Decline in nurse numbers is much more than a blip

Front line nurses, think tanks and the Nursing and Midwifery Council all agree that the nursing workforce is shrinking

Front-line nurses, think tanks and the Nursing and Midwifery Council all agree that the nursing workforce is shrinking

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Most nurses don’t need to be told there aren’t enough of them. Advertised posts that go unfilled, call bells that can’t be answered and growing case lists as the increasing level of work is spread across a thinning workforce are familiar scenarios.

Figures from NHS Digital and the Nursing and Midwifery Council have confirmed this decline. The King’s Fund, which looked at NHS Digital workforce statistics, says there has been the first year-on-year drop in the number of nurses and health visitors since 2013.

An analysis issued by the think tank in April found there were 461 fewer full-time posts than a year earlier. This drop continued over the next three months, with 282,603 nurses and health visitors in post in June, 1071 fewer than in June 2016. In July there were 281,363 full time equivalent nurses and health visitors, a drop of almost 1,350 on the previous July, and in August 280,307, a decline of more than 1500 on the previous August.

‘There are flat or falling numbers of nurses while all the indicators of demand and activity are going up’

Richard Murray, King’s Fund director of policy

So the fall is not just a blip, but appears to be gathering pace each month. King’s Fund director of policy Richard Murray says: ‘It is concerning that there are flat or falling numbers of nurses while all the indicators of demand and activity are going up. We are seeing increasing admissions to hospital, particularly emergency admissions, which use up most of the beds.’

NMC register is shrinking

The Nursing and Midwifery Council said in July that the register was shrinking for the first time in recent years. There was a 96% decline in the number of nurses from the EU applying to join the register since the Brexit vote and, in 2017, 45% more UK nurses and midwives left the register than joined.

NMC figures published at the beginning of November showed that the trends have continued, with a 67% rise in the number of EU nurses and midwives leaving the register in the 12 months to September compared with the previous year, and an 89% drop in EU applications to join the register.

The biggest impact, however, is the number of UK graduates leaving the profession, which increased by 9% over that period.

Reasons for leaving

In a survey on reasons for leaving, published by the NMC in July, 44% said it was due to working conditions, 28% cited a change in personal circumstances such as ill health or caring responsibilities, and 27% said they were disillusioned with the quality of patient care.

Poor pay was among the top three reasons for leaving for 16% of the 4,500 respondents, all nurses and midwives who had left the register during the previous 12 months.

Indications of the shortage of skilled staff have been ringing alarm bells for nurses and unions for months. In May, the RCN said that England alone had 40,000 unfilled nursing vacancies as employers struggled to find suitably qualified staff. A report published in September called Safe and Effective staffing, based on a survey of 30,000 members revealed that 55% said their team was at least one nurse down on their most recent shift.

‘The decline of staffing and resources in both community and mental health settings is worrying’

Richard Murray

The Department of Health says the number of nurses in hospitals is increasing: 'Patients should be told that we actually have more nurses on our hospital wards since April 2016 not fewer, which… underlines our commitment to ensuring the NHS has the nurses it needs to provide the best possible care for patients, both now and in the future.’

But Mr Murray says pressure on hospital beds and services is increasing due to struggling community and mental health services. The Care Quality Commission highlighted the difficulties that many children and young people face in accessing suitable services in a review published in October. The watchdog found one child had even waited 18 months to receive support.

Mandated staffing levels

A King’s Fund report in March looked at the crisis in the number of district nurses, finding full-time posts in England fell by almost half between 2000 and 2014, and by a further 15% between 2014 and 2016.

‘The decline of staffing and resources in community and mental health settings is worrying, and a lot of the pressures that show up in mental health relate to poor quality of care,’ Mr Murray says.

RCN chief executive Janet Davies said the shortages reinforced the need for mandated nurse staffing levels to protect patient safety.

Unison head of health Sara Gorton said: ‘If more nurses continue to leave than join, staff-patient ratios will become even more dangerous. Ministers must address the recruitment crisis in the NHS now.’

‘Trusts must be supported to continue to recruit internationally’

Paul Myatt, workforce policy adviser at NHS Providers

Health secretary Jeremy Hunt pledged in October to increase the number of training placements for nurses by 25%. But at the same time there has been declining interest in nursing courses since the NHS bursary was removed. The number of applicants to nursing courses this year in England was down 23%.

Nursing leaders point out that any increase in workforce numbers through training takes years to come to fruition. Employers and the King’s Fund say international recruitment is likely to be the short-term solution.

Paul Myatt, workforce policy adviser at NHS Providers, says trusts describe workforce difficulties as their biggest concern. ‘Trusts are working hard to engage with and improve the wellbeing of staff. Some have introduced ‘grow your own’ nursing courses in partnership with universities to boost supply locally, and many are recruiting nurses internationally,’ he says.

‘But boosting domestic supply will take time, and trusts must be supported to continue to recruit internationally and to make the NHS a great place to work for staff, including nurses.’

‘We’re overstretched and safe care is a struggle’

Annique Simpson, a band 5 community nurse, first raised concerns formally with her employer about staffing levels in 2014. She has been told repeatedly since then that the organisation is trying to recruit but is unable to find sufficient staff.

An external audit carried out late last year found her team was understaffed. While there have been some agency nurses, recruitment is still difficult and more staff are leaving, she says.

‘I have worked two unpaid hours today, one yesterday, and two the day before,’ she says. ‘My employers are trying to improve morale, but when I looked at my list of patients this morning, it was long and complex, and I can’t see all of them.’

Holistic care and patient safety is a struggle for overstretched staff, who become task-oriented, Ms Simpson says. ‘I know many hospital nurses are counting the days to retirement and everyone is well and truly on their knees.’

Health visiting workforce in crisis

Health visitor numbers have declined to their lowest level since November 2013 as the specialty faces a recruitment 'perfect storm', the Institute of Health Visiting has warned.

NHS Digital statistics reveal that in July 2017 there were 8,449 full-time health visitors in England compared with 9,311 a year earlier, meaning almost 17 health visitors a week were leaving.

The Labour Party said the reduction in numbers was failing some of the most vulnerable in society. Shadow health secretary Jonathan Ashworth says that in the fourth quarter of 2016/17, 12% of babies missed their newborn visit and 16% did not get their eight-week review.

The declining figures come despite a major investment by the government to boost the number of health visitors.

Apprenticeships only the only funded route

Major changes in the education of health visitors are compounding workforce difficulties, says Karen Stansfield, head of the institute’s education and quality department.

The uptake of health visiting education places has fallen sharply over the past three years, with 44% of places not taken up last year. From 2018, funding for places will be removed by Health Education England, with apprenticeship places the only funded route.

Dr Stansfield says the apprenticeship places have complex funding arrangements, which is making them unattractive to employers, and there will no longer be funding to backfill the role of the member of staff who is training.

‘Apprenticeships are an expensive model for employers and very complex to understand,’ she says. ‘What we are finding is that employers don’t know that much about apprenticeships, although it is an employer-led initiative.’

Erin Dean is a freelance journalist

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