16.Growing numbers of UK trained nurses are leaving the profession–around 29,000 UK nurses and midwives (5%) left in 2016–17, up from just under 21,000 (3.6%) 2012 - 13. Around 33% of those who left in the past year were over 60 years of age. Figures show that the percentage of nurses leaving the NHS has also increased over that period. Since 2012–13, 8,000 nurses have left social care.
17.Health Education England told us that “if we had kept the 2012 retention figure right the way through, we would have 16,000 more nurses now than we do at the moment, which is about 50% of all the vacancies we have in the NHS. These numbers are very large”. However, most Government policy has focused on increasing the number of new nurses, rather than working to retain existing nurses. It takes at least three years to train a new nurse, meaning that the Government’s new routes into nursing may help in the medium and long term, but will not address the immediate nursing shortage. Unless pressures are addressed, we also know that there is a greater chance that more of these newly qualified nurses will leave. There needs to be a greater focus on retaining the current nursing workforce.
18.The nurses we met described nursing as a rewarding, fulfilling and dynamic career, full of possibilities - in the words of one nurse, “the world is your oyster”. They described colleagues as ‘doing an incredible job’, all with immense “cheer and care and kindness”. However, despite their clear and undisputed value in all clinical settings–across the community as well as hospitals and mental health services–nurses report that they do not feel valued. That needs to change.
19.Although not enough research has been done to understand why nurses leave nursing, difficult working conditions, exacerbated by staffing shortfalls, are likely to be playing a significant part. According to the Nursing and Midwifery Council (NMC) working conditions are a major factor in nurses leaving the profession.
20.Jackie Smith, Chief Executive of the NMC, told us:
The 4,500 who responded said that the issue for them was working conditions. That can encompass a lot of things. That is about staffing levels; about flexibility; about pay; and about not investing in their future. Cuts to CPD are a major issue. That’s what I hear when I go around the UK. The nursing profession does not feel valued. What it does is not recognised sufficiently. For them they think “I may as well go elsewhere and do something else”. That is tragic. That is not what we need.
21.The Royal College of Nursing gave a similar assessment:
They feel that they are not valued … . there are not enough staff, you are not getting a pay rise, and your education budget is being cut. Every which way you look, everything that supports nurses has been reduced over time.
22.For nurses returning to practice through Health Education England return to practice schemes, lack of flexibility was the top reason for initially leaving, for example to fit in with childcare or other personal circumstances.
23.We heard that ongoing pay restraint is having an impact on both recruitment and retention. During the course of this inquiry, the removal of the pay cap for nurses has been announced, which we welcome.
24.We were assured that additional funding above the 1% current cap will be provided separately from the existing Budget settlement for the Department of Health. The Government has said, however, that any future pay deal will be on the condition that the pay award enables improved productivity in the NHS. NHS productivity is already higher than the background rate of the wider economy. We urge the Government to come forward with realistic proposals as nursing is already an overstretched workforce. recommended in this pay review in full rather than expect the NHS to fund it from already overstretched resources.
25.It is essential that pay rises alone are not seen by Government as the sole solution to the problem of nurse retention, as we have heard in this inquiry that pay is only one element amongst many.
26.During the focus groups with nurses in Birmingham, the Chair heard a clear message–nurses working in all sectors need “more hands on deck”. As we have noted above, nurses are clearly concerned that the increasing pressure is having an impact on their ability to deliver safe care, for which they bear personal professional responsibility.
27.Staff shortages have been reported in RCN surveys, and were described very clearly by nurses in our focus groups from across a wide range of settings and geographical areas. HEE reports that most (92%) of the 36,000 nursing vacancies are filled by agency or bank staff, rather than actually being vacant. However, agency staffing is not only costly, but can create other difficulties. Some nurses prefer to carry out bank or agency work as it may give greater flexibility and higher rates of pay. This itself may be contributing to perceived staff shortages. Whilst bank staff allow some flexibility in meeting variations in demand, the priority, in order to provide the best standards of care and continuity, must be to recruit and retain permanent staff. Permanent posts must not be deliberately left vacant or recruitment delayed to ease financial pressures.
28.Nurses described often arriving early for shifts and finishing late, and not being able to take breaks because there are too few staff on duty. The Royal College of Nursing argued that nursing shortages are impacting on handovers between nurses at the beginning and end of shifts, again potentially threatening the quality of care to patients.
29.Nurses also told us that they lack even basic facilities on the wards where they work to prepare food and drink for themselves. The RCN explained, for example, that having food available in canteens that are a 10 minute walk from the ward where nurses are working is no good if the nurse’s break is only 15 minutes long. Nurses told us that even where some trusts do provide wellbeing initiatives, they struggle to find the time to attend.
30.We also heard about these issues from independent commentators outside the nursing profession. Sir Robert Francis QC, Chair of the Mid Staffordshire inquiry and honorary President of the Patients Association, gave the following view:
A huge number of staff are working in, frankly, unacceptable and unsafe conditions. I believe that must impact particularly on nurses, because of their role in the front line, being professionally responsible for the standard of care delivered on a minute-by-minute basis to patients, allied sometimes to the feeling that they cannot do it—I have heard a lot about that—and the stress of not being able to deliver what a nurse or a professional knows should be delivered. That must make life impossible. That will discourage people from joining the profession. It will encourage people to leave it.
31.We were concerned to hear that some nurses lack basic facilities during their breaks or even the time to take them and felt that they were not allowed to sit down and spend time talking to patients over a cup of tea. We believe there are times when this may enhance care and were reassured to learn from the Chief Nurse that there is no prohibition on this happening.
32.Our evidence argues that reductions in the availability of funding for continuing professional development (CPD) is a major issue contributing to nurses leaving the profession. The budget for nurses’ CPD has fallen from £205 million to £84 million in two years.
33.NHS Employers highlighted this as a ‘fundamental’ priority for national action, arguing that “the level of disinvestment … limits … not just the opportunities for advanced practice, but a standard way of investing in the training of people to carry out the jobs they need to carry out, particularly in specialist settings such as intensive care and community settings”.
34.The RCN also raised this as a major issue:
I am talking to Directors of Nursing all the time, who are trying to get their nurses on an intensive care programme, or accident and emergency, or community providers who need someone to do the district nurse programme. There is no money for those programmes at the moment. It has been pretty much decimated.
35.For nurses working in social care, the situation regarding access to continuing professional development is even worse.
36.Nurses we spoke to in our focus groups felt that even if funding were available for their training, they were so busy they would be unlikely to be able to take time away to attend. One nurse told us “You are lucky if you can get released to go to a meeting, let alone a study day”.
37.Health Education England told us that reducing nurses’ CPD funding had been a conscious decision taken in the context of the decision to invest in training more of the future workforce. However, they indicated that they now intended to increase funding again for nurses CPD. We would like to see evidence of a clear plan for reintroducing this.
38.We heard that nurses want increased flexibility in the way they work. Staff shortages make it even harder to enable nurses to work flexibly. We heard from the RCN that organisations could make far better use of tools like e-rostering.
39.NHS Employers told us about the work they had undertaken to support providers to improve nurse retention, indicating three areas of focus:
40.The first point, increasing support for newly qualified nurses, is a clear area for further action. The Capital Nurse scheme told us that nearly 20% of newly qualified nurses in their area leave within their first year and about their plans to tackle this.
41.Nurses at our focus groups told us that staff shortages mean that newly qualified staff face a hugely challenging working environment and that established staff simply do not have time to support them adequately.
42.On career development, we heard that often nurses want to broaden their experience by transferring between departments, providers and specialities. However current employment practices do not always make it easy to do so. We heard about bureaucratic barriers to nurses applying for internal vacancies within their own organisation. We also heard about other barriers needlessly preventing the recognition of skills when nurses move organisations. This not only gets in the way of flexible career paths but denies patients and professional colleagues the benefit of nurses’ expertise. We heard that nurses have to specialise very early in their training, and opportunities to switch to a different speciality later in their careers are limited. The Capital Nurse scheme in London is attempting to overcome these problems and offer early career stage nurses increased choice and flexibility over their career paths.
43.We welcome the focus to date on the supply of new nurses but these will take time to deliver. There therefore needs to be a greater focus on retention, driven by an explicit commitment to making the nursing workforce feel valued including increasing the opportunities for professional development.
44.Our evidence suggests a clear need for national action to:
45.We note the work that is already under way by NHS Employers and NHS Improvement to support trusts with retention, and we recommend that this work should continue, with a specific focus on initiatives that will increase the opportunities for nurses to access high quality continuing professional development, flexible career pathways and flexible working. NHS England, NHS Employers and HEE should facilitate transfers and training for nurses who wish to move between departments, organisations and sectors and remove unnecessary bureaucratic barriers which prevent recognition of their skills
46.Health Education England must reverse cuts to nurses’ continuing professional development budgets. Funding allocated to trusts should be specifically ringfenced for CPD for nurses, and specific funding should be made available to support CPD for nurses working in the community. We also recognise the need for Health Education England to be able to support training in areas where the NHS has skills shortages. We heard a clear message that access to continuing professional development plays an important role in retention. It will also need to reflect skill shortages and patient needs. This change should be clearly communicated to nurses both by national bodies and by employers, and a clear audit trail should be available to ensure that funding reaches its intended destination. We will review progress on this recommendation in one year, and will expect HEE to be able to demonstrate clear action on each point.
47.The Chief Nursing Officer should take a lead in setting out how to ensure that nurses are working in safe and acceptable working conditions. Nurses must be able to hand over patients to colleagues safely, without routinely staying late; nurses must be able to take breaks; and nurses must have access to facilities to make food and drink near their place of work.
48.There needs to be a greater focus on staff wellbeing in all areas. This work should be driven forward as a national policy priority, and nurses of all grades and from all settings should contribute to it.
49.As a first step, we recommend that the Chief Nursing Officer should write to all Directors of Nursing, including in social care providers, asking them to confirm whether their nurses are able to complete handovers without routinely staying late, and whether they have time to take their breaks.
50.The Chief Nursing Officer should establish a nursing wellbeing reference group, with membership of nurses from all grades, career stages and settings, which should design and oversee a programme of work to monitor and help to advise on improving nurses’ working conditions.
51.Underpinning all this is the pressing need to expand the nursing workforce at scale and pace. Without that action, many nurses will continue to experience unacceptable pressure, and will continue to leave the nursing profession.
32 Nursing and Midwifery Council, , November 2017. In their publication , 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.”
33 Percentage of leavers in age 61 and above age categories calculated by NMC for Committee
34 Department of Health ) p9
35 Skills for Care
37 Annex 1
38 Annex 1
39 The term ‘community’ includes community nurses, district nurses, primary care nurses, and nurses working in social care settings.
40 Nursing and Midwifery Council, , July 2017, p9
45 HC Deb, 10 October 2017, [Commons Chamber]
46 HM Treasury, , p3
47 Centre for Health Economics, University of York, , April 2017, p48
48 Annex 1
50 Annex 1
51 Health Education England, ,, December 2017; p108
52 See for example Annex 1; Care Quality Commission pp1–2
53 Annex 1
54 Q34; Royal College of Nursing
56 Annex 1
58 Q247 - Q256
59 Q54; Q89;.
60 Royal College of Nursing para 2.16
64 Annex 1
67 Annex 1
71 Annex 1, Annex 2
74 Annex 2
75 Capital Nurse
76 The term ‘community’ includes community nurses, district nurses, primary care nurses, and nurses working in social care settings.
25 January 2018