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News analysis: Urgent need for action on nursing workforce ‘perfect storm’

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A further fall in the number of nurses and midwives registered to work in the UK was revealed this month, setting alarm bells ringing among employers, nursing leaders and unions.

The Nursing and Midwifery Council, which released the figures, said more UK and European Union staff leaving its register, plus fewer EU staff joining, were behind the loss of 1,678 registrants in the space of a year.

Over the summer the NMC published data from March showing its register had shrunk in size for the first time in recent history – from 692,556 in 2016 down to 690,773 in March 2017.

This month it published more data, showing a drop from 691,416 people on the register in September 2016, down to 689,738 this September, highlighted the “major” staffing challenges facing the health and care sectors.

Nurse staffing shortages – particularly in the NHS – have been a known problem for years, but this is the first time in recent history that the register has shrunk, following a period of growth since 2013.

Nursing leaders from the independent sector and NHS are in agreement that the workforce is reaching crisis point, but what is causing more nurses to leave and what can be done to stop the problems from getting worse?

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When the NMC first pointed to signs of its register becoming smaller over the summer it said a recent survey it had carried out had shown working conditions – including staffing – was the most commonly cited reason for nurses giving up their PIN.

Anne Marie Rafferty, professor of nursing policy at King’s College London, told Nursing Times her own research had shown nurses in England had some of the highest workloads and burnout among their European peers.

“It’s really tough out there for nurses and that’s a big decision to make, to leave the register,” Professor Rafferty noted.

She suggested an “unprecedented” set of factors were likely playing a part in nurses’ decisions to leave – including dwindling budgets for ongoing nurse training, the government’s cap on NHS pay rises, and restrictions on the use of agency workers. The removal of student bursaries also threatened to reduce the supply further.

“There are a complex convergence of factors impacting simultaneously,” she said. “The perfect storm is already with us and is producing some serious climate changes in the nursing workforce.”

“The perfect storm is already with us and is producing some serious climate changes in the nursing workforce”

Anne Marie Rafferty

Recently retired trust chief nurse Jan Stevens agreed the figures were “worrying” and also pointed to a range of problems – such as rising workplace stress and the “age time bomb” due to many staff now within retirement age.

More flexible working arrangements were urgently needed for all staff, but especially for older nurses who will otherwise leave, she told Nursing Times.

“It’s no use just focussing on creating less stress for nurses, because the reality is it’s going to be busy for a long time,” she said. “So, what sort of things can be done to keep more experienced nurses?”

She suggested new roles for them needed to be created, including with more of a training focus. But the number one issue that had to be addressed to stop nurses leaving organisations for other employers – and eventually other careers altogether once disillusionment had set in for some – was the lack of continuing professional development (CPD) training opportunities, according to Ms Stevens.

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“CPD budgets have been cut at a national level and that is really significant,” she said. “It’s within the gift of the government, Health Education England and trusts to stem the people moving around because they are not getting CPD to develop – and it’s essential that they do.”

Money handed out by HEE that was previously used for CPD has been more than halved in the past two years, from £205m in 2015 to £83.49m this year, though the body denies it ever had a budget for that specific use

Some part of that funding may need to be restored, but new regional and national strategies were also required to deliver ongoing training in new ways and within limited budgets, said Ms Stevens.

Meanwhile, she said she believed the uncertainty about whether EU staff would be able to stay following Brexit was the reason behind fewer European nurses joining the register, and also more leaving.

The profession has “no time to wait” for the government to negotiate its Brexit strategy over the next two years and should, instead, immediately lay out clear plans allowing EU nurses to work in the UK beyond Brexit, she said.

There was also a pressing need to “ramp up” recruitment of nurses from the rest of the world, including India and Australia, she told Nursing Times.

But Professor Rafferty disagreed – saying this would only delay plans to ensure the UK had enough of its own nurses.

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Jackie Smith

Sharon Blackburn, policy director at the National Care Forum, which represents not-for-profit care home providers, also stressed that there was a worldwide shortage of nurses.

It meant the focus in the long-term had to be on more effective workforce planning in the UK, rather than looking to other countries, she said.

Though in the short term, she agreed EU nurses were needed to prop up staffing and that the government should reassure them they would be able to stay beyond Brexit.

Otherwise, in the care sector, further nursing homes would be forced to close because of a lack of nurses to staff them, warned Ms Blackburn.

“We are already seeing people closing care homes with nursing, because they cannot guarantee quality,” she said. “Unless people work locally across health and social care to come up with solutions we will probably continue to see this happen.”

Staffing agency HCL Workforce Solutions, which recruits nurses on behalf of NHS trusts, said fewer EU staff were coming to the UK because of new language tests brought in for European nurses by the NMC last year.

The agency has previously said the test is too difficult and has been lobbying the regulator, along with employers, to lower the pass score for the International English Language Testing System (IELTS) exam.

In response to the concerns, as of the beginning of this month, the NMC has started accepting an alternative test – the Occupational English Test – which employers had also said would aid recruitment.

While HCL welcomed the change, it said the length of time it would take for the OET to be introduced would not help with the immediate staffing crisis.

Teresa Wilson, HCL’s operations manager for international recruitment, said healthcare employers were “up against the clock” and stressed if the IELTS score were lowered slightly there were many EU nurses waiting to come and work in the UK who could pass at the reduced level.

She also argued that the increase in EU nurses leaving the NMC’s register was not largely due to Brexit, but was down to the same reasons more UK nurses were departing – namely burnout, pay, and additional hours being worked due to staffing pressures.

“Both EU and UK nurses are leaving due to the pressure they are under,” she said. “We keep in touch with our EU nurses and those that are going back home have not cited Brexit as a reason.”

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NMC chief executive and registrar Jackie Smith told Nursing Times that the regulator’s figures indicated the UK did not have a big enough supply of its own nurses, that European staffing was unreliable and also that international recruitment was static.

She agreed the UK could not afford to see a continuation of the drop in EU nurses coming onto the register and noted that the regulator had responded to the concerns around language testing.

“If the OET makes a difference, expect us to start seeing signs of that December and January,” she said, though she also called for a more strategic approach to recruitment.

“We have published the figures of applicants by country to help support employers recruit strategically,” she said. “The drop off from Spain is 95% – we were getting 2,000 applications, and are now getting 100. So, if employers are seeking to go to Spain to recruit – they are unlikely to come.”

Nursing Times asked whether the drop in the number of nurses on the register indicated there was a risk to patient safety.

“There is an argument that it becomes a patient safety issue if there is no one to care for patients but, equally, if you have wrong people with wrong standards caring for patients,” said Ms Smith.

“We are not quite at the point of it being a serious issue yet, but we do want the people in charge of workforce planning to take note,” she added.

“We are fully committed to supporting hardworking NHS staff”

Department of Health

However, in its response to the figures, the Department of Health referred to the shrinking of the NMC register as a “mere 0.2% decrease”, adding that “there are in fact more nurses on our wards since last year”.

“We are fully committed to supporting hardworking NHS staff through helping them to balance work-life commitments and we are also ensuring the NHS has the staff it needs for the future through our 25% increase in nurse training places – the biggest in the history of the NHS,” said a DH spokeswoman.

While the loss of 1,678 nurses and midwives from the register in a year may seem a relatively small number, the myriad of reasons contributing to that drop are significant.

Added to a potential reduction in the number of trainee nurses at university following the removal of bursaries this year, it is clear that nursing leaders are raising the alarm not only to flag immediate staffing concerns but also to warn that they will only worsen unless there is intervention now.


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