It’s the workforce stupid! That is the key message of the Nuffield Report, “Reshaping the workforce to deliver the care patients need.” Workforce solutions are rarely quick fixes so policy makers often find it is more appealing to introduce new types of workers rather than grind away at trying to make what we already have work better. So it is gratifying that the Nuffield Trust report takes such a measured view of what might help to make the system work better and rightly focusses on the largest part of what we’ve got in the system, the so-called non-medical workforce (though no one likes to be referred to as a “non” anything).

The report was commissioned by NHS Employers, but its audience is much broader and there are key messages for Health Education England, trust boards, regulators, and professional bodies as well as the professions and care workers themselves to chew on. The key premise of the report is that workers further down the food chain can find more rewarding career paths; address workforce gaps; improve quality of care and outcomes; improve team working and support-patient focussed care; better use resources by working to their full scope; and grow new workers such as assistant practitioners, advanced practice nurses, and pharmacists to fill skill gaps in medicine. What’s not to like?

There is plenty of evidence to suggest all this is possible. It is primarily a question of alignment and the balance of opportunity between developing new roles and roles that currently exist. The majority of the current workforce will be the workforce in ten years time so they are vital in workforce strategy. The report is right to point to the need to focus here. But the current balance is not working. We know the demand for care in some areas, notably older people, mental health, emergency and primary care are major areas in which care needs to continue to rise with growing care and funding gaps.

The famous Christmas tree structure of the nursing profession suggests there are many opportunities to expand and scale up scope of activity and practice. Sure nurses could fill the shoes of some doctors some of the time given the time, training, and the tools to do so. Advanced practice nurses have been doing so since the Working Time Directive gave them a boost in 2006, but they are vulnerable to cuts at times of austerity. Realpolitik tends to trump evidence when the economic climate demands. With 1.3 million workers in 300 different roles it is astonishing that the NHS works as well as it does. Innovations need to be supported by good role and service re-design and that is where there is a major capacity gap.

But whose responsibility is the workforce anyway? Whose is in charge of workforce planning to ensure alignments between the different streams are in synch and capable of translating into good care (I’ll settle for that!)? Health Education England supports workforce development but only spent 4% of its budget—£205 million—on workforce development in 2014 and this has been cut in 2016. Does anyone have the answer to the exam question? It’s scary to think that the largest resource and element in the NHS budget might be the least well understood and evidenced and I’m not talking about RN numbers and patient outcomes where the evidence is strong. We can reshape the workforce and topiary the Christmas tree, but only if we can move the money around and invest in the career pathways for everyone and not just doctors. It’s not just the workforce stupid, it’s the economy and I’m afraid to say the grind too!

Anne Marie Rafferty is professor of Nursing Policy, Florence Nightingale Faculty of Nursing and Midwifery, King’s College, London. Her research expertise is in workforce, health policy and history of healthcare.

Competing interests: I am collaborating on an NIHR funded research project with The Nuffield Trust.