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A long-term workforce plan for the NHS – which the UK government promised four and a half years ago – has finally been unveiled. Its arrival, days before the NHS turns 75, is welcomed.
The ambitious plan sets out a 15-year strategy to address the increasing demand for healthcare and decreasing supply of healthcare professionals in England. An investment of more than £2.4 billion has been agreed to fund a 27% increase in training places by 2028-29. The total NHS workforce would grow from 1.4 million in 2021-22 to around 2.3 million in 2036-37.
This investment targets the current shortfall of NHS staff, which has around 150,000 vacancies. This shortfall is forcast to grow to 260,000–360,000 staff vacancies by 2036-37 without any intervention.
The main emphasis of the 151-page plan is on training and increasing the number of healthcare professionals – not only doctors and nurses, but also allied health professionals, such as physiotherapists, speech and language therapists and podiatrists, as well as pharmacists and healthcare scientists.
Existing apprenticeships for nurses and other healthcare professionals will be expanded, and a new apprenticeship scheme for doctors will be introduced to meet the required number of 12,000–15,000 medical school places by 2030-31.
New healthcare roles have been promised, including “enhanced practitioners”, who have specific knowledge and skills in a field of expertise, and the more senior “advanced practitioners”, who manage the whole episode of a patient’s care. These posts will combine with the more generalist roles that provide basic care across a range of patients and free up the time of those more specialist practitioners.
To mark the 75th anniversary of the launch of the NHS, we’ve commissioned a series of articles addressing the biggest challenges the service now faces. We want to understand not only what needs to change, but the knock-on effects on other parts of this extraordinarily complex health system.
Retention in the NHS is a considerable problem. The overall staff leaving rate increased from 9.6% in 2020 to 12.5% in 2022. The plan acknowledges the importance of retaining workers, offering them more flexibility, and improving the culture and leadership in the NHS. But details of how this will be achieved are limited in the current plan.
Reform and innovation are also part of the plan to improve productivity by including staff with a more varied mix of skills and expertise within multidisciplinary teams, combining generalists and specialists. For example, a dental practice might have only one dentist, but two dental therapists and two dental hygienists. The therapist and hygienist would do most of the basic dental care, with the dentist intervening when more specialist care is needed.
The plan also draws on the increased use of technological advances to enhance and transform healthcare, such as AI technology, which can decrease diagnostic screening times in radiology.
While the plan is certainly a positive step, it is only the first step in a longer trajectory, setting out clear markers for growth and improvement. Much more detail is needed on how the plan will be implemented and what measures will be used to judge its success.
The emphasis of the plan is on boosting the quantity of staff and services. However, aspects of quality of care, type and level of staffing required and overcoming obstacles to this expansion, need to be explored further, such as the feasibility of shortened medical degree programmes, medical apprenticeships and the student take-up of all the new university places.
The plan acknowledges that NHS staff are working in highly pressured environments and many are exhausted since the COVID pandemic. The recent nursing strikes are not only about pay but also poor working conditions and lack of support and leadership. To make this plan viable, a clearer blueprint on how to retain staff must be included.
Where will this expansion come from? Universities do not always fill their quota of places for some health courses, including nursing, midwifery and allied health professions. It is difficult to see where the students will come from to fill the government’s proposed 92% increase in adult nursing training places by 2031-32 if current places are not being filled.
During the pandemic, people saw the value of working in healthcare as they clapped weekly for those working in the NHS who they regarded as heroes. But this perception of feeling valued in society has not endured in the NHS workforce. More NHS staff are leaving – the overall number rising by more than 25% from 2019 to 2022.
Meanwhile, nurses, doctors and some allied health professionals are taking strike action. About 170,000 NHS workers left their jobs in 2022, more than 41,000 of whom were nurses, the highest rate for a decade.
Improving the culture, wellbeing and work environment of staff in the NHS will lead to people valuing NHS roles and seeing the opportunities they bring. This will encourage people into health and social care careers.
The availability of clinical placements during training is a major obstacle to this ambitious expansion plan, mainly due to the shortage of experienced staff to supervise students. All healthcare courses incorporate “practice-based hours” where students work in a variety of healthcare settings.
This shortage of experienced supervisory staff means that clinical placements are notoriously hard to find and universities are sometimes forced to cut target placement numbers, despite the need, because of a lack of capacity.
Partnership working is essential if the plan is to be successful. Close collaboration between training institutions and NHS trusts will ensure that the appropriate type and number of health courses are offered at the right time and with the right balance of skills.
A closer alliance between schools, colleges and universities will allow students to step on and step off at different points in their learning trajectory, depending on their abilities, experience and choice of occupation. Showcasing the benefits and opportunities of healthcare as an occupation both in primary and secondary school will lead to more people choosing to join the NHS and fill these newly released places.
If working conditions for NHS staff are improved, the current trend of people leaving can be reversed. This, in turn, can lead to a more positive image of working as a healthcare professional in the NHS.
And, combined with the development of more active and well-defined partnerships across education, health and social care, the hope is that more people will opt to enter the health and social care sector.
If all of the above issues are addressed, the ambitious expansion, retention and reform targets of the NHS long-term workforce plan are more likely to be achieved. And in 25 years, at the NHS’s 100th anniversary, the NHS workforce will hopefully meet the healthcare needs of the population.
Victoria Joffe is a professor of Speech and Language Therapy and Dean of the School of Health and Social Care, University of Essex. She has received research grants from the ESRC, The Nuffield Foundation and the NIHR.
An Islamic State-linked group in Uganda attacked a school in June, killing more than 40 people, mostly students, in what seems to be an escalating trend of terrorism against schools. The attackers set fire to school dormitories and used machetes to kill and maim students.
This was the latest in a cycle of shocking attacks on schools around the world. The Nigerian group Boko Haram infamously kidnapped more than 200 girls from a school in 2014, and it has attacked other schools throughout the country.
Many more attacks have occurred since then. In Afghanistan, IS affiliate IS-K has repeatedly bombed educational institutions in recent years, often killing dozens of children or teens. In 2020 in Cameroon, sources suggest that separatists fighting for their own, independent state attacked a bilingual school, killing eight children.
Why would a group carry out such an attack, killing schoolchildren? These attacks are happening more frequently in recent years, and they also tend to be carried out by particular types of groups.
I recently co-wrote a book, Insurgent Terrorism: Intergroup Relations and the Killing of Civilians, with political scientists Victor Asal and R. Karl Rethemeyer, examining the use of terrorism (intentional civilian targeting) by rebel organisations in civil wars. We dedicated a chapter to understanding attacks on schools and discovered a few patterns.
First, attacks on schools are on the rise. In the years examined in our book, 1998-2012, we found a marked increase starting in the late 2000s during civil wars. In the 1990s and early 2000s, there fewer than 20 attacks per year on schools by rebel organisations. But between 2009 and 2012, there were more than 90 such attacks per year.
Examining more recent data on terrorism generally, and not only during civil wars, we see a similar increase starting in the late 2000s. The graphic below shows a massive increase in terrorist attacks on schools.
Terrorist attacks on schools, 1970-2020
The annual average number of terrorist attacks on schools in the 1980s and 1990s, according to the Global Terrorism Database, was less than 60. In the 2000s, the average year saw nearly 80 school attacks. In the 2010s, there was an average of 250 terrorist attacks on schools per year. After the early 2010s peak, the number of attacks started to decrease, but numbers are still far above what they were in the 1990s or early 2000s.
The increase in terrorism against schools is in part because influential global networks such as al-Qaida and IS seem to encourage it, but also because groups learn from others that this is a good way to bring attention to their cause, to force a government to give in, or to intimidate a rival community.
Read more: Nigeria's new national security bosses: 5 burning issues they need to focus on
A second pattern we noticed was that the organisations that carry out these kinds of attacks tend to have a few attributes in common. Groups that attack schools tend to be in alliances with other rebel or terrorist organisations. These alliances provide extra resources to groups, which are essential for large-scale attacks. For example, allies might provide explosives, vehicles or recruits. Cooperative relationships with other rebels can also contribute to heinous attacks because groups learn tactics from each other, and they might pressure each other to use extreme tactics.
This seems to be the case with the group behind the recent Uganda attack, the Allied Democratic Forces (ADF). It has been cooperating with IS since 2017 and has received funding from it. The funds and propaganda support seem to have enabled ADF to carry out increasingly vicious attacks. Additionally, other IS-affiliated groups have attacked schools, so it is possible that the main IS encourages this, or that the groups are learning from each other.
We found that groups that had recently been subjected to government crackdowns were more likely to subsequently target schools, while groups that had recently received government concessions didn’t attack schools the following year. This is consistent with other research finding that government repression of religious freedom seems to lead to terrorist attacks on school.
The Uganda school attack, where boys and girls were killed and buildings set alight with people inside, was apparently intended to send a message to the government and its president Yoweri Museveni. Victims reported that the attackers said: “We have succeeded in destabilising Museveni’s country.”
Interestingly, in our research, we did not find that religiously oriented groups, such as Islamist groups, were more likely than other types of groups to attack schools. Certainly, some Islamist groups have carried out these attacks – such as the recent Uganda school killings.
IS-K’s attacks are intended to intimidate the mostly Shia Hazara minority community, consistent with IS-K’s extreme religious views. But non-religious groups, such as the Revolutionary Armed Forces of Colombia and the Communist Party of India (Maoist), have also repeatedly attacked schools.
Overall, attacks on schools occur because militant organisations see that they bring a great deal of attention – including from international news media – to their cause. Terrorism is fundamentally violent propaganda, and groups that use terrorism constantly innovate, seeking new tactics to help them stand out. They also hope the increasingly extreme methods will pressure governments to give up.
It seems likely that terrorist attacks against schools are going to continue. Governments should prioritise safeguarding educational institutions, and the international community should work harder to prevent these kinds of attacks.
Brian J. Phillips does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
The Georgian government has been forced to withdraw its controversial “foreign agent” law after days of mass protests against what many saw as Russian-inspired legislation which would limit press freedom, making its chances of ever joining the European Union near impossible.
Over two nights this week, thousands of protesters have packed the streets of Tbilisi demanding “No to Russian law”. Riot police used teargas and water cannons. More than 60 people were detained. But the scale of protests led the ruling Georgian Dream party to back down, saying in a statement it would “unconditionally withdraw the bill we supported without any reservations”.
The bill, which had only recently been introduced by the Georgian government, would prevent non-government groups and the media from taking more than 20% of funding from abroad. It is similar to a law passed in Russia in 2022 which has been used to crack down on media freedom.
Georgia was once the darling of the international community – a shining example of how a post-Soviet country could overcome a legacy of corruption and authoritarianism, and come back from the brink of state failure.
But Georgia’s relationship with the west started to change after billionaire businessman, Bidzina Ivanishvili – Georgia’s richest man – came to power in 2012 (and holds de facto power as the leader of the Georgian Dream party, despite officially stepping down in 2013). Initially Ivanishvili appeared to be trying to build good relations with the west. But he did so while also maintaining close relations with Moscow on the grounds that this was critical to Georgia’s security.
Experts I interviewed, during a visit to Georgia in late 2022, claimed that Ivanishvili has no intention of ceding power. Thus, remaining friendly with Russia serves this objective better than trying to please the west – which has always come with strings attached such as adhering to human rights and ensuring the integrity of elections.
Ivanishvili may also be compromised by the Kremlin. He was reported to have sold all his Russian assets in 2012 but last year Transparency International reported he still owns businesses in Russia through a network of off-shore companies as well as through his family and other representatives.
The tycoon is thought to owe Russia for his surprise election victory in 2012, a victory made all the remarkable by his refusal to criticise Russia, which had invaded Georgia just four years previously.
The obviously pro-Moscow leaning of Ivanishvili and his Georgia Dream Party has been a source of growing discontent among ordinary Georgians. Many Georgians feel their government has little interest in protecting the country from Russia’s political and psychological aggression, and possibly not even military aggression.
There is also widespread concern among Georgians about what they perceive as the government’s lack of commitment to true democracy. A report from the Organisation for Security and Cooperation in Europe said that while elections had been assessed as competitive and fair, “pervasive allegations of pressure on voters and blurring of the line between the ruling party and the state reduced public confidence in some aspects of the process”. Journalists and the NGO directors I interviewed claimed that they were constantly being spied on by the regime.
Regardless of whether Ivanishvili is a Russian puppet or merely shares the Kremlin’s political vision, Russia has gained more leverage over Georgia under his control.
But the protests show the extent to which the government’s clear pro-Russian leanings have outraged much of the Georgian population. With Russian troops only 25 miles away from the capital, Tbilisi, many fear that Georgia could share the same fate as Ukraine – especially if it looks as if a government of a different stripe could continue to move the country closer to the west by joining the EU and continuing as a candidate member of Nato. The appetite for such a shift is clear – a survey conducted in August 2022 found that at least 75% of Georgians want to join the EU, and only 2% are pro-Russian.
And anti-Russian sentiment has only increased with the influx of Russians fleeing Georgia since the invasion of Ukraine. There was even an online petition calling for Russians to be allowed to stay in Georgia for only three months.
Historically Georgians have shown they are willing to take to the streets to protest what they see as injustice: whether to protect the rights of the gay and lesbian community, to reject what they see as electoral fraud or to demonstrate against police brutality and corruption.
The protests leading to the “Rose Revolution” in 2003 brought an end to the country’s Soviet-era leadership and led to a break from Moscow. And the country’s political leadership also has a track record of making concessions in response to citizens taking to the streets. This could be seen in 2019 after months of protests forced the Georgian Dream-led government to promise electoral reform.
But Moscow’s man still holds the reins of power in Tbilisi and his government’s attempt to pass the “foreign agent” law is further evidence that Russia will continue to influence and inspire some of the countries it considers to be in its orbit.
The failure to pass the reform, however, suggests there is a limit to Moscow’s power in Georgia. Much may now hang on the outcome of Vladmir Putin’s war on Ukraine.
Natasha Lindstaedt does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.
Listening to people talk about views that clash with your own can be galling. Families all over the world avoid controversial topics. In the UK, for example, mention Brexit and watch everyone in the room tense up.
But if you only speak to people who think the same way you do, you live in an echo chamber. Being around people who think differently from you can increase your self-awareness and acceptance of others and is vital for learning. That’s why we carried out our recent study into whether focusing on your core values can help you engage more openly with others.
Conflict is part of life. Difficult conversations may feel uncomfortable but research shows there are things you can do to make talks with people who have directly opposing views more productive and less combative. For example, one study published in 2019 found that reminding people they have more in common than they think with members of groups they dislike can diminish people’s hostility towards those groups.
Researchers have argued receptiveness to opposing views and intellectual humility lie at the heart of healthy debates. Intellectual humility is owning or accepting your own shortcomings out of a genuine desire for knowledge and truth. It is about developing an increased awareness that you do not have all the answers and it is possible your views might be mistaken. An unassuming attitude makes people more open to appreciating others’ views. It doesn’t mean you have to suspend critical thinking though.
We tested whether there’s a way to enhance intellectual humility. We used an approach called values-affirmation, in which people reflect on one or two cherished personal values, such as freedom, equality or family security. Previous research found a brief period of reflection on personal values may increase people’s sense of integrity when they feel threatened. Contemplation also seems to make people more thoughtful and open-minded in response to text that challenges their views.
In our experiment, we invited participants in groups of two or three to the lab. After completing a range of psychological questionnaires assessing personality, intellectual humility, and self-esteem, half of the participants were asked to reflect on their most important value (for example freedom and equality) by writing about the significance their chosen value has in their lives and how it informs their behaviour. The second group, the control group, instead wrote about their attitudes to beverages such as tea and coffee. Afterwards, participants took part in a 15-minute group discussion about the pros and cons of raising student tuition fees to pay for university education.
Recordings of the debates were analysed by linguists from our team for conversational markers that indicate high or low intellectual humility. They coded participants’ contributions to discussions along with several other features including tendency to dominate the discussion, to engage with others’ opinions, or to convey their own convictions as certain, obvious and unchallengeable.
Participants who reflected about their most important value engaged in the discussion in a more humble way compared to participants in the control group. For example, they were more supportive of other speakers even when they were at odds; they tended to avoid dominating discussions; they were less likely to treat their own opinions as facts. Afterwards we asked participants to rate how they much they were feeling different emotions on a five-point scale (ranging from very slightly to extremely). The values-affirmation group reported feeling more empathic, giving, grateful, and humble compared to the control group.
Our research showed how a simple intervention can enhance intellectual humility in conversations. More than half (60.6% of participants) in the values-affirmation group showed more intellectual humility in debate than the average person in the control condition. This finding, as well as the enhanced feelings of tolerance people experienced, suggest reflecting on values can improve the quality of discussions on controversial issues.
Many conversations about controversial issues happen online, however. Face-to-face dialogue is very different from online communication, particularly when the people involved don’t know each other or obscure their identity. In theory, an intervention that supports intellectual humility in face-to-face dialogue may help online dialogue, but we can’t be sure without more research. If one thing is clear from science it’s that we shouldn’t avoid discussions about controversial topics, but we do need to change the way we approach them.
Research leading to the paper was partially funded by a subaward agreement from the University of Connecticut with funds provided by Grant No. 58942 from John Templeton Foundation. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of UConn or the John Templeton Foundation.
Research leading to the paper was partially funded by a subaward agreement from the University of Connecticut with funds provided by from John Templeton Foundation (Grant No. 58942 ). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of UConn or the John Templeton Foundation. Alessandra Tanesini was also the recipient of a Fellowship funded by the Leverhulme Trust
The UK government has not yet resolved the thorny issue of ongoing public sector pay disputes, despite the fact that these workers are suffering much more from the cost of living crisis than their private sector counterparts. The government is worried about wage increases pushing up inflation that is already sky-high, but recent data shows that giving these workers more pay is unlikely to have that effect.
In the year to October 2022, private sector pay increased by 6.8% compared with only a 2.9% increase for the public sector. This disparity has lead to widespread industrial action in the UK in recent months. On a longer-term basis, a growing pay gap is contributing to acute labour shortages, which is seriously affecting the delivery of public services such as healthcare and education.
Voters largely support public sector workers’ current industrial disputes. When a recent poll asked the public who they thought was responsible for the nurses’ strike, nearly half (49%) of respondents blamed the government and only 20% blamed the trade unions. Another poll showed 55% of the public support teachers’ current pay dispute – up from 33% recorded in a similar poll ten years ago. Voters seem to see years of falling real wages for public sector workers as a problem, even if the government is not acting to raise them.
So why is the government refusing to offer a better pay deal to these workers? It argues that it is merely following the advice of the various pay review bodies which make recommendations on pay in the public sector. However, these bodies are not independent of government. For example, when the government imposed a pay freeze for workers earning more than £21,000 a year in 2011 and 2012, these bodies followed this lead by making no recommendations on pay for staff on higher salaries.
Since industrial action first started to gather speed last year, concerns have been raised about a wage-price spiral causing entrenched inflation. This happens when rising prices prompt increased pay settlements, which in turn produce further price rises, wage increases, and so on. It happened in the UK in the 1970s when, similar to now, the rate of unemployment was very low.
Indeed, the unemployment rate is key to this discussion. In the 1950s, a New Zealand economist called A.W. Phillips published research showing an inverse relationship between wage inflation and unemployment in the UK that had existed for nearly a century, from 1861 to 1957. During this period when unemployment was low, wage inflation was high, and vice versa. Since then the Phillips curve, as it has become known, has been widely used to measure price inflation.
If this relationship still holds, it would mean that the current low unemployment level of 3.7% could trigger a wage-price spiral, particularly if public sector pay is increased. So it could be argued that the government’s refusal to raise public sector pay is a strategy to control inflation.
But the problem with this idea is that the Phillips curve no longer works in Britain, as the chart below shows.
Unemployment versus inflation in the UK (2001-2022)
Using monthly data over the period from 2001 to 2022, this chart shows the relationship between inflation, as measured by changes in the consumer price index, and the unemployment rate. Below an unemployment rate of about 4%, there appears to be a steep negative relationship between joblessness and inflation, in line with the original Phillips analysis.
Read more: An economist explains: What you need to know about inflation
But although this is happening right now – inflation is very high – it is the product of supply-side influences, not wage inflation. The UK (alongside many other countries) has been plagued by supply-side inflation in recent years due to the effects of Brexit, the pandemic and the war in the Ukraine on the supply of goods and services. Recent increases in energy costs in particular have really boosted inflation over the past year.
At levels of between about 4% and 7% unemployment in the above chart, there is essentially no relationship between inflation and unemployment. The latter is expected to rise in 2023 as recession conditions set in, which means that raising wages in this situation will not affect inflation.
When unemployment exceeds 7%, inflation appears to increase alongside it, producing what is often described as “stagflation”. This occurs when prices and joblessness increase together – a difficult combination for any economy to recover from, since it produces low growth.
Read more: 1970s-style stagflation now playing on central bankers' minds
This indicates that reasonable pay settlements in the public sector to compensate for falling real wages over the years could easily solve the present impasse without triggering a wage-price spiral.
This finding is reinforced by the widespread expectation that inflation has now peaked and will start to fall over the next few months. Indeed, the OECD is currently forecasting that inflation will fall quite rapidly across the world.
And for Britain in particular, it’s also worth remembering that public sector employment is only a relatively small percentage of total employment, further reducing the prospects for a wage-price spiral caused by public sector pay rises. Private sector employment in the UK exceeded 82% of the workforce in 2022, implying that “catch-up” wage settlements to compensate for declining real wages in the public sector would have much less impact on total labour costs than they would in the private sector.
All in all, the current government intransigence on public sector pay looks like it’s based on both bad economics and bad politics. The former because there is little prospect of wage inflation at the same time as there is a serious labour shortage in the public sector. The latter because many voters think the government is basically hostile to the public sector.
This view could strengthen as the general election approaches. With the state of the NHS, in particular, set to loom large in voters’ minds, this does not seem like a winning strategy.
Paul Whiteley has received funding from the British Academy and the ESRC.
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