Education is essential for implementing the NHS workforce plan

Scale of challenge for health professions’ education

The current global healthcare workforce of roughly 65 million people is insufficient to meet global health needs. In 2020, the shortfall was estimated to be 15 million,11 but this shortage is not equally distributed, with high income countries being net importers of key health professionals.1112 In 2022, 52% of doctors who joined the UK’s medical register were international graduates,13 as were 49.9% of new entrants to the UK’s nursing and midwifery register between April and September 2023.14 This heavy and increasing reliance on international healthcare workers, two thirds of whom come from less affluent countries, shows the urgent need for expansion of healthcare training both in the UK and internationally.15

The UK challenge is amplified by the current global crisis in medical education. The UK, US, and Australasia all report chronic underinvestment in medical education, declining numbers of clinical academics and teachers, and resultant impacts on care.15161718 The proportion of the total UK medical workforce engaged in education and training has remained static and is ageing. Using data from the UK medical regulator, the General Medical Council, we calculate the proportions engaged in 2017 and 2022 were 15.7% and 15.9%, respectively, with growing proportions in the over 50 age bands and decreasing in the under 40s. Over the same period, clinical workload and the number of learners has been increasing: the number of students by 6% and doctors in training by 20%.19202122

Key stakeholders, including the royal colleges and UK Medical Schools Council, as well as major think tanks and the BMJ Commission on the Future of the NHS have recognised these challenges23242526 but underestimated their scale. Each has made relatively modest proposals to increase the educator workforce or made only broad statements that “capacity is needed.”26 Specific proposals have included minor initiatives such as the use of recently retired educators and expansion of some specific teaching roles, as well as consideration of ways to reduce costs for placement activities.24

The King’s Fund and British Medical Association (BMA) have further highlighted a lack of detail in plans to double medical student numbers by 2031,2728 particularly regarding objectives and funding and pay as a factor in retention. This lack of clarity is already manifesting in the slow start of efforts to double places; only 555 have been allocated in the first two of eight planned years, with 6945 more needed over the subsequent six years.

Strain is already evident across the educational system. A continual decline in the number of clinical academics to train the next generation is affecting curriculum delivery. This is compounded by clinical educators based in the NHS feeling under increasing pressure to prioritise service delivery over education activities, resulting in bigger learner groups, reduced clinical placement opportunities, and fewer hands-on opportunities to prepare learners for future practice.

An important limitation on the speed of education and workforce policy change and implementation has been the continual reconfiguration, reconstitution, and dissolution of organisations with strategic responsibility for national healthcare education, training, and workforce development. Examples include the NHS University (2003 to 2005)2930 and, most recently, the merger of Health Education England with NHS England along with NHS Improvement, NHSX, and NHS Digital.3 These organisational changes limit the development and use of organisational expertise. Such expertise requires sustained engagement and capacity building of individuals to gain sufficient knowledge and scholarship relevant to particular roles, growth and use of professional networks, and leveraging of relationships and influence across relevant institutions and organisations.

Rising costs and falling budgets

Globally, the annual total spend on healthcare education is estimated at $110bn (£86bn; €103bn).31 In England it is £5bn.32 The percentage of the NHS budget spent on health education has been steadily falling, from 5% in 2006-07 to 3% in 2018-19, and now stands at roughly 2.8% of the current total annual NHS budget of £181.7bn.3334 Medical education is routinely labelled as expensive,26 and cost effectiveness is a priority in the current financial climate.35 However, decision making is too often short term and fails to recognise the long term value that can be gained from investment in education and training to enable and support service delivery.

The failure to match educational capacity and funding to the increasing demand is at least partly the result of pressures of service commitments and overall strain on healthcare funding. Education is often perceived as being less important than delivering care, particularly at times of financial restrictions, and is vulnerable to cuts at times of service pressures.26 This reduces the ability to deliver effective educational activities and implement strategies in both the short and the long term. This challenge is compounded by staff who choose to take on key educational roles facing a lack of clear career pathways, inconsistent reward, and little recognition.36 Instead of education and service being recognised as mutually dependent, they are often framed as competing for resources, with the demands of service delivery competing directly with and trumping training and continuing professional development.37

To underpin the LTWP, the 2023 educator workforce strategy promised an implementation plan for the educator workforce. It proposed that NHS England should provide guidance for regional systems, integrated care systems, and integrated care boards on actions addressing capacity and quality of educators. The King’s Fund has questioned whether such boards are equipped or ready for this crucial role and if devolving responsibility could create local inconsistency and inequity.33

Two specific recommendations include the development of an “educator survey” and of “educator communities of practice.”8 However, further surveys are likely to echo what is already known,2193638 and educator communities of practice are already well established. If the NHS in England is to achieve the necessary workforce expansion envisaged in the LTWP, the approach to education and training provision has to change in order to enable substantive increases in system-wide NHS educational capacity.

Bringing change

To enact the LTWP, policy makers must give education equal priority to service provision and research. Demonstrable increased investment in medical education capacity and expertise is required, ideally ahead of major expansion. The challenge is not just about how to increase workforce numbers but how to increase and develop the educator workforce needed to train them. This requires dedicated education expertise to lead, design, and evaluate implementation, alongside resourced integration of education into clinical service to meet contemporary training needs.

Our call for education leadership underpinning action on workforce, and thus on care, stems from the interdependence of education and health policy and the role medical education has on promoting public good.2 Neither of the workforce documents give much attention to the importance of capacity building and leadership by educators, with no suggestions for the problem of education having insufficient strategic priority.

Experts with knowledge of the theory, evidence, planning, and delivery of education can offer key insights to strategic policy making. For example, the LTWP proposal for the expansion of medical school places and associated changes in course structure and delivery sets out several proposals:

• Courses should be shortened to four years and potentially further through accreditation of previous experiential learning

• Simulation should play a bigger part in training

• The academic endpoint will be the same, with all graduates taking the national UK Medical Licensing Assessment

• Placements should be more multiprofessional and “system based.”6

Although these are interesting and potentially useful considerations, they do not arise from educational evidence. Educational expertise is needed to analyse needs and design solutions. The LTWP proposals are made without reference to learner journeys, relative cost effectiveness, or longer term educational implications. Nor do they acknowledge the effect on clinical outcomes and quality of care, which could conceivably be adverse.

Educational leaders bring scholarly insight and familiarity with existing and emergent evidence. They codify the educational need before designing and evaluating proposed solutions. Their current absence from key decision making risks only partially considering impacts, potentially never knowing if changes were the most effective or, indeed, if they caused harm. Importantly, such input is not necessarily a cost. The ability to critically analyse the impact of educational investment and to adapt in response to emerging evidence can result in more efficient use of resources.

We propose actions in six key areas to support educators in the implementation of the workforce strategies: policy and leadership, career recognition, normalising clinical education, protected education delivery, clinical education research, and sustainability (table 1).

Shifting attitudes

The need to invest in and build the educator workforce to support workforce capacity may seem obvious, but until the narrative stops being that staff take time “out” or “away” to train or train others, education will remain a low NHS priority. Instead, clear action is needed to address the mismatched needs of a growing healthcare workforce and a dwindling clinical academic discipline. For clinical workplace learning and workforce expansion to be implemented and sustained, investment is required both for the institutions which support this through leadership, training, and research (eg, undergraduate, postgraduate, and continuing professional development) and for initiatives to integrate and embed this support within the clinical workplace.

Following the review by Ara Darzi3 and as part of the Change NHS national conversation,10 it is critical that the new 10 year heath plan enables educators to make the leadership contribution required to ensure the NHS becomes a “learning organisation” that is fit for the future. Crucially, the expansion of healthcare educators is not needed as part of or indeed after workforce expansion, it is needed in advance—and that means now.