Urgent action needed to head off ‘dire’ nurse shortages in future

They said the NHS in England could be recruiting and retaining enough nurses domestically in five years’ time to meet demand if their suggestions were taken seriously.

“We’ve had some own goals in nurse training”

Candace Imison

However, they warned that the recommendations will need to be backed with a £900m annual funding increase. The alternative if nothing changes will be a 70,000 nurse shortage by 2023-24 with the risk of this rising to 108,000 in a decade.

The ultimatum is laid out in a new report called ‘Closing the gap’ released today by three independent think-tanks – Health Foundation, the King’s Fund and the Nuffield Trust.

At a press conference ahead of the publication of the document, Anita Charlesworth, director of research and economics at Health Foundation, said while the current outlook for nurse staffing was “dire” it was not “inevitable”.

“The government could do something to radically transform the situation with nursing over that decade; we could have enough staff domestically to meet demand,” she said. 

Anita Charlesworth

Anita Charlesworth

Anita Charlesworth

“That’s really important but it won’t happen without action and that action requires investment,” Ms Charlesworth added.

NHS Improvement chair Baroness Dido Harding, who is overseeing a new staffing strategy for the health system, has agreed to take account of the proposals as part of the development of that plan. 

The report authors said that to secure a sustainable pipeline, 5,000 more nurses must be brought into undergraduate training each year from 2021 and the number on postgraduate courses should be tripled.

This must be backed by improved retention rates and by slicing the number of student nurses dropping out of training by a third.

“It won’t happen without action and that action requires investment”

Anita Charlesworth

However, the report authors warn that the NHS must ramp up international recruitment in the short-term to plug immediate gaps.

They suggest England will need to recruit an additional 5,000 nurses ethically from overseas each year until 2023-24, by which time the domestic supply should be healthy enough to rely.

At the press conference, Candace Imison, director of workforce strategy at the Nuffield Trust, described the decision to remove the bursary for nursing students in 2017 as an “own goal” by the government.

“We’ve had some own goals in nurse training, of which probably the most dramatic was removing the bursaries two years ago,” she said.

Ms Imison highlighted how the motivation for scrapping the bursary had been to expand nursing places but in reality it resulted in a 4% fall in undergraduate student acceptances.

For every five people that join a nurse training course the NHS only gets three recruits, the report noted, adding that finances are the number one reason cited by students for the high attrition rate.

NHS Improvement

Dido Harding

Dido Harding

To help ease the financial burden, the think-tanks called on the government to offer every undergraduate and postgraduate student nurse a £5,200 “cost-of-living grant” on top of the means-tested maintenance loan they already get.

The report authors said this would “recognise the impact of time spent on clinical placements on the scope for nurses to work part-time” at a cost to Health Education England of £560m in 2023-24 – around half the budget reduction it faced as a result of the bursary reform.

In addition, the think-tanks are calling for postgraduate nursing students to be exempt from tuition fees.

Ms Imison said postgraduate nursing applicants had “absolutely fallen through the floor” and revealed that Sheffield Teaching Hospitals NHS Foundation Trust, where she is a non-executive director, had been forced to suspend a course due to lack of interest.

In addition, she said funding and availability of clinical placements were acting as a “bottleneck” on the nursing pipeline.

The new NHS Long Term Plan pledged in January to fund up to 50% more nursing placements from 2021.

However, the think-thinks revealed that providers currently received around 10 times more funding for a medical placement per year than for a nurse one.

“So it’s perhaps not surprising that trusts haven’t been opening their doors to nurses in training,” said Ms Imison.

The three organisations are recommending that the allocation of placement funding be “rebalanced towards nursing”.

In addition, the health experts are joining the chorus of voices calling for greater flexibility in the use of the apprenticeship levy for nursing students.

The report authors warned that pay must continue to rise for nurses after the current settlement for Agenda for Change staff ends in 2021-22, highlighting how before this was secured last year nurses’ starting salaries fell by almost 10% in real terms since 2010-11.

“The staggering numbers in this report should cause alarm in Whitehall”

Donna Kinnair

They also suggested that pay could be used in a more “flexible and targeted” way to help improve recruitment and retention in struggling areas such as learning disability and mental health nursing.

“Although financial incentives alone will not solve these problems, as part of the pay review process, targeted increases, pay premia, loan write-offs and ‘golden hellos’ should all be explored to encourage staff to join and stay in these shortage groups,” the experts suggest in the report.

They also recommended that the government consider ways in which varying pay, terms and conditions between the NHS, primary care and social care systems could be better aligned as organisations are being urged to deliver more joined-up services.

Richard Murray, chief executive of the King’s Fund, said the different contract arrangements ”makes it quite difficult sometimes for staff to move between different parts of the service” and also created competition for staff when one sector saw a pay rise but the others were not. 

“So, we are suggesting that the department and the pay review bodies look at that system to try and make sure that those pay arrangements that have really evolved since the 1940s still make sense today as we move towards integration,” he added.

The think-tanks highlighted an urgent need for investment in upskilling staff to be able to keep up with medical and technological advances.

They said healthcare workers will also need to be prepared for more “boundary-spanning working”, as traditional borders both between and within sectors are blurred.

“I welcome this report which will help inform the development of our workforce implementation plan”

Dido Harding

They said there were “considerable opportunities” for nurses to develop new roles and take on responsibilities previously held by other professionals.

However, they are recommending that the government considers introducing formal regulation of advanced nurses.

They noted there was currently “considerable variation” in job titles, roles and training, which had caused “professional and public confusion” around advanced practice.

At the press conference, Ms Imison highlighted research that showed there were currently 600 job titles for 18,000 specialist nursing posts.

“That is not a sensible place to be,” she said. “How do you know which type of skills someone has in that scenario?”

To help retention, the authors called for more focus on supporting nurses at the start and towards the end of their career when people are more likely to leave.

They also want to see a “full review” of return to practice processes to help employers understand what works.

In addition, the think-tanks concluded that the shortfall in the number of GPs was so serious that it cannot be filled at all.

They said the only way forward was to use the skills of other staff primarily pharmacists and physiotherapists much more widely and routinely.

Royal College of Nursing

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Source: Kate Stanworth

Donna Kinnair

In addition, they said mental health practitioners must embedded into the general practice team structure, noting that 90% of adults with mental health are mainly supported in primary care.

“Large-scale” pilots should be carried out in general practice to explore different workforce models, the think-tanks recommend.

Reacting to the report, Dame Donna Kinnair, acting chief executive and general secretary of the Royal College of Nursing, said: “The staggering numbers in this report should cause alarm in Whitehall and focus the minds of ministers on the cash they must put on the table to close the gaps.

“Nursing staff are the first to admit that, despite straining every sinew, the care of their patients is too routinely compromised by these shortages,” she added.

The first draft of the NHS workforce implementation plan is due to be released in April and will lay out how promised around staffing made in the NHS Long Term Plan would be achieved.

Barones Harding said: “Our staff are our biggest asset and so, it is vital we do more to retain, recruit and develop them across both health and social care.

“The NHS Long Term Plan set out our ambition to make the NHS a great place to work, to transform our workforce and grow the number of doctors and nurses so that we can deliver a 21st Century NHS for our rising and ageing population,” she added. 

“I welcome this report which will help inform the development of our workforce implementation plan, the interim plan for which we expect to publish in April,” she said. 

A Department of Health and Social Care spokeswoman said it was making funding available to increase university training places for nurses by 25% and exploring how flexible working could better support existing staff.

She added that the upcoming workforce implementation plan would set out further future plans around staffing.  

Glen Garrod, president of the Association of Directors of Adult Social Services, said: “This report rightly highlights that a comprehensive overhaul of social care funding is needed immediately to stop staff leaving the sector due to lower pay and conditions.

“In the last year, social care has shown how vulnerable it is with both national and local providers struggling to run a viable business and retain essential staff,” he said. “Social care is fragile and critically needs the people working in it to want to continue and for others to be able to join.

“Given the number of people working in social care that come from the EU, it is likely that the sector will struggle to cope unless there is an absolute guarantee from government that our colleagues from EU countries can continue to come to work here, without disruption,” he added.