Before the Covid-19 outbreak, the Government proposed to magic up 50,000 more frontline nurses. Nursing in Practice’s Mimi Launder looked at whether the Government was on track to reach this target prior to the global pandemic.
In its election-winning mandate at the end of last year, the Government promised to deliver 50,000 extra frontline nurses for the NHS in England by 2024/25. This was before the Covid-19 pandemic took hold of the world and 7,510 – as of 27 March – retired nurses answered the call of the Nursing and Midwifery Council and offered to come back to the workforce. Health Education England also announced on 6 April that last month 5,553 third-year students from 35 universities had signed up to a paid placement in the final six months of their programme to help in the fight against the coronavirus.
How does the Government hope to deliver the 50,000 figure?
What will all this cost?
Before the Covid-19 outbreak, there were 38,785 full-time equivalent vacancies in nursing. More nurses were desperately needed. Shortly after the target was announced in November last year, it was revealed that 18,500 of the 50,000 total would be nurses who planned to leave and might be dissuaded, or nurses who had left and might be attracted back. That left 31,500 to recruit from scratch. Of these, it was expected 5,000 would come from apprenticeships (expanded schemes or nursing associates); 14,000 from undergraduate and postgraduate degrees; and 12,500 recruited from overseas.
Clearly the picture has changed since the coronavirus outbreak. Retired nurses have returned to the workforce and student nurses will be fast-tracked into the profession. The government may decide the 50,000 figure is no longer relevant. The figures may change. But the desire to boost the nursing workforce is likely to still be there – and if nurses who have joined to help with the Covid-19 crisis leave again after the pandemic is over, the government still faces an uphill battle to achieve its aim of increasing the nursing workforce. For a start, there is usually quite a dropout rate among student nurses.
A total 19,566 UK students were due to finish their nursing degrees in 2018, but 4,659 (24%) left their courses early or suspended their studies, according to research conducted last year by the Health Foundation. The new recruits will still be entering a highly stressful job. Perhaps even more stressful with the mental and physical toll the coronavirus pandemic is likely to leave on medical staff. The Government backed its pledge with between £759m and £879m a year until 2023/24, to go towards recruitment, training and retention. But will this be enough to bring nurses into the workforce and keep them?
The plan to boost student nurse numbers
To deliver 14,000 more student nurses, the Government said it will increase the number of places on courses, reduce student nursing attrition and expand clinical placements. As part of this, student nurses will receive a £5,000 maintenance grant from September 2020. An extra sum of up to £3,000 will also be available for students in disciplines that are ‘struggling to recruit’ – such as mental health and learning disabilities – and for nurses who need to cover childcare.
Student nurse applications increased for the second year running in England, according to figures for the January 2020 cycle from the University and College Admissions Service. However, numbers are still down by 25% compared with the same point in 2016, the last year the student bursary was available. At the time the Government covered tuition fees as well as a contribution to living costs. Also, the rise in application and acceptance rates is partly offset by the high dropout rate.
Some have described the new maintenance grants as ‘bringing back the bursary’, but there is a key difference: the new bursary does not cover tuition fees. Chief executive and general secretary of the Royal College of Nursing (RCN) Dame Donna Kinnair says this is an issue and the College will ‘not give up the fight’. ‘We know that we’re not appealing to that older, more mature student that used to come in because they’re not prepared to take the debt on,’ she tells Nursing in Practice.
Clare Carmichael, a newly qualified nurse working in general practice, agrees that free tuition could help attract more students to the profession. ‘I got the bursary and my course fees paid for and it has made such a big difference,’ she explains. ‘People worry about the amount of debt they will be in once qualifying and I fully understand why. I would be the same.’
However, Ben Gershlick, senior economist at independent charity the Health Foundation, argues that the maintenance grant is more important and that removing tuition fees should not be so high on the priority list. Paying tuition fees would be ‘an important signal’ to nurses that they were valued but ‘it shouldn’t be a big barrier for most people going into nursing.’ The real issue, he says, ‘is nurses’ finances during nursing and the maintenance grant is a massive part of tackling that’.
It’s not all about money
However, Mr Gershlick adds: ‘It’s not enough to just [introduce maintenance grants]. They are really important but we should also be actually thinking about the system that people are going into.’
Clare Davies, a third-year adult nursing student at Liverpool John Moores University, stresses to Nursing in Practice that more than cash is needed to keep students on board an ‘extremely demanding’ course. ‘I ultimately feel [grants alone are] not good enough for the hard work, dedication, and sacrifice that is made when considering a nursing degree.’ Although she adds grants could stop some students dropping out because of financial issues.
Negative experiences on placement can also cause students to drop out, she argues. ‘Unfortunately, under-staffing can impact the overall student nurses’ experiences while on placement, as you can be used as a stopgap.’
Research on attrition and retention from Health Education England in 2018 has shown the reasons that students drop out. Not just finances, but academic issues, placement quality, workload and support.
‘A lot of it is about people’s experience training to be a nurse,’ explains Mr Gershlick. ‘If you don’t do something about that, you’re not going to make major improvements. Especially on this scale. What’s nurses’ experience of placements? What sort of pressures are they under? And what can be done about that?’
Apprenticeships could be a solution to the attrition problem, by making training more affordable to the student nurse. The Government has promised to introduce 5,000 more nurses through apprenticeships and nursing associates converting to become registered nurses. However, the jury is still out on these relatively new routes into the profession.
The retention plan
The retention and returners plan is controversial too. Some critics accused the party of misleading voters. However, the Conservatives insist this policy will yield 18,500 ‘more’ nurses that could otherwise be lost to the profession. A misleading policy? Either way, there is no doubt that retention is crucial to building the workforce.
The Government says it intends to hang onto more nurses in part by expanding NHS Improvement’s National Retention Programme, including into general practice. Previously, the programme was confined to 145 NHS trusts.
Since it was started, quit rates dropped by the equivalent of 800 fewer full-time nurses in two years. Through retention masterclasses and online support, the scheme saw the lowest turnover rate in five years.
Another aim is to ‘enhance’ continuing professional development (CPD). As part of this, every nurse, midwife and allied health professional will receive a personal CPD budget of £1,000 to help with revalidation. But Sharon White, chief executive of the School and Public Health Nurses Association points out that this is only available to nurses working for the NHS.
‘The failure to recognise that we all deserve the same opportunity to further our learning will negatively impact morale and will further impact recruitment and retention issues in this workforce,’ she tells Nursing in Practice.
Similarly, Nicola Ashby, RCN head of practice education, learning and development, says the £1,000 budget is nothing more than a ‘start’. ‘There is still a significant way to go to return us to a place where we can be supported to have our education and learning,’ she says. ‘It’s not just about funding. It’s about the whole package and the recognition of that, because nurses have no protected time for CPD.’
Mr Gershlick warns that CPD and retention initiatives are unlikely to be enough to turn the heads of people considering leaving nursing. ‘People leave because they are overworked or underpaid or their work-life balance is out of whack, or they feel they’re not able to provide a high quality of care,’ he explains. ‘Those things need to be solved within the system so that people feel like it’s a better place to be.’
‘At the end of our tether’
Dr Crystal Oldman, chief executive of community nursing charity the Queen’s Nursing Institute (QNI), agrees that improving working conditions is the key to better retention. ‘Nurses thrive on being able to do a great job for the people they serve, but if the workload becomes unmanageable, they will consider retiring earlier than anticipated,’ she says.
Ms Oldman highlights a 2019 QNI survey, ‘District Nursing Today: The View of District Nurse Team Leaders in the UK’, which showed 22% of district nurse team leaders work additional hours amounting to one extra day every week. ‘This is unsustainable and will lead nurses to consider retiring earlier than might otherwise have been planned,’ she adds. ‘We need to be sure that workloads are planned and managed so that additional hours do not become routine in order to enable work to be completed.’
Sarah*, a district nurse in Somerset who wished to remain anonymous, tells Nursing in Practice that district nurses leave to join secondary care and other professions because of the pressure. ‘District nursing is a difficult job and we’re all up against it in the NHS,’ she says. ‘Our team is probably roughly 30% smaller than what it was 10 years ago. When the pressures get worse in nursing, morale goes down.’
Sue Murray, a recently retired practice nurse, also believes that the Government must offer more to retain an underpaid, ‘undervalued’ workforce. ‘Better training would help and might keep people in a few more years, but I don’t think there’s much chance. Older and more experienced nurses get to the end of their tether and go “it’s not worth it. I’m not getting what I came to nursing for.” You’re not getting financially rewarded for it – and you look elsewhere.’
‘Returners need more financial support’
‘If there are more schemes, nurses will not have to travel so far to access a return-to-practice course,’ said Ann Walsh who recently completed a return-to-practice course at the University of Northampton. ‘In my experience, the application was easy with lots of support while I applied. If every university offers this level of support and guidance, then I think it is a relatively simple process. However, return-to-practice applicants need more financial support. A living wage paid for the duration of the course would widen access for those not able to reduce hours in their current job.’
In addition, Ms Murray believes return-to-practice schemes could be a ‘waste of money’ without major system changes. ‘Unless the Government changes the beast, all you’ll do is retrain them, get them in and lose them.’
Questions remain over whether enough new nurses will join community services, where the NHS Long Term Plan aims to shift care. ‘It’s very hard to do any more in those services if there aren’t the staff in those areas,’ says Mr Gershlick.
‘In a lot of those areas we’ve seen reductions in the numbers of staff, so turning the tide on that is a massive challenge.’
The Government hopes to attract an extra 12,500 extra overseas nurses by expanding existing international recruitment efforts and promoting the new NHS visa, which offers fast-track entry and reduced visa fees for doctors, nurses and allied health professionals. But this could be ambitious in light of Brexit plans to increase the health surcharge – which is paid to cover an overseas worker’s care needs should they arise – and extend it to EU workers. The NHS would also need to remain attractive enough to keep these overseas workers.
Devil in the detail
The £759m to £879m a year of new money the Government has pledged to achieve its target comes with additional funding from NHS England, taking the total to over £1bn a year. But as the money largely covers the cost of the training and maintenance grant, there is concern that this will not be enough to pay the salaries of 50,000 extra nurses. The starting salary of a nurse on Agenda for Change pay rates is £24,214.
John Appleby, chief economist at the Nuffield Trust, tells Nursing in Practice that the cash needed for salaries will probably be sourced from the £20.5bn increase to the NHS England budget, as promised in real terms by 2023/24. The Nuffield Trust says this is enough cash to pay for the required increase in nurses’ salaries, but that it would take a ‘significant chunk’ from spending on GPs, hospitals and mental healthcare.
However, attracting and retaining more nurses is not just about paying them but paying them properly, which means the next Agenda for Change pay deal could be crucial to meeting the target, says Mr Gershlick. He warns it is hard to reach both a ‘generous’ agreement and properly fund patient care. There must be ‘more detail’ on funding and policy, he adds, which is expected in the long-awaited NHS People Plan. Although, NHS England has now postponed the People Plan during the coronavirus outbreak to ‘remove routine burdens’ of producing the publication on health staff.
Professor Alison Leary, a qualified nurse and chair of healthcare and workforce modelling at London South Bank University, tells Nursing in Practice the 50,000 pledge could be hard to fulfil. ‘A failure to address fundamental issues such as pay, conditions and workload may mean the leaky bucket of the nursing workforce will spring more holes,’ she cautions. Which could be more true than ever after the coronavirus pandemic.
*Not her real name