How many doctors does a health system need? Histories of workforce planning in the NHS

Abstract

Health systems across the world are currently facing profound workforce shortages. This is, however, not a new phenomenon. Drawing on the case study of the British National Health Service (NHS), we explore how it has struggled to answer the fundamental question of how many doctors it needs with any accuracy or certainty. While the NHS is organisationally complex, it remains one of the world's most monopolistic health care systems. Despite this, the task of workforce planning has always been beset with basic problems of data accuracy and availability, and a lack of integration with resourcing. Given this, we first explore how fears over doctor ‘shortages’ have, historically, been intimately linked to concerns about the possible over-supply of doctors. We then examine the mechanistic ways in which current and future doctor numbers have been calculated before setting these efforts in political and policy context. These efforts have consistently revealed that there are numerous “imponderables” that, while crucial to answering the question of how many doctors the NHS needs, remain largely unknowable: how to achieve a ‘balanced’ system; understanding the work done by doctors and their productivity; and the impact of technology. Drawing on the work of British health economists writing in the 1970s, we examine how the expanded capacity to address medical need has only reinforced the need (and case) for ever more doctors. In conclusion, we argue that the insatiable need of the NHS for more doctors shows no sign of abating. Responding to this will inevitably require politically unpalatable resourcing trade-offs of the kind that have been largely absent from public debate.