One of my favourite books of the past few years has been Daniel Kahneman’s Thinking, Fast and Slow and his exploration of the ways in which our immediate, unconscious reasoning often leads us to the wrong conclusions.
Reaction to Labour’s pledge for an extra 20k nurses in the NHS workforce by the end of the next parliament made me think about Kahneman’s book again. I’ve read a lot of comments suggesting that increasing registered nursing numbers in the workforce (which I don’t argue with) will require immediate and huge increases in education places – with some claims this would mean a rise from 19k to 28k nursing places a year. This has a kind of instinctive logic to it; but is it right?
Take a notional workforce of 100, with turnover of 10 per year. 25 student places are commissioned each year. 20 students complete, join the register and join that workforce each year; overall, the workforce grows by 10. Keep the education commissions steady and the workforce is still increasing; in fact, in our notional example you could cut to 20 places with the same completion/participation rate and the workforce still grows by 6 a year. In the relationship between education commissions and overall workforce numbers, theoretically, down could be up.
But in our example we made a lot of assumptions. We assumed that all students who finish their course join the professional register and join the health workforce. Most importantly, we assumed that the workforce demand was predictable. If it suddenly rockets (as it has in nursing) even substantial planned increases may seem like a drop in the ocean. HEE’s 2015/16 workforce plan (see pp. 53 and 54) predicts that it will already be supplying an additional 13,000 FTE adult nurses and 5900 children’s nurses into the workforce by 2019 on current education commissions (i.e. it’s already not far off achieving the 20k extra in the workforce); but whether that answers the critical question of whether there will be enough staff is another matter.
So where does that leave us?
Firstly, although all serious initiatives to get staffing back on an even keel are welcome, there are no quick fixes. We need to be looking now at how to develop a fundamentally more resilient system that is better able to cope with what we’ve seen in nursing and what is emerging for some other professions, such as paramedics: a shock to the system where shifts in policy (in nursing, from QUIPP to Safe Staffing) and pressure from turnover means that the demand for registered professionals rockets beyond all the affordability predictions of the previous years.
Although new ‘home grown’ workforce is only one part of the picture, one way of creating greater resilience would be to decouple the inherently long term decisions on education numbers from full reliance annual recurrent NHS budgets and predicted affordability. Could the NHS use its workforce intelligence to set out its view of the minimum predicted workforce requirement but allow universities to recruit above that? Attractive perhaps, but it would force us to bite the bullet about fears of oversupply and look at alternative ways of funding education itself.
Secondly, we need to unpick the relationship between the number of education places and the number of students that complete their course, go on to join the professional register and then seek employment. There are pinch points at each stage where we could take action to improve the likelihood of increased education commissions converting to increased workforce numbers. Universities and the NHS have worked hard over many years to improve the numbers of students finishing their courses but is there more that we could do at other stages? What about a concerted national focus on the transition into employment?
However you look at it, there are debates to come in this next Parliament that will require slow as well as fast thinking.
Lizzie Jelfs, Director, CoDH