From Organisations to Places: Rethinking Workforce Ownership in the NHS

There are two dominant workforce stories shaping the conversation this week: the publication of the NHS Staff Survey (with its now familiar signals around pressure, morale and retention) and alongside it, the Commons Committee report examining the NHS’s reliance on international recruitment (raising uncomfortable but necessary questions about sustainability and the strength of domestic supply). Both matter. Both are important. And both have already been dissected, at length and with varying degrees of heat, across policy circles, LinkedIn threads and the wider health media.

But stepping back from the immediacy of those debates, there is a quieter, more structural question sitting underneath them, one that receives far less attention yet arguably shapes both issues more profoundly than we care to admit.

Have we designed a workforce system that is fundamentally misaligned with the model of care we are trying to deliver?

The Health and Social Care Committee is clear in its assessment that

“the NHS has become over-reliant on international recruitment”(Health and Social Care Committee, 2026)

At the same time, NHS England reports that

“staff continue to report high levels of work-related stress and pressure”(NHS England, 2026)

These are not isolated issues. They are symptoms of something deeper.

The structural tension: organisations versus places

The NHS remains, at its core, an employer-led system. Staff are recruited into organisations, whether Trusts, community providers or primary care settings, and their employment, identity and progression are largely tied to those institutional boundaries.

This model has deep historical roots and it brings with it clarity, accountability and a strong sense of belonging. But it also embeds a particular logic, that workforce is an asset to be owned, managed and retained by individual organisations. This is where the tension begins, because the strategic direction of travel, articulated repeatedly through Integrated Care Systems, neighbourhood health models and the broader shift towards prevention, is fundamentally place-based. It is about populations, pathways and partnerships rather than institutions. Yet the workforce model has not kept pace.

The result is a system in which organisations compete for scarce staff rather than stewarding them collectively, where workforce decisions optimise for institutional resilience rather than system outcomes, and where staff mobility is often constrained by contractual, cultural and operational barriers even when need is clear. In short, we continue to organise workforce around who employs people, rather than where they are needed most.

A different proposition: regional workforce stewardship

Against this backdrop, an idea emerging from the Netherlands is particularly striking.

The Municipality of Utrecht, working in partnership with Utrechtzorg, is launching a new initiative known as Care Amplifiers, which seeks to reframe workforce ownership at a regional level. The premise is deceptively simple: rather than organisations recruiting and retaining staff for their own benefit, participating employers are asked to place the needs of the region first, creating a model of regional employership that supports both attraction and retention across the system as a whole.

This includes coordinated recruitment, shared education pathways and flexible employment arrangements that enable staff to work across multiple organisations rather than being tied to a single employer. At its heart is a subtle but powerful shift, from organisational employment to regional stewardship.

Or, put more plainly, from “my workforce” to “our workforce”.

Is this idea new?

Not entirely. Elements of this approach can be seen, albeit often in partial or evolving forms, across other health systems. In Denmark, strong municipal responsibility creates closer alignment between workforce deployment and population need, particularly in community and social care services. In Canada, regional health authorities enable workforce planning and movement across organisations within defined geographies. In New Zealand, recent reforms have explicitly reframed workforce as a national asset, with greater emphasis on equitable distribution and system-level planning. Each of these models operates differently, but the underlying principle is consistent.

Workforce is organised around place, not institution.

The NHS context: a system designed for fragmentation

In England, Integrated Care Systems were intended to move the NHS towards collaboration over competition. And in many areas there are genuine examples of progress, including shared staffing banks, collaborative workforce strategies and system-wide roles. But these remain, in many cases, additions to an underlying model that has not fundamentally changed. Contracts are still held at organisational level. Workforce data remains fragmented. Financial incentives continue to reinforce institutional boundaries. Regulatory frameworks still focus primarily on organisational accountability.

As the Nuffield Trust has observed

“structural reform alone does not deliver integration”(Nuffield Trust, 2024)

This is the crux of the issue. Even where there is intent to act collectively, the system itself makes it difficult to do so. What is more, a renewed focus by ICBs on commissioning rather than place-based solutioning runs the risk of sidelining the ambition to collaborate.

Linking back to the “big stories”

Viewed through this lens, this week’s headline workforce stories take on a different complexion. The Staff Survey highlights issues of workload, burnout and retention. But if staff experience is shaped not only by how much they work, but also by how flexibly and meaningfully they can move across roles and settings, then a more fluid, place-based workforce model may offer part of the answer.

Similarly, concerns about international recruitment are often framed in terms of supply pipelines and ethical considerations. But they also raise a more fundamental question about how effectively we are utilising the workforce we already have. A fragmented system, in which staff are unevenly distributed and not easily redeployed, will inevitably appear more dependent on external supply.

The cultural challenge: from ownership to stewardship

Perhaps the most difficult shift is not structural, but cultural. Moving towards a regional workforce model requires organisations to relinquish a degree of control and to accept that retaining staff at all costs may not always be in the best interests of the system as a whole. It requires leaders to view workforce not as a competitive advantage, but as a shared resource.

This is not a trivial change. It challenges deeply embedded assumptions about leadership, accountability and organisational success. It also raises practical questions about contracts, indemnity, professional development and line management that cannot simply be set aside. And yet, without this shift, there is a risk that the ambition for neighbourhood-based, integrated care remains constrained by a workforce model designed for a different era.

A provocation

If we were designing the NHS workforce model from scratch, knowing what we now know about population health, integration and system working, it is difficult to imagine that we would start with organisational employment as the default. We would start with place.

The Utrecht model does not provide all the answers. But it does offer a glimpse of a different way of thinking, one that aligns workforce more closely with the needs of communities rather than the boundaries of institutions. And perhaps that is the real question for the NHS. Not whether we can recruit more staff, but whether we are organising the workforce we have in the right way.