Leading nurse John Unsworth describes how he would like to see wider conversations on the value of nursing, and why this is vitally important for the changes that government needs for the healthcare system and for people’s health more widely.
The overall NHS deficit is around £6bn and there remains around 25,500 registered nurse vacancies in England alone. Yet we are now seeing posts being deleted from establishments, a freeze on international recruitment and thousands of newly qualified nurses who are unable to secure their first post.
While this seems like a perfect storm, more pernicious is the comparison to the cost cutting measures instigated by the Mid-Staffordshire NHS Trust in order to secure Foundation Trust status between 2005-2009. Time will tell whether we are about to see this repeating itself on a monumental scale. Either way, we appear to have learnt little about the value of nursing since the Mid-Staffs scandal.
Articulating the economic value of nursing
Understanding and articulating the economic value of nursing matters, because time and time again we see managers and governments viewing nursing as a cost to be minimised. This is referred to as the outcomes-over-cost value framework. Reduce the cost to achieve the outcome and the profit margin will be greater. Within this framework, nursing is viewed as a commodity the same as petrol for a car – the cheaper the petrol the cheaper it is to drive.
This is a massive over-simplification as it assumes all nurses and the same and bring little value to the system other than powering it to deliver care. Yet, nursing brings huge economic benefit to the system, to patients and to society more widely.
World-leading researchers like Professor Olga Yakusheva and her team at John Hopkins University in the United States have written widely about the economic value of nursing. The economic value of nursing can broadly be attributed to three main areas, these are: outcomes for patients, enhancing productivity and growth as well as wider benefits to society.
There is strong evidence that registered nurses reduce mortality, provide safer care with fewer complications, avoid unnecessary admission to hospital, reduce length of stay and promote self-management for long-term conditions
There is strong evidence that registered nurses reduce mortality, provide safer care with fewer complications, avoid unnecessary admission to hospital, reduce length of stay and promote self-management for long-term conditions. Much of this work happens in general practice and in the wider community with a tiny fraction of the overall NHS budget.
Professor Yakusheva and her team also developed the human-capital value model, seeing nurses as asset to be nurtured and developed. Nursing is then seen as a driver behind organisational success and income. There is considerable return-on-investment when nurses are able to work to their full potential and develop the ability to meet population health needs.
We need to reduce demand on healthcare services
Strong primary care and community services lead to a healthier and more economically productive population with reduced demand on other healthcare services. This is important because the UK has a significant issue with economic inactivity. In February 2024, a total of 9.4 million working age adults were economically inactive with long-term sickness reaching a record high of 2.8 million. The benefits bill alone is set to rise beyond the £132bn it is currently estimated to cost. That is staggeringly more than half of the total cost of the entire NHS. Many of those individuals who are economically inactive have physical and mental health problems which can be better managed by primary care and by nurses.
Furthermore, the economic benefits to society of nursing and health visiting include addressing health inequalities, tackling fatalism and improving people’s quality of life and life chances.
Nursing has a significant impact on health outcomes
Despite the fact that nursing has a significant impact on health outcomes, we know very little about the income nursing generates for NHS organisations and general practices. Rather nursing is subsumed, in many cases, into the overall operating costs with the same value as estates costs. But we do know the income generated by medical staff as they are costed in most costing models as separate entities – their economic value is not in question.
We know very little about the income nursing generates for NHS organisations and general practices
The ‘do more with less’ prevailing NHS philosophy is flawed from the outset. While nursing associates add value to the nursing team, their scope of practice is, and should be, more limited than that of a registered nurse. The use of associates brings additional costs because of supervision and because of wasted opportunities to address holistic needs as part of an episode of care.
At the same time, the three big shifts that form the backbone of the NHS 10-year plan can only be achieved through investments in human capital including nurses. More care at home will require greater investment in primary and community care, including social care, with an increase in staff numbers.
Looking to the future, while artificial intelligence and digital present many exciting opportunities, they will never replace human beings. For example, robots in nursing may be well equipped to offer care support but they are unable to complete many of the aspects of holistic care which a registered nurse would offer. A robot may be more than able to take someone to the toilet, but can it really simultaneously assess mood, balance, walking gait, skin integrity, colour, hydration and a whole host of other things? As one robotics engineer put it: ‘Nurses do more than one task – I didn’t know that’.
Does this really matter in the bigger scheme of things?
Yes, it does. Surveys of NHS managers about how they can reduce costs invariably place things like reduced staffing, skill mix and workforce changes at the top of the approaches. This means nursing is seen as a cost to be minimised and this plays out with role substitution, lower pay, as well as roles in primary care and community seen as less important than hospital services.
A safety critical profession adding significant value to the health system
Where do we start to address this? The first step is for nurses to know and to articulate their economic value. People need to start talking about the care they provide and nursing as a safety critical profession which adds significant value to the health system.
People need to start talking about the care they provide and nursing as a safety critical profession which adds significant value to the health system
Nurses themselves need to stop talking about tasks, as if the task itself is the whole episode of care. If all you do is tasks, then robots can replace you, and tasks can be done by anyone with a little bit of training.
At the same time, we need more evidence about the economic value of nursing and on outcomes. Without this, we will always be seen as the first thing to be axed as part of cost reduction.
John Unsworth is a registered nurse and Professor of Community Nursing Workforce and Policy at Northumbria University. He is a former NHS Director and district nurse. He is the chair of Council of the Queen’s Institute of Community Nursing and a Fellow of the Royal College of Nursing and the American Academy of Nursing.
