Below you can find a summary of the book ‘The Economics of the UK health and social care labour market’, by Robert Elliot. Most of the data is from 2019, but it is still useful in order to discuss general trends within the health sector and to raise questions for further research. We are not engaging in this kind of work because we like statistics, but because we try to understand the changing conditions for our struggle for better working and care conditions.
The historical development of the health sector in the UK
The author starts with a few general figures about the current dimension of the health and care sector. Since the establishment of the NHS in the 1950s, employment in the sector has grown quicker than in the rest of the economy – something that is not UK specific, but true for most developed capitalist nations in the global north. The total number of frontline health workers in the UK in 2019 was 2,995,700. Just five occupations, GPs and hospital doctors, nurses, midwives, nursing auxiliaries and care workers and home carers accounted for 70 per cent of the frontline workforce. Nurses, midwives, and nursing auxiliaries alone numbered over one million. In 2019 or almost one in every ten workers in the UK in 2019 was a frontline care worker. Women account for almost 80 per cent of the workforce. Today one in every five jobs done by women in the UK is in frontline care.
In March 2018, the NHS employed almost 1.7 million people, some of whom worked part time. When adjusted onto a full-time equivalent basis, the total number of people working for the NHS in 2018 was 1.5 million. Thus in 2018, 1.7 million from a total of 32.3 million people, or one in every nineteen people working in the UK, worked in the NHS. While the health sector is dominated by the NHS, the care sector is less concentrated and dominated by private enterprises. There were estimated to be around 9500 long-term care homes in the UK in the first decade of this century, with 90 per cent of residential capacity provided by the private sector. Among these providers there were many single home providers and small multi-home organizations, and around 85 per cent of these providers were for-profit. There were also some large commercial chains, and their presence has grown in recent years.
A growing health sector
He then looks at the development over the last century, from the 1910s to the 2010s. Over the century as a whole, the number of qualified nurses and midwives increased nearly seven-fold from 83,662 to 558,834, while the number of doctors increased over eight-fold, from 23,469 to 195,329. In terms of the share of frontline health workers in the total working population we can see a significant increase from 1.1% in 1911 to 8.0% in 2011. The number of auxiliary nurses grew the most of all job categories. This increase will be slightly less pronounced if we take into account that in 1911, the unpaid work of women will have been more significant and that some of the increase will be due to a shift from unpaid to paid care work. If we look at the total employment not just of frontline workers, but of workers in the health and social care industry as a whole (including workers who supply hospitals or manufacture pharmaceuticals), the increase is significant: in 1951 one in every thirty-six of the working population worked in health, by 2011 they accounted for one in every eight.
More doctors
We can see how the massification of university access after World War II expressed itself in a growing number of doctors. Only 0.2 per cent of the working population were working as doctors in 1951, just one in every 500 people. By 2011, one in every 140 of the working population in England and Wales was a doctor – compared to nurses, who account for one in every fifty jobs. In total numbers, there were 11,735 full-time equivalent (CF) hospital doctors, including 3,488 consultants, working in the NHS in England and Wales in 1949. By 2018 the number of FTE hospital doctors had risen to 109,509, including 46,297 consultants. Thus, between 1949 and 2018 the number of consultants increased 50 per cent faster than the medical workforce in general. This compared to nurses: in 1949 there were 73,650 registered nurses and midwives working in NHS hospitals in England and Wales, by 2018 their number had risen to 346,941.
Workforce concentration
The workforce in hospitals grew quicker than in the community, meaning, we saw a process of concentration. In hospitals, lower skilled workers are more significant quantitatively: In general practice, GPs account for 51.5 per cent of the frontline workforce, while in hospitals, doctors account for only 14.6 per cent of the frontline workforce. In hospitals, nurses and AHPs play a more prominent role than they do in general practice. Nurses account for 38.9 per cent and AHPs 46.6 per cent of the frontline workforce in hospitals but only 26.4 per cent and 22.1 per cent respectively in general practice.
Workforce composition
In terms of sex composition we saw a stronger shift amongst doctors, than amongst nurses. In 1963 90 per cent of all GPs were men, by 2018 men accounted for just 48 per cent. In comparison, in the 1980s only 10 per cent of all nurses were men – today it’s still only 11 per cent. In 1970, women accounted for around 75 per cent of employees in frontline health and social care jobs, and this had risen to 78 per cent in 2019. It would be important to discuss why this sex segregation has become even more pronounced over time: while more women were able to enter university and better paid ‘professional jobs’, it’s still mainly women who do the general nursing work. An easy answer would be that nurses’ wages are still comparably low – but is that true when we compare them with traditionally male ‘skilled jobs’ such as plumbing or other construction trades? How important is the fact that mainly women nurses come from the global south to work in the UK?
The UK Compared to Other Countries
Among Scandinavian and large Continental European countries, Norway at the top of the range had over 20 per cent of its workforce employed in health and social care in 2017, while Spain at the bottom had just 7.2 per cent. The UK ranged in the lower middle with 12.3 per cent. France, the USA, and Germany also have larger shares of employment in these industries than does the UK. OECD data show that in 2017 the UK employed fewer doctors and nurses per head of population than France, Germany, and the Scandinavian countries and fewer doctors, though more nurses, per head of population than either Italy or Spain. With 2.8 doctors per 1000 population in 2017, or one doctor for every 357 citizens, the UK had fewer doctors per head of
population than any of the countries reported. The highest provision was in Norway, which had 4.7 doctors per 1000 population.
Labour Supply to Frontline Care
The author looks at how workers enter the health sector, e.g. through training or migration, and the role of the state in this process. Each year, nearly 7000 people enter medical training, around 25,000 start nurse training, and around 90,000 start apprenticeships in social care in the UK. In 2017 in England the total direct cost to the government of putting a UK or EU national through medical school was around £230,000. In the academic year 2017/18 there were 42,190 medical students in the UK. That year tuition fees in England totalled less than £40,000 and so the net cost to the government was of the order of £190,000. It is estimated that in England in 2014 the total costs of training a consultant amounted to £727,000, while the total costs to train a GP was £485,000 – two thirds paid for by the state, the rest by the trainee. It is unclear if the large amount of unpaid labour that medical students supply is deducted from this amount! It has been estimated that in 2014 it cost £79,000 to train a general nurse. After the government cut the financial support for nursing students in 2017, there was a 17.6 per cent fall in applications to study nursing in 2018. There are not enough people in the UK who train to become a healthcare worker. Between 6,000 and 14,000 foreign-trained doctors register to work in the UK each year. Of the 17,000 doctors who joined the workforce in the year to end June 2019, around 45 per cent trained in the UK, while the balance of more than 9,500 qualified outside the UK.
Health spending
In the financial year 2018/19, total spending on health and social care in the UK amounted to almost £220 billion. Spending by central government accounted for about 80 per cent of total spending on health care, and spending by central and local government accounted for around 60 per cent of total spending on social care. The balance of spending in each case was accounted for by private spending. By far the largest part of government spending on health care is spent on the NHS. This spending comes out of the DHSC budget and totalled £122.9 billion in 2018/19 in England. Most of the NHS money is spent on hospitals and their daily upkeep, rather than in new investments. Of the total of £122.9 billion, £116.8 billion, or 95 per cent, was current spending and just 5 per cent capital spend. Of the £116.8 billion, £75 billion of NHS current spending was distributed to Care Commissioning Groups, and by far the largest part of this sum, nearly £60 billion, funded hospital activity. In 2018, spending on hospitals was six times greater than spending on either residential long-term care facilities or GP surgeries.
International comparison
In 2018 the USA spent nearly 17 per cent of its GDP on health and social care, France, Germany, Sweden, and Japan spent around 11 per cent, Denmark and Norway spent over 10 per cent, while the UK spent 9.8 per cent. Here we have to note that a significantly higher share of the health spending in the US will go towards the profits of health corporations compared to the UK. In 2018, the United States spent almost three times as much on health and social care per head of population as the UK. In 2018, the US spent $10,586 (OECD 2019a) per head on health and social care, while the UK spent $3783, a difference of $6803.
Productivity
Like everyone, the author struggles to define ‘productivity’ in a health care setting. He quotes sources that claim that in the decade after 2005, labour productivity growth in health and social care outstripped that in the rest of the economy. Between 2010 and 2020 Outpatient Attendances increased by over 60 per cent and Finished Consultant Episodes (FCEs) by nearly 40 per cent. In contrast, clinical workers’ input increased by just 13 per cent. He summarises the current ways to calculate productivity changes beyond such a simplistic ‘input – output’ calculation.
“The NHS measures its output in many different ways. It reports the volume of different activities, such as the number of hospital discharges each quarter, the number of attendances at accident and emergency (A&E), the number of consultant-led referrals to treatment, and the number of diagnostic tests. Health economists have also developed a number of methods which can be used to measure the contribution of different procedures and interventions to health improvement. The two most widely used are Quality Adjusted Life Years (QALYs) and Disability Adjusted Life Years (DALYs). NICE currently appears to judge that new medicines and procedures which have been developed to produce an improvement in health and which can be produced at a cost to the NHS of £30,000 or less per QALY gained are cost-effective and can therefore be adopted by the NHS.”
The author reckons that substituting doctors with lower paid advanced nursing practitioners (ANPs) or physician associates PAs are a way to increase productivity, but also admits that their number is still fairly small, with around 6,000 in total across the UK in 2019.
The UK and the global health and social care labour market
Health care is more heavily dependent on foreign-born workers than the UK economy as a whole. In 2019, 29 per cent of all doctors working in NHS hospitals were foreign-born. In 2019, 18 per cent of all nurses working in NHS hospitals and 21.9 per cent of nurses working in the UK health care system as a whole were foreign-born. In 2000, the share of foreign-born nurses working in the UK was 15.2 per cent and by 2016 it had risen to 21.9 per cent. The foreign-born share of the health workforce in 2015/16 was 39.9 per cent in Australia and 32.1 per cent in Canada, while among large European countries it was 15.6 per cent in Germany and 15.7 per cent in France, compared to 22.1 per cent in the UK.The old imperialist ties are still important. In 2018, one in every seven doctors working in the NHS came from an Asian Commonwealth country and a large number of nurses working in the UK came from India and Jamaica.
But workers don’t just arrive in the UK, they also leave the UK. Nine thousand doctors who left the UK between 2012 and 2014 had not returned by 2019. The largest group among them were doctors who originally trained abroad, though UK trained doctors numbered nearly 2,000 among this total.
Wage development
In nominal terms, the average pay of full-time doctors (medical practitioners) increased twenty-four-fold between 1970 and 2019, that the pay of auxiliary nurses increased thirty-fold, and that of qualified nurses increased forty-one-fold. Over the shorter period between 1990 and 2019, when inflation was much lower and nominal rates of pay increased much less rapidly, the pay of adult social care workers increased almost three-fold.
Health workers wages increased faster than other wages. The pay of nurses and midwives advanced from 68 per cent of the average national wage in 1970 to 103 per cent in 2019. The pay of full-time auxiliary nurses advanced, much more modestly, from 54 per cent of the average in 1970 to 63 per cent in 2019. In contrast the relative pay of doctors deteriorated over the period. It stood at 225 per cent of the all employees average in 1970 but had fallen to 195 per cent of the average by 2019. The gender composition of the doctor workforce has changed. In 2000, women accounted for 27 per cent of all doctors, by 2019 this had increased to 42 per cent – can this explain the decrease in wages?
A study revealed that many NHS consultants received substantial additional earnings from private practice. In that year, average consultant income from NHS work was £76,628 and income from private work added an additional 44.6 per cent, £34,144, to the average earnings of consultants, resulting in average total income of £110,773 in 2003/4.
Expenditure on agency workers increased from 3.4 per cent of total workforce costs in 2011–2012 to 7 per cent or £3.3 billion, in 2014–2015. In 2016, in an attempt to reduce the attractiveness of this form of working, NHS England capped pay for agency workers at 155 per cent of basic NHS hourly rates. Currently a lot of Trusts have blocked the use of agency work.
