This extended blog explores recent trends in the demand for healthcare and the supply of nurses, before reflecting on how government policy changes are impacting on the ability of the nursing sector to meet rising needs. We argue that with nursing shortages gripping the NHS, it is time to evaluate how recent policy has failed to get to grips with the problem, and develop a new strategic framework to improve the participation of nurses in the health service.
Amid a severe and ongoing winter crisis, it was revealed last week that the NHS has been “hemorrhaging” nurses, and the consequences may be dire. An ageing population will inevitably lead to greater demand strains on the NHS, but evidence has shown that an increasing patient-to-nurse ratio can increase the risk of inpatient deaths. Furthermore, it also exacerbates the risk of “burnout” and “job dissatisfaction” potentially creating a downwards spiral where fewer and fewer people wish to pursue a career in nursing, entrenching and worsening the situation.
Ensuring the NHS is supported by qualified and skilled staff is a key priority, however, the problems facing the nursing profession are not new. These issues are a consequence of numerous policies which have diminished the attraction of the profession, in favour of short-term cost cutting. Recent data has shown that the year on year changes in nursing staff has slipped into negative territory towards the end of 2017 – meaning that more people are now leaving the profession than joining. Between September 2009 and September 2017, the number of nurses rose by 0.8%, while the numbers of people aged over-65 rose by 17.6% during roughly the same period.
Source: HES NHS Workforce Statistics, October 2017
Increasing demand is worsening the situation, but there are other factors at play, inhibiting the supply of nurses into the NHS: workload, bursaries and migration. It is imperative these issues are addressed, not only to ensure that there remains a steady stream of qualified nurses into the NHS, but also to encourage nurses to stay and build careers. Without coherent policies to address these problems, the current winter crisis may evolve into a permanent crisis.
Working under pressure
During nursing training, students are expected to participate in placement schemes, involving long hours on hospital wards. Upon graduation, the workload does not relent. Numerous news reports have highlighted concerns regarding the over-working of nurses, who are struggling to deal with the increased demand on the health service. Statistics from the OECD show that the number of nurses per 1,000 of the population has fallen considerably from its peak of 10.2 in 2005, to just under 8 in 2015. In contrast, other major economies such as the USA, Germany and France have all seen the number of nurses relative to the population rise.
Source: OECD Health at a glance (2017)
Although the pay cap has been recently scrapped, there remains a lack of confidence that future pay increases will match inflation particularly due to the previously prolonged pay freeze. This, combined with increasing workload pressures is likely to make the prospect of working as a nurse in the NHS daunting. This ultimately means it is harder to retain and recruit staff.
Between July and September 2017, over 34,000 nursing vacancies for full time jobs in England were posted (up 3,000 on the same time last year), amounting to almost 40% of overall vacancies (across the labour market as whole) advertised. Furthermore, the number of nurses leaving the NHS is beginning to exceed the number joining. The growing number of those leaving the NHS does not simply reflect an ageing workforce either. Over 33,000 nurses left the NHS in 2016-17, with almost a third between the ages of 25-34. The proportion of those between the ages of 25-29 who are leaving is noticeably higher than what it was in 2012.
Source: HES and NHS digital
Salaries and workload might not be the sole reasons a nurse chooses to join the NHS, but they are invariably powerful economic and psychological factors. Skilled, qualified nurses are in demand all over the world, and it is imperative that remaining in the NHS is an attractive option, especially if the government invests in training nurses. In recent times however, the way in which the training of nurses has been resourced has changed.
The end of bursaries
Students joining a nursing course in 2017 will not have had to access the nursing bursary, which was abolished and replaced by the student loan system. Students will have to borrow to pay their tuition fees, which in recent years have trebled. In short, the cost of a nursing degree has never been higher.
In economics, the intuitive law of demand stipulates that an increase in price will result in a decrease in demand. The combination of fees and removal of bursaries is a de facto increase in the cost of becoming a nurse. Nursing application data would seem to support the assertion that such a cost increase has had an adverse impact on demand for nursing studies. In 2017, applications to nursing courses in the UK fell by over 19% from the previous year, significantly larger than the 3.7% decline seen across applications to all university courses.
Source: UCAS 2017 cycle applicant figures
Despite the fall in applications, the total number of applications is still likely to exceed available places. Indeed, part of the proposed motivation to eliminate bursaries was so that additional funding could be allocated to increasing the capacity of nursing courses. While the government maintains the position that 10,000 new training places will be available at the end of this Parliament, there has been skepticism on behalf of university leaders about whether such capacity will be available. Given the growing nursing shortage in the UK, it is crucial that the government addresses the issue of excess demand, and improve the capacity to train nurses. However, if the sharp decline in nursing applications continues, then excess demand will be the least of the government’s worries.
The migrant workforce
While ensuring that nurses trained in the UK are encouraged to remain in the NHS, it is also important to remember a significant proportion of NHS nursing staff are from abroad. A concern is what post-Brexit immigration policy might look like.
An estimated 7% of nurses in the NHS are EU nationals, yet more and more are leaving the NHS. In 2016, only 12% of new nurses joining the NHS were from the EU. The year before this figure was 19%. Furthermore, in 2016, 11% of the nurses leaving the NHS were from the EU. This is likely to pose a concern for the nursing workforce as a whole and in particular London, where an average of 11% of NHS staff are from the EU, significantly higher than other areas of the country.
Demand for health care fluctuates seasonally, and forecasting increased demand, especially in specialist areas is an impossible task. An incredibly centralised approach to immigration, characterised by arbitrary targets is unlikely to benefit the NHS, and so future immigration policy must be flexible enough to encourage and support talented nurses from across the world to join the NHS. Creating any atmosphere which undermines the role that nurses from abroad play in the NHS would only serve to undermine the entire workforce.
Nurses serve an important purpose in the NHS, and their role is constantly changing as new technology and innovations are introduced to health care. Providing top-quality, clinical care involves skills, experience and compassion.
Efforts must be taken to expand the number of training courses available to student nurses. The contribution of student nurses via their placement work must also be recognised when discussing funding, especially if we are to support individuals from all backgrounds to pursue a career in nursing. Long-term investment into training new nurses will go a long way to relieving some of the current pressures on the NHS.
Once trained, nurses must be retained, and this is unfeasible if working conditions are harsh and the wages poor. There are opportunities across the world for trained nurses, and incentives to stay in the NHS are a necessity. The consequences of work strain on a smaller workforce has been shown to increase the risk of death for patients and worsen the morale and capabilities of nurses. Investments to reward and promote the current workforce will help stave off these potential long-term costs.
Finally, recognising the role of migrants in the NHS is inevitable, and following Brexit, this issue will be more pressing. Creating an environment where the contributions of migrant nurses are valued and respected goes beyond just health policy, but the NHS has the potential to lead the way in creating an industrious and prosperous relationship with migrant workers in the UK.
Addressing these issues is no easy task, but the consequences of a diminished workforce in the NHS has been laid bare this winter. The ageing population of the UK needs a health service stocked with world class professionals, and while nursing may be only one of many professions which provide the vital care to so many, it is a profession which has borne the brunt of many recent health policy changes. For this reason, the task of ensuring a long-term, stable stream of nurses into the NHS, and creating a vibrant, pleasant workplace where nurses can thrive, is key for the future of the NHS.
Maguire, D (2017) “Why we shouldn’t panic about nursing students…yet” The Kings Fund
Baker, C (2017) “NHS staff from overseas: statistics” House of Commons Library, Briefing Paper, No.783
NHS Vacancy Statistics England – February 2015 to September 2017 Provisional Experimental Statistics
 HES, NHS Digital, Nurse turnover by region, nationality and age, September 2012 to 2017 (this information was produced in response to a supplementary information request).
Aiken, L.H., Sloane, D.M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R., Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E. and McHugh, M.D., 2014. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. mortality, 13, p.17.
Aiken, L.H., Clarke, S.P., Sloane, D.M., Sochalski, J. and Silber, J.H., 2002. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA, 288, pp.1987-1993.
Growth rate calculated using Population Estimates data found on NOMIS. We use yearly population estimates between the period 2009 and end of 2016.