Pressure point: Staff retention – holding on, or letting go?


Improving NHS staff retention has recently been flagged as a major objective by both HEE and NHS Improvement. This is understandable given the costs of staff replacement, and the loss of skills and knowledge when staff leave. The chief executive of HEE recently stated that staff retention was the biggest single challenge in tackling NHS workforce shortages.

Annual turnover in some NHS trusts was reportedly as high as one in three nurses moving jobs, with lack of flexible working opportunities flagged as the number one reason for nurses moving. This section reviews NHS trust-level data on staff leaving rates and indicators of retention to provide a clear backdrop for any future initiatives aimed at improving staff retention in the NHS in England.

Nurses leaving means supply is not matching demand

A starting point is to look at official estimates. HEE estimated that the NHS in England had 30,000 fewer FTE nurses than it needed in 2015 – equivalent to nearly one in 10 positions. HEE has since released its nurse supply modelling for 2016 to 2021 (replicated in Figure 24), through which it aims to highlight the impact of nurse leavers on achieving the overall nurse supply target. The HEE nurse supply modelling shows that, in 2016, there were still 29,000 vacancies across the NHS in England.

Figure 24: Nursing supply and demand, 2016–21

Source: Health Education England presentation, NHS Confederation Conference 2017.

HEE anticipates that 87,000 (non-retiring) nurses will leave the NHS between 2016 and 2021, resulting in the NHS requiring 84,000 joiners (over and above newly qualified staff). This gives a sense of the scale of the impact of nurse leavers on overall staff in post numbers, and highlights the extent of the replacement challenge. The relatively high turnover of NHS nurses contributes to a relatively short estimated average working life. This has been calculated at only 16 years for an NHS nurse, compared to around 24 years for AHPs and 28 years for pharmacists.

Significant variation in staff retention across England

In order to examine in more detail the data underpinning estimates on retention – which will shape any likely effective action on the issue – we now present new analysis on staff leavers and stability. The review of staff leavers (other than doctors, which are not included because of the rapid turnover of medical staff moving between postings) highlights that there is huge variation in turnover rates between NHS organisations (Figure 25). The median leaver rate in 2016/17 for the 221 NHS trusts across England for which data could be obtained†† was about 15% – of the almost 1 million staff in post at the beginning of 2016/17, just over 150,000 had left 1 year later (some will be moving to jobs elsewhere in the NHS). The leaver rate from NHS trusts varied from less than 10% to more than 30% across the NHS in England. Community providers had an above-average leaver rate, with a median of 18%.

Figure 25: Leaver rate from NHS trusts in England by provider type, 2016/17

Note: Data from 221 trusts. Excludes doctors.

Source: NHS Digital. Provisional NHS (HCHS monthly workforce statistics, bespoke extract.

Despite concerns about shortfalls and vacancies in certain staff groups, in general most staff who leave are replaced, even if there may be some delay in sourcing a replacement. As a result, most NHS providers will not change headcount establishment‡‡ significantly over a year, but this apparent headline stability masks significant instability – some NHS trusts are effectively ‘running hard to stand still’, having to repeatedly replace staff leavers across a 12-month period (Figure 26).

This can lead to high rates of both staff joiners and leavers within some trusts. This is the driver of increased turnover costs, can lead to high use of temporary staff cover, and can impact on continuity of care. For example, one trust’s headcount increased by 4% with a 9% leaver rate in 2016/17, while another saw the same level of headcount increase with a leaver rate of 24%.§§

Figure 26: Leaver rate, joiner rate and net position from NHS trusts in England by provider, 2016/17

Note: Data from 221 trusts. Excludes doctors.

Source: NHS Digital. Provisional NHS HCHS monthly workforce statistics, bespoke extract.

There is also marked regional variation in leaver rates across England. Leaver rates are significantly higher in London: the three London regions (north west London, south London, and north central and east London) have the highest reported rates, which are well above the England average and much higher than rates in the north of England (Figure 27). For example, the rate for north west London (21%) is eight percentage points higher than that for Yorkshire and the Humber (13%).

Figure 27: Leaver rate from NHS trusts in England by region, 2016/17

Note: Data from 221 trusts. Excludes doctors.

Source: NHS Digital. Provisional NHS HCHS monthly workforce statistics, bespoke extract.

Region and related differences in labour market conditions are factors that may explain varying levels of ability among trusts to retain staff. Other factors include variations in the type of trust (some have a very different staff profile to other trusts, eg ambulance trusts have fewer doctors and nurses), workforce profile and skill mix (some occupations, grades and roles are more mobile and transient than others), as well as the culture and management of the trust.

Falling stability across NHS trusts

Joiner, leaver and turnover data can give some indication of the varying challenges facing NHS trusts in managing the level and impact of staff movements. However, an alternative indicator that can provide deeper insight into retention is the stability index: an index indicating the percentage of staff that stay at an organisation over a defined period of time, usually expressed in annual terms.¶¶

Figure 28 illustrates the stability indices at NHS trust level across two years: 2010/11 and 2016/17 (these data exclude doctors in training). These two point-in-time measures give some sense of how patterns of workforce stability (and therefore retention) vary across the NHS in England, and if the stability rates have changed markedly at trust level between the two points in time. The figure shows if a trust had an above-average or below-average stability index in 2010/11 and whether this had changed in 2016/17. About half of all trusts were in the same quartile in 2016/17 as they were in 2010/11, indicating there was relatively little change in stability between the two points in time. Only about one in five trusts had below-average staff stability in 2010/11 but above-average staff stability in 2016/17, or vice versa.

Figure 28: Stability of staff in NHS trusts, 2010/11 and 2016/17

Note: Lines indicate median value. Doctors in training excluded.

Source: NHS Digital, Provisional NHS HCHS monthly workforce statistics, bespoke extract.

Overall, however, workforce stability in the 210 NHS trusts for which data are available has reduced since 2010/11 and was lower in 2016/17 – the median stability rate fell from 89% in 2010/11 to 85% in 2016/17 (Figure 29). Alongside this has come more variation. In 2010/11 most trusts were clustered around the median, but in 2016/17 the range was much larger (illustrated by the elongated distribution shown in Figure 29).

Figure 29: Change in workforce stability of trusts in England, 2010/11–2016/17

Note: Width indicates number of trusts, dots indicate median. Data from 210 trusts; a small number of outliers removed from graphic. Doctors in training excluded.

Source: NHS Digital, Provisional NHS HCHS monthly workforce statistics, bespoke extract.

There is great scope to improve retention

This section has provided some insight into national and regional NHS leaver and retention rates. It has highlighted that the available evidence suggests NHS workforce stability has reduced in recent years, and that there remains significant trust-level and regional variation. The potential impact of improving retention by reducing the leaver rate is significant. For example, targeted action to improve staff stability in trusts reporting higher leaver rates or lower stability could have substantial results. More focused action on trusts in the top quartile of leaver rates in 2016/17 to reduce their rate to the bottom quartile’s average rate of 13% would result in almost 30,000 fewer leavers in 1 year.

The focus on improving staff stability and retention, in part by reducing turnover, is understandable, given costs and impact of staff turnover on quality and continuity of care, and team cohesiveness. Turnover costs will vary depending upon the replacement strategy being adopted (eg replacing an experienced worker with a less experienced worker is likely to lead to lower productivity, in the short term at least) and are likely to also vary according to the clinical setting. Studies on staff turnover in the health sector of different countries vary in approach, but point to significantly increased costs and potentially negative impacts on care outcomes.,,,

One US study in 2004 estimated that total turnover costs for a hospital system employing 5,000 people was between $17m and $29m. Another study from the same year estimated a rough ‘rule of thumb’ that the cost of staff nurse turnover normally sat between 0.75 and 2.0 times annual salary, depending on seniority and specialty of the nurse. There are few studies examining the relationship between turnover and care outcomes, but there is some evidence of a relationship between higher turnover of nurses and nurse assistants and reduced care outcomes, using indicators such as pressure sores and urinary tract infection incidence.,,,

NHS Improvement has recently announced a programme ‘to improve staff retention in trusts across England and bring down the leaver rates in the NHS by 2020’. It reported that ‘A large proportion of leavers are for unknown reasons’. Initial data presented on NHS Improvement’s website show that flexible working ranked below pay, work–life balance and access to continued professional development as reasons for NHS staff leaving voluntarily. Details of the programme are not clear at the time of this report, but NHS Improvement indicates that the intention is to target NHS providers with above-average leaving rates for nurses, and support them to analyse their staff turnover and design tailored improvement plans targeting the drivers of staff leaving.

The potential for improved retention and reduced turnover to help NHS organisations contain costs and maintain quality has risen on the NHS national agenda in recent months. However, it is unrealised, in part because of an incomplete evidence base on patterns and reasons for leaving (or staying), as well as limited data that can be used to measure and track turnover or retention. And within the limited evidence base, there has also tended to be an analytical focus on leavers and reasons for leaving, rather than on stayers and what retains staff. Evidence on both is needed to enable organisations to effectively address retention concerns. The analytical approach to stability the Health Foundation has presented in this section can be used to help target efforts where they are most urgently required.

†† This excludes doctors, and trusts that merged, significantly changed provision or did not supply data, leaving 221 trusts (94% of all trusts).

‡‡ The total number of authorised posts allocated for a budget, which reflects the maximum number of FTE staff that can be employed.

§§ Some NHS trusts report variation in headcount due to service changes or services being moved to a different provider. This will be a factor in explaining high leaver or joiner rates in some trusts.

¶¶ The higher the stability index, the higher is staff retention. 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%.

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