1.On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England and NHS Improvement (NHSE&I) and Health Education England (HEE) on the NHS nursing workforce.
2.Nurses are critical to the delivery of health and social care services, and have played a vital role in caring for people during the COVID-19 outbreak. In 2019, the NHS employed around 320,000 nurses in hospital and community services, making up a quarter of all NHS staff, with a further 24,000 employed in GP practices. Around one in ten registered nurses works in social care.
3.In January 2019, the NHS Long Term Plan set out future service commitments and acknowledged the need to increase staff numbers, noting that the biggest shortfalls were in nursing. By the start of 2020, there were nearly 40,000 nursing vacancies in the NHS, a rate of 11%. The Long Term Plan has set a goal of reducing the nursing vacancy rate to 5% by 2028.
4.A range of national and local NHS bodies are responsible for (nursing) workforce planning as well as supply, which includes training, recruitment and retention of staff. The Department of Health & Social Care (the Department) retains overall policy for the NHS and social care workforces. Health Education England (HEE) oversees NHS workforce planning, education and training, while NHS England and NHS Improvement (NHSE&I) supports and oversees the performance of NHS trusts, including in relation to workforce retention and other workforce responsibilities. Local NHS trusts, foundation trusts and GPs employ nursing staff, and are responsible for their recruitment, retention and day-to-day management. Non-NHS bodies, such as universities, also play an important role in individual supply routes.
5.The NHS Long Term Plan, published in January 2019, stated that a workforce plan would be published later in 2019, following agreement of HEE workforce education and training budgets in an anticipated Autumn spending review. In June 2019, the Interim People Plan reiterated that there would be a fully costed five-year plan later that year. However, at the time of the NAO’s report in March 2020, the People Plan had still not been published, in part due to the postponement of the full spending review, and the December 2019 general election. The full People Plan was rescheduled for publication in spring 2020. However, NHSE&I told us that due to the outbreak of COVID-19, the People Plan has been delayed further so that the NHS can focus on responding to the crisis.
6.NHSE&I now plans to publish the People Plan in two parts. The first, published in July 2020 a few days after our oral evidence session, set out national and local actions for the remainder of 2020–21, with a focus on enhancing NHS culture and leadership. The second will cover plans to ensure the NHS has the nurses it needs. NHSE&I told us that it would publish the later document after the next Spending Review, as its plans are dependent on long-term funding for workforce education and training, which the Review will set. This is a repeat of the situation at the time of the NHS Long Term Plan, which also deferred publication of a workforce plan, because long-term HEE budgets for workforce education and training had not been agreed. Currently, NHS England’s budget has been agreed up until 2024, while HEE’s budget is only agreed up to 2021. This will mean nearly two years going by between the NHS Long Term Plan and the workforce plan that was meant to support it.
7.NHSE&I told us that the advent of COVID-19 meant that workforce planning over a horizon of three to four years was not currently possible, and at the moment the main focus of the system was on winter planning. It thought it would be possible to make a longer-term plan after winter, once the impacts of COVID-19 on service levels are clearer.
8.It is essential that the NHS understands not just how many nurses it needs, but where and in what specialisms. However, the NAO and other stakeholders have noted that the NHS Long Term Plan contained service commitments that did not have a complete assessment of the type and number of nurses needed to deliver the plan. For example, for cancer service commitments, there were no separate estimates of the overall cancer nursing capacity required, but an assumption that cancer needs would be met from the overall increase anticipated for the nursing workforce. In December 2019, while the People Plan was still in development, the government made a pledge to deliver 50,000 more nurses by 2025. However, the NAO’s report found that, in March 2020, NHSE&I and HEE were still developing their model to understand and quantify the demand for nurses.
9.The Department acknowledged that the demand for nurses and the extent of nurse shortages vary between specialisms and regions. For example, in the period July–September 2019, NHS trusts in England reported an overall nursing vacancy rate of 12%, but these ranged as high as 16% for mental health trusts and 15% in London. Macmillan Cancer Support noted that the number of specialist cancer nurses is not rising at the pace that patients need. Similarly, Unison reported that the number of nurses registered with specialist community and public health qualifications has fallen every year since 2016. Between 2010 and 2019, the overall number of NHS nurses in hospital and community services rose by 5%, but numbers in some specialisms reduced—for example, a 38% reduction for learning disability nurses.
10.The Department explained that estimates of the number of nurses the NHS needs and where are not determined centrally but are produced locally through a bottom-up approach. NHSE&I said that local areas are currently revising their workforce plans in light of COVID-19. These will take account of the staff needed to reintroduce some of the non-urgent care that stopped during the peak of the pandemic and to prepare for a possible increase in the number of COVID-19 cases during winter. NHSE&I said it intends to publish its overall estimate of the number of nurses the NHS needs with the second part of the People Plan, after the publication of the settlement for education and training.
11.Nursing students cover both health and social care in their training and decide which sector to work in after they graduate. This means that social care providers recruit from the same overall pool of nurses as the NHS. The Department noted that approximately 80% of nursing graduates join the NHS and the other 20% start work in social care, primary care or the independent sector, or do not practise as nurses. It acknowledged that there are currently around 4,000 vacancies for social care nurses. As Skills for Care has reported, the vacancy rate for nurses in social care has increased from 4.1% in 2012–13 to 9.9% in 2018–19. The Royal College of Nursing also noted that the number of registered nursing posts in social care has fallen by 1,000 in the last year and by 10,400 (20%) since 2012–13.
12.The Chief Nursing Officer of NHSE&I emphasised how the COVID-19 pandemic has illustrated the importance of social care and the value of better integration between health and social care. She commented that “if anything good can come out of it [the pandemic], that will be the focus on social care” and “if there is anything to learn from the pandemic, it is about how we have closer integration between health and social care … which therefore includes the workforce.” However, the Department told us that social care will not be included in the NHS People Plan as the focus of the plan is on developing the workforce to deliver the Long Term Plan for the NHS. Social care nurses are also not included in the NHSE&I and HEE model of the supply and demand of nurses to the NHS, which supports the People Plan . The Department argued that it would be too challenging to develop an integrated workforce plan for health and social care as the sectors have different statutory bases and its powers and influences over them are not the same.
13.The Interim People Plan envisages a more pivotal role for integrated care systems, which are local partnerships of health and social care bodies that are jointly involved in local workforce planning and strategy. However, the NAO reported that partnerships are not statutory and therefore have no organisational accountabilities, and rely on the goodwill of constituent bodies. The King’s Fund and Sue Ryder also noted that partnerships vary in their readiness and capacity to take on wider workforce planning. In 2018, the Care Quality Commission reported, on the basis of 20 local system reviews, that it had not been assured of effective joint workforce planning across health and social care. HEE told us that integrated care systems are “working much more seamlessly” between the NHS and social care but acknowledged that there is “much more work to do” to bring the two sectors together.
14.The Department told us that its initiatives to increase the supply of nurses into the NHS should benefit social care as both sectors have the same entry route. However, our Committee remains concerned about potential barriers to moving between sectors such as nurses who move from the NHS into social care dropping out of their NHS pension. Locally, health and social care providers can also be in competition with one another for nursing staff. The Department argued that the fact it has separate plans for health and social care does not signify one being dominant over the other, and said it takes “a whole series of actions” for the social care sector. However, our Committee has warned before that the Department gives relatively little consideration to adult social care compared with health, including in reports on The adult social care workforceand Readying the NHS and social care for the COVID-19 peak. For example, the latter report illustrated the stark contrast in the approach taken towards protecting the NHS from the pandemic compared with the care sector, with an action plan for adult social care published four weeks after the initial NHS letter on plans to respond to the COVID-19 outbreak. The Department acknowledged that the social care system is highly fragmented, for example, in the way it is run by a number of different providers, and told us there are some “yet-to-be-answered questions” about whether the Department will retain some of the national oversight and interventions in social care that it has used during the COVID-19 pandemic. The Permanent Secretary of the Department said that “we will certainly be wanting to look at what we have learned about social care during COVID and baking that into future policy.”
1 C&AG’s Report, The NHS nursing workforce, Session 2019–21, HC 109, 05 March 2020
2 C&AG’s Report, paras 1.1, 4
3 NHS Digital, , data based on NHS England and NHS Improvement information, February 2020
4 C&AG’s Report, para 2, 1.4, 3.3
5 C&AG’s Report, para 1.10
6 Q 22; C&AG’s Report, para 11 & 3.9
7 Q 20
8 NHS, , July 2020
9 Qq 21–22
10 C&AG’s Report, para 11 - 12
11 Qq 20, 24
12 C&AG’s Report, para 4, 3.4a; Sue Ryder submission, para 10; - The King’s Fund submission, para 14
13 Q 23; C&AG’s Report, paras 11, 3.11
14 Q 71
15 C&AG’s Report, para 1.4
16 - MacMillan Cancer Support submission, para 2.2; - UNISON submission, para 15
17 C&AG’s Report, para 1.2
18 Qq 20, 21, 34, 36
19 Q 37
20 Skills for Care, , Chart 28, October 2019
21 - Royal College of Nursing submission, para 1.6
22 Qq 18, 65
23 Qq 15–17, 19,
24 C&AG’s Report, para 3.11
25 Qq 17, 29
26 C&AG’s Report, paras 1.12
27 - Sue Ryder submission, para 2; - The King’s Fund submission, para 12
28 C&AG’s Report, para 1.12
29 Q 37
30 Qq 29, 65
31 C&AG’s Report, para 1.6
32 Qq 17, 30
33 C&AG’s Report, The adult social care workforce in England, Session 2017–19, HC 714, 8 February 2018
34 C&AG’s Report, Readying the NHS and adult social care in England for COVID-19, Session 2019–21, HC 367, 12 June 2020
35 C&AG’s Report, Readying the NHS and adult social care in England for COVID-19, para 8
36 Q 19
Published: 23 September 2020