Executive summary

 

Ensuring that the NHS has the workforce it needs with the right skills and support is fundamental to an effective and sustainable health care system. Health care is labour intensive and people centred. The Health Foundation’s 2016 report Staffing matters; funding counts found that the ability of the NHS to deliver its services is being compromised by staff shortages, planning inadequacies and an inability to make best use of the skills of its available workforce.

It identified significant challenges to the NHS in England including substantial staff shortages in nursing and primary care. Yet these are not isolated problems – rather, they are symptoms of a more fundamental fault line. The approach to planning for the million-plus NHS workforce in England is not fit for purpose and there is no overall discernible strategy to ensure that the NHS has the workforce it needs. A year on, the effects of a lack of a coherent and comprehensive workforce strategy continue to be apparent and, if anything, the situation is worse. Health Education England (HEE) publishes an annual workforce plan, but the plan for the current year (2017/18) has not yet been published. In its place, 2017 has been characterised by a series of one-off announcements and initiatives whose positive intent is too often let down by unrealistic timescales and fragmented and uncoordinated implementation.

Analysis of the NHS staff profile in 2017 shows that the trends of concern identified in 2016 have largely continued in a negative direction. The analysis shows the following.

  • The number of people in the NHS workforce increased by 2% in the year to April 2017. But growth has been uneven. The staff groups with the highest rates of growth were those who provide support to clinical staff (2.5%), medical consultants (3.5%), and managers and senior managers (4.3%).
  • While there has been continued growth in hospital-based doctors, the number of full-time equivalent (FTE) GPs has fallen. This comes amid increasing demand pressures in primary care and despite the government’s commitment to grow the number of GPs by 5,000.
  • The number of FTE nurses employed in the NHS in England fell between April 2016 and April 2017. There were 469 fewer nurses and health visitors in April 2017 compared to a year before, despite rising activity pressures.
  • The fall in the number of nurses has been most notable in community nursing and mental health – two areas identified as critical to the success of the Five year forward view. Staffing challenges in priority areas are likely to persist, with a recent HEE report showing that 11% of nursing posts in mental health are vacant.
  • The UK is below the Organisation for Economic Co-operation and Development (OECD) average for both doctors and nurses per head of population. However, the expansion of medical training places in the UK in the last two decades, and the recent announcement of a further increase in medical student intake numbers of up to 25% by 2019, means the UK will be training many more doctors per head of population. The UK is currently training 13.5 doctors per 100,000 population – above the OECD average and significantly higher than the US, Canada and New Zealand.
  • OECD data also show that the UK trains many fewer nurses than comparable countries. In 2014 the UK had 29 nursing graduates per 100,000 population; the OECD average was 45 per 100,000. The US trained more than twice that of the UK (63), while Australia trained even more, at 76 per 100,000 population.
  • The differential path of nurses and doctors employed in the NHS has resulted in a marked change in skill mix. In 2010 there were 7.6 FTE nurses in hospital and community health services for each consultant. By April 2017 that had fallen to 6.1 FTE nurses per consultant.
  • Decreases in length of stay and increases in the number of nurses in 2014 and 2015 led to the number of nurses per bed day recovering to almost the same level as in 2011, despite rising admissions. But  recent data suggest continued rising admissions and falling nurse numbers. This means unprecedented decreases in length of stay will be required to stop the recovery falling back to previous levels.

Building on analysis of the updated workforce profile, this report looks in detail at two important pressure points: the impact on student numbers of the removal of the NHS bursary and the central issue of staff retention.

Nurse bursaries: mature student applicant numbers fall, but limited impact on younger applicants?

By ending the system of bursaries available for nurses and allied health professionals (AHPs), the government is seeking to expand the number of training places in England while limiting the cost to the public purse. It has replaced them with the standard tuition and maintenance loan schemes available for other higher education degree programmes.

Students starting in autumn 2017 in England are the first cohort not to receive the bursary. The other three UK countries are continuing with some variant of the bursary approach. Early data on student numbers indicate that overall applications to university have fallen by 4% across all subjects in 2017 compared to 2016, reflecting demographic changes in the population (there are fewer 18-year-olds than in previous years). Medicine, which is not directly affected by the bursaries reform, has seen applications fall by 3.8%. With medicine applications significantly exceeding the number of places on offer, the intake of students into medicine in 2017 has risen from 8,680 to 8,980 – this is the largest intake for many years.

In contrast, nursing and allied health subjects, which are directly affected by the abolition of bursaries, have seen a sharper reduction in applications (23%), which has gained much media coverage. While the number of applicants still exceeds the number of places on offer, the initial indications are that the number of nurses starting training in 2017 may fall. The number of nursing students domiciled in England placed at UK education providers was 5.5% lower 1 month after A-level results day than on the same day in 2016. Similarly, the number of students from Northern Ireland starting nurse training was 2.7% down on 2016. In contrast, the numbers of students from Scotland and Wales starting nurse training have increased.* In England, at the end of the clearing round on 14 September, about 1,200 fewer students are starting nursing education in autumn 2017 than the year before, which takes the number back to 2015 levels. In addition to the fall in overall numbers for 2017, there has been a shift in the age profile. The number of students aged under 20 starting nurse training is 6% higher, but there are around 10% fewer people aged 20 and over starting a nursing degree.

The Health Foundation’s analysis shows that this is the result of complex changes. Applications to nursing are down across the UK, despite Northern Ireland, Scotland and Wales retaining the bursary system. The fall in England is sharper and is most notable among mature applicants.† Until 2017, 40% of applicants to nurse education were aged 25 and over. The end of bursaries in England is one of several factors that may be affecting applications from this group: pay on graduation and wider opportunities in the labour market may also have an impact.

Other reforms such as apprenticeships and nursing associate roles may also provide alternative attractive routes for some of these applicants, but it seems that the apprenticeship model is being implemented behind schedule. It was announced in November 2016 that the government would support up to 1,000 nurse apprenticeships each year. Yet it has been reported recently that only two higher education training providers have nurses starting training via the apprenticeship route in 2017, with a combined total of less than 50 students. Places at other institutions will become available in 2018 but the programme is significantly delayed.

At the Conservative Party conference the Secretary of State for Health announced a further expansion of nursing associate roles and apprenticeships. These routes into nursing will be very important, particularly for areas such as mental health, which have relied more heavily on older applicants. But the government must learn the lessons from the bursary reforms and initial apprenticeships and plan implementation early, in a coordinated way across education providers and NHS employers.

The motivation for shifting from the bursary to student loans was to allow the number of student nurses and AHPs to expand – by up to 10,000 by 2020. Two critical elements in the fall in the number of students placed in nursing courses for the start of the 2017 academic year have been poor implementation of the reforms to student funding, and even poorer communication from government departments. Most critically, the arrangements

for funding clinical placements, so that higher education institutions could expand places, were finalised too late in the process. Universities were only made aware that additional funding for such placements would be available on 9 August, less than a week before A-level results and long after the initial application process. In addition, there has been insufficient focus on the specific needs of older potential applicants to nurse education.

Any drop in the number of nurses starting training is clearly a cause for concern. The transition to the new student funding arrangements are part of this, but not the only cause. The government must examine how the loan system is working, but also consider what can be done to address the high rate of attrition from nursing courses. A recent survey estimated that one in four student nurses do not complete their training within the scheduled 3 years. The government had set a target to halve this rate but there are no robust data on performance against this target. This must be a priority for universities, employers and HEE.

Retention: is the workforce on shaky ground?

HEE analysis shows that the NHS in England had a shortage of 29,000 FTE staff in 2016 – one in 10 of all nursing posts. Based on current plans, HEE expects the gap between supply and demand for nurses to narrow slightly, but is projecting that the NHS will still not have enough qualified nurses by 2021. It argues that the high rates of nurses leaving the NHS before retirement age is a key contributor to staffing shortages. Official projections anticipate that the NHS will lose 84,000 nurses before retirement age over the next 5 years.

Staff leaving the NHS contribute to overall shortages, can impact negatively on continuity of care, and add to organisational costs. Estimates suggest that it costs the taxpayer approximately £78,000 to train a nurse over 3 years, and that there is an additional cost impact of up to the equivalent of 2 years’ salary when a nurse leaves an organisation. Some employers in the NHS also deal with a continuous high level of turnover (also known as staffing churn).

Despite recent policy emphasis on improving staff retention, the analysis in this report suggests that workforce stability in NHS providers has fallen between 2010/11 and 2016/17. Overall, workforce stability in NHS trusts – measured by the percentage of staff that stay at an NHS trust in a given year‡ – fell from a median of 89% in 2010/11 to 85% in 2016/17. Over the 7-year period the variation in stability between trusts also increased. In 2010/11 most trusts were clustered around the middle, but in 2016/17 the range was wider, with the range of the middle 80% of trusts growing by a third. This points to a worsening picture of overall workforce stability, with the likelihood of added costs being incurred at a time when the NHS cannot afford them.

While the overall size of the NHS workforce increased between 2015/16 and 2016/17, the numbers of nurses (particularly in the community and mental health) and GPs have fallen. There is no immediate or easy end in sight to nursing or GP shortages across the NHS. This is of particular concern given the importance of primary care and community health services for the NHS’s ambition to transform services as outlined in the Five year forward view.

The NHS needs an effective, coordinated workforce policy

The Health Foundation has explored two key pressure points in the NHS – the abolition of bursaries for nurses with the aim of increasing staff in training, and retention of non-medical staff. Never has it been more important to manage training, recruitment and retention well. It is clear that while providing more training places for nurses, reducing attrition from training and increasing retention are all identified in national rhetoric, there is a substantial disconnect between headline statements and actual policy implementation and local delivery – the gap between national rhetoric and the reality for the NHS workforce is growing.

No-one involved in shaping or supporting the NHS workforce in England sets out to create staff shortages, exacerbate their impact, or respond to them inefficiently. However, many of the indicators assessed in this report point to a worsening situation in the NHS, with demand for services growing much faster than key staff groups. There is no quick fix to these problems, but the absence of a sustained and nationally focused approach to workforce policy and planning – compounded by the ongoing disconnect between identified staffing groups needs and funding decisions – prevents effective and coordinated policy interventions.

* Final data on the number of students starting nursing degrees in 2017 will be available in December 2017.

† UCAS defines mature students as any student aged 21 or older at the time they start their studies.

‡ For instance, if trust X had 100 staff and 75 of those were still in post at the end of the year then its 1-year stability index would be 75%. The higher the stability index, the higher is staff retention.

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