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The Brexit effect

Alice Harrold on why there has been such a sharp drop in the number of EU nurses joining the register – and how this could further impact the UK’s nursing crisis

The number of nurses on duty has a direct impact on quality of care, patient experience and treatment outcome, yet the workforce shortage is worsening every day.

According to modelling by the Department of Health (DH) revealed in April, after Brexit the NHS could be hit by a shortage of up to 42,000 nurses by 2026 if immigration laws are altered.

And new figures from the Nursing and Midwifery Council (NMC) suggest we may already be seeing an effect. Only 46 nurses from the EU have registered with the NMC to practise in the UK since the Brexit vote – a sharp 96% drop since July 2016.

Any drop in workforce supply from the EU, combined with the increased demand on services, could place considerable pressure on an already overstretched NHS and its overworked nurses.

So just how much of an effect could Brexit have on the profession, and what are some of the other factors contributing to the nursing crisis?

Bad for nurses, bad for patients

International recruitment has been used repeatedly by the NHS as
a temporary solution to the staffing shortages. In England alone, there is currently a shortage of 30,000 nurses.

Yet according to the NMC, as of July last year, there were 1,304 EU nurses who registered to work in the UK. This fell sharply to 344 nurses in September, following the EU referendum on 23 June.

The numbers have since continued to fall, with just 46 EU nurse registrants in April 2017. And the introduction of more rigorous language testing for nurses from outside the UK is likely to contribute to the decrease.

Since 2008, the majority of international nurses registering in the UK have come from within the EU. However, the new figures indicate the need for a more sustainable long-term approach to workforce planning.

Jackie Smith, NMC chief executive and registrar, said: ‘Earlier this year, we released figures that showed the number of EU-trained nurses and midwives joining our register was reducing. At the same time, figures also showed the number of EU-trained nurses and midwives leaving our register was increasing.

‘Latest figures for April and May 2017 show that these trends have continued. However, it is still too early to say definitively that this is due to any one reason. It is more likely that a combination of factors are at play, including the recent introduction of English language controls and the uncertainty about the effect of Brexit on individual nurses.

‘As a result, we will shortly be undertaking research to help us better understand why these nurses and midwives are choosing to leave our register.’

Figures released by the NMC earlier this year showed a small but significant increase in the numbers of EU nurses opting to leave the register. A survey of 247 EU nurses who left the NMC register over the past 12 months shows that their top three reasons were that they were leaving or had already left the UK (58%); Brexit had encouraged them to consider working outside the UK (32%) and unhappiness with working conditions (32%).

After the NMC’s figures came to light, the Royal College of Nursing (RCN) warned that such a drop in nursing numbers would leave the NHS ‘unsafe’. Janet Davies, RCN chief executive and general secretary, said: ‘The NHS has never been self-sufficient and has always relied on staff from outside the UK. The Government must take an early decision on the status of our European nurses and those from beyond Europe. To lose their talent would be foolish when faced with this potential crisis.

‘Without urgent action, the Government may struggle to provide a safe health service in the future.

‘And tens of thousands of nursing jobs are already lying vacant. In some areas, the NHS is currently finding it difficult to provide safe and effective staffing.

She continued: ‘Our nursing workforce is in a state of crisis, with more than 40,000 vacancies in England alone. Across our health service, this puts patients at serious risk.

‘These figures should act as a wake-up call to the Government as it enters Brexit negotiations. EU staff should be left in no doubt that their contributions are welcome and valued.’

A Department of Health (DH) spokesperson said: ‘We understand the need to give valued NHS staff from the EU certainty, which is exactly why we have made clear that the future of those EU nationals working in our health and care system should be a priority in Brexit negotiations. We also have over 52,000 nurses in training to ensure the NHS has the nurses it needs.’

Fortunately, there are hopeful signs that the Government may be waking up to the calamitous potential of falling nursing numbers. In its 2017 manifesto, the Conservative Party promised to improve the nursing shortage by making EU NHS staff a priority during Brexit negotiations, promoting other routes into the nursing profession, and encouraging the development of new roles.

It said: ‘We will ensure that the NHS and social care system have the nurses, midwives, doctors, carers and other health professionals that they need. We will make it a priority in our negotiations with the European Union that the 140,000 staff from EU countries can carry on making their vital contribution to our health and care system. However, we cannot continue to rely on bringing in clinical staff instead of training sufficient numbers ourselves.

‘We will break down the barriers to public-sector workers taking on more qualified roles because of their prior educational attainment. For instance, we will ensure that healthcare assistants can become nurses via a degree apprenticeship route, in addition to other routes.

‘We will also help the million and more NHS clinicians and support staff develop the skills they need and the NHS requires in the decades ahead. We will encourage the development of new roles and create a diverse set of potential career paths for the NHS workforce. And we will reform medical education, including helping universities and local health systems work closer together to develop the roles and skills needed to serve patients.’

Last year’s GP Forward View also demonstrated some recognition of the workforce issues in primary care. It pledged an extra £15m to improve training capacity and increase the number of pre-registration nurse placements, including £1.75m to support practice nurse development. That total fund will also supposedly improve retention of existing practice nurses and aid those who wish to return to the profession.

Just a Brexit issue?

While the NMC’s figures seem to indicate a correlation between the Brexit vote and a reduction in EU nurses, not everyone agrees this is the only contributing factor to the problem.

Anita Charlesworth, director of research and economics at the Health Foundation, said: ‘The findings should be a wake-up call to politicians and health service leaders.’ 

‘Clearly, action is needed to offset any further loss of EU nursing staff in the near future. But the overall shortage of 30,000 nurses is not a shortage caused by the Brexit vote. 

‘The chronic shortage of nurses is the result of years of short-term planning and cuts to training places. A sustainable, long-term approach to workforce planning is desperately needed.’

Despite Prime Minister Theresa May’s insistence that the Conservative Government is able to provide a ‘strong and stable’ leadership, some nurses have yet to be convinced. Nurse adviser Marilyn Eveleigh says the drop in EU nurses is ‘not surprising’ because many will feel uneasy about Britain’s uncertain political future. 

‘Nurses are an in-demand profession. There are many other countries that are calling to recruit nurses from abroad that are in greater stability than ours,’ she says.

‘Our EU nurses are uncertain of their future at the moment. With Brexit negotiations barely even started, they don’t know whether they will even be able to stay.

‘Those nurses are propping up our health service and we are very worried about that workforce. So new EU nurses are not going to take the chance that they may be turned away. They don’t feel that they would be welcome.’

According to Ms Eveleigh, the appreciation of the role EU nurses play in Britain’s ailing healthcare system isn’t necessarily echoed by those in power. ‘Healthcare organisations have spent a lot of time reassuring their EU nurses how welcome and needed they are. So at a grassroots level, there is a lot of appreciation for our colleagues from the EU, but that’s not matched by the higher levels.

‘The Government should make an immediate decision that all EU nurses working in the UK can remain and can carry on pushing their careers and supporting our health service.’

Niall Dickson, chief executive of the NHS Confederation, said: ‘EU nationals make a hugely important contribution to the delivery of health and care services, and it is only right this this is recognised.

‘Their status after the UK leaves the EU is still uncertain and we continue to urge the Government to guarantee the rights of EU nationals as soon as possible.

‘This would be the first step towards ensuring the system is able to recruit and retain a motivated and qualified workforce fit for the 21st century.

‘A clear public commitment from the Government is needed, along with a firm agreement with the EU early in the negotiations.’

Ironically, while the UK may seen as an increasingly unattractive option for EU nurses, growing numbers of UK-trained nurses are seeking new career opportunities abroad.

The NMC has also seen an increase in the numbers of verification requests made about UK nurses. Verification requests are made by licensing authorities – often the equivalent of the NMC in different countries – when a nurse or midwife wants to practise outside the UK. Verification requests are an important indicator of the numbers of nurses and midwives who have left or may intend to leave the UK to work in a different country.

In fact, UK registrants accounted for 69% of all verification requests in 2013, which rose to 75% in 2017. Most requests come from licensing authorities in Australia, the USA and the Republic of Ireland. There were 4,153 verification requests made in 2017 for UK registrants.

A wider problem

But although the falling number of EU nurses is contributing to the workforce crisis, it is just one of a number of factors at play in nursing’s retention problem.

The NMC’s register has increased every year since 2013, reaching a peak of 692,556 in March 2016. However, between March 2016 and March 2017, the register reduced by 1,783 registrants to 690,773. The numbers for April and May this year show a further reduction of 3,264 registrants. The highest numbers on the register each year are after the September/October peak of initial registrations, followed by a drop in subsequent months.

Some 85% of the NMC’s register is made up of nurses and midwives who first registered in the UK. Those who first registered overseas make up 10% and those who first registered in EU countries account for the other 5%.

The new figures published show an increase in the numbers of nurses and midwives leaving the NMC’s register. At the same time, the numbers joining the register have slowed down – resulting in an overall reduction in the workforce.

Between 2016 and 2017, 20% more people left the register than joined it, the first time this has happened in recent history. While attention has recently been focused on the reducing numbers of EU nurses applying to work in the UK, these figures show that UK nurses are also leaving the register in their droves. 

During the same period, 45% more UK registrants left the register than joined it.

Ms Smith of the NMC said: ‘Our figures today show for the first time that there are now more nurses and midwives leaving the register than joining it. At a time of increased pressure on the healthcare workforce to deliver quality patient care, we hope our data will provide evidence to support the Government and employers to look in detail at how they can reverse this trend.’

Pastures new

Naturally, questions must be asked about why so many nurses are opting to move away from their chosen profession.

Earlier this month, the NMC conducted a survey of more than 4,500 nurses and midwives who left the register over the previous 12 months to gauge their reasons for leaving. 

The top three reasons cited, excluding retirement, were working conditions, including issues such as staffing levels (44%); a change in personal circumstances such as ill health or caring responsibilities (28%) and disillusionment with the quality of care provided to patients (27%).

Other reasons given included poor pay and benefits and difficulty in meeting the revalidation requirements – sometimes because the nurses no longer practised for the required number of hours.

The number of nurses leaving the register before retirement age is also increasing. The average age of non-retirees leaving the register has reduced from 55 in 2013 to 51 years of age in 2017. The rates of leaving are increasing across all age groups below 60 years. This is particularly noticeable for those aged under 40.

Ms Smith said: ‘Nursing and midwifery are widely acknowledged to be ageing professions, with significant numbers on the register coming up to retirement age. While there’s no denying this is true, our figures show that people below retirement age are leaving in increasing numbers.’

Whatever individual nurses’ reasons for leaving the register, it’s clear that something has got to change if the sector is to weather the numerous pressures heaped upon it by an ageing and growing population. 

While nursing bodies and nurses themselves must take measures to drive changes that keep the profession an attractive proposition for potential trainees, the onus must surely be on the Government to show nursing the financial recognition it needs to evolve for the better. But the 1% pay increase cap is still firmly in place for the seventh year in a row.

It remains to be seen whether any action the Government takes will make a difference, or whether its efforts will be too little, too late.