Rethinking the problem of staff shortages in the NHS.

(Or – Since everyone agrees staff shortages are one of the NHS biggest problems, why do we think about it in such old fashioned ways?)

The direction of nearly every discussion with leaders in the NHS turns quickly to staff shortages. Whether the care is primary, mental health, acute or community – everyone has problems acquiring and retaining staff.

This week I am going to publish five posts on this issue.

What’s bad for the NHS is also chronic for social care. For a raft of long-term reasons, no national body has really concerned itself with the social care workforce so employers are left scrabbling around trying to create a career ladder with very little assistance. In a couple of weeks’ time I’ll examine social care – where the problems of staff shortages are the same, but the causes and solutions are slightly different.

But this week I’m going to focus on the NHS.

Given the fact that the NHS is a people-intensive industry there is a surprising failure to think about labour issues in new ways. Some of this is down to the problems caused by the very old-fashioned ways in which we have been led to think about the labour market.

The first of these is that we have been led to believe that the labour market works. There is a demand for labour – there is a supply of labour – and the labour market is the mechanism that links the two. Capitalist economics 101 describes markets this way and it’s the way we tend to think about why people do or do not go to certain sorts of work. This simple belief, that labour markets work, influences much of the day to day behaviour of many of the NHS leaders. The reasoning goes something like this:

We need 10 nurses → we advertise for them → the labour market supplies them.

Or, more simply still, “we have a demand, ergo supply will deliver.”

If they don’t turn up, we simply pay for a bigger advert. But by now we need 15 nurses – and still there’s no supply.

Given the fact that this approach has not been working for some time, the real puzzle is why so many people go on expecting it to.

It seems to work fine for washing machines – or eggs (advertise lower prices on TV over a bank holiday and people will rush to their laptops to order them) so all the evidence implies that the same approach will work for labour.

At the same time though part of us knows that labour is different from other products because it is carried out by human beings and humans can do all sorts of things with their lives. They can go for walks, cook meals, love their children – as well as go to work. Washing machines go round and round, and eggs make breakfast.

Labour is different because it is human and interacts with all these things in ways that impact them. Washing machines don’t change the market in washing machines at all. When I buy a washing machine it doesn’t say “I don’t much fancy washing Paul’s clothes”. (Yes I know we ought to consider its feelings much more..). But humans change the labour market all the time and only return to it because they want to.

In the NHS one of the clearest examples of this is the way in which younger GPs do not want to become partners in the way that older GPs did. Young doctors have chosen to live a different life and are changing the labour market because of their preferences. If the GP labour market doesn’t pay attention to this change it is it that will fail, not the young GPs.

So labour (the humans) has the ability to challenge the simple way in which we think about labour markets. And the historical truth is that it does.

The second problem comes from the other end of the political spectrum. Workforce planning in the NHS (there hasn’t been any in social care, so they can’t be blamed) is based upon the Soviet tractor model of circa 1936.

That worked like this. A five-year plan called for 3,721 wheel makers to be distributed across tractor making factories so workforce planning had to create this 3,721 by the right date and in the right place. They would then be sent to the factories to meet the five-year plan targets.

This is the same role that workforce planning has been expected to carry out in the NHS. This expectation that this sort of planning works has led to a series of rows with planners – “Why do they always get their sums so wrong? Wasn’t it clear10 years ago that in 2018 we would need 3721 midwifes?”

But when you look back you see that they in fact said we needed 1753.  How could they get it so wrong? (If you got this sort of thing wrong in the Soviet Union in 1936 bad things happened to you).

But the problem is not getting the numbers so wrong, the problem is how we think about labour and people. Because this approach didn’t work in Leningrad in 1936 and it won’t work in Liverpool in 2020.

The problem with both approaches – the simple belief that labour markets work and the belief that the state can plan for and create the numbers of all of the different types of workers needed, is that they assume people can be moved around the board of life like chess pieces. The right-wing view of markets assumes people will be attracted by the demand for labour as and when that demand is made. The tractor factory view of the supply of labour assumes that people can simply be allocated to tasks at the right time and place – and will simply do it.

But then of course you encounter real people and everything stops working because individuals act as if they have some say about their life. They reject both the labour market and the state planners shouting at them to do something. They consider alternatives and say, “I think I’d rather do this”. Whilst they are not totally free to do anything that they want, neither are they totally determined to do the thing the labour market tells them to.

For some time, in many structured labour markets in the UK, this simple labour market model has been proven not to work. Whilst it’s true that the ‘gig’ economy operates in this way in some sectors – where people are treated as a pair of hands to be bought or sold as the labour market requires – in most it does not. Much of our economy needs not just a high level of technical skills to do a job, but also the experience of being a worker. Train drivers and nurses need to be there on a regular basis – their industries need them not only to be there but to want to be there with some consistency.

The philosophy of a market that believes that shortages will suddenly ‘magic up’ labour with the right skills and at the right time doesn’t work for people who don’t want to be there.

If structured labour markets – such as the NHS – are to work they will need a lot of organised help that goes beyond the market itself. This is not just about skills training (though it is this too) it’s also about how civil society thinks about the industry and its skills. How do we collectively and individually feel about this work – these jobs – about me spending my life doing this here, in this country?

I’m sufficient of an old lefty to celebrate the fact that without active agency from people going to work labour markets don’t work very well.

Sure you might think you can scare people into work by making life without work so horrible that they have to do it. In 1834 the New Poor Law created developed the principle of ‘less eligibility’. The purpose of the law was to make life more horrible for those who did not have work, than for those that did. Given that life was in fact horrible even for those that did have work, making it worse for those without it took some Victorian ingenuity! Making life in the workhouse worse than grinding poverty was hard – but they managed it. (What they did was to put your family in different wings of the workhouse to make your life as unbearable as possible.)

Up until 1948 the New Poor Law was a pretty awful way of getting labour markets to work. And though it was marginally effective in supplying unskilled 19th century work,  good luck to you if you think that’s going to have any impact on the supply of nurse associates in 2020. People won’t be scared into working for the NHS. They need to want to.

People will develop the skills to work in the NHS if they feel that the types of jobs available are ones that they want and have a chance of getting. At the moment too few people in this country feel that this is the case.

Over the next few days I want to try and answer the social and political questions that might change that.

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