Falling number of nurses in the NHS paints a worrying picture

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Pressures on nursing staff and the potential impact on patients are again in the news just as Jeremy Hunt promises more nursing training places – for good reason as the latest NHS workforce statistics show.

The number of nurses employed in the NHS follows a stable seasonal pattern. Numbers rise in the autumn as newly qualified staff complete their training and then decline again until the following summer as some staff resign or retire, before beginning the cycle once more as another year’s newly qualified staff arrive.

To get a clearer sense of the nursing workforce it is important to see past these seasonal changes and instead look to the year-on-year growth: how does the number of nurses in the NHS this year compare to the same time last year? Doing this reveals a worrying picture: the number of nurses employed in the NHS (on a headcount or full-time equivalent basis) is falling for the first time in more than three years. The number of nurses is also not keeping pace with population growth: the number of nurses per 100,000 population in England declined from 604 in 2009 to 576 by 2016.

Year-on-year percentage change in number of nurses and health visitors, NHS hospital and community health services
Source: NHS Digital, http://digital.nhs.uk/media/32393/NHS-Workforce-Statistics-June-2017-National-and-HEE-tables-xlsx/default/N

Figure 1 shows the year-on-year growth in the number of full-time equivalent nurses and health visitors employed in the NHS since 2010. As context, it is worth remembering that the highest growth rate achieved in any of these years is lower than the 2.3 per cent average annual growth rate in the number of nurses, midwives and health visitors between 2000 and 2010.

After a decade of rapid growth in both budgets and staff in the 2000s, the slowdown in NHS spending growth began in 2010 as the government attempted to push down the UK’s budget deficit. For the NHS this meant a switch to low real-terms growth in spending rather than actual cuts, but this still meant increasing the number of staff was no longer affordable once other cost pressures were taken into account. This should not be surprising given that staff pay accounts for between 60–70 per cent of a hospital’s overall costs – sooner or later holding down NHS spending hits the workforce and equally, the NHS cannot increase its staff significantly unless more money is made available.

The upshot was that the early days of the efficiency drive (quality, innovation, productivity and prevention (QIPP) programmes) soon saw the number of nurses falling. This was the era when NHS trusts were able to continue delivering a net financial surplus despite the financial squeeze and to maintain most of the waiting times standards set in the previous decade.  

Whether this would ever have been sustainable as hospital admissions continued to rise (and indeed accelerated) is debateable. In any case, in February 2013 the Francis report into the lapses of care at Mid Staffordshire NHS Foundation Trust was published. A reinvigorated Care Quality Commission began its inspections. Nurse-staffing ratios came to the fore, and QIPP receded into the background. Acute trusts went on a recruitment round they ultimately could not afford and at the outset at least, the Department of Health tolerated rising deficits as ‘quality trumping finance’.

However, it is not possible for the entire NHS to go on a recruitment round unless, a few years earlier, the Department of Health put sufficient extra nurses into training or lots more nurses were brought in from abroad. Regarding more training, exactly the opposite had happened (the number fell from 2010 to 2012) and signs of overheating soon followed as NHS trusts turned to more expensive agency staffing to fill in the gaps.

Recruitment from the EU also helped reduce some of the pressure, though we should remember international recruitment is nothing new to the NHS: in 2003/4 around 15,000 overseas nurses joined the UK register (overwhelmingly non-EEA), far greater than the slightly more than 8,000 that joined in 2014/15 (overwhelmingly EEA). As rising hospital deficits began to threaten NHS finances at a national level, the Department of Health and NHS Improvement increasingly targeted more expensive agency staff in order to reduce overspends, but remained relatively more positive about (cheaper) permanent staff, at least while NHS budgets have continued to rise slowly.

Why then has the growth in nursing numbers tailed off by the start of this year and indeed now for the past three months actually gone into reverse? Certainly, the number of staff leaving the NHS for work-life balance and ill health issues has risen sharply since 2010. But of course, alongside this the traditional safety valve for the NHS in times of staff shortages (international recruitment) is not working so well. It’s hard not to point to the double whammy of a 96 per cent reduction in the number of EU nurses joining the UK register since the Brexit referendum alongside an increasing number of EU staff leaving the NHS. This fall is not driven solely by the vote itself (new English language requirements were also introduced in 2016 for example), but just as with the Francis report, the timing is hard to ignore.

It takes years to train a nurse, so increasing the number of UK training places doesn’t help in the short term but will this provide the answer to current shortages in the long-term? Not on current indications. The recent removal of bursaries for nursing was partly justified as a way to increase the numbers in training as it meant governments would no longer limit the number of places to save money. However, the current indications are not good as (to date) the number of successful applicants actually looks to have fallen this year, not risen. The Secretary of State’s announcement of a 25 per cent increase in training places will hopefully turn this around but cannot do so quickly.

With winter on its way, everyone will be hoping that these numbers turn around so that the NHS can start winter with more, not fewer, nursing staff. After all emergency admissions rose by 3.4 per cent this August over last year. This is challenging enough (if hardly surprising, given the established long-term trend) in the quieter months of the summer but when combined with staff shortages, may yet undermine all the undoubted additional hard work that has gone into winter planning this year. On latest numbers, the nursing workforce of 2017 is 0.7 per cent higher than it was at the same point in 2010 (and around 4 per cent higher than it was at the 2012 low point). This compares to a more than 14 per cent increase in emergency admissions, whether measured from 2010 or 2012. No wonder nursing staff feel hard pressed.

Similar recruitment and retention problems have arisen with GPs, but here, interestingly, the government is intending to pull the international recruitment lever with a vengeance. Time will tell how successful this will be in the current environment: the plan is to attract at least some of these from other EU countries and as the nursing numbers show us, the UK is no longer quite so attractive a destination for clinical staff for obvious reasons.

At a deeper level, Brexit has again exposed the fragility of NHS workforce planning. This may be most immediate for nursing but the need for an integrated short and long-term plan for the NHS workforce long precedes Brexit. After all, there will be little point in giving the NHS its (disputed) extra £350 million a week if there are no staff to spend it on.

Comments

Cidalia Eusebio

Position
Staff nurse,
Organisation
Barts Hospital
Comment date
12 October 2017
It's not a surprise. Different factors contribute for that finding. I think this problematic deserves a more deep analysis on the variables that are leading to it but also more importantly than that: is nursing not an attractive career anymore? We need innovation and a new approach in nursing in order to guarantee the future of it but more importantly to guarantee the future of people’s health.

Geraldine Maguire

Position
Assistant Director Specialist Child Health & Disability Services,
Organisation
Southern Health & Social Care Trusts
Comment date
14 October 2017
Patient care impact of this information cannot be overstated. Another major concern is that in addition to the significant and longer term implications of the current shortfall in qualified Nurses & Health Visitors, there appears to be a reduction in recruitment to Auxiliaries and Health Care Assistant posts. These staff also undertake significant training and are an essential part of the overall Nursing workforce. Salaries in other occupations, with regular hours etc appear more attractive. Do you have similar information in relation to these members of the overall Nursing workforce?

Pam Eardley

Position
In charge night prof nurse. Neuro rehab. South Africa,
Organisation
Pvt
Comment date
14 October 2017
Nurses world wide still get raw deal re salaries, horrendous hours and benefits. Only the USS seems to have the finger on the pulse as far as I can see. So, yes, it is not a very attractive career if you want to get rich, but it is a very satisfying job. I qualified as Prof Nurse way back in 76 and Midwifery in 78. I have nursed all my life, and have experience in multiple areas, but because S Africa in not part of the EU, if I wanted to work in UK, I would have to do Academic exams at great cost, before I could register. I am British born and would seriously consider relocating and using my skills in NHS, but to face exams now is daunting. I still have 5 working years left before retirement but they make it hard to get a Prof Nursing job in UK. Surely experience could be taken into account? I am in contact with a Recruitment Agency. Any comments?

Jennifer Hunt

Position
Visiting Professor,
Organisation
Anglia Ruskin University
Comment date
16 October 2017
Excellent article. The shortfall is even more worrying given the increase in patient numbers, acuity and dependency making the workload higher. I wonder too whether there is any connection with the increasing use of 12 hour shifts and the current decline in nurse numbers ?

Benny Goodman

Position
Lecturer,
Organisation
Plymouth University
Comment date
16 October 2017
I can't help but suspect that there is a hidden agenda, although one hiding in plain sight, that underpins decisions around the 'NHS' and its staffing. That agenda is the increasing move to 'Accountable Care Organisations' and more private health insurance and to get there via Sustainable and Transformation Plans. ACO's such as the US Kaiser Permanente require the break up of the NHS as completed by the Health and Social Care Act 2012. Governments know the NHS is a British 'religion' and therefore any major changes require stealth. You do need the public to either provoke the change or to respond to a failing service by calling for change or for accepting radical shifts which the HSC Act prepare for. If the nursing staff issue is not a deliberate policy to either garner support, it is incompetence. Another reason could be that deficit reduction trumps everything else, absolutely everything else. Hunt et al are not stupid, this is their day job with armies of civil servants, NHS digital, and organisations such as the King's Fund to provide the necessary data and analysis. It has to be deliberate policy rather than incompetence. Their public defence excludes mention of ACO's and STPs. and instead asks us too believe they have employed 'more' which they know is not the same as 'enough'. They have dropped mention of Austerity in this regard also - they don't justify it in terms of requiring the 'NHS' to do with 'not enough'. They also do not mention that there is no such thing as the NHS in any case (thinking of it as 'The NHS' is a category error). If you can get ACO's and STPs to take the flak for essentially a political decision, you might be able to avoid being trashed in elections. You decide if that strategy is working. One clue might to to see if there are links between lobbyists in US health care corporations and the UK Government: https://www.theguardian.com/society/2015/jul/05/private-health-lobbyist-nhs-privatisation-dalton-review

Benny Goodman

Position
Lecturer,
Organisation
Plymouth University
Comment date
16 October 2017
Nursing as an attractive occupation? It is difficult to see when you have reports such as this from the RCN :http://www.bennygoodman.co.uk/safe-and-effective-staffing-nursing-against-the-odds/

Susan Oliver

Position
Nurse Consultant Rheumatology,
Organisation
Independent
Comment date
17 October 2017
There are numerous challenges to nurses. Defining the role, ensuring that career pathways reflect other career opportunities for the graduate nurse but also a greater recognition of the role in daily practice. In addition we need to have better indicators to define high quality nurse caring that are embedded into patient care. Nurses fill the gaps of care - and often this work fails to be adequately accounted for. Yet patient outcome are shown to be linked to number of trained nurses.
The Brexit issue has compounded what was already a fragile balance of sufficient nursing staff in the UK.
If we are to manage the future needs of our society with growing elderly and chronic disease patients nurses are vital to be the practical first port of call for many patients, working with evidence based pathways of care....we have to be effective with our health professional resources and nurses appropriately trained and supported can do this.
I have worked for many reasons to have the role of specialist nurses in long term conditions adequately recognised - whenever cuts and economies come along these roles are seen as expensive and so they are axed or down graded. The level of expertise that specialist nurses have cannot be immediately replaced when a bit of money is found. Equally why would a bright young person want to be nurse when there is a distinct lack of clinical career pathways and certain of these pathways and job security are even more vulnerable than in other fields.
Alison Leary's work on demonstrating the value of the specialist nurse across many long term conditions and recent work highlighting the need to clarify who has the right to use the term 'nurse' adds to this debate.

Carol Munt

Position
Patient Partner & Advocate,
Comment date
21 October 2017
I qualified as a nurse in the mid 60's and the issue of both patient and staff safety in 12 hour shifts was being raised then. We have seen varying shift patterns tried in the half century since but to go back to 12 hour shifts must be not only a safety issue but also a negative as far as recruitment is concerned.

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