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.
Source: NHS Digital
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.