House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Evidence submitted by the Royal College of Nursing (WP 42)

1. INTRODUCTION

1.1 The Royal College of Nursing (RCN) represents over 380,000 registered nurses, midwives, health visitors, nursing students, health care assistants and nurse cadets in the UK. This makes the RCN the largest professional union of nursing staff in the world. The RCN promotes patient and nursing interests on a wide range of issues by working closely with government, the UK parliaments and other national and European political institutions, trade unions, professional bodies and voluntary organisations.

2.0 SUMMARY AND RECOMMENDATIONS

2.1 The RCN recommends a comprehensive centralised function for workforce planning across the UK health sector. This approach will ensure that the gaps in knowledge about the workforce are filled, trends can be monitored, including movement between countries and different health sectors (private and independent) and also the profile and aspirations of the workforce.

2.2 This approach is fundamental to ensuring NHS care is fair and equitable rather than dependant on local circumstances or markets which could lead to variation in healthcare staffing and care quality.

2.3 Worryingly it is unclear where workforce planning lies under the reconfigured NHS. This is especially important with the increase in choice and plurality of providers.

2.4 There is a growing body of evidence that links the numbers of registered nurses in the acute hospital sector to patient outcomes. Effectively, patients are more likely to die in the surgical settings studied when there were fewer registered nurses on the ward. The RCN recommends that further research is urgently needed to ascertain impacts of the workforce on patient outcomes in order to base changing roles within the health care workforce rather than merely cost.

2.5 The patient: nurse ratio findings are particularly worrying given the context of financial pressures on the NHS in which the RCN has noticed a growing trend to limit workforce numbers. All Trust should have the option to stage deficits for an agreed period of one to three years as agreed within the health economy where achieving in year balance may restrict choice and adversely impact service provision.

2.6 Advanced and extended nurse roles have made a considerable contribution in a number of areas for instance reducing junior doctors hours, and caring for patients at home avoiding hospital admissions. The RCN recommends more attention is paid to advanced nursing roles within workforce planning including investment in nurse education.

2.7 Technology must be properly integrated into working systems, alongside increased access for nurses and healthcare staff supported by training and education.

2.8 The RCN welcomed the Governments drive to increase the number of nurses. However, sustainability in the level of growth of registered nurses is unlikely in the future. Continued focus on recruitment and retention is vital including sustained use of good employment practices.

2.9 Agenda for Change (AfC) incorporated into service contracts in the same way that soft facilities AfC rights have been safeguarded in the private sector, likewise NHS pension regulations.

2.10 Code of Practice on international recruitment is extended to the independent and private sectors and made mandatory.

3. HOW EFFECTIVELY WORKFORCE PLANNING, INCLUDING CLINICAL AND MANAGERIAL STAFF, HAS BEEN UNDERTAKEN?

3.1 Until recently, healthcare workforce planning in England was more centralised. National data has been collected and trends monitored by the national Workforce Review Team with implementation by Workforce Development Confederations aligned to each Strategic Health Authority (SHA). However, responsibility for workforce planning does not appear to be included as part of the newly configured SHA and we do not know where this function will lie in the future or even if it will still exist.

3.2 Information on the health care workforce has been and remains limited and imperfect which works against effective planning. The RCN commissions an annual Labour Market Review (LMR) of the nursing workforce and an annual employment survey of RCN members to monitor workforce developments. The RCN identified shortcomings in workforce information in 2002 and compared progress made on these gaps in 2005 (Appendix 1).

3.3 The RCN welcomes the Governments drive to increase the number of nurses which has seen an increase in registered nurses in the NHS by 23% full time equivalents in England since 1997. However, the recruitment drive has not ended staffing shortages, prevented nurses working unpaid overtime or reduced reported heavy workloads. [108]Furthermore, increased student nurse commissioned places is being undermined by vacancy freezes due to deficits. These graduates will be lost to the system.

3.4 The growing demands of the health service combined with a growth in evidence linking the numbers of registered nurses in the acute hospital sector to patient outcomes including quality of care and patient satisfaction, and clinical outcomes including adjusted mortality rates and morbidity rates, contribute to the imperative that nursing numbers should be maintained at an appropriate level.

3.5 For example, recent independent research in the UK setting by Professor Anne Marie Rafferty, University of London, reveals that for surgical patients in 30 NHS acute hospitals their chance of associated mortality was increased by 12 to 49% in hospitals with the lowest registered nurse to patient ratios. [109]Put another way patients are more likely to die in the surgical settings studied when there were fewer registered nurses on the ward. This is supported by a review of research by West, Rafferty and Lankshear[110] research that demonstrated links between higher numbers of registered nurses in the nursing workforce with improved patient outcomes in the US.

3.6 Determining the threshold or ideal equation of registered nurse to patient ratios is complex and not amenable to national prescription, for a number of reasons including seriousness of patient illness and case mix, treatment and support function facilities and even ward lay out. However there are some key principles which ward managers can apply to determine appropriate (rather than minimum) nurse: patient ratios. The RCN is currently developing work in this area.

4. IN CONSIDERING FUTURE DEMAND, HOW SHOULD THE EFFECTS OF THE FOLLOWING BE TAKEN INTO ACCOUNT?

4.1 Recent policy announcements, including Commissioning a patient led NHS (CPLNHS)

4.1.1 There is uncertainty and low morale amongst the nursing workforce about the impact of CPLNHS. A major concern relates to issues of employment, specifically who will employ them. This may impact on their decision to take early retirement or leave the service.

4.1.2 The drift of the Government's White Paper "Our health, our care, our say" proposes moving care away from the acute and into community settings. However, the increased role for nurses in the primary and community sector indicated by the White Paper could be undermined by the age profile of this group of nurses. When compared with the average age of all NHS nurses, this particular workforce has the oldest age profile with about 23% of District nurses, Health visitors and Community nurses aged between 40 and 50 years. Moreover, some nurse specialisms for example Health visitors have seen no growth in numbers and others, such as District nurses have experienced a decline in numbers.

4.1.3 Under the CPLNHS proposals Primary Care Trusts would remain employers as long as they wanted to, the reality is that PCTs service provision in many cases may be outsourced. The TUPE protection for staff moving from the public to the private sector is a very weak provision and easily eroded

4.1.4 The RCN want to see Agenda for Change (AfC) secured. This means that AfC terms and conditions are incorporated into service contracts in the same way that soft facilities AfC rights have been safeguarded in the private sector.

4.1.5 Similarly, there is no provision for the independent sector or private businesses to adhere to NHS pension regulations. The RCN does not want to see the reforms delivered through a two-tier workforce and recommends that if a provider supplies an NHS service is should be under NHS conditions.

4.2 Technological change

4.2.1 The RCN welcomes the introduction of new technology and the impact that this could have on the nursing and healthcare workforce. Currently, the amount of time nurses spend on administrative work is estimated to be around 25%. The evidence of the impact of technology use ie Telehealth on the clinical workforce suggests that a decrease in workload would be achieved only where integrated technological solutions are used and where workflows are changed to reflect new ways of working.

4.2.2 In 2005, an RCN survey of members highlighted access and training as key issues. Access to IT is mixed although 88% of members used a computer daily about a third shared a computer with around 20 people. Also, community nurses have very limited access if at all. The survey also found a major lack of IT training opportunities within the NHS. The user needs to have the knowledge to use the technology effectively.

4.2.3 In addition the data—patient records—need to be complete and current in order to provide appropriate care. Of those who responded to the survey 63% felt that without timely access to accurate and complete records, the care they deliver could be ineffective or even unsafe.

4.2.4 The RCN recommends that technology must be properly integrated into working systems, alongside increased access for nurses and healthcare staff supported by training and education.

4.3 The increasing use of private providers of services

4.3.1 The Government's drive toward increasing patient choice and the diversification of providers will undoubtedly make workforce planning more complex, with increased competition for nursing staff in local labour markets.

4.3.2 With the increase in providers it is likely that there will be more variation in terms and conditions of nurses' employment contracts. The RCN recommends using Agenda for Change pay scales in all sectors incorporated into service contracts. If organisations are providing an NHS service it should be under NHS conditions.

4.3.3 The contract for Wave 1 of the Independent Sector Treatment Centres (ISTC) contained an additionality clause which prevented providers from employing staff who either worked in or had worked in the NHS in the previous six months. This clause is being relaxed in the current procurement for phase 2 ISTCs. The clause will only apply to staff in specialist areas where there is a known shortage. The work undertaken to identify shortage has raised concerns regarding the lack of workforce information in relation to nursing.

5. HOW WILL THE ABILITY TO MEET DEMANDS BE AFFECTED BY:

5.1 Financial constraints

5.1.1 The RCN has been monitoring the impact of financial constraints on patient care services. [111]The RCN believe that deficits in trusts in England could hit £1.2 billion. Last year's National Audit Office report indicated that deficits totalled £140 million, however, for this year there have been reports that the total level of deficits could be between £750 million (Health Service Journal) and £1.6 billion ( (Health Emergency)

5.1.2 We have noticed a general trend in how NHS organisations progressively respond:

— Bans on the use of temporary staff;

— Vacancy freezes—this impacts on the intake of students;

— Limitations on service provision, for example, health visiting;

— "Disinvestment" in some clinical services;

— Staff redundancies, voluntary or compulsory.

5.1.3 In order to prevent instability in service provision Trusts should be allowed to operate within a more flexible financial regime. Short term cost cutting can seriously impact medium and long term improvements in service provision. In an RCN survey of 1,000 nurses in February 2006 over a quarter of those surveyed cited that patient treatments were being delayed in order to save money.

5.1.4 All Trust should have the option to defer deficits for an agreed period of one to three years as agreed within the health economy where achieving in year balance will restrict choice and adversely impact service provision.

5.1.5 Furthermore, sustainability in the level of growth of registered nurses is unlikely in the future, partly as a result of increased government funding in the NHS ending in 2007-08. [112]

5.2 The European Working Time Directive (EWTD)

5.2.1 Implementation of the EWTD, without compromising patient care, demands new approaches to staffing and service deliver with Nurse practitioners and other advanced nursing roles making a positive impact on patient outcomes.

5.2.2 Advances and extended nurse roles have made a considerable contribution to current compliance with EWTD/reduced junior doctors working hours and this is recognised within the Department of Health evaluation of the "Hospital at Night" scheme. Nurses are now often the first point of contact and deal with a substantial proportion of patients who are acutely ill and need intervention. As of June 2005, over two dozen hospitals across England have implemented the Hospital at Night concept for out-of-hours cover.

5.2.3 More generally, a joint Department of Health/RCN recent survey Maxi Nurses: Advanced and Specialist Nursing Roles[113] reveals that advanced nursing practice (by nurse practitioners, clinical nurse specialists, specialist nurses and nurse consultants) has significantly contributed to improved patient care and service capacity, including caring for patients at home thus avoiding hospital additions. In addition these roles aide meeting targets in a variety of settings including accident and emergency departments and clinical diagnostic services:

— 60% of these nurses' time is spent in clinical activity;

— one third say patients can access their expertise directly; and

— one quarter provide on-going and continuous care and treatment of the same patients.

5.2.4 There is also hard evidence to demonstrate the effectiveness of nurse practitioners in patient care. For example a recent Cochrane review[114]—which is a "gold standard" structured review of research—found that nurse practitioners in primary care had at least equivalent patient outcomes to doctors, and in fact scored higher in terms of patient satisfaction.

5.2.5 However there are difficulties for nurses in obtaining funding for national courses in advanced practice such as the nurses practitioner programme, and also problems with "backfilling" their posts whilst they study. Yet appropriate education and support is an essential prerequisite for advanced nursing roles.

5.2.6 The RCN recommends more attention is paid to advanced nursing roles within workforce planning including investment in nurse education for advanced nursing roles across a range of sectors including mental health and learning disabilities.

5.3 Increasing international competition for staff

5.3.1 International recruitment grew rapidly in the late 90s and last year accounted for about 40% of new entrants Nursing and Midwifery Council (NMC). Apart from data from the NMC register on nurses entering the UK, there is no monitoring of the movement of international nurses either in the NHS or the Independent sector. There is no available data on the flow of UK-trained nurses going to work abroad or the movement of nursing staff between the four UK countries.

5.3.2 Buchan's report[115] for the Kings Fund reports on the country and demographic profile, motivations, experiences and career plans of recently recruited international nurses working in London, and gives a detailed insight into why they have come to the UK, and what their future intentions are. In order to put these findings in context, the paper also outlines the overall trends in the number of nurses coming to the UK, and examines the policy context in which international recruitment activity has been conducted.

5.3.3 The NHS in London has more staff vacancies and shortages than the rest of the country and employers have become increasingly reliant on overseas health workers to make good the staffing shortfall. [116]The annual survey of RCN members in 2003 found that 14% of nurses based in London had qualified outside the UK compared with just 4% in the UK as a whole.

5.3.4 London is also more vulnerable to outflows of these workers. Buchan argues that alongside the challenge to develop effective human resources strategies to support and integrate these staff in the NHS will be the challenge to retain these staff as other countries seek qualified staff to boost their own workforces. Sustained use of good employment practice that encourages staff to stay in, and return to, the NHS and the local recruitment of new workers as part of a "grow your own" strategy, will, according to Buchan reduce the need for international recruitment.

5.4 Early Retirement

5.4.1 The RCN annual employment survey 2005[117] shows that one in six of all nurses intend to continue to work in nursing beyond retirement age which is 60 for current employees. There is some variation between sectors; the planned retirement age of respondents in the independent sector is 60 (NHS, 59) and respondents' ideal retirement age is 57 (NHS 56). [118]

5.4.2 In 1991 one in four (26%) nurses on the register was aged under 30 but by 2005 this had dropped to only about one in 10. At the same time, the proportion of nurses on the register who were 55 or older had risen from 9% to 16%. More than 100,000 nurses are now aged 55 or older and a further 80,000 are 50 to 55 years-old.

5.4.3 Buchan argues that the level of nurses leaving the register is bound to grow as the large numbers aged 50-plus increases over the decade. It is also likely that fewer of the older nurses who remain on the register are likely to continue working and older nurses who do continue to work are less likely to work full-time.

5.4.4 This is partly because of the reductions in student nurse intakes in the early to mid-1990s. It is also partly the result of a trend towards an older age profile of students with more mature entrants, and the emphasis on attracting those returning to the profession.

5.4.5 The main challenge for workforce planning will be to replace the 180,000 nurses who are 50 plus and who are considering retirement or to encourage them to delay retirement.

5.4.6 The impact of phasing in a higher pensionable age for new entrants will also need to be monitored in terms of retirement behaviour and its effect on the attractiveness of nursing as a career.

6. TO WHAT EXTENT CAN, AND SHOULD DEMAND BE MET, FOR BOTH CLINICAL AND MANAGERIAL STAFF BY:

6.1 CHANGING THE ROLES AND IMPROVING THE SKILLS OF EXISTING STAFF

As stated above, nurses have expanded and advanced their roles in order to accommodate reform, and improve patient care. However, further investment in educational preparation for advanced practice roles is needed in order to continue to progress this trend.

6.1.2 There are difficulties for nurses in obtaining funding for national courses in advanced practice such as the nurse practitioner programme, and also problems with "backfilling" their posts whilst they study. Changing the roles of healthcare staff is much more complex than simply passing work from one group, for example doctors, down to another, for example nurses, and so on. Changing roles is also a dynamic process and depends upon the numbers of staff, their skills and expertise, patient acuity and case mix, but especially how health care staff function and work together as a team.

6.1.3 The evidence base in this area is limited, but growing. There are three main areas of research, which can inform current policy and practice: improving multi-disciplinary team work; skill mix within nursing; and, skill mix between nurses and doctors.[119], [120]

6.2 Better retention and the recruitment of new staff in England

6.2.1 The 2004 report on improving recruitment and retention in primary care commissioned by the Department of Health[121] aimed to find out what will assist Primary Care Trusts and Workforce Development Confederations to establish flexible and supportive entry routes and programmes that will enable nurses to work in primary care at registered nurse level.

6.2.2 The RCN Labour Market Review 2004-05[122] also gives some figures on the number of nurses completing return to practice courses and other data on retention and recruitment of nurses.

6.2.3 Research suggests that nurse choice in shift decisions may alleviate some of the ill effects of shift work, and may promote nurse recruitment, retention and return to practice. Work schedules impact on many aspects of nurses' working and domestic lives, and on their retention in the workplace. A number of studies suggest that nurse retention is related to control or choice over working lives and conditions, and that rigidity of rostering results in increased nurse turnover. [123]

6.2.4 Student attrition is another area of concern. A survey carried out by Nursing Standard magazine revealed that around one in four student nurses are failing to complete their training courses. The RCN recommends monitoring students' reasons for leaving their training in order to provide evidence that could help to reduce attrition rates in the future.

6.3 International recruitment

6.3.1 A report, by the Health Systems Resource Centre, [124]provides an overview of the implications of international recruitment of health workers to the United Kingdom. The authors recommend that data on the numbers of international nurses recruited by and working in the NHS be routinely collected. They also suggest that Department of International Development examine the potential of working with representative bodies from the independent sector to develop a parallel Code of Practice on international recruitment.

6.3.2 Our member survey indicates the heavy reliance that nursing has on overseas recruitment. Although all registered nurses are included on the UK Work Permits shortage list, this is currently being reviewed with a steer from the Department of Health to remove nursing from the list. If this is actioned it will create difficulties for ensuring an adequate nursing workforce.

6.3.3 The RCN recommends that data is collected on the numbers of international nurses recruited from overseas and working in the NHS and private sector and monitored.

6.3.4 The RCN also recommends that the Code of Practice on international recruitment is extended to the independent and private sectors and made mandatory.

7. HOW SHOULD PLANNING BE UNDERTAKEN?

7.1 To what extent should it be centralised or decentralised

7.1.1 In the early 1990s workforce planning was left to local planning decision and direction. This led directly to shortages of registered nurses because insufficient numbers of pre-registration nurse education places were commissioned, insufficient attention was paid to independent health sector recruitment, and local and national problems with recruitment and retention of qualified nurses were not detected or remedied. [125]

7.1.2 The RCN believes there should be a centralised function for workforce planning across the UK health sector in order that trends can be monitored, including movement between countries and different health sectors but also the profile and aspirations of the workforce. This is fundamental to ensure NHS care is fair and equitable rather than dependant on local circumstances or markets which could lead to further variation in healthcare staffing and care quality. The approach will also avoid "see-sawing" with drives to recruit then redundancies.

7.1.3 The international literature seems to support workforce planning for the entire health service "integrated workforce planning" taking into account changing roles and the reconfiguration of services. [126]

7.2 How is flexibility to be ensured?

7.2.1 Knowledge about local and regional workforce and labour market issues will be vital, however as the number of employers increase and job mobility and flexibility increases, monitoring movement between employers will need to be centralised in some way.

7.2.3 Without this approach, there will be more scope for ever increasing gaps in knowledge about the healthcare workforce as nurses move in and out of the NHS or increasingly work through banks and agencies, making strategic planning increasingly more difficult to manage.

7.3 What examples of good practice can be found in England and elsewhere?

7.3.1 The growing recognition of the linkages between effective staffing levels and outcomes (including patient safety) have led to attempts to identify the "best" methods of determining staffing levels.[127], 128[128] However there is evidence that different systems applied in the same care environment will give different staffing "answers".[129]

7.3.2 Examples of computer-based projections and simulation models used to forecast human resource needs are discussed along with their limitations. [130]Best practice examples are given from Scotland where planning involves projections, combined with involvement from stakeholders (see below).

MULTI STAKEHOLDER WORKFORCE PLANNING IN SCOTLAND

The nurse workforce planning system in Scotland is one working example that involves employers and the private sector in national level nurse workforce planning. [131]This annual system uses "bottom up" planning involving all health service employers, as well as representatives from nursing associations and the education sector. The approach attempts a whole system perspective by factoring in estimates of future demand for nurses from the private sector. There is now a statutory duty on the NHS in Scotland to carry out workforce planning.

7.3.3 Some countries have used national recommended staffing rates but these vary in terms of definition, source, and the extent to which they could be regarded as mandatory or minimum, and they often apply to narrow, precise specialties.

Alison Cairns

Royal College of Nursing

15 March 2006

APPENDIX 1

MIND THE INFORMATION GAP: GROWING THE WORKFORCE[132]

Things we need to know	The reality
(1) We do not have accurate UK wide attrition rates during pre-registration of nursing and midwifery education.	A common definition has been agreed in England for common measurement but there is currently no complete and comparable data across the UK.
(2) We do not know with any accuracy how many newly qualified nurses and midwives take up employment in the NHS or elsewhere.	No improvement: has been made more problematic because of changes in student indexing
(3) We have little published evidence of the actual retirement behaviour of nurses; a vital issue given that so many are in the 50+ age group.	Little improvement: and the issue is now even more significant because of ageing workforce and proposed changes in NHS retirement scheme for future entrants.
(4) We have no accurate knowledge of how many of the growing number of overseas registrants are actually working in the UK, or where they are based.	No improvement. NHS in England does not record how many international nurses it employs, despite this being recommended by House of Commons Committee. No accurate information on outflow of nurses.
(5) We have only scant information on the "cross border" flows of nurses between the four UK countries—this is likely to become a growing issue with devolved government and diverging health policies in the four countries.	No improvement in published information
(6) We have no recent detailed information on the actual number of "re-entrants" who stay working in the NHS after refresher training, where they are working, and the hours they work	Worsened. Return to practice data no longer collated in national level in England.
(7) We do not have consistent or complete information on vacancy rates across the four countries to assess the impact of shortages	No improvement; and more questions being asked about relevance of "point in time" three month vacancy rate.
(8) We do not have complete data on flows of "joiners and leavers" in the NHS to assess with any accuracy the current sources of recruits and destinations of nurses leaving the NHS.	No improvement in England; major source is OME sample survey, with worsening response rates.
(9) We have only scant information about the dimensions of the growing non-NHS nursing labour market and the "flows" of nurses between the NHS and other nursing employment.	Worsened. Data no longer collated nationally in England
(10) We do not have UK wide information about the ethnic composition of the UK nursing population or workforce, to enable any assessment for potential to recruit, or to monitor equal opportunities in employment.	Attempts at improvement, but changes in definitions, and large "unknown" response rate limit utility of data.