Warning nursing shortages could jeopardise NHS long-term plan

The National Audit Office’s (NAO) annual report on the financial sustainability of the NHS also highlighted that additional funds guaranteed by the government may be used to fill nursing gaps with “expensive” agency costs, instead of on the plans pledged under the 10-year plan.

“The impressive ambition of the plan could be derailed, simply because we do not have the nursing staff to deliver it”

Patricia Marquis






According to the NAO, its previous work has highlighted that past funding boosts have been spent “dealing with immediate, short-term pressures, with less devoted to the changes required for long term sustainability”.

The report, published today, claims that, while the recent long-term plan sets out a “prudent approach” for achieving its priorities, a number of risks remain to the delivery of the plan.

It states that trusts told the finance experts that, even with the extra £20.5bn the government is providing to the NHS, it was “unlikely they will meet their performance standards, because of difficulties recruiting staff”.

According to the report, in September 2018 trusts had 41,000 nurse vacancies and more than 9,000 vacancies for medical staff. It noted that vacancy rates varied widely between regions giving an example of a 14.6% nurse vacancy rate in London, compared to 9.3% in the North of England.

It states: “There is a risk that the NHS will be unable to use some of the £20.5bn of funding optimally due to difficulties recruiting staff.”

The NAO report also pointed out that there was a risk that funding may be used to pay for expensive agency staff to fill nursing positions.

The report stated: “We and the [Commons’ Committee of Public Accounts have previously reported that trusts had used temporary staff to fill short-term workforce pressures, which was a costly and inefficient use of resource.”

Concerns around nurse shortages impacting on the long-term plan were also raised by health services leaders earlier this week. As previously reported, the senior figures said that lack of nurses in key areas like mental health, district and practice nursing also risk scuppering the delivery of the 10-year plan.

In terms of money, the NAO report explained how the long-term funding settlement promised by the government equates to 3.4% average real-terms increase in funding from 2019-20 to 2023-24.

This only applies to the budget for NHS England and not to the Department of Health and Social Care. Therefore, it does not cover other key areas of health spending such as education, public health and capital investment – which could also affect the delivery of the priorities in the long-term plan, it noted.

The NAO also warned that without a long-term funding settlement for social care, local NHS bodies were concerned that it will be “very difficult” return the health sector to financial balance.

“The long-term plan cannot be delivered while there are still over 100,000 staff vacancies across the NHS”

Chris Hopson

The report noted that NHS nearly achieved overall financial balance in 2017-18. However, it added that “it continues to offset surpluses and deficits, which hides local disparities in financial health and patient experience”.

In addition, it said that NHS England had an underspend of £1.183m though clinical commissioning groups reported an overspend of £213m and trusts stated a combined deficit £991m, leaving a combined deficit of £21m. The provider sector has a self-reported underlying deficit of £1.85bn, added the NAO.

For trusts, the report identified that most of the combined trust deficit is accounted for by 10 trusts whose position deteriorated significantly in 2017-18. It added there are “other indications that underlying financial health in some trusts is getting worse”.

The report also pointed out that patient waiting times continue to slip, though NAO estimates that it would cost £700m to “reduce the waiting list to the level last seen in March 2018, based on current trends”.

Responding to the National Audit Office study, Patricia Marquis, director of the Royal College of Nursing in England, said: “This report confirms our greatest fear – that the impressive ambition of the long term plan could be derailed, simply because we do not have the nursing staff to deliver it.”

The RCN director reiterated the 41,000 nurse shortage in England which she said is “already jeopardising patient care”.

Ms Marquis added: “But this is not just about numbers. Treating and caring for patients safely and effectively relies on having the right number of nurses with the right skills in place.

She said: “We are calling for an immediate £1bn investment in nurse higher education to develop the nursing workforce patients need.”

“This should come as part of a comprehensive workforce plan that responds to patient need, and is underpinned by legislation to ensure we have enough nurses on duty to deliver high quality and safe care to patients,” she added.

Chief executive of NHS Providers, Chris Hopson, said it welcomed this “accurate reflection of the current financial state of the NHS”.

“The provider sector faces a number of challenges to deliver the ambitions of the long term plan and return to financial balance,” he said.

“This is the culmination of four years of rising demand, the biggest financial squeeze in NHS history and growing workforce shortages,” he added.

Mr Hopson claimed that NHS trusts “welcomed” the long-term plan, however added that the average 3.4% yearly increase is “not enough to meet every aspiration” of the plan.

He continued: “The NAO is right to say that workforce shortages remain a significant risk to the NHS and its ability to deliver on this investment effectively,”

“The long-term plan cannot be delivered while there are still over 100,000 staff vacancies across the NHS. We need urgent action on this and it is a major concern that we will have to wait until later in the year for a comprehensive workforce plan,” he added.

Anita Charlesworth, director of research and economics at the Health Foundation, said: “The health service has a new long-term plan but this is not “job done”.”

“NHS England has received a welcome 3.4% funding increase, but growth is more modest in the early years, with the biggest increase not planned until 2023-24,2 she said. “There is, therefore, a very real risk that acute short-term pressures crowd out investment that is vital to putting the NHS on a stable and sustainable footing.”

Ms Charlesworth also claimed that workforce shortages are the “greatest threat to delivering high quality care”.

“But spending on training and education has fallen by 17% in real terms over the last five years. Cuts of this scale to investment in people undermine the future sustainability of the NHS,” she added.

Ms Charlesworth continued: “It is essential that the government takes heed of this clear, independent evidence and recognises that further investment is needed to shore up the health service and deliver the commitments outlined in the plan.”