Workforce

Staff shortages

The pandemic brought into sharp focus how much people depend on the skills and extensive experience of a rich resource of health and social care staff. But across the breadth of health and social care services, providers are struggling desperately to recruit and retain staff with the right skills and in the right numbers to meet the increasing needs of people in their care. Despite their efforts, in many cases providers are losing this battle, as staff are drawn to industries with higher pay and less stressful conditions.

In a report to Parliament, the House of Commons Health and Social Care Committee said that NHS and social care services now face the greatest ever workforce crisis. Sickness, vacancy and turnover rates are having a deep impact. In its report, the Committee went on to conclude that persistent understaffing in the NHS poses a serious risk to staff and patient safety, both for routine and emergency care; and that shortages in social care are even worse than they are in the NHS.

Retaining staff is just as big a challenge as recruitment – one that in many cases is crucial to maintaining relationships between staff and patients. These relationships can be lost if there is a high turnover of staff or increased use of agency or bank staff.

NHS vacancy statistics published by NHS Digital show that, while reported vacancy rates fell during the pandemic, they have risen over the past 12 months, with the overall vacancy rate for England now above pre-pandemic levels. At the end of June 2022 there were more than 132,000 vacant posts, which was a vacancy rate of 9.7% – two percentage points higher than 12 months before and the highest they have been for 5 years (figure 11).

Figure 11: Total NHS workforce vacancy rates, England, June 2017 to June 2022

 

In all regions, the mental health vacancy rate is higher than for acute healthcare services. For example, London has the highest mental health vacancy rate at 30 June 2022 at 16.0% and an acute vacancy rate of 11.9%.

 

While vacancy rates have fluctuated in all regions over the past 4 years, London has had the highest vacancy rate throughout most of the period (12.5% at 30 June 2022), with North East and Yorkshire consistently having the lowest (7.9% at 30 June 2022). However, the data does not show a consistent pattern across regions when looking by sector, with different regions experiencing workforce pressures to varying degrees in particular sectors. For example, the highest vacancy rate in the North East and Yorkshire is for the ambulance sector at 10.5%, which is now more than 4 percentage points higher than at June 2018. However, in London the lowest vacancy rate has consistently been in the ambulance sector (7.0% at 30 June 2022), with the highest vacancy rates seen in mental health care (16.0% at 30 June 2022) and community health care (14.8% at 30 June 2022).

 

There is a similar pattern to the overall NHS vacancy rate for both nursing and medical vacancies. However, the nursing vacancy rate is higher at 11.8% at the end of June 2022, representing almost 47,000 vacant nursing posts, the highest recorded number of nursing vacancies.

 

 

While data indicates that the NHS is on course to hit the government’s headline target of an additional 50,000 full-time equivalent number of nurses in the NHS by March 2024, analysis by the King’s Fund highlighted that:

 

• The supply of nurses into the NHS is not keeping pace with demand.
• Increasing the number of nurses is having no substantial impact on the number of vacancies or the shortfall of nurses in the NHS.
• There is wide regional variation in the scale of the challenge.

 

In a March 2022 survey by NHS Providers, NHS leaders were asked which services or professions they were most concerned about in terms of workforce shortages. In the survey:

 

• Significant shortfalls in nursing staff, midwives and radiographers were mentioned most frequently.
• Shortages in psychiatry, community district nursing teams and ambulance call handlers were also frequently mentioned.

 

Through our monitoring and assessment of services in prisons and other secure settings, we have seen a huge gap in the provision of nurses and psychologists.

 

Challenges around the recruitment and retention of adult social care staff have become particularly difficult over the past year. They are widely recognised as a major cause of the gridlock in the whole health and care system. NHS Confederation reported in July 2022 that, in a survey of NHS leaders, 99% of them agreed there is a social care workforce crisis in their area, which they expect to get worse this winter.

 

Providers have told us that a key concern has been staff moving out of the sector to take up jobs in other industries. For example, areas with high levels of tourism or expensive housing can be particularly badly affected, with cleaning and catering staff leaving as well as care workers. The government decision to make vaccination a condition of deployment also had a significant impact on the care home workforce.

 

Care homes have found it very difficult to attract and retain registered nurses. Through our regulatory activity, we have seen nurses moving to jobs with better pay and conditions in the NHS, and we heard about care homes that stopped providing nursing care. This meant that people either had to move to another care home or have their care transferred to community nursing teams.

 

In December 2021, we introduced our adult social care workforce survey. As at 30 June 2022, this survey had been completed over 5,500 times by our inspectors. It explores with care home and homecare providers the impact of workforce challenges and staffing shortages on the services they deliver to people. In the survey, 36% of care home providers and 41% of homecare providers said that workforce challenges have had a negative impact on the service they deliver.

 

For care home providers, of those that reported workforce challenges and went on to provide further information (2,820):

 

• 87% said they were experiencing challenges related to recruitment.
• 48% said they were experiencing challenges related to retention.

 

Two-thirds (66%) of care home providers that gave further information about their retention challenges said staff were leaving the sector.

 

For homecare providers, of those that reported workforce challenges and went on to provide further information (526):

 

• 88% said they were experiencing challenges related to recruitment.
• 41% said they were experiencing challenges related to retention.

 

Like care homes, two-thirds (65%) of homecare providers who gave further information about their retention challenges said staff were leaving the sector. Other challenges included pay and conditions (36%), staff burnout (28%) and increased cost of petrol (23%).

 

In terms of recruitment, as well as the sheer lack of applications, both care home and homecare providers reported challenges including candidates lacking necessary skills and experience and issues with pay and conditions.

 

 

Recruitment and retention issues are also reflected in the vacancy and turnover data that we collect through our provider information return from care home providers. Across England, the vacancy rate increased from 6.0% in April 2021, peaking in December 2021 at 11.5%. It has been slowly falling since, but remains high at 10.1% at August 2022 (figure 12).

 

These vacancy rates are mirrored in Skills for Care data, with the vacancy rate across the adult social care sector estimated at 10.7% in 2021/22, compared with around 7% in the previous 2 years. Homecare services saw the highest vacancy rate for 2021/22 at 13.2%. These high figures reflect a 50,000 fall in filled posts across the whole of adult social care, which is the first time a reduction has been recorded by Skills for Care since their records began in 2012/13.

 

Figure 12: Care home staff vacancy rates, England, April 2021 to August 2022

The turnover of care home staff, measured by the number of staff leaving in the previous 12 months, has also been high. Our provider information return data shows that, across England, the turnover rate increased from 26.5% in April 2021 to 38.2% in February 2022. It has since fallen but remains high at 34.8%, over 5 percentage points higher than 12 months previously.

 

 

To gauge current views on workforce challenges, we conducted a snap poll of providers in August 2022. Many adult social care providers who responded cited pay as having an impact on recruitment and retention issues – “People are not wanting to work in the care sector. Low pay and long hours”.

 

Responses to our poll also reflected recruitment and retention challenges in primary care. Ninety per cent of GP practices who responded (217 of 241) and 92% of dental care providers who responded (88 of 96) agreed or completely agreed that they are currently struggling to recruit staff. Similarly, 71% of GP practices (170) and 59% dental providers (57) who responded said they are struggling to retain staff.

 

GP practices have been at the front end of efforts to tackle the pandemic, but there are concerns about the sustainability of the workforce. According to NHS Digital data, there has been a fall in the ratio of fully qualified GPs per 100,000 patients from 49.8 in June 2017 to 44.6 in June 2022.

 

A Royal College of General Practitioners (RCGP) survey of over 1,200 of its members between March and April 2022 indicated that 42% of GPs plan to quit the profession within the next 5 years, with 10% in the next year and 19% in the next 2 years. The RCGP said that, even at the current level of GP training intake, there will be a net reduction in the GP workforce, further exacerbating workload pressures and affecting both patient safety and quality of care.

 

We are seeing the difficulties with recruitment and retention, and the resulting workforce shortages, in our assessments of dental practices. There is a shortage of both dentists and dental nurses in the NHS. This is partly due to professionals moving into private practice.

 

The NHS Dental Statistics for England 2021/22 Annual Report shows that the number of dentists performing NHS activity during the year was below 2017/18 levels, and the number of dentists per 100,000 population fell from 44.1 in 2014/15 to 42.9 for 2021/22. Regionally this varied, with the number of dentists per 100,000 population highest in London (49.8) and lowest in the Midlands (42.0). Only the North West saw an increase compared with 2017/18.

 

We have been told by dental providers that the international registration route to recruit overseas qualified professionals is slow, and delayed further during the pandemic because the examination used to register them was suspended.

 

We have also seen that NHS hospital providers continue to review and use overseas recruitment, but this takes time before a person can start in their role. And adult social care providers have said they have been trying to source nursing staff from abroad – but this can be costly and involve a lot of re-training, with no guarantee the person will stay at the service once they have retrained and obtained their personal identification number in the UK.

 

Impact on care

 

Staffing shortages are reflected in the responses in the latest NHS staff survey, which indicate heavier demands on the workforce.

 

Only 43% of staff in 2021 said they could meet all the conflicting demands on their time at work, which is a 5-year low.

 

Responses varied for staff in different occupation groups. Midwives had the lowest results – only 17% said they are able to meet all the conflicting demands on their time at work, compared with 28% in 2020, and only 7% said they never or rarely had unrealistic time pressures. More than half of midwives (52%) said they often think about leaving their organisation, with 71% saying they find their work emotionally exhausting and 63% saying they often feel burnt out because of work.

 

A Royal College of Nursing report in February 2022 declared that “dire shortages in the nursing workforce were compromising patient care even before the COVID-19 pandemic” and that this won’t have improved given increases in demand.

 

This is supported by our recent Adult inpatient survey findings, which show that only 55% of patients felt there were always enough nurses on duty to care for them in hospital. Additionally, 11% of patients responded that they ‘never’ felt there were enough nurses on duty during their hospital stay. This is an increase of 4 percentage points in one year. Similarly, the number of people that said they were always able to get enough help from staff to wash or keep themselves clean declined from 75% in 2020 to 70% in 2021. We can infer that shortages in the workforce are tangibly impacting on the quality of care being provided to people in a hospital setting.

 

We have also seen challenges across a number of hospitals for patients with mental health needs because of a lack of specialist staff, as well as a lack of beds. This has meant, for example, that some have been admitted to acute services or unsuitable settings.

 

 

During our inspections, we have seen the effect of staff shortages, such as a lack of midwife leaders causing inconsistent practice and difficulty in embedding a good culture.

 

In some cases, staff shortages can have a severe impact on people’s human rights. For example, in some services in the North West there was an increase in restrictive practices, due to limited staff numbers. This included examples of staff removing frames from people when they sat down, so they were unable to get up and move around, and the locking of corridors and other areas of a service.

 

In a March 2022 survey, NHS Providers asked a range of executive directors about the impact of staff shortages on services and backlog recovery. The survey received 236 responses from 142 trusts and found that:

 

• 97% thought current shortages were having a serious and detrimental impact on services (60% strongly agreed, 37% agreed).
• 98% thought current shortages would slow down the care backlog recovery (68% strongly agreed, 30% agreed).

 

Responses to the survey also indicated that, as consequences of staff shortages:

 

• The shortfall in radiographers was preventing progress towards developing community diagnostic hubs.
• Some services were being closed or reduced (including midwifery services).
• There were concerns that, in recruiting to midwifery roles, services would not be able to match the standards set out in the Ockenden report.
• Reliance on agency staff had increased.

 

GPs in England are also feeling the impact of demands on their time. In a 2021 survey of over 2,200 GPs, more than 8 out of 10 GPs reported experiencing considerable or high pressure from rising workloads (86%) and increased demands from patients (84%), with the latter growing since 2019.

 

A report commissioned by the Association of Dental Groups pointed out that every time a dentist leaves the NHS and isn’t replaced, approximately 2,000 patients could lose access to NHS care.

 

In our adult social care workforce survey, completed more than 5,500 times with providers, 25% of care home and 26% of homecare providers said there has been a delay in accessing health and care services for people (for example, GPs, mental health care and speech and language therapy). For those that said that workforce challenges have had a negative impact, this was higher with 42% of care homes and 43% of homecare providers saying people have experienced a delay.

 

In the survey, care homes that reported workforce challenges having a negative impact were asked how staffing shortages were having an impact on their ability to provide the previous level of service. Of those that provided information, a third (32%) said there had been a reduction in group and one-to-one activity sessions due to a lack of staff. Also, workforce pressures were clearly having an impact on access to care homes, with over a quarter of services telling us that they had made an active decision not to admit any new residents.

 

 

Homecare providers that reported workforce challenges having a negative impact were also asked how staffing shortages were affecting their ability to provide the previous level of service. From those that provided information (525):

 

• 46% of services told us that they had not accepted any new packages of care.
• 38% said they were being selective about which packages of care to accept.
• 18% said they had handed back individual packages of care to the local authority and 3% told us they had terminated contracts with local authorities.

 

Impact on staff

 

The pressure on health and social care workers can be seen in staff sickness data. Clearly these have been affected by COVID-19 infections, but compared with other areas of work, health and social care professionals will have felt the impact of the pandemic considerably, which has manifested itself in stress, burn-out and staff leaving the profession.

 

The sickness absence rate for all people in employment in the UK in 2021 was 2.2% – the highest it has been since 2010. Workers in caring, leisure and other service occupations had the highest rates, at 3.8%.

 

These figures only tell part of the story. In our inspections of NHS hospitals last year, all trusts have reported significant issues due to short and long-term absences related to COVID-19.

 

According to NHS Digital statistics, NHS sickness absence in England rose to its highest level of 6.7% in January 2022, which is 1 percentage point higher than January 2021. The past 4 years have seen a steady increase in NHS sickness absence rates (figure 13).

 

Figure 13: NHS sickness absence rates for England, 2017/18 to 2021/22

Source: NHS Digital, NHS sickness absence rates

 

Sickness rates for some groups are higher than others. They continue to be highest for staff within ambulance trusts, and were at their highest recorded level in 2021/22 averaging 8.1%. While sickness rates for ambulance trusts have always been higher, the gap appears to be widening. The April 2022 rate of 9.1% for ambulance trusts was 3.4 percentage points above the England average (figure 14).

 

Figure 14: NHS sickness absence rates by organisation type, Ambulances compared to England, April 2017 to April 2022

Source: NHS Digital, NHS sickness absence rates

 

Anxiety, stress, depression and other psychiatric illnesses are consistently the most reported reasons for sickness absence across all staff groups, accounting for more than 463,000 full-time equivalent days lost and 20.4% of all sickness absence in April 2022.

 

The impact of stress was shown in a December 2021 survey of 532 doctors released by the Medical Defence Union. Over a third of doctors said they felt sleep deprived on at least a weekly basis and over a quarter had been in a position where tiredness had had an impact on their ability to treat patients. Over 1 in 4 doctors responding (26%) said tiredness had affected their ability to safely care for patients, including almost 40 near misses and 7 cases in which a patient actually sustained harm.

 

These findings are reflected in a 2022 survey of over 48,000 trainee doctors across the UK. Two-fifths of trainees who responded (39%) said that they felt burnt out to a high or very high degree because of their work. This is a 6 percentage point increase compared with the previous year.

 

NHS Digital statistics show that, for some staff groups with the highest sickness rates, days lost as a result of psychiatric illnesses have risen notably:

 

• ambulance staff – days lost rose by 56% from 85,000 in 2020/21 to 132,000 in 2021/22
• midwives – days lost rose by 27% from 132,000 in 2020/21 to 167,000 in 2021/22.

 

Experiences of staff at ambulance trusts are particularly concerning. They have consistently reported the poorest experiences of all trust types in every year of the NHS Staff Survey. The gap between ambulance trusts and the national average widened between 2020 and 2021 in many questions – most notably in areas such as whether there are enough staff to do the job properly, feeling unwell from work-related stress, thinking about leaving the organisation, and whether they had an appraisal or development review.

 

Ambulance services have been under sustained pressure, exacerbated by handover delays at emergency departments. While ambulance crews wait at emergency departments, they must continue to care for their patients. This can affect their ability to take breaks and finish their shifts on time.

 

Over the last year these pressures have, all too often, become business as usual for ambulance crews. In some NHS ambulance trusts we have inspected, staff have told us they have started their shift relieving a fellow paramedic waiting outside an emergency department, taking over caring for the patient in the back of the ambulance. Furthermore, while ambulance crews wait outside emergency departments they are, inevitably, aware that they are unable to respond to emergencies in the community. These pressures undoubtedly have an impact on the wellbeing and morale of crews.

 

It is not just ambulance crews who experience the impact of current service pressures. Staff in emergency operation centres also provide support over the telephone to patients and their loved ones while they wait for an ambulance to arrive. Due to delays, the support offered over the telephone has been particularly important, and undoubtedly more emotionally challenging for staff. As people are often waiting much longer than they expect due to delays, they may also be more likely to call operation centres many times for updates, further adding to the workload pressures. We have heard about, and witnessed on our inspections, the increase in abuse experienced by call handlers during this period.

 

In adult social care over the past year, the pandemic has caused significant challenges in terms of staff absence, either because of COVID-19 infection or the need to self-isolate. Average sickness rates, measured by the average number of days lost to sickness in the previous 12 months, vary by service type. According to Skills for Care data, as at July 2022, care homes with nursing had the highest sickness rates of 8.2 days, which is more than 3 days higher than before the pandemic (4.8 days). Although sickness rates for care homes without nursing (6.9 days) and homecare services (7.5 days) were lower, they were still above pre-pandemic levels.

 

There is also regional variation. As at July 2022, average days lost to sickness varied from 4.8 days in the South East, which is slightly lower than its pre-pandemic rate (5.1 days), to 9.6 days in Eastern England, which is almost double the pre-pandemic rate (4.9 days).

 

Tackling workforce issues

 

We have seen how providers and staff are trying new ways to ease the pressures, at both a provider level and a system level.

 

Some initiatives have been short-term solutions to immediate workforce challenges, such as maintaining morale and wellbeing during the worst periods of the pandemic. These are creative and praiseworthy and have undoubtedly supported staff during particularly challenging times. Others, in areas like recruitment and retention, aim to drive longer-term changes.

 

 

Through our inspections of urgent and emergency care services, we have seen partnership work to address systemic issues, such as an increase in the use of multidisciplinary teams with more diverse skill mixes. For example, we saw NHS 111 services making additional use of midwives, mental health practitioners and pharmacists. By providing access to a wide range of healthcare professionals, they could give more appropriate clinical advice to people accessing NHS 111 and support local systems to keep people out of acute services.

 

Staff shortages are a problem in many of our recent mental health inspections reports. This is a particular issue in London due to increased costs of living and where staff have more of a choice of employment. We are seeing lots of innovative approaches, such as international recruitment, training and apprenticeships, and pay incentives being taken forward.

 

 

We have heard from adult social care providers in our Market Oversight scheme about initiatives to bolster recruitment and retention. These include:

 

• building better career pathways beyond the support worker role, so that staff see a future for themselves in social care. For example, implementing a nursing associate role that aims to bridge the gap between carers and nurses
• working with local universities on a nursing apprenticeship programme, to support staff to become qualified as registered nurses
• broadening their talent base and attracting new people into social care, by looking for the right behaviours and capability, rather than social care experience. Also, offering apprenticeship programmes for young people and school leavers, as a route into a care career
• striving to make clear the development opportunities, as well as other allowances and benefits, afforded by a career in care when placing recruitment adverts
• involving staff who have progressed from support workers to manager roles in recruitment activity, so they can tell their stories.

 

In primary care, one example of notable practice was a dental provider that had implemented a wellbeing policy and created personal holistic wellbeing action plans for each member of staff. These were regularly reviewed. The provider also organised weekly in-house meditation sessions for all staff, which were well received.

 

To support GP practices, a number of online primary care providers have been contracted to provide remote consultations for individual patients and have direct access to the GP clinical record. This is particularly helpful for areas where it is difficult to recruit permanent GPs.

 

On a larger scale, the Additional Roles Reimbursement Scheme (ARRS) was introduced in 2019 as a key part of the government’s commitment to improve access to a GP practice. The scheme aims to support the recruitment of 26,000 additional staff into general practice by 2023/24, to create bespoke multidisciplinary teams. It appears to be on track to meet that target (NHS England: Letter from Dr Ursula Montgomery and Dr Nikita Kanani to all GP practices in England). While the wider team working in general practice that ARRS will introduce is to be welcomed, there is a need to ensure that there are appropriate governance, oversight and supervision arrangements and that staff are not working beyond the scope of their competence.

 

Developing the workforce

 

More needs to be done to maintain and develop the workforce, especially in adult social care, with system-wide workforce planning a priority.

 

Valuing staff

 

The people who make up the health and social care workforce need to feel valued, rewarded and supported. Ensuring staff feel valued is important to retaining a diverse workforce with the right skill mix across health and care organisations.

 

In its Workforce Disability Equality Standard, NHS England identified a link between NHS trusts being rated as outstanding for our well-led question and showing evidence of being better employers for disabled staff.

 

In the first year of the pandemic, we saw health organisations working together to rotate places of work. This not only helped workforce capacity issues, but also enabled staff to develop new skills. Continuing and developing this model would help to break down barriers and give staff a shared understanding of a person’s journey through the health and social care system.

 

Through our provider collaboration review work, we found that training and upskilling of new and existing staff members was crucial to maintaining a workforce able to deliver high-quality care during the pandemic. We heard that, where staff had been redeployed to different services, their employers were keen to make use of their newly acquired skills on their return. This could benefit both the quality of care they deliver and their personal career prospects.

 

 

We have heard how adult social care staff are now expected to perform a wider range of tasks than before the pandemic, many of which would have been carried out by health professionals. However, time for staff training isn't consistently factored into care costs. This means there is a 'triple whammy' for the provider:

 

• First, they have to pay for the training.
• Second, they have to pay the staff member to attend the training.
• Third, they have to pay someone else to cover their shift.

 

We also heard about problems for adult social care staff in accessing it:

 

• Workforce and capacity challenges meant it was often difficult for providers to release staff for training.
• Online training was not suitable for many staff.
• There were issues around assessing competence following online training.

 

Around 1.5 million people work in the adult social care sector in England, which is more than work in the NHS. We need to champion the adult social care workforce and dispel once and for all the notion that it is low skilled work. The ability of staff to continue to work to a higher skill level will need investment in workforce development, higher overall levels of pay to increase the competitiveness of the market, and good terms and conditions to ensure employers can attract and retain the right people.

 

 

The government has dedicated £500 million funding to support the recovery of the adult social care workforce. This funding is welcomed, and urgently needed to attract and retain staff.

 

However, if the funding for social care is to have a long-lasting impact, it needs to tackle the systemic problems that all providers are faced with. Stronger workforce planning should make sure that social care is seen as an equal partner and that caring is seen as a respected and sustainable career. Workforce shortages need to be treated as a national issue with local solutions. We are calling for funding and support for ICSs so they can own and deliver a properly funded workforce plan that recognises the adult social care workforce crisis as a national issue and offers staff better pay, rewards and training linked to career progression – a plan that encourages investment in long-term solutions rather than short-term sticking plasters.

 

System-level change

 

Our urgent and emergency inspection programme has highlighted how increased strategic workforce planning across health and social care is needed. For example, we found that care homes across Gloucestershire were reporting significant spare capacity, which could be used to support patients to leave hospital in a timely way. However, staffing shortages in social care restricted system leaders’ ability to use this capacity. This shows how vital workforce planning at a system level is, and how all partners within health and care need to be involved.

 

Our data shows that workforce issues do not follow consistent patterns across the country, as seen in the NHS vacancy figures above, indicating that different areas have different challenges. As a further example, although figure 12 above shows that residential adult social care vacancy rates in England have been slowly reducing since March 2022, the South West and South East regions continued to rise (figure 15). The data also shows that vacancy rates vary regionally, with the South West having the highest rate for the quarter to June 2022 (13.1%) and London the lowest rate (9.0%).

 

Figure 15: Quarterly percentage staff vacancy rates by region for care homes, England, April 2021 to June 2022

Note: regional breakdowns are calculated using quarterly aggregated data to ensure sufficient coverage

 

To maintain and develop the workforce, and plan for the future, providers and systems need to review workforce demands for the longer term, including skill sets. A full understanding of the needs of the local community must be maintained to ensure services meet demand. This should include preventative health measures, as well as maintaining and improving health outcomes.

 

Strong, visible system leaders are important in ensuring that a local area has a sufficient staff with the right skills in the right places to supportpatients.

 

Integrated care systems (ICSs) will become increasingly important over the coming months and years, with significant responsibilities for planning services and managing NHS resources, and providing the basis for collaboration across health and care organisations. Crucially, ICSs have a key role in workforce planning.

 

A successful ICS will have plans in place to address national and system workforce priorities, using clinical and non-clinical skills effectively across an integrated pathway, with a focus on staff health and wellbeing.

 

An effective ICS will also be able to identify and prioritise training and learning needs for the people who care for their population, commissioning and coordinating training for all sectors.