The NHS stands at a pivotal moment. With the NHS 10-year Health Plan for England in motion and a NHS 10-year workforce strategy expected next spring, the government hopes to fundamentally reshape how we deliver care: moving from hospital to community, analogue to digital, and sickness to prevention.

At RSM’s recent quarterly NHS audit chairs forum, we brought together experts and audit chairs from Integrated Care Boards (ICBs), Integrated Care Systems (ICSs) and NHS trusts to candidly discuss the workforce challenges behind this seismic shift. What emerged was both sobering and clarifying: a collective acknowledgement of underlying tensions alongside practical perspectives on the path forward. We would like to thank our panellists for sharing their valuable insights, as follows.

NHS workforce planning: it's about more than numbers

While the new NHS workforce strategy promises stronger focus on skills and capacity, leaders in the room highlighted an uncomfortable truth. Currently, 80% of workforce planning centres on the 'what' – KPIs, headcount and budgets while underplaying the 'how' – culture, leadership and engagement. Unless there is more focus on implementation, the numbers won't deliver.

The ICB workforce challenge is balancing the delivery of high-quality, safe services today with enabling new ways of working, cross-boundary collaboration and digital adoption for tomorrow. Leaders agreed they need to move beyond top-down transformation to genuine co-production, enabling teams to lead change themselves.

Key people pressures affecting NHS workforce sustainability

As discussions moved beyond workforce planning in theory, leaders highlighted a set of interconnected people pressures that are increasingly shaping how NHS organisations operate in practice.

How can leaders create capacity for transformation when the NHS is under such relentless pressure? This was perhaps the most urgent question in the room. The solutions, while not revolutionary, require commitment:

• Leveraging digital tools to genuinely free up time
• Applying lean methodologies to identify and release hidden capacity
• Investing in a permanent workforce to break the expensive cycle of agency dependency.

The leadership challenge is creating breathing space for staff to learn, innovate and adapt. This must be prioritised as an investment alongside everything else – even when it feels impossible. NHS digital transformation: the challenge beyond technology

The NHS 10-year plan calls for a shift from analogue to digital, but technology alone won't resolve systemic challenges. Progress hinges on culture, not tools. Here are the key principles that emerged.

• Digital tools should enhance human connection, not replace it.
• Co-design is crucial to ensure solutions ease workload rather than adding friction.
• Universal access to tools for both staff and patients will reduce bureaucracy.

The pressure point is capability. The NHS continues to face shortages in key digital roles – particularly cyber security and digital leadership – creating a strategic risk boards can’t ignore.

Technology, particularly AI, offers real potential to energise the workforce, but only with strong safeguards, human oversight and investment that helps people build the skills to work confidently across organisational boundaries.

Audit committees typically rely on people committees for assurance on ‘people risks’ through metrics such as retention rates, sickness absence and agency spend. This works for designated people risks, but it doesn’t address a broader issue:every organisational risk has a people dimension, but this is not always captured.

Audit chairs should expect to see people considerations embedded in all risks on the NHS board assurance framework, for people teams to be involved in major projects, and for human factors to be reflected in strategic decisions.

The sticking point is where this assurance should sit. Existing governance structures don’t always make it obvious who is responsible for testing these embedded people elements.

Across many ICBs and large provider trusts, a shift is underway: headcount is tightening as part of savings plans, yet demands are unchanged or growing. The imbalance creates a challenge that digital tools and AI may only partially address.

Despite this, many board assurance frameworks still capture people risks the same way they did years ago. This raises important questions for audit chairs:

• Have we captured these emerging people risks properly?
• Are people considerations integrated into wider business risks, not just HR silos?
• Can we see the human element in each major risk?
• Do we have proper assurance routes for people aspects of non-HR risks?

NHS people risks can't live solely in workforce plans. They must be woven throughout the entire risk framework if boards are to see the full picture.

Three strategic people risks for NHS board assurance frameworks

Workforce measures are proxy indicators for overall organisational performance. Three interconnected risks form the core people focus. When KPIs in these areas deteriorate, everything else follows.

This includes staff engagement, and diversity, equity and inclusion factors that affect how staff experience their workplace. It is often identified as a gap in existing NHS board assurance frameworks.

Unprecedented sickness absence levels require an evidence-based approach. Research shows latent Covid-19 effects peak three to seven years post-pandemic – we are in that peak now. Strategic responses might include dedicated clinical psychology resources focused on the healthcare staff wellbeing agenda.

The constant pressure around recruitment, retention, operating plan delivery, headcount reductions and financial constraints has become all-consuming. This must be front and centre at both people committee and board level.

NHS culture and morale: the hidden risk

Culture emerged as a recurring theme at the audit forum. Staff surveys consistently highlight concerns around inclusion, wellbeing and feeling heard.

Psychological safety requires multiple visible channels for staff to voice their opinions, such as networks, listening forums and Freedom to Speak Up. These should be supported by values and behaviours that shape decisions and help people cope with change. Leaders should treat listening as a core part of their role, not something to delegate.

Emerging risks include morale dips due to new performance metrics that staff feel don't reflect their work, and anxieties over personal legal accountability following recent court cases. This could stifle innovation if left unaddressed.

One striking example shared was that during recent industrial action, organisations with deeply embedded values and behaviours held together more effectively than those without. Culture isn't soft – it's the infrastructure that holds everything together when times are hard.

Risks of losing NHS workforce collaboration progress

The transition from clinical commissioning groups (CCGs) to ICBs brought something valuable: dedicated people teams, formal committees with teeth and real collaboration between system and provider organisations that enabled meaningful workforce planning.

Now, as financial pressures force ICBs to become leaner, chief people officer roles are disappearing in some areas. The system-wide collaborative infrastructure that leaders worked hard to establish is being quietly dismantled just as we're starting to understand its value.

Without conscious effort to preserve collaborative mechanisms like provider collaboratives, is the NHS about to slip back into the organisational silos that took years of effort to break down?

The fear factor: governing for compliance or transformation?

Recent legal cases, including one that resulted in a custodial sentence for a ward manager, are creating ripples of anxiety across the service. While accountability matters, staff will struggle to make decisions in a climate of fear, never mind innovate.

The challenge for audit committees is to maintain rigour while creating space for the strategic risk-taking transformation requires. The answer is not to lower standards. It's to be clearer about risk tolerances, define boundaries for experimentation, and protect people who follow proper procedures even when outcomes aren't perfect. Without these protections, the result will be compliance theatre rather than meaningful change.

Key recommendations for NHS audit committees and boards

Maintain strategic oversight: use qualitative insights such as staff voice and engagement alongside quantitative metrics such as retention rates and sickness absence to understand what’s really happening.

Be proactive, not reactive: ensure people considerations are woven through all organisational risks, not isolated within HR. Move beyond compliance checking to actively challenge assumptions.

Demand evidence-based interventions: track return on investment for interventions and monitor impact over time.

Probe effectiveness: move past 'Is the policy in place?' to ‘Is it working for the people using it?' and ensure assurance frameworks reflect this.

Strengthen healthcare leadership capacity: equip leaders to set vision, model behaviours and empower local teams.

Prioritise culture and engagement: how change is implemented matters as much as the strategy itself.

• Review risks regularly: ensure people considerations are integrated everywhere, not just in workforce plans.

The path forward for healthcare workforce transformation

What became clear through these discussions is that we're at an inflection point. The choices made now – about preserving collaborative infrastructure, creating space for innovation, and supporting people – will shape what kind of health system we have in five years' time.

The challenge for everyone in NHS governance roles is maintaining rigour while enabling experimentation, protecting staff while demanding accountability, and responding to financial constraints while preserving the infrastructure that enables system thinking.

The NHS workforce challenge is not just about numbers – it's about creating the conditions for transformation. That means bold healthcare leadership, cultural change and governance that goes beyond compliance to enable innovation.

There are no easy solutions. But by asking the hard questions in forums like this and wrestling with the answers, together we can find ways forward.

How we can support your organisation

At RSM, our specialist NHS team works with over 80 NHS ICBs and provider trust clients. Our experts are here to support you with developing your system assurance map, internal audit and controls, fraud risk, tax services and tax risk governance, technology and cyber risk and transformation projects.

Our NHS audit forum provides a confidential space for senior leaders to explore governance challenges under the Chatham House Rule. To learn more about future forums please get in touch with Clive Makombera, Nick Atkinson or your usual RSM contact.

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