But there is a limit to the extent to which ISPs can support elective activity. The vast majority of more complex elective work will continue to be conducted within the NHS for the foreseeable future. ¹ Coughlan E, Keith J, Gardner T and others, ‘Waiting for NHS hospital care: the role of the independent sector in delivering orthopaedic and ophthalmic care’, The Health Foundation, 30 April 2023, retrieved
19 October 2023, https://www.health.org.uk/publications/long-reads/waiting-for-nhs-hospital-care-the-role-of-the-independent-sector-in
  For example, only 0.3% and 0.7% respectively of thoracic and neurology procedures were carried out in ISPs in 2022/23, due to their relative complexity. ISPs also compete with the NHS for staff, meaning that it is difficult to expand capacity without reducing the NHS’s ability to deliver elective activity. ² Coughlan E, Keith J, Gardner T and others, ‘Waiting for NHS hospital care: the role of the independent sector in delivering orthopaedic and ophthalmic care’, The Health Foundation, 30 April 2023, retrieved
19 October 2023, https://www.health.org.uk/publications/long-reads/waiting-for-nhs-hospital-care-the-role-of-the-independent-sector-in
  Work by The Health Foundation also shows that those living in more affluent parts of England use ISP-delivered elective care more than those in the most deprived parts of the country. ³ Coughlan E, Keith J, Gardner T and others, ‘Waiting for NHS hospital care: the role of the independent sector in delivering orthopaedic and ophthalmic care’, The Health Foundation, 30 April 2023, retrieved
19 October 2023, https://www.health.org.uk/publications/long-reads/waiting-for-nhs-hospital-care-the-role-of-the-independent-sector-in
  If the expansion of ISP capacity follows existing distributions, then those in more affluent areas will benefit the most. Finally, in a report examining the efficacy of different approaches to reducing the elective waiting list, The King’s Fund concluded that there is “little empirical evidence that the additional capacity provided/activity undertaken by the private sector in England from 2003 to 2008 contributed to the rate at which waiting times were reduced”. ⁴ Blythe N and Ross S, Strategies to reduce waiting times for elective care, The King’s Fund, December 2022, p. 13, https://www.kingsfund.org.uk/sites/default/files/2022-12/Strategies%20to%20reduce%20waiting%20times%202022.pdf

Virtual wards require longer to reach their full potential

During the pandemic, to reduce in-person contact, the NHS greatly expanded the use of so-called ‘virtual wards’, where a hospital provides a patient with monitoring equipment so that they can stay in their own home rather than occupying a hospital bed; remaining at home is often preferable to a hospital stay. Hospitals have used this as a way of expanding capacity without investing in physical beds. The NHS has an ambition to create “40-50 virtual beds per 100,000 population”, ⁵ NHS England, 2022/23 priorities and operations planning guidance, 22 February 2023, p. 22, https://www.england.nhs.uk/wp-content/uploads/2022/02/20211223-B1160-2022-23-priorities-and-operational-planning-guidance-v3.2.pdf meaning a total of approximately 22,400–28,000 virtual ward beds in England. Data from NHS England shows that the government hit its target ⁶ NHS England, ‘Monthly operational statistics – August 2023’, last updated 14 August, retrieved 19 October 2023, https://www.england.nhs.uk/long-read/monthly-operational-statistics-august-2023 to have 10,000 virtual ward beds operational by September 2023, with 10,421 opened. ⁷ NHS England, ‘Virtual wards – September 2023’, (no date), retrieved 19 October 2023, https://www.england.nhs.uk/statistics/statistical-work-areas/virtual-ward Of those 10,421 virtual ward beds, only 65.3% were occupied in September. ⁸ NHS England, ‘Virtual wards – September 2023’, (no date), retrieved 19 October 2023, https://www.england.nhs.uk/statistics/statistical-work-areas/virtual-ward
  Given bed occupancy levels in the rest of the health service are close to 95%, this raises questions as to why there is so little uptake of the available virtual ward capacity.

Work by The Health Foundation shows that 63% of NHS staff are ‘very’ or ‘quite’ supportive of the use of virtual wards. ⁹ Thornton N, Horton T and Hardie T, ‘How do the public and NHS staff feel about virtual wards?’, The Health Foundation, 29 July 2023, retrieved 19 October 2023, https://www.health.org.uk/news-and-comment/charts-and-infographics/how-do-the-public-and-nhs-staff-feel-about-virtual-wards And a report from the NHS Confederation claims that: “When done well the model is seen as a successful way to keep people out of hospital, discharge early to home, reduce clinical time and give patients autonomy and choice in their own surroundings.” ¹⁰ Hakim R, ‘Realising the potential of virtual wards’, NHS Confederation, 23 May 2023, retrieved 19 October 2023, https://www.nhsconfed.org/publications/realising-potential-virtual-wards

But there are still barriers to effective implementation. The NHS needs to upskill staff to maximise the effectiveness of virtual wards, as well as employ enough health care workers to properly staff them. The report from the NHS Confederation mentioned above also calls for flexibility in how the model is applied locally, with less prescription from the centre of government. Respondents also highlighted the importance of senior clinician buy-in for virtual wards, something that is currently frequently lacking due to concerns about the risks of managing patients remotely. ¹¹ Hakim R, ‘Realising the potential of virtual wards’, NHS Confederation, 23 May 2023, retrieved 19 October 2023, https://www.nhsconfed.org/publications/realising-potential-virtual-wards
  Some of that concern from older doctors may be due to an aversion to new methods. But some of it may be warranted. There is still little evidence about the efficacy of virtual wards or the effect on patient outcomes – work that the NHS should prioritise if it plans to continue the expanded use of virtual wards.

Government’s cuts to integrated care systems’ budgets will prevent them working effectively

One of the Johnson government’s flagship pieces of NHS reform was the creation of integrated care systems (ICSs), which were intended to improve the co-ordination and co-operation of a fragmented health and social care system. ICSs bring together representatives from acute trusts, primary care, local authorities (which are responsible for commissioning adult social care) and some social care providers. ¹² Charles A, ‘Integrated care systems explained: making sense of systems, places and neighbourhoods’, The King’s Fund, 19 August 2022, retrieved 19 October 2023, https://www.kingsfund.org.uk/publications/integrated-care-systems-explained The government put ICSs on a statutory footing in July 2022, leading to the creation of 42 of them across England. ¹³ NHS Digital, ‘ICS implementation’, last updated 21 November 2022, retrieved 19 October 2023, https://digital.nhs.uk/services/ics-implementation

ICSs faced a difficult first year, dealing with arguably the most severe winter crisis in the health service’s history. Despite that, ICSs were beginning to embed themselves into their local health and care ecosystems and were creating initiatives to deliver more integrated care. One interviewee told us that they created teams for major conditions that worked across a range of primary care, secondary care, community care and social care. ¹⁴ Institute for Government interview. But it is difficult to give a full picture of all ICSs’ activity from a small number of interviews due to wide variation in the initiatives ICSs are implementing and the progress they have made.

In March 2022, the government told ICSs that they would need to cut 30% of their management spending in 2023/24. ¹⁵ Local Government Chronicle, ‘Integrated care boards told to cut running costs by 30%’, 3 March 2023, retrieved 19 October 2023, https://www.lgcplus.com/services/health-and-care/integrated-care-boards-told-to-cut-running-costs-by-30-03-03-2023 These cuts will require a reduction in the staffing of integrated care boards ¹⁶ Local Government Chronicle, ‘Integrated care boards told to cut running costs by 30%’, 3 March 2023, retrieved 19 October 2023, https://www.lgcplus.com/services/health-and-care/integrated-care-boards-told-to-cut-running-costs-by-30-03-03-2023 and interviews revealed that it has hurt the morale of at least some ICS staff and contributed to people leaving their roles. One interviewee told us that the funding cuts and the changes that accompanied them had taken up all the attention of leadership within their ICS, meaning that the transformation programmes they had started were either delayed or scrapped entirely. ¹⁷ Institute for Government interview.

The workforce plan is welcome but does not address key issues

The government committed to releasing a long-term workforce plan at the 2022 autumn statement. That plan was released at the end of June 2023. ¹⁸ NHS England, NHS Long Term Workforce Plan, last updated 18 August 2023, retrieved 19 October 2023, https://www.england.nhs.uk/long-read/accessible-nhs-long-term-workforce-plan The plan sets out an ambition to increase training places for doctors and nurses and outlines new routes to becoming a doctor. There is also an ambition to recruit more staff from within the UK.

It is certainly welcome that the government has supported the NHS to deliver a workforce plan, but laying out an ambition for the size of the workforce is not the same as delivering the plan and there remain risks to successful implementation.

First, the expansion of training places represents an enormous and ambitious shift in higher education. The Health Foundation estimates that if the government sticks to the plan, then clinical health professionals will account for one in six of all university enrolments by 2031/32, compared to one in nine now. ¹⁹ Shembavnekar N, Kelly E and Charlesworth A, ‘How feasible are the NHS Long Term Workforce Plan commitments on training? ‘, The Health Foundation, 13 August 2023, retrieved 19 October 2023, https://www.health.org.uk/publications/long-reads/how-feasible-are-the-nhs-long-term-workforce-plan-commitments-on-training The Health Foundation points out that supporting those students with sufficient good-quality clinical placements is crucial for effective training, but that there is currently a lack of capacity. It notes that implementing the plan “will require sustained discussion and action on the part of government, NHS England, NHS providers and universities”. ²⁰ Shembavnekar N, Kelly E and Charlesworth A, ‘How feasible are the NHS Long Term Workforce Plan commitments on training? ‘, The Health Foundation, 13 August 2023, retrieved 19 October 2023, https://www.health.org.uk/publications/long-reads/how-feasible-are-the-nhs-long-term-workforce-plan-commitments-on-training

Second, the plan assumes that staff productivity will increase by 1.5% to 2% per year. ²¹ NHS England, NHS Long Term Workforce Plan, last updated 18 August 2023, retrieved 19 October 2023, https://www.england.nhs.uk/long-read/accessible-nhs-long-term-workforce-plan This is optimistic given that real-terms output per hour in the health sector* – a proxy for NHS labour productivity – was completely flat between 1997 and 2019. ²² Office for National Statistics, ‘Output per hour worked, UK’, last updated 7 July 2023, retrieved 19 October 2023, table 25, https://www.ons.gov.uk/economy/economicoutputandproductivity/productivitymeasures/datasets/outputperhourworkeduk The plan acknowledges that “boost[ing] labour productivity will require sustained investment in the NHS infrastructure, a significant increase in funding for technology and innovation”. ²³ NHS England, NHS Long Term Workforce Plan, last updated 18 August 2023, retrieved 19 October 2023, https://www.england.nhs.uk/long-read/accessible-nhs-long-term-workforce-plan But as this chapter has shown, the government has historically underinvested in capital, raising doubts about the likelihood of a step change in capital investment to meet this requirement.

Third, the plan focuses predominantly on front-line staff, without any mention of administrative, management and support staff. The plan itself acknowledges that, in addition to more capital investment, achieving the plan’s productivity ambition of 1.5% to 2% would require “reducing the administrative burden on clinicians”. ²⁴ NHS England, NHS Long Term Workforce Plan, last updated 18 August 2023, retrieved 19 October 2023, https://www.england.nhs.uk/long-read/accessible-nhs-long-term-workforce-plan That is certainly a view with which the Institute for Government agrees, but the NHS has repeatedly shifted resources away from management and administrative capacity, as this chapter has pointed out.

Fourth, the rapid expansion of the workforce implies an increase in the wage bill, and therefore spending on the health service. The IFS estimates that implementing the workforce plan would require the government to increase funding for the NHS by 3.6% per year in real terms for the duration of the plan. ²⁵ Warner M and Zaranko B, Implications of the NHS workforce plan, Institute for Fiscal Studies, August 2023, p. 2, https://ifs.org.uk/sites/default/files/2023-08/R272-Implications-of-the-workforce-plan-IFS%20%282%29.pdf The IFS points out that this would bring annual rises in line with historic average increases, but would be well above the 2.4% average since 2009/10. ²⁶ Warner M and Zaranko B, Implications of the NHS workforce plan, Institute for Fiscal Studies, August 2023, p. 4, https://ifs.org.uk/sites/default/files/2023-08/R272-Implications-of-the-workforce-plan-IFS%20%282%29.pdf The government currently has plans for 1% real-terms increases in day-to-day spending across all departments between 2024/25 and 2027/28. The government could certainly choose to increase spending on the health service by 3.6% per year in that time, but as we argue elsewhere in the ‘Cross-service analysis’ chapter of this report, it would require difficult choices about spending elsewhere.

Overall, the plan is a good starting point and lays out a strong aspiration for how the government would like to staff the NHS, but faces a number of risks to its successful implementation.