The report from independent think tank Nuffield Trust says 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.

The NHS Employers commissioned study, In the balance, 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 report's 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 39% of hospital staff in England, compared to 63% in Italy and 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, 78% of the growth in staff in general practice over the past five years has been through the Additional Roles Reimbursement Scheme, a central scheme to increase direct patient care staff in general practice. 

The report finds that 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.

In addition, 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 on 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. 

Nuffield Trust senior policy fellow Dr Billy Palmer said: ‘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, added: '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.'

The Nuffield Trust's report comes as an independent review is underway, examining the safety of physician and anaesthesia associates and their contribution to multidisciplinary healthcare teams.

Reaction

Dr Mumtaz Patel, who is acting as president of the Royal College of Physicians, said: ‘The introduction of new healthcare roles must fully account for critical factors such as the time doctors need for education, supervision, and quality improvement. Without proper planning, these pressures can become unsustainable, jeopardising the success of both new and existing roles.

‘The report's findings highlighting the NHS's unusually high ratio of non-doctor and non-nurse roles compared to other healthcare systems are particularly concerning. Doctors have a unique role as senior expert decision-makers, and as we revise the LTWP, it is crucial to focus on achieving the right skill mix in the NHS - one that prioritises the best outcomes for patients, supports staff wellbeing, and leverages the unique expertise of all professions.'

RCN general secretary and chief executive Professor Nicola Ranger said: ‘Those working in support roles are a hugely important part of the nursing workforce and large parts of the NHS would not run without them. But this report brings into sharp focus how the lessons of the past have gone unheeded and those on the frontline of care are being left to take accountability for failures out of their control.

‘Nursing staff are regularly being asked to carry out tasks and deliver care beyond their competencies, this puts them and their patients at risk. Despite repeated warnings, we are now witnessing a devastating impact on patient care meaning many are regularly left waiting too long for treatment, particularly those with complex needs, and corridor care is becoming routine.

‘Any future plans for the nursing workforce must ensure the right mix of skills to ensure those with complex needs get the care they need and no member of the nursing team is left to carry the weight of failed investment.'