NHS People Plan: the crucial gap in the nursing workforce target

Varied data collection methods make it hard to gauge exact nurse numbers and vacancies

• Interim NHS People Plan to tackle biggest challenge facing NHS – a shortage of nurses
• But lack of overall system to record nurse numbers and vacancies hampers planning
• RCN review shows falls in mental health, learning disability and community nurses

The NHS is in the grip of a workforce crisis, and nothing is more pressing than the shortage of its biggest resource – nurses.

Health unions, charities, patient groups, academics, the media and even the UK governments all agree on one point: the nursing shortage needs to be addressed urgently.

This shortage is the ‘biggest single challenge’ facing the NHS workforce, according to the Interim NHS People Plan, which sets out how the health service will recruit and retain staff.

The government has set out its ambitions to increase the nursing workforce in England by 40,000 over the next five years (see box).

• RELATED: Mumsnet, online degrees and more CPD funding: government ideas to boost nurse numbers

How many nurses are missing?

But one thing that seems harder to pinpoint is just how many nurses are working in – and crucially, missing from – the health system.

At present there is no catch-all system to record nurse numbers and vacancy rates across the health and social care services as a whole.

Instead there are varied data collection methods at national and organisational level, which makes it difficult to obtain a true picture of nursing shortages.

That absence of clear data has hampered workforce planning, experts say.

Unison head of health Sara Gorton says: ‘Joined-up workforce planning ‎across sectors is never going to become a reality without building a comprehensive picture to pinpoint the gaps.

‘This absence of robust data on vacancies risks masking the scale of the challenge.

‘And it gives the government an excuse to duck the issues.’

The current staffing picture

Latest figures from the Nursing and Midwifery Council (NMC) show that as of May this year there were 698,237 nurses on the UK-wide register.

What is less clear, however, is where these nurses are working – and where the shortages are.

In response to questions from Nursing Standard in 2018-19 about the number of nurses in the workforce, the Department of Health and Social Care (DH) has tended to say that there are ‘thousands more nurses working on wards than in 2010’. For example, it has said:

‘There are 16,100 more nurses on our wards since 2010’  (February 2018).

‘There are 11,900 more nurses on our wards since 2010’  (November 2018).

‘There are 16,300 more nurses on wards than in 2010’ (March 2019).

Children’s and mental health services omitted

Full Fact, an independent fact-checking charity that scrutinises claims made by politicians and the media, says no specific data captures the total number of nurses working on all hospital wards. It says the figures cited by the DH only cover nurses working in adult acute, older people’s and general care.

 The figures do not include nurses working in other fields such as children’s and mental health services.

Full Fact health and social care lead Claire Milne says it is common for May 2010 to be used as a comparison point for figures, as that is when the Conservative-led coalition took power.

What would be a better comparison

But Ms Milne says comparisons with May 2010 can be unfair, because of the seasonal nature of nursing – there are natural points during the year when the workforce sees a boost, such as when new nurses join the register after completing their training.

• RELATED: Interim NHS People Plan promises to tackle mental health nurse shortages

‘The problem is, because the nursing workforce numbers are very seasonal, it is not really fair to compare May with a different month,’ says Ms Milne. ‘A better comparison would be May 2010 with May 2018, or 2019 when those figures are released.’

The DH told Nursing Standard it is now calculating change by looking at the corresponding month in previous years ‘to take account of variations noted as an impact of seasonality’.

The staffing picture beyond acute care

Ms Milne also says that even if areas of nursing such as adult acute, older people’s and general care have seen increases in the number of nurses, other areas – such as community and mental health – have seen falls.

According to the most recent RCN review of the UK nursing labour market, the following drops in nurse numbers were seen across three specialties in 2014-18:

• Mental health nursing down from 37,951 in 2014 to 36,053 in 2018 (-5%).
• Community health nursing down from 36,605 to 35,377 (-3%).
• Learning disability nursing  down from 3,969 to 3,305 (-17%).

In addition, data on nurses working outside the NHS, such as those health visitors who are employed by local authorities, are not always collected routinely.

For health visitor data that has been captured, numbers fell by 8% in England between 2014 and 2018  (from 8,926 to 8,172).

• RELATED: NHS People Plan is refreshingly honest about the causes and extent of nurse burnout

Some jobs may have been transferred out

RCN employment relations researcher Rachael McIlroy warns that the fall in the number of community nurses, health visitors and mental health nurses is part of a more complex picture.

‘We don’t know whether those declining figures are just because jobs have gone or whether some of those jobs have been transferred out to social enterprise organisations and the private sector.

‘As an example, mental health services run by (private care provider) the Priory Group are not counted in NHS figures, but nurses there are still doing NHS work.’

Data on children’s, community and mental health nursing are collected by NHS Digital, the organisation that supplies information and data to the wider health service.

According to the Health Foundation charity’s senior economics analyst Benjamin Gershlick, NHS Digital receives the data via organisations using electronic staff records. Yet there is no mandatory requirement to use this system, and a number of organisations do not.

Lack of data on social, private and voluntary healthcare

Mr Gershlick highlights another gap in workforce data: ‘In terms of social, private or voluntary healthcare, we have really little data on nursing in these areas, and what we don’t have is comparable data.’

• RELATED: You want to boost the social care workforce? Then invest in it, RCN tells ministers

There are separate data available on practice nurses in England, but the figures are from 2015 and relied on general practices providing the information.

Independent workforce development charity Skills for Care estimates there are 5,000 nursing vacancies in the social care sector.

Care suffers when nurse numbers fall

The evidence is clear: when the number of registered nurses falls, care suffers. 

In a Nursing Standard survey of 2,000 UK nurses working in acute, community and care home settings, respondents had one message – they cannot provide the level of care they would wish because there are just not enough of them.

Nine out of ten respondents said an understaffed environment affected the quality of care and treatment they were able to provide.

• RELATED: Revealed: what nurses say about short-staffing and how it’s harming patient care

Research by University of Southampton nurse academic Jane Ball, published in May, found hospitals still face major challenges in recruiting and retaining registered nurses, despite warnings and policy actions in the wake of the scandal over failures of care at Mid Staffordshire NHS Foundation Trust.

Nurse vacancy rate as high as 20% in some trusts

Professor Ball found an average nurse vacancy rate of 10% across England, jumping as high as 20% in some trusts.

Patients Association charity chair Lucy Watson says having enough nurses is vitally important for patients to feel safe and experience good care, whatever the setting.

‘We need sufficient numbers of registered nurses with the right combination of skills to meet the needs of patients in all health and care settings, including settings such as nursing homes and in district nursing teams and the community.’

Ms Watson said a lack of data on nurse numbers in nursing homes and general practice was particularly worrying.

‘We hear from patients and their families who are worried when there is only one registered nurse on duty in nursing homes, at a time when these patients have increasingly complex needs.

• RELATED: NHS must attract lapsed registrants back to nursing – but get better at keeping staff too

‘Patients also tell us how busy nurses are on hospital wards and that they do not have enough time to spend with patients.’

‘The first thing to do is to identify where the workforce gaps are within the nursing profession, and then to address these shortfalls.’

‘We need to know about long-standing vacancies’

The RCN’s Ms McIlroy says better understanding is needed on the length of UK vacancies. ‘We need to know what long-standing vacancies there are,’ she says.

‘There is always going to be churn in organisations, so we need to be able to work out the length of vacancies and be able to map that against what the establishment should be.’

• RELATED: Wards in England are still failing to achieve safe staffing levels, new report warns

‘And we need to know if and how these vacancies are being filled to be able to see what is happening – where these jobs are. We need to be able to drill down into this – are these vacancies just being held open or are they being filled by bank staff?’

Assessing and agreeing staffing levels

Ultimately, says Ms McIlroy, more data on vacancies and agency and bank staff is not all that is needed to offer a full picture.

‘We also need some kind of consistency across the UK to be able to tell the full story of what is going on.’

Ms Watson says there is a clear need for systematic data collection to provide consistent and quality care for patients.

‘We need an agreed approach to assessing and agreeing staffing levels across all health and social care providers, now and in the future, to secure care that is both high quality and safe.’

Find out more

• Interim NHS People Plan
• Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
• Closing the gap: key areas for action on the health and care workforce (The King’s Fund)