Jeremy Hunt has acknowledged to nurse leaders in England that the NHS workforce is his “biggest worry” and that the fall since last year in the number of nursing staff is of particular concern.
He cited the government’s decision to scrap the bursary for student nurses and replace it with loans and uncertainty surrounding Brexit as the “two reasons” driving the reduction in the workforce.
“Workforce is my biggest worry as health secretary at the moment”
But he claimed that an expansion in degree course places available, the introduction of nursing associates and nurse apprenticeship training and efforts to boost staff retention were possible solutions.
Specifically on retention, he highlighted plans to introduce a smartphone app to make it easier for staff to book bank work, moves to make shift patterns more predictable and the end of the 1% cap on Agenda for Change pay rises.
In addition, he said he wanted to thank nursing staff for their “incredible resilience” over one of the “most difficult winters we’ve had for a very, very long time”.
“I think there are two reasons. The first is the new policy on nurse bursaries and the second is related to Brexit”
Speaking at the chief nursing officer for England’s annual summit last week, Mr Hunt said: “I want to share with you quite openly that workforce is my biggest worry as health secretary at the moment.
“I think it’s where we have the biggest challenges and the biggest pressures and particularly the nursing workforce is a concern and, in fact, the size of that workforce went down in the last year, which is also a concern,” he said during the speech, which was almost entirely focused on nursing.
He said: “Since I’ve been health secretary, the number of nurses has gone up by 14,900. So we’ve seen a significant increase but in the last year we’ve started, very slightly, to go in the wrong direction.”
Last year the Nursing and Midwifery Council published data showing its UK register had shrunk in size for the first time in recent history – from 692,556 in 2016 down to 690,773 in March 2017.
Meanwhile, last month, figures published by NHS Digital revealed a further decrease in the number of nurses and health visitors employed by the NHS in England, following a similar trend in 2016.
As of 30 September 2017, it said the number of whole-time equivalent nurses and health visitors in England stood at 284,000 – a decrease of 435 since 2016. In January it also revealed that the number of vacant nursing jobs reached a new high in the three months to the end of September 2017.
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Mr Hunt identified “two reasons” for the fall in the number of nurses. “The first is the new policy on nurse bursaries and the second is related to Brexit,” the health and social care secretary told delegates at the event in Liverpool.
Based on other examples of education funding reform, Mr Hunt indicated that he hoped the impact of swapping from bursaries to loans, which has seen course applications fall, would be temporary.
“It’s the mature students who appear to have been concerned by the nurse bursary policy”
He said: “We always have an impact on admissions to higher education institutions when you introduce a reform to funding. That happened when the loan system was changed in 2012.
“There was an initial dip and then it went back up again. That’s obviously what we hope will happening to nursing numbers,” he said during his annual address to the yearly summit of national nurse leaders, trust directors of nursing and other influential members of the profession.
The minister highlighted that the scrapping of the bursary for trainee nurses seemed to be having a “particular impact” on discouraging mature students to apply, as previously shown by official figures.
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“There are actually record numbers of 18-19 year olds applying to nursing, according to UCAS, but it’s the mature students who appear to have been concerned by the nurse bursary policy,” he said.
Regarding the decrease in NHS nurses from the European Union since the referendum, he said: “Since Brexit we have seen a decline in the nursing staffing from the EU of about 1,100.”
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He told nurse leaders there was “nothing we can do about that while we are in the middle of the Brexit negotiations” in terms of government policy.
However, he called on them to “reassure EU colleagues that they are part of our NHS family, that we value what they do and we want them to stay”.
Mr Hunt reiterated previous suggestions from prime minister Theresa May that NHS staff from other EU countries would “be able to remain in the UK with broadly the same rights as they have now”.
But he also suggested the NHS had previously relied too heavily on recruiting from abroad to cover dips in numbers being trained at home, especially as demand for nurses was growing everywhere.
“We all know that the EU workforce makes an absolutely indispensable contribution to the NHS,” he said. “We would fall over without them. But the truth is we aren’t the only country with an ageing population.
“Spain and Portugal are significantly expanding their nursing workforces at the moment. It was always a false economy, to think that we could cut down on the number of nurses we trained here because we could get them from other countries,” he said.
Mr Hunt has previously announced that a new national workforce strategy will be published this year, which is designed to help secure the long-term supply of nurses and doctors for the NHS.
However, in his speech to the CNO conference, the health secretary mostly concentrated on existing policies as his “three things” that were going to ease the nursing workforce pressures.
The first two were 25% expansion on degree course places and “new routes” in to the profession that are currently being piloted and rolled out, such as nursing associates and nurse apprenticeships.
But while highlighting the final one – the importance of efforts to retain existing staff – he outlined several new measures being developed that he said he needed help from directors of nursing with.
“It could be a very, very powerful way of helping you tap into an additional supply of nurse hours”
These included some smartphone applications, or apps, that being piloted from next month to make it “easy for the people who used to work agency shifts to work additional shifts through their bank”.
“It could be a very, very powerful way of helping you tap into an additional supply of nurse hours,” he said, calling on trust chief nurses to also get their own organisations involved in the technology.
Mr Hunt also questioned whether the current system of shift planning, where six-week patterns were “sort of plucked from the sky and could be completely random” was still “fit for purpose” for modern life.
“If we are going to fundamentally reduce the sickness rate, which is very closely linked to stress, and the number of people who choose to work four-day weeks and three-day weeks, then we need to think about what they need,” he said, highlighting the growing popularity of flexible working.
He said: “What many nurses would like, would be able to say for the next year I want to work Monday to Thursday, 7am to 3pm, and Sunday afternoons, and I want to be able to build my life around that.”
Mr Hunt said software was now becoming capable of being used to plan these “more predictable shift patterns”, but told nurse leaders that the “speed of roll out across the NHS is something that’s in your hands not in mine”.
Lastly, he said he wanted the current pay negotiations to conclude “with something that is a strong signal to nursing staff and all Agenda for change staff about how valued they are and how we recognise those pressures that they are under”.
As has previously reported, unions and employers are discussing a potential multi-year pay deal in the wake of the government’s scrapping of the unpopular and long-standing 1% cap on salary increases.
Leaked reports have suggested that the deal could see staff receiving a 6.5% pay increase over a period of three years if they sacrifice a day of holiday.
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More to come…
What Jeremy Hunt said on:
Resilience and winter
I really wanted to thank you for your incredible resilience over one of the most difficult winters we’ve had for a very, very long time. It’s not just me and Theresa May and the government but actually the whole country is incredibly grateful to the NHS and the nursing profession that is so central to it.
First of all, compared to January and February last year, every single day we actually saw an additional 2,000 people within the four-hour target. So, a massive increase in activity. We also had the worst flu spike for seven years which has still not gone away and is taking up a lot of bed capacity. Around 2,600 beds across the system.
And that puts immense pressure on frontline staff – doctors, nurses, everyone who is involved in patient care. And so I just want to say a very big thank you for that and I’d like to ask you to convey that to your colleagues as well… but I think everyone recognises just how tough it’s been.
The second really big thankyou I want to make is to say thank you for is a total transformation in approach that your profession and the NHS more broadly has taken to patient safety over the last five years.
When I think of patient safety, I think of nurses, because I think you are the people who think about patient safety before anyone else and you have led most of the major campaigns on patient safety that we’ve had and are having now. But I think it is just worth thinking about some of the progress we’ve made since we’ve had the Francis report, which was almost exactly five years ago.
If we look at the patient safety thermometer that shows that the proportion of patients suffering harm has gone down from 7.2% to 5.8%. This is over a period where the number of emergency admissions has gone up by 2,300 every single day and when it comes to elective care we’re doing 6,000 more procedures every single day.
But we’re seeing, on most of the major safety indicators and particularly the main hospital harms – urinary tract infections, VTEs, pressure ulcers and falls – we’re seeing a fall in the proportion of patients being harmed. And that is extremely impressive.
Increasing nurse training places
We announced last September a 25% increase in the number of nurse training places. Now that is not going to relieve any pressure in the next few years because it takes three years to train a nurse. But nor should we underestimate the significance of this in terms of people thinking about giving their lives to nursing.
From 2021, we will have an extra 5,170 qualified nurses coming into the NHS workforce, not just in 2010 but in 2022, 2023 and 2024 – a permanent increase in the number of nurses that we train. And this is a hugely significant decision.
If we are going to prepare the NHS and the country for the tsunami that we face of a million more over 75s in 10 years’ time, then we are going to have to massively increase the capacity of our NHS and social care system.
The truth is we don’t have enough doctors, we don’t have enough nurses and the only long-term way to sustainably improve the care we offer to patients is to improve the pipeline of additional doctors and additional nurses.
New routes into nursing
We need to make a success of the new route into nursing that we are pioneering which is the ability to become a nurse after four years of effectively on the job training – by being a nurse associate; doing the training for that over two years and then moving into the nurse apprenticeship route.
It’s a very profound and significant change. What we’re trying to do is create a route into nursing where someone can train to be a nurse, basically at the hospital where they work.
We’ve got 5,000 nurse associate places that will be taken up this year and then in terms of the nurse apprenticeship route we’ve got places like Leeds that have got 30 nurse apprentices starting this year, Cambridge have got 40, Imperial have got 50.
This is going to be a new way into nursing for some of our very best nurses of the future – people who have actually worked in the NHS, who know what nursing is about and have got experience on the ground, who know that with that extra academic training they could become absolutely first class nurses. That door is now open.
Making it easier to do bank shifts
We have made heroic efforts to reduce the use of agency staff. But we now need to make it as easy for the people who used to work agency shifts to work additional shifts through their bank.
What we have in mind is a system where every nurse on a bank could have an app and they could decide on a Saturday morning to work an extra shift on a Saturday evening, they could book themselves in and if they chose to they could not make a pension contribution to get higher take home pay on that additional part of their salary and they could be paid within a week for it.
We’ve got some apps that are being launched in pilot sites in April but this is something that everyone in this room could be involved in in their trust… it could be a very, very powerful way of helping you tap into an additional supply of nurse hours.
Making shift patterns more predicable
Something that I don’t think we’ve talked about enough is the desire that many people have, when they are doing a pressured job, to have more predictable shift patterns. Many people are juggling a busy home life with a busy work life.
We have to ask ourselves whether the system we have at the moment – where every couple of months you’re told what your shifts are going to be in the next six weeks and they’re sort of plucked from the sky, and you’ve then got to turn your whole life upside down when it comes to things like childcare – is really fit for purpose.
What many nurses would like, would be able to say for the next year I want to work Monday to Thursday, 7am to 3pm, and Sunday afternoons. And I want to be able to build my life around that. If we are going to fundamentally reduce the sickness rate, and the number of people who choose to work four-day weeks and three-day weeks, then we need to think about what they need.
The software systems that people use are all starting to be capable of this. So we are doing what we can at the centre to make that possible.
End of the 1% cap on nurse pay rises
I was successful in persuading the chancellor and the prime minister that we should be allowed to breach the 1% cap for people in Agenda for Change professions last year and we are having discussions with the unions.
And I want those discussions to conclude successfully and I want them to conclude with a very strong signal, no one goes into the NHS because they want the money, but money is very important because it’s a sign of how valued you think you are.
And so I want to conclude those discussions with something that is a strong signal to nursing staff and all Agenda for change staff about how valued they are and how we recognise those pressures that they are under.
Introducing e-prescribing to reduce errors
A couple of weeks ago we launched a medication error campaign. We commissioned some research by the universities of York, Sheffield and Manchester and, we think, across the NHS that every day four to five people die because of medication errors.
A lot of that is in the community but we know that e-prescribing systems can cut medication errors by half in hospitals. So we are going to have a big push on e-prescribing systems and the more effort, the more pressure you can put on your boards to introduce e-prescribing systems, the better.
Speaking up more about clinical mistakes
We still make it far too difficult for people in the NHS to speak up when they see something that worries them. The difference between you and me is that at the start of your working lives you have the courage to go into a profession where the price of ordinary human error is sometimes tragedy.
If we are going to continue to I prove patient safety, then we need to be much better at supporting you and your colleagues to speak openly when things go wrong, about mistakes they’ve made or mistakes they’ve seen.
You have an absolutely massive impact on that culture, because as directors of nursing the one thing that will encourage other people to speak up about mistakes they’ve seen, or mistakes they’ve made, is if they see you doing the same.
When I’ve been on these presentations with [CNO for England] Jane Cummings and [NHS Improvement executive chief nurse] Ruth May, they’ve both stood up in hospitals and talked about mistakes that they’ve made and that is incredibly powerful in terms of the signal it sends to staff.
More news from CNO Summit 2018:
- Exclusive: CNO warns against too much negativity about nursing
- Nurse leaders appeal for enough CPD funds and pay rises to aid retention
- NHS chief executive thanks nurses for ‘going extra mile’ this winter
- England’s CNO to announce national drive to ‘end PJ paralysis’