Nursing numbers in Britain: the argument for workforce planning

British Medical Journal, April 15, 2000 by James Buchan, Nigel Edwards

This new system is intended to improve career opportunities for clinical nurses. The current government and its advisers should, however, look back at the successes and failures of the Conservatives. The last (Conservative) government made three attempts at changing the way nurses were paid. Two failed: neither local pay nor performance pay became a reality for the vast majority of NHS nurses. Clinical grading was implemented in 1988 but was problematic; although improved career prospects were expected, the new grading foundered because of underfunding and mismanaged implementation. If the system proposed under the Agenda for Change is to be effective, it will need more attention in the design phase and more management capacity in implementation than was the case with clinical grading.

New pay systems can have high implementation costs. Poor implementation can produce dissatisfaction, public relations problems, and many grading appeals. A second lesson from the past is that it is important to have Treasury support and to ensure that the new pay system is congruent with NHS management requirements and capacity.

The Treasury has never been keen on unfettered local pay bargaining in the NHS, particularly in conditions of a labour market in which demand exceeds supply. It fears that local pay would allow unions to exploit problems in the local labour market by using their bargaining power to highlight anomalies and use pay increases in one trust to ratchet up pay in others. The Agenda for Change strategy avoids this, by maintaining a national structure. Old-style "local pay" is now off the agenda, replaced by "flexibility within a national framework," which so far has kept both unions and the Treasury at the bargaining table. It is important, however, that the price of keeping the Treasury at the table is not a promise of cost savings or efficiency improvements.

It is easy to dismiss the last government's failure over local pay as simply an expensive distraction with a huge opportunity cost in terms of management time and effort. It indirectly prepared the ground for a more considered review of the way NHS pay and conditions of employment are determined. The Agenda for Change has the potential to take this considered approach.

Conclusions

The rapid change in many aspects of the nursing profession, and the changing boundaries of work between doctors and nurses, has produced a challenge that the NHS has not met fast enough and which it must now address. The variable and often poor quality of workforce planning, its lack of coherence or relation to other plans, the failure to consider the private sector, and changes in workload have been contributory factors. A further problem is that the NHS has a tendency to focus on the costs of training and education, without considering the costs associated with staffing shortages. Perhaps of greatest concern is the requirement for year on year efficiency gains. This has led to a cycle of increasing pressure, often in the form of unpaid and unrecognised overtime. Workload has increased and skill mix has been diluted as the search for efficiency has turned into simple cost cutting. Evidence is emerging that a dilution in skill mix, level of workload, and other aspects of the work environment have important implications for quality. Developing a systematic and integrated approach to workforce planning can deliver improvements in the mid to long term, but some urgent and concerted action is also required in the short term.