This was the question that we posed in our latest Daring to ask debate – held jointly with the NHS Confederation.
Crisis – what crisis?
Nursing is a shortage occupation: the current nurse vacancy rate in England is 9.4 per cent, and there are geographies and sectors that have even worse problems. In London, the RCN puts the vacancy rate at 17 per cent and one London mental health trust recorded an overall nurse vacancy rate of 30 per cent. In community settings there are vacancy levels of over 21 per cent for district nurses and 46 per cent for children’s nurses, which is worrying at a time when policy is encouraging a shift to community-based care. There are also pressing gaps in the nursing workforce within social care, gaps often neglected by NHS workforce planners.
New trainees are failing to compensate for the 'hole in the leaking bucket'. More nurses are leaving the profession than joining it. In 2014, there were 13,400 graduates from nursing school while 7,500 nurses retired, but most worryingly 17,800 nurses left before retirement. The gap was largely filled by nurses recruited from abroad and an increase in use of agency staff. It is a position that could be exacerbated by Brexit, an anticipated bulge in retirement (triggered by changes to pension rules), the continuing constraints on pay and staff carrying increasing workloads.
We have an urgent and growing problem in the supply of the nursing workforce. It is a problem that is threatening the quality of patient care and the ability to transform the current model of care.
What are the solutions?
The current median pay for nurses is £31,500, which is £7,500 below the median in other graduate occupations. When there was a severe nurse shortage in the late 1990s and early 2000s, the Pay Review Body responded with substantial real pay increases. According to the Migration Advisory Committee review of the nursing workforce, “available pay flexibility is insufficiently used”. Possible adjustments include recruitment and retention premia and greater local pay flexibility. The current financial situation suggests that increases in pay are off the table. However, the costs of recruitment and the high spend on agency staff demonstrate that there is a strengthening business case for pay adjustments in some areas.
Increase the number of nurse graduates
In 10 years (2004-2014), the United States managed to turn a prospective gap of almost one million registered nurses by 2020 to a projected surplus of 340,000 registered nurses by 2025 through rapid growth in nurse training numbers, supported in many states by offers of bursaries and other financial benefits. The shift away from centrally funded bursaries for nurse training in England means that future training numbers will be driven by the perceived attractiveness of nursing as a profession. This was not a problem in the past, but the current pressures on pay and services could act as a major deterrent. There are also constraints on training placements with limited training budgets and placement availability. Given the scale of the problem facing nursing, the Government cut to nurse training budgets seems short sighted, if not reckless.
Grow your own and widen participation
There was marked enthusiasm at our debate for the opportunities offered by training and developing the support workforce, enabling them to enter training for skilled nursing roles. Not only does this expand the potential training pipeline, it widens participation and creates a clinical workforce that better mirrors its local community. While there was a difference of opinion as to whether the new Nursing Associate role would help, there was incredulity that Nursing Associate courses are being developed with no clear national guidance on job role and content. As one participant said, it is “like Gromit having to rapidly lay down the track for Wallace and his train”.
Adopt best human resource practices and improve staff retention
As the National Audit Office figures show, one of our biggest problems is retention. There is strong evidence to show that empowering and developing your workforce can significantly improve nursing retention rates. This can be achieved by creating opportunities for staff to develop professionally; offering increased autonomy and participation in decision-making; flexible employment; and access to continuing professional development. Many of the debate participants highlighted the challenges created by the recent cuts to central budgets for continuing professional development. There is a particular need to support new nursing graduates, many of whom leave nursing in their first five years at work.
Changing skill mix
Could changes in skill mix help solve the problem? Many of the tasks undertaken by qualified nurses can safely be undertaken by other staff, which could relieve pressure on nurses. On the other hand, there is growing evidence of the potential risk to patient safety from skill dilution on acute hospital wards. Our recent research showed many opportunities to change skill mix, but argued that the starting point should always be an in-depth analysis of the competences and skills required in any setting – an analysis that is lacking in many cases. The potential for changes to skill mix will be context and team specific.
A way forward
There is no magic bullet that can solve the nursing workforce crisis. Action is needed at all levels. In an ideal world there would be national funding and support. But even without this, higher education institutions can reduce high rates of student nurse attrition and work collaboratively with local providers to design training routes that widen participation and support retention. Providers can empower, develop and celebrate their workforce, paying particular attention to support for new nursing recruits and job design.
There is a lot that can be done. But this is not a problem to be contemplated, nor a future agenda for action. It is action that is urgently needed now.