Five years on: A workforce for the future

Co-Chairs of Workforce Working Group foreword

In its first year, the Taskforce for Lung Health made recommendations designed to ensure a sufficient number of highly trained respiratory staff within the NHS England (NHSE). To provide accessible, high standard, evidence-based care for people living with lung conditions at every stage of their journey. Here’s what happened in 2023, the 75th anniversary year of the NHS.

Nurses and health visitors make up the largest staff group in the NHS, but the respiratory nursing workforce is drawn from an ageing population, with up to 50% of the respondents being eligible to retire by 2022. In 2023, the Association of Respiratory Nurses sponsored further respiratory nursing workforce research aimed at characterising the current nursing workforce providing care for people with respiratory disease across all four countries of the UK.

Despite an overall increase in the NHSE clinical workforce of just over 5% from September 2022 – September 2023, there was a fall in the number of respiratory medicine doctors. Pressure on respiratory services remains high, with ongoing increases in waiting times.

The burden on the NHS as a whole has also been highlighted by strike action taken in the last year by nursing and medical staff, more of which is not unlikely in 2024. Meanwhile in the year to October 2023, voluntary resignation due to ‘work life balance’, ‘health related issues’ and other unknown reasons remained amongst the top three reasons for staff leaving the NHS each quarter, which has more than doubled since 2013/2014.

Recognising these challenges, the Government commissioned the NHS England Long Term Workforce Plan which, after long delays, was published in June. This document makes the case for action to address pressures in the NHSE workforce, highlighting the growth in the population living with major conditions including respiratory conditions, and the increasing lifespan of those living with such conditions. It models that current vacancy levels of 112,000 may rise to 360,000 in 2037 without “concrete and immediate action”.

To address the challenges of understaffing, training and retention, the Long Term Workforce Plan sets out a long-term strategic direction, as well as short and medium-term action to be taken at local, regional and national level. At its launch £2.4 billion was announced to fund increased training places, including a doubling or near doubling of undergraduate medical and nurse training places and GP training posts by 2030/31. This strategy is undeliverable without an accompanying increase in educator and trainer capacity. So far no plan for this has been revealed. Increased numbers of GPs will lead to more referrals, placing a greater burden on the multi-professional specialist workforce. Therefore none of the proposed workforce increases will definitively improve respiratory care without accompanying increases in training in respiratory conditions, respiratory postgraduate specialist training places for doctors, and investment in respiratory nursing posts.

Improvements to “culture, leadership and wellbeing” are pointed to as means of increasing retention in the NHS workforce, although a more detailed retention strategy is expected in 2024. Due to the money and time involved in training respiratory specialists this is an essential measure. The plan also proposes to improve productivity by working in different ways, building broader teams with flexible skills to deliver services where they are needed most, and using new technology to free up clinicians’ time to care. For example, work is already underway to expand NHS @home pathways to develop and test new approaches to managing major conditions, including respiratory conditions.

The Co-Chairs of the Workforce Working Group:

  • Dr Charlie Addy, Respiratory Consultant and Chair of the British Thoracic Society Workforce and Service Development Committee 
  • Maria Parsonage, Respiratory Consultant Nurse and Chair of Respiratory Diseases Subcommittee & Pleural Lead of the Association of Respiratory Nurse Specialists (ARNS)

Following a review of the Taskforce’s original workforce-related recommendations, and in the context of the NHSE Long Term Workforce Plan, the workforce working group took the decision instead to work towards four new aims in 2023. Progress against each of these is detailed below:

A. To influence NHSE’s workforce plan due out in March/April 2023, to champion the patient voice, and develop clear pragmatic asks for NHSE on how to improve workforce number in the short to medium term.

Publication of the Long Term Workforce Plan was delayed until the end of June 2023 and, while the Taskforce engaged with the responsible NHSE team before this, opportunities to significantly influence its contents were limited.

The plan being high level, we have focused our efforts on engaging with the health service to help to develop and deliver more detailed plans for the respiratory workforce, and with government to advocate for appropriate levels of funding. In November the Chair of the Taskforce was invited to the NHSE Long Term Workforce Plan Summit to discuss how the health service will work with external stakeholders to enact the plan.

We were also informed of the timeline for assessing progress, and invited to put forward a representative to join one of three NHSE-run working groups of stakeholders, which will hold ‘deliberative events’ on each strand of the strategy (Train, Retain and Reform). Due to the specialised, multi-disciplinary nature of respiratory workforce, shortages in each of these areas, and the need to upskill health professionals in more general roles, we have opted to contribute to the ‘Train’ strand. These meetings will serve as an opportunity to promote our patient-focused vision of the future respiratory workforce as a means to improve care and reduce workforce burdens.

B. To promote a patient-focused vision of gold standard respiratory care that addresses the workforce needed to deliver the vision across health and social care. Vision will be fit for 21st century with a focus on integration, innovative new roles and co-creation of care pathways with patients.

To inform our patient-focused vision of the future respiratory workforce, we conducted a survey of people living with lung conditions in May and June of 2023. The responses we received helped us to build a picture of how people currently access routine and urgent respiratory care, their concerns with their care, and how they would prefer to access care in future.

This survey confirmed some known trends, for example the predominance of general practice in the routine care of people with lung conditions (84% of those surveyed accessed routine care via a GP practice in the past year), and the untapped potential of other health care settings (only 22% had accessed routine care via their community pharmacist).

Responses related to general concerns about the care that those surveyed had received show that, 61% reported workforce-related disruptions to their routine care and 20% reported that it was poor or very poor. Just over half said their routine care was good or very good.

Our survey also provided insight into the specific problems which patients experienced. Several of these should be considered and addressed in the rollout of the Workforce Plan. For example, less than half (44%) of those surveyed thought the health professionals they saw in general practice had a good understanding of their condition. Even in a hospital setting only 64% felt the health professionals understood their condition.

Approaches to addressing these issues were suggested by feedback about what those living with a lung condition value about their care, and how they prefer to access care. The majority (73%) stated that  “being able to see someone quickly when I am unwell, whoever that may be” was important to them. This may point to an opportunity to increase the capacity of health professionals and settings which are currently not dominant in respiratory care, like community pharmacy. In the context of the ‘Train’ strand of the Workforce Plan, this reinforces the view that upskilling existing health professionals with a wide range of roles, in addition to increasing the size of the specialist workforce, has the potential to deliver a workforce in which the burden is better distributed and care quality and satisfaction are increased.

In other areas of the plan, like the ‘Reform’ strand, our respondents were clear about the changes they would like to see in the organisation of the respiratory workforce. Themes such as continuity of care, improvements to data sharing and means to access rapid appointments in the event of respiratory flare-ups were all evident.

Our survey did not provide direct insight into how to improve retention in the respiratory workforce. However, several of the actions discussed so far are likely to reduce the burden and improve conditions for the workforce, and other research and conversations have enabled us to produce a set of policies which we believe could help to deliver gold standard respiratory care. These include calls for the expansion of of dedicated multi-professional respiratory teams, specific funding to increase access to spirometry in primary care and innovative integration between the primary and secondary care workforce. These, along with the swift introduction of the pre-diagnosis Breathlessness Pathway, and rapid access to respiratory specialists in the event of an exacerbation, must ultimately be supported by well-funded increases in respiratory training.

C. To raise the profile of the specific challenges faced by the multi-disciplinary respiratory care workforce and impact on patients as a result, with a focus on the problems encountered by respiratory not being seen as an important specialism in its own right.

The Taskforce has raised the profile of the specific challenges faced by the respiratory care workforce with policy makers in a number of ways. Perhaps foremost amongst these has been our representation at a series of select ministerial roundtables, at first with the former minister Will Quince MP, at which we discussed the implication of workforce shortages on treatment backlogs. At the roundtable, which was held before the publication of the Workforce Plan, and in a follow up letter to the minister, we stressed the importance of including funded recruitment targets for a wide range of professionals involved in respiratory care.

To increase understanding of the state of respiratory care, drive improvements and inform funding decisions, we have also called for improved monitoring and data collection. We have highlighted the opportunity to make this change which is presented by the establishment of new Community Diagnostic Centres (CDCs). Most recently, we have been able to confirm through two parliamentary questions that NHSE will be expanding its national diagnostics data collection in 2024, which will include data on spirometry for the first time.

The next ministerial roundtable, which will now be with Andrew Stephenson MP, the new Minister of State for Health and Secondary Care, will discuss the delivery of the Workforce Plan. The Taskforce will once again make the case for specific support for the training of respiratory health professionals, and the upskilling of a range of existing health professionals.

D. To support and amplify specific policy calls and campaigns by Taskforce members and others, in line with the Taskforce recommendation

Our co-chair, Dr Charlotte Addy, has been involved in successful efforts to re-distribute Specialty Registrar (SPR) positions across England, as a member of a Health Education England task and finish group. These changes, which are designed to address health inequalities, will take effect from 2024. Other relevant work by Health Education England includes its Virtual Wards Group, which is actively addressing workforce-related issues – particularly regarding access to respiratory specialists in the event of exacerbations. The workforce working group continues to share updates on activities such as these, and many others, amongst members at its regular meetings. 

Four years of working on workforce

In 2018, when the Taskforce for Lung Health first published its recommendations, the respiratory workforce was already too small to cope with the demand for diagnosis and treatment. As a result of COVID-19 many more people were affected by this chronic shortage as the specialist respiratory workforce was redeployed to the forefront of the NHS’s pandemic response. While the Workforce Working Group was not established until April 2022 the Taskforce was not inactive in the face of this situation.

Individual member activity has greatly contributed to bringing attention and solutions to the respiratory workforce crisis. For example, in 2022 the British Thoracic Society published the pivotal paper A Respiratory Workforce for the Future, which quantified the vacancies across all of the many professions involved in respiratory care and called for changes to recruitment, training and commissioning. This was produced in consultation with a number of other Taskforce members including The Royal Colleges of Physicians (RCP) and Radiologists (RCR), the Primary Care Respiratory Society, and the Association of Chartered Physiotherapists in Respiratory Care, and has served as a basis for much of the subsequent Taskforce activity.

Progress has been made on some of the Taskforce’s workforce-related recommendations. The RCR and the College of Radiographers have produced the Quality Standard for Imaging, and guidance has been developed by NHSE on implementing diagnostic imaging networks (6h). In another area Health Education England published guidance and developed a curriculum for the creation of consultant pharmacist roles. While other recommendations are now out of scope or have been superseded, the Taskforce has renewed its commitment to advocating for action to grow the respiratory workforce in size and expertise through the aims set out above, for the mutual benefit of health professionals and those living with a lung condition.