The nursing workforce Contents

The current situation

1.In too many areas and specialties, the nursing workforce is overstretched and struggling to cope with demand. Over the course of our inquiry, we heard concerns about the impact of these pressures on morale, retention and standards of care for patients and patient safety.

The following data gives an indication of nursing workforce numbers:

There is no agreed measure of the shortfall in the nursing workforce in England. Health Education England state that there are 36,000 nursing vacancies in the NHS in England, equating to a vacancy rate of 11%,1 while the Royal College of Nursing give a figure of 40,000.2 There is a 9% nursing vacancy rate in social care.3

Vacancy rates mean that posts are not substantively filled, but they may be being filled by bank or agency staff on a temporary basis. HEE estimate that 33,000 of the 36,000 nursing vacancies in the NHS are being filled by bank or agency staff4 This leaves an overall rate of posts wholly unfilled of around 3,000 (1%).

Vacancy rates differ between nursing specialties – learning disabilities nursing is the specialty with the highest vacancy rate at 16.3%, followed by mental health (14.3%) children’s nursing (10.9%) and adult nursing (10.1) 5 The community nursing vacancy rate is estimated at 9.5%.6

Vacancy rates also differ by geographical area. For adult nursing, the highest vacancy rate, 15.7%, is in South London; the East of England has a vacancy rate of 13.4%; the East Midlands 10.1%; and the North East is the lowest at 8%. 7

This significant vacancy rate has in part been driven by the NHS’s response to the public inquiry into poor care at Mid-Staffs, following which many new nursing posts were created, but without a matching supply of new nurses to fill them.

Since 2010 there has been a 1% increase in nurses and health visitors working in the NHS (1,653); however, the increase in nurses has not kept pace with the increase in doctors (12%), consultants (27%) or the population (5.7%).8 There has also been an increase in the complexity and severity of the conditions for which people are receiving treatment in the NHS. It is a tribute to the success of public health and the NHS that people are living longer but many more of us are living with multiple long term conditions.9

The UK has fewer nurses relative to the population than the OECD average, and it is also below many EU countries and traditional comparator countries.10

There is also great variation between sectors. Most of the increase in nurses since 2010 has been in the adult acute sector, with many other sectors experiencing significant reductions:

+7% (+11,983) in general, elderly and adult nurses

+10% (+1,468) in children’s nurses

+11% (2,056) in midwifery

-11% (-4,985) in community services11

-45% (-3,431) in district nurses

-19% (-554) school nurses

-38% (-2,023) across all learning disabilities settings and

-13% (-5,168) across all mental health settings.12

Turnover (nurses moving between different NHS organisations) has also increased from 12.3% in 2012–13 to 15% in 2016–17.13

The total number of nurses working in the NHS fell by around 1,000 in the year June 2016- June 2017.14

Increasing numbers of UK nurses are leaving the profession each year.15 Just over 29,000 UK nurses and midwives left the NMC register in 2016–17, up 9% from the previous year. 16 Around 33% of these were over 60.17

In recent years this has been partially offset by increases in EU nurses working in the UK, but this trend has been reversed in the past year. In 2016–17, 1,107 people from the EEA joined the NMC register, an 89% drop on the previous year, and 4,067 left the register, an increase of 67%. The total number of EEA professionals on the NMC register has decreased by 2,733 in the past year.18

2.Witnesses to our inquiry told us that there is currently a crisis in the nursing workforce.19 However, disentangling the causes, and possible solutions, is challenging because of the rapidly changing training and professional landscape.

3.2017 has seen major changes to the routes into nursing, with the removal of bursaries and the introduction of nursing associates and nursing apprenticeships. The UK’s decision to leave the EU, alongside changes to language testing, have also made an impact on recruitment and retention. We welcome the Government’s decision to publish its Workforce Strategy in draft form, for consultation, and call on the Government to take full account of our recommendations in its final Workforce Strategy which is due to be published in July this year.

4.Issues relating to the nursing workforce span many different but interrelated organisations. But as well as meeting representatives from national organisations, we were particularly keen to hear directly from nurses working at the front line. Therefore, with the help of the Nursing Times, we held two focus groups where we met with nurses from across the country, from a wide range of specialities and at different stages of their careers. The Chair, representing the Committee, met with two nursing focus group at a national team leaders’ conference held in Birmingham.20 The Committee heard from a further focus group of nurses from across the country at its visit to the Royal London Hospital.21 We also heard from trainees in the new nursing associate role as well as those involved in teaching them.22 We are extremely grateful to everyone who contributed to this inquiry, but in particular to those individual professionals who spoke to us so thoughtfully and frankly about their work.

5.We heard evidence that nursing shortages are now having a negative impact on the quality and safety of patient care within both community and hospital settings.23

6.The potential impact of staffing levels on safety was clearly articulated by Sir Robert Francis QC, Chair of the Mid Staffs inquiry and Honorary President of the Patients’ Association, at the Committee’s first session:

Nurses are the glue that keeps together delivery of the service to patients. If you do not have sufficient numbers of caring and compassionate nurses, the patient and perhaps their relatives begin to suffer immediately—there is no one to undertake observations, changes in which tell doctors what treatment is needed. Deteriorations are missed and patients who cannot care for themselves in the most basic ways are left uncared-for.24

7.Written evidence from the Care Quality Commission also raised safety concerns relating to nursing shortages:

Across all health and adult social care settings we are concerned about the shortage of nurses and the impact this is having on the people using those services … Common issues we have identified where there is a shortage of staff relate to inconsistent identification and management of life threatening conditions such as sepsis; incomplete, inconsistent and ineffective audits of key safety priorities and quality improvement projects; poor infection control procedures, including hand hygiene and isolation practices; staff not receiving essential safety training including appropriate safeguarding training; insufficient record keeping, and poor sharing of information–leading to incomplete care plans and tests and treatments being delayed or repeated unnecessarily. Although these issues are not entirely due to a shortage of nursing staff, the overall impact of staff shortages on a clinical team is that these issues occur all too frequently. We are also concerned that some Healthcare Assistants are being asked to carry out tasks which they are not qualified for, and in some cases are actually being called nurses.25

8.Working in teams that are short staffed also has a negative impact on nurses, affecting their own safety and wellbeing, as well as eroding their pride in their role. During the focus groups in Birmingham, the Chair heard a simple and clear message–nurses working in all sectors need “more hands on deck”.26

9.Nurses are clearly concerned that the increasing pressure is having an impact on their ability to deliver safe care. They bear personal responsibility for the delivery of that care. Speaking at one of our informal meetings with nurses, one nurse articulated this concern very clearly, telling us of her fears for her professional registration, “every time I walk onto the ward, my PIN is on the line”.27

10.The increasing demand for health services is well documented.28 Nurses in our focus groups described caring for people living with increasingly complex and serious conditions and the difficulties they face when workload pressures make it impossible to deliver optimal patient care.29

11.Following the Francis report, there was a justified drive to increase nursing staff numbers in acute trusts. However, we heard that this may have drawn nurses away from community and social care services, and that both community nursing and social care nursing services are overstretched.30 Numbers of general, adult and elderly nurses have increased by 7% since 2010, and children’s nurses by 10%, but over the same period community nurse numbers have fallen by 11%.31 This imbalance runs directly against moves to shift more care out of hospitals and into the community.

The current situation: summary

12.The nursing workforce needs to expand at scale and pace in order to provide high quality care, meet rising demand and reduce unacceptable pressures on existing staff.

13.There are particularly worrying shortfalls in certain sectors–district nursing and in nursing homes, mental health and learning disability nursing.

14.We welcome the diversification of the nursing workforce, both in the development of specialist roles and in new opportunities for Health Care Assistants to be able to train as Nursing Associates and, through the apprenticeship route, to be able to study for a nursing degree. The major route into nursing, however, remains the full time university degree and there are worrying signs that the removal of the bursary is having a negative impact on applications from mature students.

15.Whilst training new nurses is important, there has been a loss of focus on retaining the current workforce. The Government must pay greater attention to making nurses feel valued and to improving morale. We welcome the indication that the pay cap has been removed but the government should also reverse the cuts to nurses’ CPD. We turn in more detail to these issues in the following chapters.

1 Q289; Q245 - based on NHS Improvement analysis of trust data

2 Royal College of Nursing (NWO0113) para 2.7

3 Skills for Care (NWO0091) para 1.7. This covers nurses working in care homes with nursing services (88% of social care nurses) in domiciliary care services (7%) and the remaining 5% in other services2. The vast majority of nurses in the sector work for the independent sector, with only an estimated 200 nurses (0.7%) directly employed by local authorities.

4 Q289

6 Figure supplied by HEE

7 Vacancy rates as at March 2016. Health Education England, Facing the Facts, Shaping the Future - A draft health and care workforce strategy for England to 2027, December 2017; p26

8 Royal College of Nursing (NWO0113) para 2.5; population increase is an estimated figure based on ONS data

9 Care Quality Commission, The state of health care and adult social care in England, 2016/17, October 2017; p8

10 Health Foundation, Rising pressure: the NHS workforce challenge, October 2017; pp25–27

11 Community nurses includes district nurses, and other community nurses employed directly NHS trusts or CCGs, It does not include practice nurses.

12 All figures are from May 2010 - May 2017. Source - NHS Digital, cited from NHS Indicators: England, October 2017, Briefing Paper 7281, House of Commons Library, October 2017; p18

14 Figures are Full Time Equivalent (FTE). NHS Indicators: England, October 2017, Briefing Paper 7281, House of Commons Library, October 2017; p17

15 In their publication The NMC register 2012/13 - 2016/17, the NMC state that “it should be noted that as the number of people on the register had increased by several thousand a year until 2016/2017, it is to be expected, to a certain extent that the overall numbers leaving will have increased.”

16 Nursing and Midwifery Council, The NMC register, 30 September 2017,, November 2017.

17 Percentage of leavers in age 61 and above age categories calculated by NMC for Committee

18 Nursing and Midwifery Council, The NMC register, 30 September 2017,, November 2017

19 Q1 (Sir Robert Francis QC); Q98 (Jackie Smith, Chief Executive, NMC)

20 Annex 1

21 Annex 2

22 Annex 2

23 Annex 1 and 2; here, term ‘community’ includes community nurses and primary care nurses.

24 Q2

25 Care Quality Commission (NWO0110) pp4–5

26 Annex 1

27 Annex 1. A nurse’s PIN number is his or her professional registration number, provided by the NMC, which entitles them to practice as a registered nurse.

28 See, for example, King’s Fund, How hospital activity has changed over time, December 2016

29 Annex 1, Annex 2

30 Q17; Annex 2.

31 Figures are from May 2010 - May 2017. Cited from NHS Indicators: England, October 2017, Briefing Paper 7281, House of Commons Library, October 2017, p18

25 January 2018