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Heading for the door? The changing role of nurses in social care

Heading for the door? The changing role of nurses in social care

In the wake of new data on staffing trends in social care from Skills for Care, Cyril Lobont from the Nuffield Trust explores the latest numbers on social care nurses and what this means for the care sector.

Providing a quality service in health and social care relies on an array of skilled and dedicated staff. Registered nurses are one group which are a fundamental component of both sectors. Whilst the vast majority of registered nurses in England work for the NHS or private healthcare providers, approximately 33,000 work in adult social care, providing care to individuals who are among the nation’s most frail, with the most complex needs.

Nursing homes, as the name suggests, are care homes which have a registered nurse on duty 24 hours a day, 7 days a week, 365 days a year. These are where 30,600 of the registered nurses in adult social care work (with the others being spread across other settings, such as domiciliary care). The number of registered nurses on duty varies by the size and structure of a nursing home. Although there are no definitive national criteria for who should reside in a nursing home, they tend be people with multiple severe physical and cognitive conditions. Nursing homes are often a more appropriate setting for many people with complex needs than, for example, hospitals or care homes, making them a vital form of provision.

How has the profile of the registered nurse workforce in social care changed?

Back in 2012/13 there were 51,000 registered nurses (filled posts) in adult social care (3.4% of the total workforce), far more than the 33,000 recorded in 2022/23 (2% of the total workforce). This might come as a surprise – as the population aged and the number of people needing support with complex needs grew, we may have expected the number of registered nurses in adult social care to have grown over time, at least proportionally to the size of the care workforce as a whole. In fact, between 2012/13 and 2022/23, the total number of registered nurse posts (filled or unfilled) went down by a staggering 29%, from 52,000 to 37,000.

Why are there fewer registered nurse posts?

At face value, fewer nurses in the face of growing need seems counterintuitive. However, there are a few factors that could be behind this trend:

Recruitment and retention issues. As recognised by Skills for Care, these are central to the puzzle. Both vacancy and turnover (the proportion of staff moving jobs, both to elsewhere inside and beyond the sector) rates for registered nurses had been on a negative long-term trajectory until 2021/22. In 2022/23, though considerably improved, vacancy rates were worse for registered nurses in adult social care than for the sector as a whole (11.3% vs 9.7%). For turnover rates, a gap was also visible (32.6% vs 29.1%). Importantly, turnover was far higher than for their counterparts in healthcare (for registered nurses and health visitors in the NHS it was 10.4% for a similar period).

Whilst the entire social care sector is struggling to fill posts, registered nurses’ qualifications make them particularly hard to recruit. Pivotally, they have the readily available option of working in the NHS, which often offers better pay and progression prospects, as well as better benefits packages, including higher pensions. Social attitudes and esteem granted to the sectors may also play a role, an arena in which social care struggles to be seen on an even standing with healthcare, which was exemplified by the apparently different degrees of appreciation afforded to the two groups during the Covid pandemic.

The number of nursing homes has decreased. Between August 2013 and August 2023, the number of residential care homes that provide nursing care decreased by around 10% (from 4,684 to 4,259). This suggests more people with complex needs are being looked after in non-nursing settings, which, although there is no national guidance against it, may have implications for how well needs are being met. Whilst accurate numbers are difficult to find, some nursing homes will have transitioned to operating as care homes without nursing services, whilst others will have ceased operations completely. Care providers have cited issues recruiting and retaining nurses as a key reason for this trend. There may have been some consolidation of nursing care into fewer, larger homes, but the number of nursing home beds relative to the size of England’s population has also been decreasing. Trying to recruit and retain staff at affordable rates is an issue for providers across adult social care and almost certainly applies to registered nurses.

Non-nursing staff can now perform more tasks. In nursing homes, the number and complexity of tasks non-nurses are performing has increased, with some of the most dramatic changes happening in response to the phenomenal pressure the sector was under during the pandemic. This has been the case to the extent that Skills for Care published guidance on delegated healthcare tasks last year. These changes are also generally in line with intentions of providers to upskill care workers but are happening in absence of concurrent increases in support and pay for care workers.

A key example is the administration of medicines, which can now be delegated to a member of staff deemed competent by a registered nurse (nurses are still required to maintain oversight and scrutiny of the process). In the absence of a formal qualification framework, care workers possess a varied range of skills that are not well-captured, and some care workers even hold foreign nursing qualifications that are not automatically recognised in England. It is not clear quite to what extent a shortage of registered nurses has forced the hand of providers in making more tasks performable by non-nurses, or whether this itself has led to a drop in demand for registered nurses. Reality is likely to be a mix of the two.

Why is this important?

On the surface, the drop in the number of registered nurses working in adult social care is concerning, and it certainly should be given attention, but behind the numbers are some quite complex dynamics. For providers, commissioners and those who rely on the care sector, the big concern is whether enough people with the right skills are available to provide high quality, safe and dignified care. A lack of enough staff in the sector, including registered nurses, is currently jeopardising this. Although the most recent data shows fewer vacancies and lower turnover than in some previous years, they are still far higher than is desirable, and it is difficult to be confident that these improvements will be sustained.

For this reason, the country needs a long-term solution to staffing the social care sector that is fit for the future. For a long time, social care has been desperate for a comprehensive workforce plan which addresses the recruitment and retention of the right mix of skills for the sector, including registered nurses. A plan which complements the health service, rather than being at odds with it.

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