Unveiled on the last day of June, the Government’s much anticipated NHS workforce plan has been framed as a reboot for the service. Prime Minister Rishi Sunak described it as ‘historic’ and promised to ‘deliver the biggest ever expansion in the number of doctors and nurses’. For NHS England chief executive Amanda Pritchard it was a ‘once-in-a-generation opportunity to put staff and patient care on a sustainable footing for the long term’.
But nursing leaders viewed the proposals more sceptically. The backdrop is, after all, the worst workforce crisis in the service’s history. Too few are being trained, too many are retiring early and too much strain is being put on the ones who are left. The plan seeks to remedy this with promises of flexible working arrangements as well as broader roots into nursing, and increased investment in occupational health and wellbeing services.
The RCN described the plan as ‘hugely ambitious’, but noted a heavy focus on recruitment, at the expense of detail about how the Workforce Plan will benefit nurses now. As Pat Cullen, chief executive of the RCN says: ‘Targets alone will not deliver the staff the NHS needs to care for patients now.’
The NHS’ ‘great resignation’
Everyone agrees that the plan is required due to the extraordinary number of skilled professionals exiting the NHS. Nearly 27,000 nurses left the register in the 12 months leading up to March 2023. Over half of this number left earlier than they had originally planned and almost a quarter left ‘much earlier’ than intended. This is causing significant pressure within the system, with the highest number of open vacancies in the NHS to date. Andrea Sutcliffe, Chief Executive and Registrar at the Nursing and Midwifery Council (NMC) cites ‘burnout or exhaustion, a lack of support from colleagues, concerns about the quality of people’s care, and staffing levels’ as the main reasons why so many are leaving the register.
Most worryingly, this is being felt most sharply in the middle. According to recent data from the RCN, The number of nurses in the 41-55 age category is shrinking. Over a 12-month period, this age bracket experienced a 0.1% decrease in staff, amounting to 215 nurses and midwives leaving the register (see Figure 1).
While all other age categories experienced an increase in nurses joining the register, the NMC reports that this middle belt ‘continues to be squeezed’. This is having significant knock-on effects, with the workforce losing valuable skills and accumulated knowledge, and nurses in this category being stretched to plug the gaps left by early leavers.
A nurse, within this middle age category, who was interviewed for the NMC report says: ‘A lack of support from management and constantly working short staffed has meant that I feel unable to provide good nursing care due to staffing levels and lack of community services available.’
The same report revealed that 68% of those leaving the NHS cited burnout and an unmanageable workload as the reason for their decision to leave. One nurse, who took part in the NMC’s leaving survey commented ‘I’ve enjoyed my career in the NHS as a community nurse but I am unsure if I would recommend this career as the stress and pressure on nurses these days is intolerable.’
This testimony follows a trend of nurses leaving the profession with no plan on returning. Out of those leaving, the NMC reported 8 in 10 nurses stated that they had no plans to resume working in the NHS in the future. In a press conference, revealing the Workforce Plan, Prime Minister, Rishi Sunak addressed this concern by saying: ‘Doctors and other clinicians can spend a lifetime gaining invaluable experience and we want to hang onto those skills for as long as we can’.
The Workforce Plan aims to ‘embed the right culture’ to improve the retention of nurses. Embracing flexible working arrangements to facilitate healthier work-life balance is a key driver in the retention struggle. The Plan draws on research which reports that 30% of student of student midwives citing flexible working as a reason they were likely to recommend their placement. Also, at the other end of the scale, the government hope that flexible working will encourage ‘prospective retirees’ at the end of their careers to stay in the NHS on a part-time basis, with more flexible opportunities.
This culture will also provide increased occupational and mental health support for nurses. The Plan acknowledges that mental health issues, including depression, anxiety and stress account for the highest number of absences among nurses. Recent data from NHS England show that more than 1.5 million nurse and health visitor days were lost in 2022 due to mental health and wellbeing issues. The Plan therefore pledges greater support through the new Integrated Care Systems (ICS) which should ‘align with the national Growing Occupational Health and Wellbeing (OHWB) Together strategy to support nurses to keep well’.
But the RCN responds that the funding of mental health provision for NHS staff is ‘inadequate’ as staff struggle through a ‘deepening mental health crisis’. A third of mental health hubs, designed to provide ‘rapid access’ to free, confidential assessment and local mental health services and support, have been closed according to the RCN. This is leaving an estimated one million people unsupported.
Patricia Marquis, director of RCN England says: ‘If nursing staff can’t access support, how are they going to support their patients? Unsafe staffing levels are putting patients at risk while emotionally draining the nursing staff who are desperately trying to provide the best care they can.’
‘Recruiting our way out of the crisis’
The Government claims that strategies to recruit and retain staff must work together. The plan states: ‘we must recognise the influence staff shortages have on organisational culture, and an individual’s experience at work and their decision to leave. Increased workforce supply will help to achieve the retention ambitions in this Plan.’ The Government plans to recruit 170,000 more nurses by 2036/7. To achieve these targets, nursing intake will need to increase by 76-92% by 2030/31. Broader and longer nursing career pathways are being held up as the route to these targets with apprenticeships and increased training schemes being pushed by the government.
But the RCN fear the lack of detail provided by the plan on how nursing staff numbers will be increased on the ground. It accuses the government of overlooking the fact that there must be enough experienced nursing staff to guide, support and mentor trainees, no matter what route they enter the profession. Ms Cullen says that the RCN has ‘serious concerns’ about how realistic the recruitment targets are without ‘proper investment in the existing nursing workforce’.
Without this investment, there are fears that nursing student recruitment will continue to drop. Recent UCAS figures report a 17% drop in people applying to study nursing in the last 12 months (see Figure 2).
The RCN has described this as ‘deeply concerning’ and Pat Cullen is warning that unless ‘urgent action’ is taken ‘university places will go unfilled, vacant posts will remain empty and patient care will continue to be at risk.’ She continues to say that ‘more financial support or those seeking to join the profession’ is the best way to attract students.
Responding to this, the Workforce Plan pledges to recruit 170,000 more nurses by 2036/7. To achieve these targets, nursing intake will need to increase by 76-92% by 2030/31.
The hope is that this will also ease the NHS reliance on international staff recruitment which has reached record levels in the past 12 months. Despite bans on recruitment from red listed countries, the RCN has reported a ten-fold increase in staff being recruited from 14 countries which are facing the most severe workforce shortages.
This has led to an increased push for ‘home-grown’ staffing solutions, Howard Catton, the chief executive officer at the International Council for Nurses (ICN) says this can be achieved by ‘educating more nurses and aiming for self-sufficiency in domestic supply line, improving the retention of those they already have and by looking at how they can offset and compensate the costs of training nurses, which they are, in effect, currently exporting to less wealthy countries.’
Concerns are being raised about how exactly new nursing places will be funded, and for how long. Richard Murray, chief executive of the King’s Fund says: ‘The expansion of training places comes with some additional funding, but we haven’t yet seen the detail of how this funding will be phased – and whether it will be sustained – over many years.’
Reform from within
Growing the NHS alone is not going to ensure its long-term sustainability. Significant changes are needed to meet patient demand, according to the Government. The Workforce Plan places primary care at the heart of this pushing care ‘further up-stream’, delivering treatments closer to home and supporting people to keep well for longer.
This shifting focus towards prevention and primary care is backed by reports from the King’s Fund that show the full potential of preventative care in ICSs is going ‘largely untapped’. The report found that ‘the proportion of NHS resources invested in prevention and early intervention is inadequate’.
Another report from the King’s Fund found that the UK lag behind other countries in preventing deaths through the promotion of ‘health-seeking behaviours’. During the pandemic, mortality rates from circulatory diseases fell in many countries, because of changes in lifestyle, such as falling smoking rates. But, the report found that heart attack and strokes are still a major cause of death in the UK which is among countries with the highest rates of people dying within 30 days of admission to hospital for Ischaemic stroke and for acute myocardial infection.
The Plan proposes a national, multiprofessional, integrated community and primary care core career framework to support workforce development. This means growing the number of NHS staff working in primary, community and mental health services to boost prevention care in communities.
The Plan also commits to greater investment in technology to support workflows and meet healthcare needs in cost-effective ways. Evidence from the Government suggests that investment in AI could free up staff time and improve the efficiency of services.
While the Plan does respond to the main pinch points with the NHS workforce, nurses remain nervous about the lack of detail and funding needed to deliver on the pledges. Ms Cullen has emphasised that the RCN will work with the Government and NHS England to learn more about the plan, its implementation and its funding.
But its position remains that the Government must address the severe pressures on the current nursing workforce. The Government has committed to updating the Workforce Plan every two years to ensure it becomes an ‘established part of how the NHS plans for, and delivers, its services for patients and the public.’
But two years might be too short a timespan to measure a difference. The NHS workforce will require investment, nuture and, above all, patience. The next workforce report card might be similarly unflattering.