Analysis

NHS Long Term Plan is big on ambition, so why is it short of nurses’ support?

Critics say the 10-year strategy cannot succeed until the NHS staffing crisis is resolved

Critics say the ten-year strategy cannot succeed until the NHS staffing crisis is resolved

Online-only nursing degrees – by next year – are one of the plan's more eye-catching proposals.
Picture: iStock

Major concerns have been raised over how the vision for nursing contained in the NHS Long Term Plan will be delivered.

The plan, published this month, sets out the government's ten-year blueprint for the NHS in England, with a focus on prevention, digital access to services and sustained workforce pressures.

But critics say the strategy's aims for healthcare are undeliverable as long as the NHS staffing crisis continues. Of the current 108,000 vacancies, more than 40,000 are nurses' posts. And then of course, there is the climate of political instability stemming from Brexit.

Unrealistic promises and false assumptions

Ministers promise a workforce plan but many healthcare leaders and nurses working in hospitals and the community feel the long-term plan makes unrealistic promises based on false assumptions.

For the nursing workforce, the government's ultimate aim is to bring down the vacancy rate from 12% to 5% by 2028.

One aspect of the plan that has been greeted with widespread alarm and disbelief is a declared intention to offer online nursing degrees from as early as next year. These would ‘minimise debt and incentivise mature students’, so the thinking goes.

‘Nursing degrees demand both academic and practical skills, which students learn from contact with professionals and peers, a model not easily replicated online’

Dame Donna Kinnair, RCN acting general secretary

This is an acknowledgement that the spectre of loans to cover tuition fees has stood in the way of many would-be degree applicants since the government abolished the NHS nursing degree bursary in England in August 2017.

Investment in education

In November, the King’s Fund think tank pointed out that central investment in education and training dropped from 5% of health spending in 2006-07 to 3% in 2018-19.

Dame Donna Kinnair, acting RCN
general secretary.

'Had the previous share of health spending been maintained, investment in the NHS workforce would now be £2 billion higher,' it says.

RCN acting general secretary Dame Donna Kinnair says the college has already set out how an urgently-needed £1 billion investment in nurse higher education should be spent.

‘The only way to significantly reduce, and later eradicate, the vacancy rate is for the NHS and government to put the money into nursing education.'

Professor Kinnair adds that online courses are no 'magic bullet' for the workforce crisis.

‘Nursing degrees demand both academic and practical skills, which students learn from contact with professionals and peers, a model not easily replicated online, even with clinical placements,' she says.

Scepticism about online-only degrees

The Council of Deans of Health (CoDH), which represents UK university health faculties, is not convinced.

CoDH chair Brian Webster-Henderson says: ‘Nursing is a high-cost subject and is unlikely to be much cheaper when accessed online so the government would need to subsidise this route. Without careful implementation, this option could undermine the important local relationships between employers and universities.’

Some nurses have expressed concern about online degrees on social media.

University of Essex school of health and social care senior lecturer Sarah Lee tweeted: ‘We introduced three totally online modules in our nursing curriculum. Feedback from students was consistently so poor that we reverted to a blended learning model – they valued the classroom experience over a digital one.’

 

We introduced 3 totally online modules in our nursing curriculum. Feedback from students was consistently so poor that we reverted to a blended learning model - they valued the classroom experience over a digital one.

— Sarah Lee (@toxic_harpy) January 8, 2019

 

On Facebook, Angela Jackson, a sister at Royal Papworth Hospital outside Cambridge, dismissed online degrees as ‘madness’. She said that while online modules could add depth to learning, nothing can replace supported, practical experience for students.

It has emerged that the government did not discuss the online degree proposal with the Nursing and Midwifery Council (NMC), before publishing the plan on 7 January.

But the NMC said it was 'looking forward to' discussions and said 'flexible and blended learning' already existed, for example through the Open University.

‘We’re committed to supporting new and innovative ways of teaching and learning that give students the knowledge and skills they need to meet our standards, alongside a rich learning experience.'

'A surplus of applicants'

There is also some surprise at a claim made in the government's document that there are too many nursing student applicants for available places.

‘My main concern about the plan is its statement that thousands of highly motivated and well-qualified applicants are being turned away by universities. This is simply not the experience of our members’

Brian Webster-Henderson, chair of the Council of Deans of Health

While the total number of applicants to nursing degree programmes fell in 2018, it says there were still ‘nearly two applicants for each place offered’.

It says 14,000 applicants to nursing across the UK were not accepted on to courses and calls it paradoxical that 'many thousands of highly motivated and well-qualified applicants who want to join the health service are being turned away.’

Brian Webster-Henderson, chair of
the Council of Deans of Health.
Picture: John Houlihan

The assertion takes no account of the suitability of those unsuccessful applicants, nor of the variation between nursing fields' ability to recruit undergraduate candidates.

Professor Webster-Henderson says: ‘My main concern about the plan is its statement that thousands of highly motivated and well-qualified applicants are being turned away by universities. This is simply not the experience of our members.

‘We know that while universities are easily recruiting to some healthcare courses, such as child nursing and physiotherapy, they often struggle to attract students to mental health, learning disability, adult nursing and some allied health profession courses.’

Queen's Nursing Institute chief executive Crystal Oldman agrees.

'We know of at least two universities that could not fill their places with suitable applicants in 2018,' she says.

'This is a direct result of the withdrawal of the bursary and mature applicants no longer being able to undertake the programme.’

Other proposals in the plan

Other initiatives outlined in the plan include:

  • A 25% increase in funding for undergraduate clinical placements with a Department of Health and Social Care promise it will fund clinical placements for an extra 5,000 places from 2019-20. Universities have previously said they could not expand their intake because there were insufficient clinical placements to send extra students to.
  • New ‘earn and learn’ financial support for mature students embarking on more flexible undergraduate degrees in mental health or learning disability nursing, to get an additional 4,000 people training by 2023-24.
  • New nursing graduates to be offered a five-year NHS job guarantee in the region where they qualify.

Dr Oldman says: 'Creating extra clinical placements in an already stretched service will present challenges. How will this work and what supervision and assessment in practice will there be, given that the new NMC standards for this are very rigid?

Crystal Oldman, chief executive of
the Queen's Nursing Institute.
Picture: Barney Newman

'The DH might be able to fund an additional 5,000 clinical placements, but will it also fund the 5,000 extra student nurses to fill them, or will this still be reliant on a student loan system that has already significantly reduced admission to undergraduate courses?'

The wait continues for a workforce plan

The workforce plan, promised by the DH for 'later in the year' will contain action to boost the supply of nurses. It will be agreed by a new group led by NHS Improvement that includes the royal colleges and other health organisations.

NHS Providers, which represents hospital, mental health, community and ambulance services in England, says the timing of the workforce plan is worrying.

Chief executive Chris Hopson says: 'It’s a major concern we will have to wait to get the comprehensive plan that is needed here.'

What issues should be at the top of the workforce plan’s agenda?

We ask RCN associate director of policy and public affairs Lara Carmona:

What does the workforce group need to focus on as its most urgent priority?

To fix the supply of nurses and ensure there is a robust process for joined-up workforce planning that is based on the real and future need of the population and sets out clearly who is accountable for its delivery. This should be set out in a workforce strategy, and coordinated with the rest of the UK, given that staff and patients move around. 

How does the vague ‘later in the year’ deadline for the workforce plan affect staffing problems? 

The sooner the workforce implementation plan is produced, and the more transparent it is, the better. Until there is a clear plan for what roles are required that addresses the widespread shortage of registered nurses, particularly in hard-hit areas such as learning disability and mental health, the NHS will not be able to deliver the care patients deserve, let alone the ambitions set out in this document. 

The long-term plan doesn’t state how many nurses the NHS in England needs over the next five to ten years – do we know?

The government has to undertake a robust assessment of population need – now and for the future – and use this to inform funding allocations and resource requirements. We expect to see the development of a strategy setting out how the government is going to produce the right number of qualified people to fill these posts. We want to see decision makers made accountable in law to ensure this is delivered.

The RCN will sit on the workforce group led by NHS Improvement


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