There is no community without people: The staffing challenges facing community health services and how we can address them
The Community Network, which is hosted by the NHS Confederation and NHS Providers, has published this new briefing and an infographic which reveal the problems and solutions to workforce shortages in community healthcare.
- Staff shortages in the community healthcare sector are significant, particularly in key services such as health visiting, podiatry, speech and language therapy, and community dentistry. This is particularly concerning, translating into some of the largest backlogs of care and long waits.
- The creation of new roles, or alternative routes into existing roles, could go some way to addressing staff shortages and developing a resilient and skilled workforce for the future. Community provider leaders particularly support investment in associate routes into posts such as allied health professionals (AHP).
- Community providers can learn from each other and take action locally to address some of these challenges, including by sharing learning and best practice, developing collaboration across different parts of local health and care systems, and delivering an increased focus on supporting staff development and progression.
- However, national support and action is also needed to provide sufficient flexibility and to enable successful interventions at a local level. This includes better national workforce planning and funding; support to expand the development of new roles and alternative training routes; and support to scale up collaboration.
- This briefing sets out the key workforce pressures facing community health providers, alongside suggested solutions and policy enablers to increase workforce capacity in the sector.
The COVID-19 pandemic has exacerbated existing workforce pressures in the health and care system, with community providers facing chronic shortages across several staff groups. When we entered the pandemic in March 2020 there were 100,000 vacancies across the trust sector as a whole. Now, despite growing demand for services and strategic ambitions to boost out-of-hospital care, community provider leaders report growing challenges with recruitment and retention, with all trust sector vacancies rising to 110,000 in November 2021, and a current shortage of 4,200 full-time equivalent GPs in England. The cost-of-living crisis will compound these issues as more staff consider leaving the service for better-paid roles in other sectors, particularly as the pay award for 2022/23 has failed to deliver an uplift that sufficiently reflects the impact of inflation.
This briefing sets out the key workforce pressures facing community health providers, alongside suggested solutions and policy enablers to increase workforce capacity in the sector. The content has been directly informed by the views and experiences of community provider leaders, and will support our influencing activity on behalf of the Community Network ahead of the publication of Health Education England’s (HEE) Long-Term Strategic Framework for Health and Social Care Workforce Planning (Framework 15) and the work being done by HEE and NHS England (NHSE) towards a long-term workforce plan for the NHS.
Overview of workforce pressures in the community sector
Having the right numbers and skill mix of community staff is essential to providing high-quality care, keeping people well in their own home or in the community, and reducing additional demand on acute hospitals and other healthcare services.
However, the supply of community staff has not kept pace with increases in demand, and this has been exacerbated by the COVID-19 pandemic. Community service providers are now facing pressing recruitment and retention issues. For example, the number of district nurses fell by almost 43 per cent between 2009 and 2019, despite rising demand for services.
Community health services facing the greatest workforce pressures tend to be those with the largest waiting lists.
While there is currently no publicly available breakdown of NHS vacancy data for community roles, community provider leaders report significant staff shortages in some key services, including in community district nursing, health visiting, AHP roles, speciality registrars, midwives, radiographers, community dentistry and health and care support workers. For example, one community provider leader recently reported a 25 per cent vacancy rate for health visitor posts, while another had a vacancy rate of over 30 per cent for podiatrists (March 2022).
Community health services facing the greatest workforce pressures tend to be those with the largest waiting lists. Our research has found the most affected services include podiatry and children’s and young people’s speech and language therapy. Community providers report that it will be difficult to address these backlogs within existing workforce capacity. Responses to a recent NHS Providers survey (March 2022) show that 98 per cent of community trust leaders strongly agree or agree that current levels of workforce shortages will slow down care backlog recovery. In turn, long waits for services in the community create pressure in other parts of the health and care system, and have a wider impact on society and health inequalities.
Community provider leaders are also concerned about retaining existing staff. In a recent survey (June 2022) of community provider leaders, 76 per cent highlighted workforce recruitment and retention as the biggest challenge for their organisation. These concerns are heightened by exhaustion and low morale following two years of the pandemic, as well as the current cost-of-living squeeze and rising fuel prices, which impacts on community staff in particular as they often travel to visit several patients.
Solutions to challenges around recruitment and retention in the community sector
Recruitment of new staff
Providers need support to sustainably increase the number of new staff joining the community sector to meet increasing demand for services, changing patient needs, and new models of service delivery. In this section we explore how national funding and a flexible operating environment would support community providers to expand innovative partnerships with the education sector and wider partners to develop new roles and training opportunities.
In general, wider recruitment policy (including the government’s manifesto pledge to secure 50,000 more nurses by 2025) focuses on overseas recruitment, which tends to have little benefit for non-acute services. While the community sector has recently benefitted from new support to encourage additional overseas nurses to join the community workforce, domestic opportunities remain key for the sector. This section will therefore focus on expanding the domestic pipeline of staff and roles that the forthcoming NHS workforce strategy could focus on.
- National support, flexibility and funding to expand the use of new roles and alternative training routes.
- National guidance to support the development of blended health and care roles.
- Sharing good practice on developing recruitment partnerships with the further education sector, and national funding to embed this approach.
- Sharing good practice around value-based recruitment, alongside national workforce planning and funding to enable this.
- Sharing good practice around value-based recruitment, alongside national workforce planning and
funding to enable this.
1. National support, flexibility and funding to expand the use of new roles and alternative training routes
Expanding and developing new roles will attract more staff into the community sector. Innovative work is already taking place to support this at both a national level, through the development of nursing associate and healthcare support worker roles, and at a local level, through apprenticeships and volunteering programmes. However, there have been barriers to scaling this up, relating to a perceived lack of flexibility over skills mix, inadequate access to training and development for professionals in these roles, and incomplete professional guidance for nursing associate roles. The recent decision to scrap vocational Business and Technology Education Council (BTEC) courses in health and social care will also put at risk an important health staffing pipeline that allows thousands of potential nursing and midwifery recruits to join degree courses each year. Time-limited funding has also hindered the expansion and sustainability of some roles.
Community provider leaders support the creation of flexible alternative routes into key professions, or expanding those that already exist, to meet changing pressures. Community provider leaders tell us that they would particularly welcome the creation of new associate programmes that mirror the trainee nursing associate, across AHP roles including speech and language therapy, podiatry, physiotherapy, dietetics and occupational therapy. This would go some way to supporting providers to recover the large backlogs in these key service areas and enhance reablement support.
2. National guidance to support the development of blended health and care roles
In line with the strategic direction of travel for the health and care system, community providers would also welcome greater national support from NHSE and from professional regulators such as the Nursing and Midwifery Council and Social Work England, for blended roles that span NHS and social care services. These roles can help reduce duplication across services and enhance the patient experience.
These roles also reflect the cross-sector working that health and social care delivery increasingly requires. However, there are ongoing challenges around pay parity within multi-disciplinary teams across the NHS and social care. In one instance, a community provider reports that staff from primary care, community services and social care are working collaboratively to deliver a domiciliary care service, but there are significant differences in pay between members of the team and this has now increased since the Agenda for Change pay uplift for 2022/23 was confirmed, as well as differences in training and development opportunities afforded by the different sectors’ staff contracts. Although these barriers are not insurmountable at a local level, at worst, they can have a negative impact on morale and retention across the team as a whole. At best, they create considerable complexity for local leaders to navigate equitably with staff.
3. Sharing good practice on developing recruitment partnerships with the further education sector, and national funding to embed this approach
Partnerships between community providers and the further education sector offer a key route into the health and care sector, and should be expanded where possible. Both local engagement and national support is important in scaling up this approach. Some community providers tell us that they are working with local further education colleges on T-Level qualifications in health and care, and level two and three apprenticeships in health and social care. T-Levels, which are technical courses designed to provide students with industry-specific skills, represent a significant opportunity for community provider organisations to tap into a new talent pipeline and make careers in healthcare more accessible to a broader talent pool, including those at the start of their careers.
Local recruitment with further education partners is also an important way for the NHS to fulfil its role as an anchor institution and bring wider benefits to the local communities it serves, by providing secure and rewarding employment opportunities. For the NHS, building local pipelines is important in aiding retention, as locally recruited staff are more likely to stay within the geographical area in which the provider operates. National focus and support to help build these pipelines would be welcome.
4. Sharing good practice around value-based recruitment, alongside national workforce planning and funding to enable this
Community providers see an opportunity to recruit staff from outside the existing NHS workforce, broadening the talent pool with a view to increasing the overall numbers of staff across health and care, rather than competing with other NHS providers for limited staff. Based on learnings from COVID-19, some community providers have amended job descriptions to offer more flexibility within roles. For instance, one community provider organisation has stopped mandating a National Vocational Qualification in health, or car ownership, for entry-level posts, which has enabled them to accept more applications from alternative backgrounds including industry and retail. Similarly, some community providers have been exploring ways to support progression from volunteering to paid health and care roles, including through offering preferential interviews to those who are currently volunteering in the sector.
However, a move away from a qualification-centric approach towards value-based recruitment requires an increased emphasis on induction and skills training for individuals who are likely to be less familiar with key parts of their new roles. Community providers note that it is challenging to provide important induction and training in the context where existing staff are, necessarily, clinically focused and there is little flex in capacity or leadership headspace to create the infrastructure required to do this. There must be enough capacity within the team for staff to take time away from care delivery to attend training and continuous professional development (CPD), and retention of experienced staff to train new recruits. National frameworks to deliver a values-based approach at a local level would also support a national shift towards this recruitment model.
The Tameside and Glossop Integrated Care NHS Foundation Trust hosts the Greater Manchester blended assessor role and was the first trust in the country to train staff working in care homes to administer insulin.
To date, there have been no issues relating to this new approach, and frontline staff and trust leaders highlight benefits around reducing duplication and freeing up capacity to dedicate more time to those with higher levels of complexity and acute need.
The trust is now looking at how to work with home care agencies and sheltered accommodation centres to expand delivery and is considering how it can work with domiciliary care providers to support the delivery of non-complex wound care through blended roles. National guidance around the legality of blending and delegating parts of community roles would support this work to be delivered at scale.
5. Further collaboration between health and care partners and the education sector to promote careers in the community sector
More broadly, community providers say that working collaboratively with partners (including acute trusts, universities and further education colleges) to raise the profile of careers in the community sector is also crucial in boosting recruitment. Community providers report attending university open days to recruit to district nurse roles, giving a ‘golden ticket’ to third-year students who complete placements, and working with local acute and mental health providers to support the visibility of community roles. Community providers tell us that it can be challenging to recruit directly from education and training into community roles as there is a perception that it is not a suitable place to start a career in the NHS. Important local work is taking place to change these perceptions and develop new relationships. For example, in North West London, Imperial College Healthcare NHS Trust is working directly with its local college to take third-year BTEC students on placements. Providing community training placements for medical and nursing students can be important in promoting the community sector as a place to start a career, but there are challenges in providing sufficient placements opportunities at scale, often related to identifying enough mentors.
Retention of existing staff
Alongside setting up new pipelines of staff, it is essential to retain existing community staff. Recruitment must work alongside retention to have a meaningful impact on capacity. There is great potential within the community sector: in the 2021 NHS Staff Survey results, 57.2 per cent of community staff reported a good work and home life balance against the national average of 52.1 per cent.
Retention is also essential in keeping experienced staff with teaching and leadership skills, which in turn supports the training and induction of newly recruited staff. In this section we highlight several areas where providers can make progress locally, such as developing new roles and career pathways that span health and care services, as well as where national workforce planning and funding could have a real impact.
- Strengthening national workforce planning to better support the development of career pathways, flexible roles, and staff passporting.
- More funding for community providers to deliver training and development opportunities.
1. Strengthening national workforce planning to better support the development of career pathways, flexible roles, and staff passporting
Developing career pathways can support the retention of staff working in the community sector. In many community provider organisations, there is a significant unregistered workforce who have important experience of working in health and care, and with the support of a clear career path, can progress into registered roles. The 2021 NHS Staff Survey results showed that 52.3 per cent of NHS community staff feel that there are opportunities to develop their career, which is slightly lower than the national average of 52.9 per cent. Community providers tend to be smaller than acute trusts and so the opportunities for career development may be more limited, which highlights the importance, as set out below, of creating more flexible roles within system working.
Career development opportunities are key to supporting staff retention. During the COVID-19 pandemic, cross-organisational ways of working and staff passporting arrangements have increased, although some legal and logistical barriers remain. This can allow staff greater flexibility and more career development opportunities. Adopting a ‘one workforce’ approach to health and care workforce planning will be a key opportunity for integrated care boards, with place-based partnerships also potentially having a role. This joined-up approach to workforce management is valuable in supporting integrated career pathways, career development opportunities, and a whole-system approach to workforce planning.
However, greater flexibility between organisations and specialities can also impact on capacity within community provider organisations if a large number of staff are drawn to working in organisations with the most attractive employment offers. These organisations tend to be larger, with more resource to enable CPD and more opportunities for progression. As such, it is vital to ensure that silos are not created, and that neighbouring providers’ employment offers are aligned as far as possible across the system, with sufficient resourcing for all organisations to enable staff development.
2. More funding for community providers to deliver training and development opportunities
Evidence shows that increasing opportunities for CPD has a positive impact on retention rates and, consequently, the experiences of patients. Despite the benefits, with current operational pressures it can be difficult to release staff to access these opportunities, as it requires capacity within the workforce model for temporary cover or to backfill for roles on a short- or medium-term basis.
Another important aspect of professional development is affording all staff the opportunity to experience different parts of service delivery within the community sector. One community provider has implemented a rotation scheme to enable community nurses to experience each area of community nursing, such as intermediate care, district nursing, and digital health. This flexibility within community roles can support retention by allowing individuals to develop their skills and cultivate interests in other areas of community care delivery. With virtual wards set to be expanded in the coming years, rotational placements to support the delivery of the programme can play an important role in enabling staff development and progression. It is also important to offer colleagues from acute, mental health, ambulance sectors – and from social care – access to shadow, train, learn and develop within community settings. This will ensure better shared understanding of the benefits community services can offer both professionally and to patients.
In summary, the community sector is grappling with significant workforce shortages, which has an impact on the capacity of community providers to address backlogs of care and to plan for future care delivery. As we move into the next phase of the COVID-19 pandemic, and look towards the publication of a refreshed NHS Long Term Plan in autumn 2022, it is timely to explore the possible solutions to key workforce issues in the sector, particularly around the supply and retention of staff.
There is important and innovative work taking place at a local level, and community providers understand the need to work collaboratively and scale up existing good practice to address workforce pressures in the sector.
However, national support and funding will be instrumental in enabling providers to scale up local efforts and will be the key to meaningfully addressing staff shortages that ultimately impact on patient outcomes and experience. As the pipeline of community staff is insufficient to meet demand for services, community providers need a combination of improved national workforce planning and innovative local solutions, supported by national funding and guidance.
See the infographic, which summarises what community provider leaders tell us about the community services staffing crisis and what can be done.