The NHS Long Term Workforce Plan has set welcome targets for recruitment, but are its aspirations realistic given the current situation in general practice, asks Wiliam Hunter
The NHS Long Term Workforce Plan (LTWP) was finally published in June, against a backdrop of one of the deepest workforce crises in the health service’s history.
The LTWP for England promises to increase the number of training places available for nursing by between 80% by 2031, to a total of 53,858 nurses each year.1
Primary care is the subject of generous workforce commitments, with the plan aiming for a 73% increase in the number of staff working in mental health, primary and community care by 2036-37.
In short, there seem to be reason for optimism about the future of the nursing workforce, even in primary care.
However, in the months since the plan’s publication, doubts have arisen over whether this optimistic expansion is, in fact, feasible in any of the professions.
Questions over training capacity
Analysis by The Health Foundation estimates nursing would account for 65% of the total expansion in training places, with higher education institutions needing to provide an additional 32,000 places a year by 2031-32.2
This means students training to be NHS clinical professionals would make up one in six of all first-year students in the UK.
Economist and author of the Health Foundation’s analysis Nihar Shembavnekar is cautiously optimistic but warns there is much work to be done.
‘As things stand there are concerns around whether there’s sufficient training capacity,’ he says, ‘but that’s exactly what the plan is seeking to change.’
Mr Shembavnekar explains that a lack of capacity for supervision is a problem, as an ‘insufficient number of trainers’ holds back the system’s capacity to support newly qualified nurses.
Yet, he believes that, with sufficient collaboration between stakeholders such as the NHS, higher education institutions and employers, the LTWP’s commitments are feasible in the long term.
However, many of those on the front lines of the recruitment struggle in primary care do not share
this optimism.
‘To train your new workforce, you need experienced nurses’
Clinical director of North Central London Training Hub Katherine Gerrans says the plan’s ambitions are not possible ‘with the current funding of the current training apparatus’.
North Central London, like many other areas, is simply unable to provide the numbers of experienced nurses required to supervise newly recruited nurses in general practice, Ms Gerrans says.
‘To train your new workforce, you need to have experienced nurses working alongside them. As a training hub, a prime role for us is to maintain the quality and safety of training while trying to increase placement capacity. That’s a significant challenge with the current service delivery needs of general practice.’
Ms Gerrans points out that an ageing general practice workforce, combined with a higher demand on services in primary care, means nurses have less and less time to offer supervision and training.
‘We are experiencing a real difficulty trying to get nurses released from day-to-day practice,’ she says, ‘because placements are not income generating.’
Practices are eligible for a tariff of £5,000, plus an adjustment for local market conditions, per year of full-time-equivalent (FTE) placement offered.
But Kathryn Caley, lead nurse for Cambridgeshire and Peterborough Training Hub, dismisses these fees as ‘minuscule’ compared with what is offered for the supervision of medical students.
She says a medical student placement can attract £30,750 per FTE year, plus adjustments for local costs – more than six times the fee for a student nurse.
This, along with a scarcity of physical space, says Ms Caley, is ‘one of the biggest barriers’ to increasing the number of nurses coming into primary care.
‘It’s an income issue. Surgeries haven’t got enough space for their own staff, let alone having students, so they will prioritise making space for a GP registrar rather than a student nurse.’
Ms Caley says her training hub and others across the country are topping up the tariff out of their own budget, resulting in a flat rate of £40 per day in Cambridgeshire and Peterborough for taking on a student nurse.
Adjusting the tariff has had a real impact on the number of students receiving placements, but it is ‘not cheap’, she says, and the extra funding is difficult to withdraw when it has been offered once.
And initiatives designed to boost the primary care workforce are making the problem worse.
ARRS ‘takes the focus off nurses’
Louise Berwick, director at South Yorkshire Training Hub, says the Additional Roles Reimbursement Scheme (ARRS) is making it much harder to secure nursing placements.
The hub previously ‘prided ourselves’ on the number of undergraduate nurses taking practice places, but ‘it’s been more difficult to get those places because practices are supervising the new roles instead’, she says.
Likewise, Emma Thompson, lead nurse at the South Yorkshire Training Hub, says ARRS has ‘taken the focus off general practice nurses to the detriment of practices’.
The core issue, Ms Berwick explains, is that ‘there’s only so much [supervision] capacity within a practice or a PCN, and its just a matter of how that capacity is used.
‘The practices probably would have chosen nurses instead, but nurses aren’t on the list of ARRS roles.’
A number of different training hubs that spoke with Nursing in Practice reflect similar concerns.
Practices do not have the space, staff capacity or financial incentive to increase numbers of undergraduate nurses entering primary care via placements.
Creative thinking
This is not to say there is no hope of meeting the LTWP targets. Training hubs and universities are thinking outside the box to find new ways to meet the challenge.
In South Yorkshire for example, which has huge demand for positions in primary care, an innovation hub is investigating how technology can solve capacity issues.
Ms Berwick said: ‘The numbers in the workforce plan are huge and there’s no way they can be met with the capacity that’s out there at the moment, so we have to think differently about how we can achieve that.’
Likewise, Ms Caley’s nurse trainers in Cambridgeshire and Peterborough are using Microsoft Teams to support student nurses on placements to reduce staffing pressure on practice teams.
Higher education institutions are also exploring new ways of exposing students to general practice and helping undergraduates get a foot on the ladder.
The University of Cumbria launched a free remote learning module for nurses at all levels, aiming to introduce more people to general practice without being dependent on practice placements.
Senior lecturer in non-medical prescribing Janine Hill, who is leading the initiative, says it has taken students from ‘walking through the door into primary care’ to learning how to apply for jobs in practice.
Ms Hill also says there is ‘a definite move towards the use of simulation’ in nurse training for general practice.
‘We have to think outside the box because there aren’t enough nurses, so we have to be flexible and creative.’
Yet, as she points out, even with the best recruitment campaigns and the most innovative uses of technology, the LTWP might still fail if a deeper problem in general practice is not addressed.
Pay needs consideration
Since general practices remain private businesses, pay as well as terms and conditions are often notably worse in primary care than in secondary care settings.
Those who spoke with Nursing in Practice say this makes it more difficult to attract new nurses, and to retain the experienced staff who are vital for training.
Ms Hill says her personal view is that ‘if [the government] wants nurses going into primary care they need to be considered to be on the same [Agenda for Change] financial bands’.
‘You’re not offered the same remuneration or expectation, or sick pay and holidays. So, if people are to move from one area of the NHS to another, there has to be an understanding that there will be similar pay.’
At North Central London Training Hub, Ms Gerrans agrees that ‘terms and conditions can be a significant barrier as they’re rarely equivalent to Agenda for Change’.
This is also a concern that extends beyond primary care and into the wider nursing workforce.
Recent UCAS data3 show acceptances to nursing courses in England were down 13% year on year, increasing the recruitment challenge even further.
Mr Shembavnekar of The Health Foundation warns this could signal a wider ‘image issue among students of nursing being a rewarding career’.
Additionally, rising dissatisfaction with careers in nursing feeds into higher turnover rates and more experienced staffing choosing to retire early.
Mr Shembavnekar says this in turn becomes a ‘major constraint’ on increasing placement capacity, as the system loses the experienced nurses required to train the next generation.
Catherine Lawlor, lead practice nurse for South East London Training Hub, worries that even with a successful workforce expansion, these issues may ultimately undermine the LTWP’s expansion aims.
‘You can throw as much money at it as you like but if you don’t have the teachers, you don’t have the teachers.
‘My concern is that you aren’t ensuring that the training necessary to provide a safe standard of care is going to be available. There was a lot of talk about expanding placements [in the workforce plan] but no real understanding of who was going to provide the training.’
Ms Lawlor says she fears a rush to meet the commitments in the long-term plan might leave general practice with a workforce that is significantly less experienced, without securing the experienced nurses need to provide training.
While training hubs say the workforce plan is a step in the right direction for rebuilding the workforce, there are still concerns about its implementation.
Without more flexible thinking about how to train nurses, or significant investment in training capacity, ministers risk missing the LTWP’s targets, or hitting them in a way that, as Ms Gerrans cautioned, makes it hard to maintain quality and safety standards.
References
- NHS Long Term Workforce Plan 2023: Train – Growing the workforce. Link
- The Health Foundation, 2023. How feasible are the NHS Long Term Workforce Plan commitments on training? Link
- UCAS. Daily clearing analysis 2023. Link
