Fears of “emerging crisis” in nursing with 40,000 NHS vacancies and 36% of current workforce considering leaving in the next year, says PAC report

Nurses have played a “vital” role in caring for people during the COVID-19 outbreak despite nearly 40,000 unfilled nursing post vacancies which had already put staff and services under strain. The Government has committed to 50,000 more nurses by 2025, but in a report published today, the Public Accounts Committee says the Department for Health & Social Care (DHSC) does not understand the nursing needs of the NHS and does not know how many nurses are needed, or where and in what specialism.

The NHS is relying on a substantial short-term increase in overseas recruitment as part of meeting that commitment for 50,000 nurses, but the COVID-19 outbreak is just the latest illustration of the risks and problems inherent in this strategy.

Even before the pandemic, the NHS’ own numbers show tens of thousands of their nurses were leaving the profession every year, and in evidence to the Committee the NHS acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak.

A Royal College of Nursing survey showed a huge 36% of respondents considering leaving nursing in the next year, up from 28% before the pandemic. When asked about why they are considering leaving, two thirds cited low pay; while almost a half of respondents cited low staffing levels, the way nursing staff had been treated during the pandemic, or lack of management support.

However, rather than addressing this emerging crisis in nursing, there are “worrying indications that the NHS has reverted from long-term planning to short-term firefighting. This is not good enough for the over-stretched NHS workforce”. The pace of progress on increasing the number of NHS nurses was already “too slow”, with efforts to increase the numbers in undergraduate nursing degrees – which anyway take years to come to come to fruition - having “signally failed”.

It is vital that the NHS protects the mental health and well-being of nurses who have contributed so much during the COVID-19 outbreak, and the Committee is also concerned that the necessary safeguards being put in place to protect Black, Asian and minority ethnic staff, who are disproportionately affected by COVID-19, restrict their work experience and career progression.

After a highly critical PAC report earlier this year, when the Committee Chair said care homes had been “thrown to the wolves” in the pandemic, today’s report finds “the nursing needs of social care remain an unaddressed afterthought for the Department of Health & Social Care.” Vacancies for nurses in social care increased from 4 % in 2012-13 to 10% in 2018-19, while the number of registered nursing posts in social care has fallen by 20% since 2012-13.

Meg Hillier, Chair of the Public Accounts Committee, said: “The picture from the front line of nursing in the NHS and care homes is not good. I fear with the strain of a huge shortage of nurses and the worrying reports of low morale and huge numbers considering leaving in the next year, we are facing an emerging crisis in nursing.

“We fully recognise that the NHS is reeling under the strain of Covid-19, with staff unsure how they will cope with the second wave that it seems clear already upon us. But it must not take its eye off the ball and allow a slide back into short-term, crisis mode. It must press on with coherent plans to get the nursing workforce back to capacity, under the kind of working conditions that can encourage hard-won, hard-working nurses to stay in our NHS and care homes.”

PAC Conclusions and recommendations

6.There has been further delay to the overdue NHS People Plan and there is a risk that the NHS is focussing on short-term pressures at the expense of the necessary long-term strategy. The detailed plan had been scheduled for 2019 but it was still not published by March 2020, and the outbreak of COVID-19 has added further delay. NHSE&I argues that planning for a 3-4 year horizon is difficult at this time, and currently the system’s main focus is on winter planning. It now plans to publish the People Plan in two parts. The first, published in July 2020, focuses on enhancing NHS culture and leadership, while the second, to be published after the next Spending Review, will cover plans to ensure the NHS has the nurses it needs. This will mean nearly two years between the January 2019 NHS Long Term Plan and the full workforce plan that was meant to support it. It is also frustrating to hear health bodies still citing the same reason - a lack of long-term funding for workforce education and training, which will be set in the Spending Review - as a reason for not producing the complete plans.

Recommendation: NHSE&I and HEE must prioritise publication of the substantive long-term workforce plan as soon as possible utilising the NHS’s existing long-term funding allocations.

7.The Department could not show that its commitment to 50,000 more nurses by 2025 matches the actual need for nurses in the NHS. It is essential that the NHS understands not just how many nurses it needs, but where and in what specialism. The NHS Long Term Plan, published in January 2019, did not have a complete assessment of the type and number of nurses needed to deliver the plan, leaving that to the People Plan promised for later in 2019. In December 2019, while the People Plan was still in development, the government made a pledge to deliver 50,000 more nurses by 2025. However in March 2020 NHSE&I and HEE were still developing a model to understand and quantify the demand for nurses. Demand varies between specialisms and regions. For example, nursing vacancy rates are particularly high for mental health trusts and in London. NHSE&I says that local areas are revising their estimates of the number of nurses they need in light of COVID-19, which it will publish with the second part of the People Plan, after the next Spending Review.

Recommendation: NHSE&I and HEE should update and publish the results of their modelling work on the demand for NHS nurses, including details for regions and specialisms and any impacts arising from the COVID-19 outbreak.

8.We are not convinced that the Department has plans for how the NHS will secure 50,000 more nurses by 2025. The Department plans to meet the 50,000 commitment by increasing the domestic supply of registered nurses, recruiting from overseas and improving retention rates. However, it could not tell us how many nurses each of these supply routes are expected to provide, as local areas are reviewing their plans in light of COVID-19. The NHS is relying on a substantial short-term increase in overseas recruitment for nurses, but the COVID-19 outbreak illustrates that this is a risky strategy as international recruitment has been delayed as a result of travel restrictions. NHSE&I acknowledges that pay remains an important issue for NHS nursing, which has impacted on retention in the past; in international recruitment, other countries often have more leeway to pay nurses more than in the UK. Apprenticeships and nursing associate roles are potentially a more accessible, if longer, route to becoming a registered nurse, but providers are finding it challenging to deliver apprenticeships at scale.

Recommendation: As part of the published people plan, the Department, NHSE&I and HEE should include a set of costed and detailed action plans for each of the different supply routes for nursing, and how many nurses each route is expected to contribute to the overall nursing workforce. They should consider what national actions, for example on pay, they may need to take to increase recruitment and retention.

9.The nursing needs of social care remain an unaddressed afterthought for the Department of Health & Social Care. Vacancies for nurses in social care have increased from a rate of 4.1% in 2012-13 to 9.9% in 2018-19, while the number of registered nursing posts in social care has fallen by 10,400 (20%) since 2012-13. The NHS and social care providers both recruit from the same overall pool of nurses. While NHSE&I recognises the importance of social care and the value of better integration between the two sectors, social care will still not be included in the NHS People Plan. The Department considers that it would be too challenging to develop an integrated workforce plan for health and social care as its powers and influence over the two sectors are very different. The NHS expects local partnerships to develop plans across the two sectors, but such partnerships are not statutory, have no organisational accountabilities and rely on the goodwill of constituent bodies. The limited consideration of the needs of social care relative to health is sadly all too familiar from what we have seen previously, for example, when reporting on the adult social care workforce or readying the NHS and social care for COVID-19.

Recommendation: The Department should set out its understanding of the nursing requirement across health and social care, and how it expects its actions will support nurse recruitment and retention in social care.

10.The removal of the NHS bursary in 2017 signally failed to achieve the Department’s ambition to increase nursing student numbers. From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. It removed the NHS bursary and payment of tuition fees for students and moved them onto student loan arrangements. The Department hoped to increase the number of places on these courses by 10,000 by 2020, but accepts that the new policy has failed to meet all its objectives. While the numbers of people accepting a place on a nursing degree course have increased since 2017. only 430 (2%) more people accepted a place in 2019 compared with 2016. The number of applicants is also still well below pre-2017 levels, although the latest data show a 15% increase in domestic applicants for nursing degrees from 2019 to 2020. The policy change also impacted some students and regions more than others: for example, there were large falls in student numbers on learning disability nursing degrees. In December 2019, the government announced the introduction of a new maintenance grant for nursing students from September 2020.

Recommendation: The Department, NHSE&I and HEE should write to the Committee in October 2020 setting out how they expect the new maintenance loan to increase nursing student numbers overall and for different types of student, nursing specialisms and regions. This should also set out how the loan might affect drop-out during courses.

11.The COVID-19 outbreak presents new challenges, as well as opportunities, for improving the recruitment and retention of nurses in the NHS. In particular, it is vital that the NHS protects the mental health and well-being of nurses who have contributed so much during the COVID-19 outbreak. NHSE&I told us it had put measures in place to support staff, but there are worrying signs of increased levels of stress and burnout since the start of the outbreak, with 90% of nurses reporting higher levels of anxiety in a survey of staff. The NHS also acknowledges that it must do more to improve local leadership and make better use of flexible working arrangements if it is to retain nursing staff in the longer term. HEE also estimates that 20% of final-year students who stepped up to work for the NHS during the outbreak may have difficulty completing the clinical practice hours they need to graduate on time this year. We are also concerned in case the necessary safeguards being put in place to protect Black, Asian and minority ethnic staff, who are disproportionately affected by COVID-19, restrict their work experience and career progression.

Recommendation: We welcome NHSE&I’s publication of early lessons from COVID-19. NHSE&I should ensure it also makes available a full and frank assessment of the new challenges to nursing recruitment and retention specifically and how health providers should address them, particularly where this could disadvantage certain groups for example students or minority ethnic staff.

Recommendation: As part of this assessment, NHSE&I should take stock of the measures in place to support nursing staff’s mental health and wellbeing, to share good practice and identify what else staff may need./ENDS