NHS nursing workforce

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.

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 6 NHS nursing workforce 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.

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.

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, NHS nursing workforce 7 nursing specialisms and regions. This should also set out how the loan might affect drop-out during courses.

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. 8 NHS nursing workforce 1 Plans for addressing the need for more nurses

On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England and NHS Improvement (NHSE&I) and Health Education England (HEE) on the NHS nursing workforce.1

NHSE&I told us that the advent of COVID-19 meant that workforce planning over a horizon of three to four years was not currently possible, and at the moment the main focus of the system was on winter planning. It thought it would be possible to make a longer-term plan after winter, once the impacts of COVID-19 on service levels are clearer.11 Understanding how many nurses the NHS needs and where

It is essential that the NHS understands not just how many nurses it needs, but where and in what specialisms. However, the NAO and other stakeholders have noted that the NHS Long Term Plan contained service commitments that did not have a complete assessment of the type and number of nurses needed to deliver the plan. For example, for cancer service commitments, there were no separate estimates of the overall cancer nursing capacity required, but an assumption that cancer needs would be met from the overall increase anticipated for the nursing workforce.12 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, the NAO’s report found that, in March 2020, NHSE&I and HEE were still developing their model to understand and quantify the demand for nurses.13

The Department acknowledged that the demand for nurses and the extent of nurse shortages vary between specialisms and regions.14 For example, in the period July– September 2019, NHS trusts in England reported an overall nursing vacancy rate of 12%, but these ranged as high as 16% for mental health trusts and 15% in London.15 Macmillan Cancer Support noted that the number of specialist cancer nurses is not rising at the pace that patients need. Similarly, Unison reported that the number of nurses registered with specialist community and public health qualifications has fallen every year since 2016.16 Between 2010 and 2019, the overall number of NHS nurses in hospital and community services rose by 5%, but numbers in some specialisms reduced—for example, a 38% reduction for learning disability nurses.17 8 NHS, We are the NHS: People Plan 2020/21 – action for us all, July 2020 9 Qq 21–22 10 C&AG’s Report, para 11 - 12 11 Qq 20, 24 12 C&AG’s Report, para 4, 3.4a; Sue Ryder submission, para 10; NWF0002 - The King’s Fund submission, para 14 13 Q 23; C&AG’s Report, paras 11, 3.11 14 Q 71 15 C&AG’s Report, para 1.4 16 NWF0007 - MacMillan Cancer Support submission, para 2.2; NWF0003 - UNISON submission, para 15 17 C&AG’s Report, para 1.2 10 NHS nursing workforce

The Department explained that estimates of the number of nurses the NHS needs and where are not determined centrally but are produced locally through a bottom-up approach. NHSE&I said that local areas are currently revising their workforce plans in light of COVID-19. These will take account of the staff needed to reintroduce some of the non-urgent care that stopped during the peak of the pandemic and to prepare for a possible increase in the number of COVID-19 cases during winter. NHSE&I said it intends to publish its overall estimate of the number of nurses the NHS needs with the second part of the People Plan, after the publication of the settlement for education and training.18 Integrated workforce planning for health and social care

Nursing students cover both health and social care in their training and decide which sector to work in after they graduate. This means that social care providers recruit from the same overall pool of nurses as the NHS. The Department noted that approximately 80% of nursing graduates join the NHS and the other 20% start work in social care, primary care or the independent sector, or do not practise as nurses. It acknowledged that there are currently around 4,000 vacancies for social care nurses.19 As Skills for Care has reported, the vacancy rate for nurses in social care has increased from 4.1% in 2012–13 to 9.9% in 2018–19.20 The Royal College of Nursing also noted that the number of registered nursing posts in social care has fallen by 1,000 in the last year and by 10,400 (20%) since 2012–13.21

The Chief Nursing Officer of NHSE&I emphasised how the COVID-19 pandemic has illustrated the importance of social care and the value of better integration between health and social care. She commented that “if anything good can come out of it [the pandemic], that will be the focus on social care” and “if there is anything to learn from the pandemic, it is about how we have closer integration between health and social care … which therefore includes the workforce.”22 However, the Department told us that social care will not be included in the NHS People Plan as the focus of the plan is on developing the workforce to deliver the Long Term Plan for the NHS.23 Social care nurses are also not included in the NHSE&I and HEE model of the supply and demand of nurses to the NHS, which supports the People Plan .24 The Department argued that it would be too challenging to develop an integrated workforce plan for health and social care as the sectors have different statutory bases and its powers and influences over them are not the same.25

The Interim People Plan envisages a more pivotal role for integrated care systems, which are local partnerships of health and social care bodies that are jointly involved in local workforce planning and strategy. However, the NAO reported that partnerships are not statutory and therefore have no organisational accountabilities, and rely on the goodwill of constituent bodies.26 The King’s Fund and Sue Ryder also noted that partnerships vary in their readiness and capacity to take on wider workforce planning.27 In 2018, the Care Quality Commission reported, on the basis of 20 local system reviews, 18 Qq 20, 21, 34, 36 19 Q 37 20 Skills for Care, The State of the adult social care sector and workforce in England, Chart 28, October 2019 21 NWF0006 - Royal College of Nursing submission, para 1.6 22 Qq 18, 65 23 Qq 15–17, 19, 24 C&AG’s Report, para 3.11 25 Qq 17, 29 26 C&AG’s Report, paras 1.12 27 NWF0004 - Sue Ryder submission, para 2; NWF0002 - The King’s Fund submission, para 12 NHS nursing workforce 11 that it had not been assured of effective joint workforce planning across health and social care.28 HEE told us that integrated care systems are “working much more seamlessly” between the NHS and social care but acknowledged that there is “much more work to do” to bring the two sectors together.29

The Department told us that its initiatives to increase the supply of nurses into the NHS should benefit social care as both sectors have the same entry route. However, our Committee remains concerned about potential barriers to moving between sectors such as nurses who move from the NHS into social care dropping out of their NHS pension.30 Locally, health and social care providers can also be in competition with one another for nursing staff.31 The Department argued that the fact it has separate plans for health and social care does not signify one being dominant over the other, and said it takes “a whole series of actions” for the social care sector.32 However, our Committee has warned before that the Department gives relatively little consideration to adult social care compared with health, including in reports on The adult social care workforce33and Readying the NHS and social care for the COVID-19 peak.34 For example, the latter report illustrated the stark contrast in the approach taken towards protecting the NHS from the pandemic compared with the care sector, with an action plan for adult social care published four weeks after the initial NHS letter on plans to respond to the COVID-19 outbreak.35 The Department acknowledged that the social care system is highly fragmented, for example, in the way it is run by a number of different providers, and told us there are some “yet-to- be-answered questions” about whether the Department will retain some of the national oversight and interventions in social care that it has used during the COVID-19 pandemic. The Permanent Secretary of the Department said that “we will certainly be wanting to look at what we have learned about social care during COVID and baking that into future policy.”36 28 C&AG’s Report, para 1.12 29 Q 37 30 Qq 29, 65 31 C&AG’s Report, para 1.6 32 Qq 17, 30 33 C&AG’s Report, The adult social care workforce in England, Session 2017–19, HC 714, 8 February 2018 34 C&AG’s Report, Readying the NHS and ad

In December 2019, the government confirmed its manifesto commitment to increase nurse numbers by 50,000 by 2025.37 To deliver this, the Department has set up a programme board, chaired by the Minister of State, which brings together all the relevant bodies with responsibilities for nursing.38 The Department clarified that it took overall responsibility for delivery of this commitment, with NHSE&I and HEE leading on delivery for individual routes.39

The Department told us that it planned to meet the commitment to deliver 50,000 more nurses by increasing the domestic supply of graduate nurses, widening access to nursing through, for example, apprenticeships, improving retention rates and continuing to recruit from overseas. However, the Department and HEE were unable to quantify how many nurses they expect from each of these different routes. HEE told us that its plans are dynamic and changing in the light of the COVID-19 outbreak, for example, to reflect an increase in the number of people applying for nursing degrees.40 NHSE&I expects to publish details of the numbers of nurses it needs with the second part of the People Plan, after the publication of the Spending Review.41

The Long Term Plan signalled the need for a “step change in the recruitment of international nurses”. In 2019, there were 51,000 overseas nurses working in the NHS (17% of the nursing workforce), with overseas nurses already making up between 20% to 25% of new joiners since 2012.42 HEE confirmed that its global learners programme that supports trusts to bring overseas nurses to work in England had missed previous recruitment targets; over the two years 2018 and 2019, it attracted around 1,600 nurses compared with a target of 2,500.43 NHSE&I told us that COVID-19 and the resulting travel restrictions had delayed international recruitment. It said that providers report that there are over 6,000 overseas nurses in the pipeline who are willing to work in England and it anticipated that overseas recruitment will “open-up very rapidly”.44 However, it recognised that expanding the domestic supply of nurses is a more sustainable route to securing the nursing workforce. In response to our questions about the ethical implications of recruiting from overseas, NHSE&I told us that it follows the World Health Organisation’s code of practice which includes a list of 43 counties that it does not recruit from. It considered that its “earn, learn and return” programme offers an opportunity for overseas nurses to develop skills which can be taken back to the countries that nurses are recruited from.45

HEE acknowledged that there were global differences in nursing salaries, alongside other structural and market differences, with other countries having more leeway in what they can pay than the UK. More generally, NHSE&I accept that pay remains “an important 37 Prime Minister’s Office, Press Release – Prime Minister backs NHS staff with £5,000 annual payment for nursing students, December 2019; C&AG’s Report, para 11 38 Q 33; C&AG’s Report para 3.10 39 Q 39 40 Q 43 41 Q 20 42 C&AG’s Report paras 8, 2.20 43 Q 59; C&AG’s Report para 7 44 Q 55 45 Q 53 NHS nursing workforce 13 issue with regard to nurses”, and that the lack of pay rises in previous years had impacted on the retention of NHS nurses.46 In a Royal College of Nursing survey of their members, in July 2020, pay was the most common reason given for nurses to consider leaving the profession, while around three-quarters of nurses said that improved pay would make them feel more valued.47

The Department and HEE highlighted the important role that apprenticeships and nursing associates play in widening access to the nursing profession, by enabling people to earn money as they train. In the case of nursing associates, which is a separate role, people can also gain experience as an associate before deciding if they want to train to become a registered nurse.48 However, the Department recognised that it takes longer for nurses to qualify under the apprenticeship route, and the same applies to nursing associates who must study for a further two years to qualify as a nurse.49 HEE told us that it had seen “relatively early gains” with the apprenticeship model but admitted that some provider organisations had found it challenging to offer apprenticeships at scale and make full use of apprenticeship funding.50 HEE had a target to deliver 7,500 nursing associates by 31 March 2020, but the Department told us that this has been “knocked slightly off track” because the March intake was significantly reduced.51 HEE also confirmed it had targets in place for the number of registered nurses coming via the nursing associate route. It told us that it is directly supporting nursing associates in their conversion to becoming a registered nurse, such as through the use of personal development plans.52

NHSE&I emphasised that retaining staff is a “valid and important” supply route, which represents the “best investment” for increasing numbers. It told us the main factors affecting retention include staff feeling stressed by the work, lack of flexibility and a lack of continuous learning and development. It told us that its retention programme is focused on these factors, as well as creating an environment that is free from discrimination, bullying and harassment. NHSE&I acknowledged that staff are under increased pressure as a result of the COVID-19 outbreak, which had also made the job of retaining staff more difficult.53 Nursing students

From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. Prior to 2017, HEE paid tuition fees to universities and NHS bursaries to students to cover their living costs. Instead, these students moved onto the existing student finance arrangements, with most eligible for full loans for tuition fees and maintenance costs. The Department hoped to increase the number of places on these courses by 10,000 by 2020.54 However, it acknowledged that the policy had failed to meet all its objectives.55 In 2017, the first year of the new arrangements, the number of applicants for nursing and midwifery courses fell by 11,000 (21%). Universities accepted a higher proportion of applicants than previously, so there was a 3% fall in the number of 46 Qq 60, 62, 63. 47 NWF0006 - Royal College of Nursing submission, para 4.3, 4.5 & 4.8. 48 Qq 43, 44, 69 49 Q 48; C&AG’s Report, paras 2.24, 2.25 50 Qq 45, 47 51 Q 27 52 Qq 48, 69, 70 53 Qq 40, 52 54 C&AG’s Report, para 2.5 - 2.6 55 Q 71 14 NHS nursing workforce new students.56

The policy change impacted on some students and regions more than others. For example, from 2016 to 2018, there was a 10% increase in the number of students accepted onto nursing degree courses for children’s nursing and for applicants from the North East. This is in contrast to large reductions in students accepted onto learning disability courses (-41%) and for applicants from the South East (-24%).57 The Department acknowledged there was a particular drop-off in the number of mature students (aged 21 and over) who represent a big source of nurses.58

Since 2017, the number of people accepted onto nursing and midwifery degree courses has increased from 22,045 in 2017 to 23,060 in 2019. This still means that, in 2019, only 430 (2%) more people accepted a place on a nursing degree course compared with 2016 when the NHS bursary was still available. Between 2017 and 2019, the number of people applying for courses even dropped a little further, from 41,715 in 2017 to 39,665 in 2019.59 HEE told us that the latest UCAS data from June 2020 showed a 15% increase in domestic applicants for nursing degrees from 2019 to 2020.60 However, it is not yet certain whether this will translate into an increase in the number of people accepted onto courses: the number of applicants as at June 2020 (42,740) is still below the number as at June 2016 (51,730) and trends in applicants and acceptances have not mirrored each other since 2017.61

In December 2019, the government announced the introduction of a new maintenance grant for nursing students from September 2020, which consists of a non-repayable grant of £5,000 to £8,000 to help with living costs. Students will still pay their own tuition fees and the higher education market will therefore still determine the number of places.62 The Department said it was not aiming to recreate the position prior to 2017 and had sought to learn lessons in particular by its targeting of the new training grant to specific groups of people and specialisms where there are particular concerns. For example, an additional £1,000 will be made available to nurses specialising in learning disabilities and mental health, and there will be an extra £1,000 of childcare support to those who are eligible.63 Opportunities and challenges created by COVID-19

NHSE&I acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak. It cited figures from a Nursing Times survey, 56 C&AG’s Report, para 2.6. Based on England-domiciled applicants, UK universities, and includes midwifery degrees. The withdrawal of the NHS bursary applied to students on courses in England. NHS bursary schemes continued in the other home nations after 2017, but eligibility was limited either to those already resident, or committing to work, in that country. Where possible, we examine English-domiciled applicants applying to English universities, as the group potentially most affected by the bursary withdrawal, but available data do not always separate out this group. 57 C&AG’s Report, para 2.9, figure 12. Based on UK-domiciled students, English universities, and excludes midwifery degrees. 58 Q 81 59 C&AG’s Report, figure 11. Based on England-domiciled applicants, UK universities, and includes midwifery degrees. 60 Q 43 61 University Colleges and Admissions Service (UCAS), 2020 cycle applicant figures – 30 June deadline, analysis of applicants for nursing and midwifery degrees domiciled in England and applying to English universities; C&AG’s Report, figure 11. 62 C&AG’s Report, para 2.6, 2.16 63 Qq 33, 42, 71–72 NHS nursing workforce 15 which reported 90% of nurses as experiencing higher rates of anxiety than before the COVID-19 pandemic.64 In a Royal College of Nursing survey, some 36% of respondents indicated that they are considering leaving nursing in the next year, compared with 28% from before the pandemic. When asked about why they are considering leaving, nurses reported that it was pay (64%), low staffing levels (45%), the way nursing staff had been treated during the pandemic (45%) and lack of management support (44%).65

The Royal College of Nursing noted that, to retain nurses who worked during the pandemic, it will be essential to provide access to specialised mental health support, carry out risk assessments for staff and ensure people are able to take rest breaks and annual leave.66 NHSE&I told us that it has made a free mental health helpline available to all NHS and social care staff and is providing practical support, such as free tea and coffee.67 It highlighted that flexible working and better local leadership and line management are also key to retaining staff in the longer term. However, it recognised that there is currently variability in the quality of leadership and so it is expanding the number of places on its leadership academy and providing access to line management training for every line manager in the NHS. It said that it would be looking to retain some of the innovations that have helped improve the work-life-balance of staff during the COVID-19 outbreak, such as better use of technology and more flexible or remote working.68 The first part of the People Plan, published in July, covers improvements to staff support and leadership culture, as well as highlighting service innovations that have taken place over the last few months.69

NHSE&I noted that over 32,000 nurses stepped up to support the NHS during the COVID-19 outbreak, including former nurses and over 20,000 students. However, it acknowledged that there needs to be better local systems for retaining these returners, such as to establish how many wish to return to the NHS and in what capacity.70 We were also told by a number of stakeholders that some students have lost clinical placement hours due to the pandemic, and some of those who stepped up to work for the NHS had placements curtailed or cancelled.71 HEE said that it was seeking to ensure that students could still gain experience during the COVID-19 pandemic. It is prioritising those due to graduate this year and has estimated that 20% of these students may have difficulty completing the clinical practice hours they need to finish their nursing degree on time.72 The Council of Deans of Health and NHS Employers highlighted that this additional pressure on placement capacity will be compounded by extra pressures resulting from a backlog of routine work caused by COVID-19, as well as the risk of another peak in COVID-19 cases.73

NHSE&I acknowledged that COVID-19 has had a disproportionate impact on Black, Asian and minority ethnic (BAME) staff and admitted that there is variability in how well these staff have been supported during the pandemic. In response to our questions 64 Q 40 65 NWF0006 - Royal College of Nursing submission, para 4.3 & 4.5. 66 NWF0006 - Royal College of Nursing submission, para 4.6 67 Q 40 68 Qq 50, 51 & 64 69 Q21; NHS, We are the NHS: People Plan 2020/21 – action for us all, July 2020 70 Qq 9, 11 71 NWF0003 - Unison, para 7; NWF0005 - NHS Employers; NWF0001 - The Council of Deans of Health 72 Qq 86–87 73 NWF0001 - Council of Deans of Health; NWF0005 - NHS Employers. 16 NHS nursing workforce about ensuring there is no adverse impact on the career progression of BAME staff, NHSE&I told us that BAME staff are not automatically redeployed but have been offered a risk assessment to determine how to protect their health. It said that there are a range of measures that can be taken to protect staff, including enhanced infection prevention measures and Personal Protective Equipment, and training for staff working in clinical areas. It told us that, as part of the race equality standard, every trust has a plan for addressing differentials between white and BAME staff, including on career progression. NHSE&I is tracking data on the race equality standard across trusts and minority groups, and individual trusts and employers also have access to relevant data.74 74 Qq 93–96 NHS nursing workforce 17