent nursing and doctor strikes continuing to emphasise the unresolved, long-running dispute over safe staffing conditions and pay, there is an understandable fear that the government’s strategies will fall far short of what is needed to reverse the NHS staffing crisis.

My recommendation is for the NHS to take proactive steps to create a compelling, attractive working environment, which offers competitive pay, and workplace solutions as innovative as other leading, respected employers. That’s the minimum necessary if we want to ensure the future sustainability of our invaluable NHS. Only by acknowledging the important role of contractors; listening (at every turn) to the voices of medical professionals ‘on the ground’, and committing to and implementing the comprehensive workforce reforms, will the NHS navigate its way out of the staffing crisis and continue to provide exceptional and free care to the nation.