Do I Dare Ask?

Staffing the NHS for a future we have not yet funded

There is a question that sits, slightly awkwardly, at the heart of two of this week’s most significant publications on the future of the NHS. It is not a question that appears explicitly in either document, and perhaps for good reason, because once asked it becomes very difficult to answer convincingly.

But it is this: where will the people come from, and who will pay for them?

The publication of Module 3 of the UK Covid-19 Inquiry, alongside the emerging Neighbourhood Health Framework, should together represent a moment of clarity about the future shape of the health service. Instead, they expose something far more uncomfortable. A tension between ambition and capacity that has yet to be resolved.

The Inquiry report offers a sobering reminder of what happens when workforce capacity is stretched beyond its limits. The evidence is stark. In early 2021, over half of ICU staff surveyed reported symptoms consistent with severe depression, and almost as many with probable PTSD. Nurses describe moral injury, exhaustion and a sense of being, in their own words, “soul-destroyed” by the care they were unable to provide in the way they believed it should be delivered. At the height of the pandemic, critical care ratios were diluted to levels that would previously have been considered unthinkable, with one trained nurse supporting multiple critically ill patients, often alongside colleagues redeployed from other areas with limited preparation (UK Covid-19 Inquiry, 2026).

This is not simply a story about a system under pressure. It is a story about a workforce that absorbed that pressure, at considerable personal cost. And yet, the conclusions drawn from this experience are, in one sense, entirely predictable. We must plan better for surge. We must ensure sufficient workforce capacity. We must provide psychological support at scale. We must build systems that can flex. All of which are entirely reasonable. All of which, implicitly, require more people, or at the very least more available capacity within the workforce we already have.

Alongside this, the Neighbourhood Health Framework sets out a vision for a fundamentally different model of care. One that shifts activity upstream, integrates services around populations, and reimagines roles across organisational boundaries. In many cases, we are told, this will be achieved by existing staff working differently. Consultants working more closely with GPs. GPs embedded in integrated neighbourhood teams. Nurses operating across traditional divides. But in some cases, it is acknowledged, new services will be created. And new services require new roles. And new roles require new people.

It is at this point that the question begins to press more insistently. Because this is not a system with latent capacity waiting to be redeployed. It is a system that continues to carry significant vacancies, particularly within nursing, and where issues of burnout, retention and morale remain deeply embedded. The NHS Staff Survey has, for several years now, painted a consistent picture of a workforce that is tired, stretched and, in some cases, questioning its future within the service. The experience of the pandemic did not create these conditions, but it undoubtedly intensified them (NHS England, 2024).

There is also a further complication. At precisely the moment we are being asked to contemplate an expansion of roles and capacity, there is a parallel narrative gaining traction. That the NHS should invest less in people and more in technology. That productivity has not improved despite workforce growth. That artificial intelligence, automation and digital tools offer a more sustainable route to reform than continued expansion of the labour force (Health Service Journal, 2026).

This is not an unreasonable argument. It is entirely right that we question the relationship between workforce numbers and productivity, and entirely right that we explore how technology can augment clinical practice and reduce administrative burden. But it is not, and cannot be, a complete answer. Because the type of care envisaged within the Neighbourhood Health Framework is not less labour-intensive. It is differently labour-intensive. Preventative, personalised, community-based care requires time, continuity and relational capacity. It requires clinicians who can build trust, navigate complexity and work across organisational boundaries. These are not functions that can be fully automated, however sophisticated the technology becomes.

And so we arrive at a set of competing, and as yet unresolved, propositions.

We need more capacity, as the Inquiry makes clear, if we are to respond safely to future surges in demand.

• We need different capacity, as the Neighbourhood Health Framework argues, if we are to shift the model of care towards prevention and integration.

• We need to improve productivity, as the current policy discourse increasingly emphasises, potentially through technology rather than workforce expansion.

• And we are, at the same time, actively reducing one of the few mechanisms that has historically provided flexible surge capacity, through the deliberate reduction in agency usage.

Each of these positions has internal logic. Taken together, they are difficult to reconcile.

It is, of course, possible that some of the answer lies in substitution. That activity will genuinely shift out of acute settings, reducing demand for hospital-based care and freeing up workforce capacity to be redeployed into community roles. This is the implicit assumption that underpins much of the neighbourhood health narrative. But it is an assumption that has been made before, and one that has historically proved difficult to realise at scale or at pace (The King’s Fund, 2023).

It is also possible that some of the answer lies in skill mix. That the future workforce will look different, with new roles, new career pathways and a greater emphasis on multidisciplinary working. Again, this is both plausible and desirable. But changing skill mix does not, in itself, eliminate the need for sufficient overall capacity. It simply redistributes it.

And then there is the question of funding, which sits quietly beneath all of this. Expanding the workforce, redesigning roles, investing in technology and building surge capacity are not cost-neutral activities. They require sustained investment, at a time when the system is already under significant financial pressure. Which brings us back, uncomfortably, to the original question: Do we, in fact, need more people?

If the answer is no, then we must be explicit about how the existing workforce will absorb additional responsibilities, deliver a transformed model of care, and remain resilient in the face of future shocks.

If the answer is yes, then we must be equally explicit about where those people will come from, how they will be trained, how they will be retained, and how their employment will be funded.

Perhaps the most important test of the forthcoming NHS Workforce Plan is not whether it sets out an ambitious vision, but whether it confronts this question directly. Whether it moves beyond aspiration to provide a plausible account of supply, demand and affordability, particularly in relation to nursing, where the gap between what is required and what is currently available feels most acute. Because if there is one lesson that should be drawn from the Covid-19 Inquiry, it is that workforce capacity is not an abstract concept. It is experienced, day by day, in the ability of a nurse to care for a patient in the way they believe is right. It is felt in the difference between coping and being overwhelmed. Between resilience and burnout. And it is not something that can be conjured into existence at the point at which it is needed.

So yes, perhaps we should dare to ask, even if the answer is not yet clear.

References

Health Service Journal (2026) NHS should prioritise AI investment over workforce expansion, leaders suggest. London: HSJ.

NHS England (2024) NHS Staff Survey Results in England. London: NHS England.

The King’s Fund (2023) Shifting care closer to home: lessons from previous policy initiatives. London: The King’s Fund.

UK Covid-19 Inquiry (2026) Module 3 Report: Impact of the pandemic on healthcare systems. London: UK Covid-19 Inquiry.