Home Integration NHS must learn lessons of past to better integrate dramatically expanded staff mix

NHS must learn lessons of past to better integrate dramatically expanded staff mix

by Kirsty Kirsty

The recent dramatic expansion of new healthcare roles in the English NHS, including physician associates, has failed to take account of lessons from history about how to embed and integrate them effectively, a new report says today.Expanding the balance of professions is a core part of any evolving healthcare system and has been central to the NHS since its inception, but too often in recent years these changes have happened before issues to do with regulation, training, supervision, and communication have been resolved, meaning action is needed from NHS organisations to manage this transition.That’s according to a new report published by the Nuffield Trust, an independent think tank. The study, In the balance, commissioned by NHS Employers, looks at the history of how distinct and different roles – including physician associates, nursing associates and advanced nurse practitioners – have been brought into the NHS; how the mix of staff skills in the NHS in England compares to that of other countries; and what issues need to be addressed if the government’s plans to expand the workforce and invest in new and emerging roles are to succeed.The Nuffield Trust’s report draws on published data from across England and the OECD, a literature review, focus groups with NHS employers and a short survey. It does not offer a view on the right level of new and emerging roles, or what a good balance between doctors, nurses and other staff should be. It comes as an independent review is underway, examining the safety of physician and anaesthesia associates and their contribution to multidisciplinary healthcare teams.Key findings from the research include:

  • There has been a huge shift in the balance of roles in the NHS in England in recent years. This has been particularly apparent in general practice where a decade ago there was one other clinician for every fully-qualified permanent GP, whereas now there is an average of 2.6.
  • The hospital sector in England has a higher proportion of staff other than doctors or nurses than other OECD countries: doctors and nurses account for just two-in-five hospital staff in England (39%), compared to nearly two-thirds (63%) in Italy and almost three-quarters (72%) in Austria.
  • The government’s Long-Term Workforce Plan assumes significant growth in the numbers of these different roles, with nursing associates reaching 14 times the current level by 2036/37. The proportion of the workforce filled by physician and anaesthesia associates would remain small (at 0.6%), but their numbers are projected to grow to around six times the current level.
  • Financial subsidies from the government for new and emerging roles has been a key factor in their growth. For example, three-quarters (78%) of the growth in staff in general practice over the last five years has been through the Additional Roles Reimbursement Scheme, a central scheme to increase direct patient care staff in general practice.


The study draws on review papers looking at how nursing associates, medical associate professions and an array of other new and emerging roles have been embedded, and how the non-GP workforce has been expanded in primary care to identify key insights and lessons for NHS employers, policymakers and professional groups involved in reshaping the NHS workforce. These include:

  • Plans to grow some emerging roles may be jeopardised by a lack of capacity in the education sector and in over-stretched services that provide practice learning opportunities.  
  • While regulation is now being rolled out for physician associates, the previous lack of regulation has been a concern for staff: over three-fifths of doctors and staff in emerging roles, and four-fifths of managers, said regulation or certification requirements stood in the way of implementing physician associates.
  • Ongoing support like clinical supervision, mentorship and peer support is important for the successful embedding of these roles. But workforce expansion puts senior doctors under particular pressure to educate and supervise, with high workloads, lack of time, and disrupted line management making this difficult to achieve.
  • Careful planning is essential when introducing new roles to ensure they integrate with existing staff. In the absence of sufficient national leadership and guidance, more responsibility falls on already overwhelmed hospital, community and GP services who may struggle to develop a sufficiently detailed understanding of the skills, knowledge and scope of practice of the wide array of professions.
  • Existing staff can have concerns about the quality and safety of care, the negative impact on their own training opportunities, or fear of substitution or replacement. Failing to address inconsistencies in pay across professions, with some new roles having relatively high starting salaries compared with established professions, risks worsening tensions.
  • Public understanding of most emerging roles is limited, and evidence shows patients are more likely to support these roles when they see a positive impact on timeliness, quality or experience of care.


The Nuffield Trust report calls upon NHS England to urgently review the principles and impact of schemes where local NHS organisations are reimbursed for the salaries of emerging staff roles, which it says can distort local decisions about what staff to invest in.

It also calls upon NHS England to openly outline governance arrangements for new roles and publish up-to-date guidance on the scope and development of these roles; national bodies to commission research on the impact of different staffing mixes on patient outcomes; and local employers to take steps like ensuring that job descriptions reflect the latest guidance on the scope of such roles.

Commenting on the report, Nuffield Trust Senior Policy Fellow Dr Billy Palmer said:
“Introducing new and different staff roles to work alongside doctors and nurses has been a well-worn path for the NHS for decades. But in recent years, there has been a particularly dramatic shift in the size and shape of the NHS workforce, and future plans to expand staff numbers rest heavily on new and emerging roles.

“This report shows that there are big challenges to overcome in bringing on any new role –ensuring existing staff have time to supervise them, having clarity on the scope of the new role, having the right checks and balances in place if things go wrong, to name a few.

“These challenges can be overcome with careful planning, time and attention at all levels in the health system. But the NHS must take heed of the well-established lessons from history. The government’s review of physician and anaesthesia associates, and its wider refresh of the Long-Term Workforce Plan provide an important opportunity to set out some clarity over the transition and avoid further repeating the mistakes of the past.”

Caroline Waterfield, Director of Development and Employment at NHS Employers, said:
“Over recent years there have been many changes to roles and the composition of teams delivering patient care. Change has been evolutionary over several decades, rather than a recent phenomenon, and we expect to see this evolution continue. It is therefore critical to understand what has worked well, what has not been implemented well, and why.

“We are grateful to the Nuffield Trust for their work to explore this and identify tangible and practical actions which we can all work on to ensure that we deploy best practice change management approaches and reap the intended benefits for staff and patients.

“As the NHS develops a 10 year plan and revises the workforce plan to support it, it is critical that the findings from this work are central to the current design work and any future implementation plan.”

Image depicts Nuffield Trust logo

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