2Delivering the nurses the NHS needs
Increasing the number of nurses
15.In December 2019, the government confirmed its manifesto commitment to increase nurse numbers by 50,000 by 2025.37 To deliver this, the Department has set up a programme board, chaired by the Minister of State, which brings together all the relevant bodies with responsibilities for nursing.38 The Department clarified that it took overall responsibility for delivery of this commitment, with NHSE&I and HEE leading on delivery for individual routes.39
16.The Department told us that it planned to meet the commitment to deliver 50,000 more nurses by increasing the domestic supply of graduate nurses, widening access to nursing through, for example, apprenticeships, improving retention rates and continuing to recruit from overseas. However, the Department and HEE were unable to quantify how many nurses they expect from each of these different routes. HEE told us that its plans are dynamic and changing in the light of the COVID-19 outbreak, for example, to reflect an increase in the number of people applying for nursing degrees.40 NHSE&I expects to publish details of the numbers of nurses it needs with the second part of the People Plan, after the publication of the Spending Review.41
17.The Long Term Plan signalled the need for a “step change in the recruitment of international nurses”. In 2019, there were 51,000 overseas nurses working in the NHS (17% of the nursing workforce), with overseas nurses already making up between 20% to 25% of new joiners since 2012.42 HEE confirmed that its global learners programme that supports trusts to bring overseas nurses to work in England had missed previous recruitment targets; over the two years 2018 and 2019, it attracted around 1,600 nurses compared with a target of 2,500.43 NHSE&I told us that COVID-19 and the resulting travel restrictions had delayed international recruitment. It said that providers report that there are over 6,000 overseas nurses in the pipeline who are willing to work in England and it anticipated that overseas recruitment will “open-up very rapidly”.44 However, it recognised that expanding the domestic supply of nurses is a more sustainable route to securing the nursing workforce. In response to our questions about the ethical implications of recruiting from overseas, NHSE&I told us that it follows the World Health Organisation’s code of practice which includes a list of 43 counties that it does not recruit from. It considered that its “earn, learn and return” programme offers an opportunity for overseas nurses to develop skills which can be taken back to the countries that nurses are recruited from.45
18.HEE acknowledged that there were global differences in nursing salaries, alongside other structural and market differences, with other countries having more leeway in what they can pay than the UK. More generally, NHSE&I accept that pay remains “an important issue with regard to nurses”, and that the lack of pay rises in previous years had impacted on the retention of NHS nurses.46 In a Royal College of Nursing survey of their members, in July 2020, pay was the most common reason given for nurses to consider leaving the profession, while around three-quarters of nurses said that improved pay would make them feel more valued.47
19.The Department and HEE highlighted the important role that apprenticeships and nursing associates play in widening access to the nursing profession, by enabling people to earn money as they train. In the case of nursing associates, which is a separate role, people can also gain experience as an associate before deciding if they want to train to become a registered nurse.48 However, the Department recognised that it takes longer for nurses to qualify under the apprenticeship route, and the same applies to nursing associates who must study for a further two years to qualify as a nurse.49 HEE told us that it had seen “relatively early gains” with the apprenticeship model but admitted that some provider organisations had found it challenging to offer apprenticeships at scale and make full use of apprenticeship funding.50 HEE had a target to deliver 7,500 nursing associates by 31 March 2020, but the Department told us that this has been “knocked slightly off track” because the March intake was significantly reduced.51 HEE also confirmed it had targets in place for the number of registered nurses coming via the nursing associate route. It told us that it is directly supporting nursing associates in their conversion to becoming a registered nurse, such as through the use of personal development plans.52
20.NHSE&I emphasised that retaining staff is a “valid and important” supply route, which represents the “best investment” for increasing numbers. It told us the main factors affecting retention include staff feeling stressed by the work, lack of flexibility and a lack of continuous learning and development. It told us that its retention programme is focused on these factors, as well as creating an environment that is free from discrimination, bullying and harassment. NHSE&I acknowledged that staff are under increased pressure as a result of the COVID-19 outbreak, which had also made the job of retaining staff more difficult.53
Nursing students
21.From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. Prior to 2017, HEE paid tuition fees to universities and NHS bursaries to students to cover their living costs. Instead, these students moved onto the existing student finance arrangements, with most eligible for full loans for tuition fees and maintenance costs. The Department hoped to increase the number of places on these courses by 10,000 by 2020.54 However, it acknowledged that the policy had failed to meet all its objectives.55 In 2017, the first year of the new arrangements, the number of applicants for nursing and midwifery courses fell by 11,000 (21%). Universities accepted a higher proportion of applicants than previously, so there was a 3% fall in the number of new students.56
22.The policy change impacted on some students and regions more than others. For example, from 2016 to 2018, there was a 10% increase in the number of students accepted onto nursing degree courses for children’s nursing and for applicants from the North East. This is in contrast to large reductions in students accepted onto learning disability courses
(-41%) and for applicants from the South East (-24%).57 The Department acknowledged there was a particular drop-off in the number of mature students (aged 21 and over) who represent a big source of nurses.58
23.Since 2017, the number of people accepted onto nursing and midwifery degree courses has increased from 22,045 in 2017 to 23,060 in 2019. This still means that, in 2019, only 430 (2%) more people accepted a place on a nursing degree course compared with 2016 when the NHS bursary was still available. Between 2017 and 2019, the number of people applying for courses even dropped a little further, from 41,715 in 2017 to 39,665 in 2019.59 HEE told us that the latest UCAS data from June 2020 showed a 15% increase in domestic applicants for nursing degrees from 2019 to 2020.60 However, it is not yet certain whether this will translate into an increase in the number of people accepted onto courses: the number of applicants as at June 2020 (42,740) is still below the number as at June 2016 (51,730) and trends in applicants and acceptances have not mirrored each other since 2017.61
24.In December 2019, the government announced the introduction of a new maintenance grant for nursing students from September 2020, which consists of a non-repayable grant of £5,000 to £8,000 to help with living costs. Students will still pay their own tuition fees and the higher education market will therefore still determine the number of places.62 The Department said it was not aiming to recreate the position prior to 2017 and had sought to learn lessons in particular by its targeting of the new training grant to specific groups of people and specialisms where there are particular concerns. For example, an additional £1,000 will be made available to nurses specialising in learning disabilities and mental health, and there will be an extra £1,000 of childcare support to those who are eligible.63
Opportunities and challenges created by COVID-19
25.NHSE&I acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak. It cited figures from a Nursing Times survey, which reported 90% of nurses as experiencing higher rates of anxiety than before the COVID-19 pandemic.64 In a Royal College of Nursing survey, some 36% of respondents indicated that they are considering leaving nursing in the next year, compared with 28% from before the pandemic. When asked about why they are considering leaving, nurses reported that it was pay (64%), low staffing levels (45%), the way nursing staff had been treated during the pandemic (45%) and lack of management support (44%).65
26.The Royal College of Nursing noted that, to retain nurses who worked during the pandemic, it will be essential to provide access to specialised mental health support, carry out risk assessments for staff and ensure people are able to take rest breaks and annual leave.66 NHSE&I told us that it has made a free mental health helpline available to all NHS and social care staff and is providing practical support, such as free tea and coffee.67 It highlighted that flexible working and better local leadership and line management are also key to retaining staff in the longer term. However, it recognised that there is currently variability in the quality of leadership and so it is expanding the number of places on its leadership academy and providing access to line management training for every line manager in the NHS. It said that it would be looking to retain some of the innovations that have helped improve the work-life-balance of staff during the COVID-19 outbreak, such as better use of technology and more flexible or remote working.68 The first part of the People Plan, published in July, covers improvements to staff support and leadership culture, as well as highlighting service innovations that have taken place over the last few months.69
27.NHSE&I noted that over 32,000 nurses stepped up to support the NHS during the COVID-19 outbreak, including former nurses and over 20,000 students. However, it acknowledged that there needs to be better local systems for retaining these returners, such as to establish how many wish to return to the NHS and in what capacity.70 We were also told by a number of stakeholders that some students have lost clinical placement hours due to the pandemic, and some of those who stepped up to work for the NHS had placements curtailed or cancelled.71 HEE said that it was seeking to ensure that students could still gain experience during the COVID-19 pandemic. It is prioritising those due to graduate this year and has estimated that 20% of these students may have difficulty completing the clinical practice hours they need to finish their nursing degree on time.72 The Council of Deans of Health and NHS Employers highlighted that this additional pressure on placement capacity will be compounded by extra pressures resulting from a backlog of routine work caused by COVID-19, as well as the risk of another peak in COVID-19 cases.73
28.NHSE&I acknowledged that COVID-19 has had a disproportionate impact on Black, Asian and minority ethnic (BAME) staff and admitted that there is variability in how well these staff have been supported during the pandemic. In response to our questions about ensuring there is no adverse impact on the career progression of BAME staff, NHSE&I told us that BAME staff are not automatically redeployed but have been offered a risk assessment to determine how to protect their health. It said that there are a range of measures that can be taken to protect staff, including enhanced infection prevention measures and Personal Protective Equipment, and training for staff working in clinical areas. It told us that, as part of the race equality standard, every trust has a plan for addressing differentials between white and BAME staff, including on career progression. NHSE&I is tracking data on the race equality standard across trusts and minority groups, and individual trusts and employers also have access to relevant data.74
37 Prime Minister’s Office, Press Release – Prime Minister backs NHS staff with £5,000 annual payment for nursing students, December 2019; C&AG’s Report, para 11
38 Q 33; C&AG’s Report para 3.10
39 Q 39
40 Q 43
41 Q 20
42 C&AG’s Report paras 8, 2.20
43 Q 59; C&AG’s Report para 7
44 Q 55
45 Q 53
46 Qq 60, 62, 63.
48 Qq 43, 44, 69
49 Q 48; C&AG’s Report, paras 2.24, 2.25
50 Qq 45, 47
51 Q 27
52 Qq 48, 69, 70
53 Qq 40, 52
54 C&AG’s Report, para 2.5 - 2.6
55 Q 71
56 C&AG’s Report, para 2.6. Based on England-domiciled applicants, UK universities, and includes midwifery degrees. The withdrawal of the NHS bursary applied to students on courses in England. NHS bursary schemes continued in the other home nations after 2017, but eligibility was limited either to those already resident, or committing to work, in that country. Where possible, we examine English-domiciled applicants applying to English universities, as the group potentially most affected by the bursary withdrawal, but available data do not always separate out this group.
57 C&AG’s Report, para 2.9, figure 12. Based on UK-domiciled students, English universities, and excludes midwifery degrees.
58 Q 81
59 C&AG’s Report, figure 11. Based on England-domiciled applicants, UK universities, and includes midwifery degrees.
60 Q 43
61 University Colleges and Admissions Service (UCAS), 2020 cycle applicant figures – 30 June deadline, analysis of applicants for nursing and midwifery degrees domiciled in England and applying to English universities; C&AG’s Report, figure 11.
62 C&AG’s Report, para 2.6, 2.16
63 Qq 33, 42, 71–72
64 Q 40
67 Q 40
68 Qq 50, 51 & 64
69 Q21; NHS, We are the NHS: People Plan 2020/21 – action for us all, July 2020
70 Qq 9, 11
72 Qq 86–87
74 Qq 93–96
Published: 23 September 2020