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Nursing shortages: how bad will it get?

 The NHS desperately needs to keep the nurses it already has as well as attracting new recruits. Yet efforts to fill thousands of vacancies risk being overwhelmed by mounting pressures and a lack of joined-up policy, says Alison Moore. 

The NHS desperately needs to keep the nurses it already has as well as attracting new recruits. Yet efforts to fill thousands of vacancies risk being overwhelmed by mounting pressures and a lack of joined-up policy, says Alison Moore.

The NHS in England has 24,000 vacancies for nurses, leaving many trusts with more than 200 posts vacant. But the cumulative impact of a number of factors from an ageing workforce and pay restraint to Brexit could make staff shortages a great deal worse in the near future.

This is not the first time the NHS has been on the brink of a major workforce crisis. There were nurse shortages at the turn of this century, and the government responded by making it easier to recruit from overseas, increasing

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 The NHS desperately needs to keep the nurses it already has as well as attracting new recruits. Yet efforts to fill thousands of vacancies risk being overwhelmed by mounting pressures and a lack of joined-up policy, says Alison Moore. 


A shortage of nurses in NHS England could get worse. Picture: Getty Images

The NHS in England has 24,000 vacancies for nurses, leaving many trusts with more than 200 posts vacant. But the cumulative impact of a number of factors – from an ageing workforce and pay restraint to Brexit – could make staff shortages a great deal worse in the near future.  

This is not the first time the NHS has been on the brink of a major workforce crisis. There were nurse shortages at the turn of this century, and the government responded by making it easier to recruit from overseas, increasing the number of nursing students being trained in UK universities and trying to attract nurses back into the workforce. It also committed to increased spending on the NHS, which included better pay for staff.

But the current political environment is different, says Queen Margaret University workforce expert James Buchan. 'If we compare then to now, there are the same challenges, but there is little money in the kitty, so big costly initiatives are not part of the picture.'

Another difference, of course, is Brexit. According to Department of Health forecasts, leaked to the Health Service Journal, the NHS could be short of up to 42,000 nurses by 2025-26. Civil servants are said to have warned ministers that there is a severe risk of undersupply if immigration rules change and international recruitment dries up in the wake of the UK's departure from the EU.

Brexit uncertainty

Uncertainty around what will happen after Brexit in 2019 is already affecting EU nurse retention and recruitment. More EU-trained nurses are returning home and recruitment from the EU has become more difficult. NHS trusts' recruitment drives in EU countries are attracting ten or 20 nurses when once they would have recruited dozens.

Latest figures provided by the NMC show a 39% increase in those trained in the EU and European Economic Area leaving the register in the year to February compared with the year before. Professor Buchan says EU nurses have other employment options and cannot be expected to prop up the NHS at a time of huge political uncertainty. 'For EU nurses it is easy come, easy go,' he says.

Joan Pons Laplana, a Spanish nurse who has worked in the UK for 17 years, says the UK is no longer an attractive option for EU nurses. 'I feel I am no longer welcome. If I did not have kids I would leave now. People are starting to leave, especially the younger ones who have come here in the past five years. Nurses can choose where to work. My trust has Spanish and Portuguese nurses and a couple have already left. People no longer want to come to England.'

Around 37,000 nurses trained in the EU/EEA are on the UK register. Brexit is not the only factor affecting EU nurses' decisions to stay or go: the state of the economy in their home country can also be a strong influence. Predicting how many EU nurses will still be here in two or five years is extremely difficult.

Ageing workforce

The most predictable of the workforce pressures, says Professor Buchan, is the ageing workforce. Up to one-third of NHS nurses are expected to retire in the next ten years. NHS Digital figures show that 14% of nurses and health visitors are aged 55 to 64, but 31% are 45 to 54.

This could mean the NHS loses upwards of 10,000 nurses a year to retirement. Parts of the nursing workforce that are older than others – practice nurses, for example – may be disproportionately hit by retirements.

There is little sign that NHS organisations have plans to encourage staff to remain in the workforce even though delayed retirement could, potentially, make a big difference through the next decade.  

Attracting other nurses back into the profession, as well as retaining those already working, could also ease staffing pressures. Dame Donna Kinnair, director of nursing, policy and practice at the RCN, suggests that better availability of return-to-work courses, and possibly changing the format to deliver them in hospitals, could help.

Career image

The 'refresh' of the Five Year Forward View (NHS England's plan for the NHS) released at the end of March included a promise of 1,500-2,000 extra nurses being supported to return to practise over the next two years, as well as a nurse retention collaborative to work with the 30 trusts with the highest turnover. 

But efforts to improve recruitment and retention are taking place against a hugely worrying backdrop: years of pay restraint and increasing levels of stress in nursing roles, which may be making nursing unattractive as a career to potential new recruits and returners. 'We have to do something to promote the image of nursing,' says Professor Kinnair.

Applications for nursing courses for 2017-18 have fallen by 23% compared with 2016-17. How much this is to do with scrapping of the student bursary is not yet known. There are still more applicants than places available, but if there were fewer applications it could affect areas that have struggled to recruit in the past, such as mental health and learning disability.

The number of nursing places available is meant to swell over the next few years to accommodate up to 10,000 extra students. This could be a game changer, although it would only affect the workforce in the early 2020s. There is also limited evidence that those places are starting to come on-stream, and concerns remain about providing placements for increased numbers. Katerina Kolyva, executive director of the Council of Deans of Health, emphasises the need for ‘a system of placement funding that allows universities the flexibility to grow placement capacity'.

Openings for graduates

The Five Year Forward View refresh also introduced 'nurse first', a two-year training scheme for graduates wanting to come into nursing with the promise of rapid progress to leadership positions. Pilot schemes in learning disability and mental health nursing will run from September – so some of the nurses should qualify in 2019. However, Dr Kolyva says: 'We are seeking urgent clarification of the details of the programme, particularly around scale, funding and location.'

Nor is 'nurse first' unprecedented. Dr Kolyva says there are already many postgraduate pre-registration nursing courses for graduate students, around one-third of which are in mental health and learning disability nursing.

International recruitment – from beyond the EU – has been the saviour of many trusts over the past few years. But this is also becoming more difficult and expensive. Trusts now have to pay an immigration skills charge of £1,000 per nurse per year, when they come in on a tier 2 visa. Meeting the NMC's requirements has become harder, and some trusts are reporting long waits to get overseas nurses into place on the wards. The numbers of overseas trained nurses on the NMC register has grown only slowly in the past year – partly because more are leaving (a 27% increase). The falling value of the pound may also influence international and EU nurses’ decisions to come to the UK.

Grow your own

Not surprisingly, some trusts are also looking at developing their existing workforce. At the Queen Elizabeth Hospital in King’s Lynn, Norfolk, more than 30% of the nurses and midwives are from overseas and the EU. However, director of nursing Emma Hardwick says: ‘Local recruitment is important to the future of the trust, so we have developed the grow-your-own strategy. One of the aims is to offer existing staff, from across the bands, the opportunity to develop and reach their full potential.' Initiatives include foundation degrees for unregistered staff and an 18-month higher nursing apprenticeship scheme that is being launched in conjunction with two other trusts. 

Some trusts are still recruiting large numbers abroad. Medway Foundation Trust has recently offered jobs to 240 Filipino nurses and expects around 120 to eventually join it. Deputy director of nursing Simone Hay says extra practice development nurses will support them when they join the organisation.  

Ms Hay says that despite the national position the trust's EU nurses are also committed to it. ‘We are confident that they feel supported and want to stay.'

European nurses who have been here some time are now moving into specialist areas such as theatres and intensive care, she adds. And the trust is still actively recruiting in Europe as well as locally.

So will the NHS have the nursing workforce it needs in the next five years? There are concerns that not enough is being done to ensure there is a consistent supply of nurses.

Policy armoury

Professor Buchan says: 'We have a sense of a lack of joined-up government. There is little in the policy armoury in the short term that looks as if it has much potential to scale up. That means managing the demand.'

He adds that he has concerns about the potential for skill dilution with non-registered staff taking on tasks formerly done by nurses. 'It is inevitable we will see more of that, but the scope for that new category of worker to have a significant impact across the NHS is some time down the line.'

NHS Employers chief executive Danny Mortimer suggests that even if roles are adjusted locally, projected demographics mean that overall more nurses will still be needed.

While Professor Buchan believes some improvements in the situation are possible, 'these all require creative and fleet-of-foot policymaking at national level and practice at local level'.

He wants to see a clearer acknowledgement that there is a looming problem, greater coordination and joined-up policy nationally. Without that, the next few years look extremely challenging.

Workforce pressures

  • Retirement: Around one-third of the NHS' nurses are coming up to retirement age in the next ten years.
  • Students: Applications for nursing degrees have dropped by 23% this year – possibly affected by the introduction of tuition fees.
  • Brexit: In the past few years many EU nurses have come to work in the UK but there is evidence that some are now returning home, concerned they may not be able to stay after Brexit.
  • International: nurses are becoming more expensive for the NHS because of a new immigration skills charge. The process for registering with the NMC has also become more complex and lengthy.

What might help  

  • Attracting more nurses back into the profession: NHS England has now set targets for this.
  • Improving retention: Work is to start with the 30 trusts with the highest turnover.
  • More student places: Expansion of student numbers could have a significant effect but will take several years.
  • Using other staff to do nurses' work: This is controversial – as is the development of nurse associates – but may be necessary if the NHS can't recruit enough nurses.

Alison Moore is a freelance health writer

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