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Failure of nurse workforce plan has led to NHS 'financial mess'


Failure to have an adequate nurse workforce plan for the NHS over the past 10 years is one of the major reasons for current escalating deficits among trusts in England, MPs have been told.

Economics and policy experts told the Commons’ health select committee this week that savings had initially been made in the early part of the decade by holding down pay for staff and employing fewer nurses.

“That failure to have a really fit-for-purpose workforce strategy is one of the underlying issues at the heart of the deficit”

Anita Charlesworth

The plan to employ fewer nurses was based on the expectation that demand would lessen – through fewer hospital admissions – and that nurse to patient ratios could be reduced, said one expert during an evidence session on health and care finances.

But the strategy proved unsustainable, she said, causing trusts to re-employ nurses at a higher cost from 2013 onwards, when safe staffing initiatives were implemented.

Anita Charlesworth, director of research and economics at the Health Foundation think-tank, said: “I think the most important thing, both about why we are now in the financial mess we are in, and what we need to do, is about workforce issues.

“The NHS was really planning on needing fewer workers. We reduced the number of nurses we brought in from other countries in the early years of this decade, and reduced the numbers in training. And we’ve also seen fewer numbers coming through return to practice,” she told the committee of MPs.

“[Reducing nurse numbers] was predicated on both the ability to reduce demand and the belief we could work those nurses hard through reducing ratios”

 Anita Charlesworth

“That was predicated in essence on both the ability to reduce demand – the number of admissions that would be coming into the system – and the belief we could work those nurses hard through reducing ratios,” she added.

“That proved to be unsustainable….That failure to have a really fit-for-purpose workforce strategy is one of the underlying issues at the heart of the deficit,” said Ms Charlesworth.

The current NHS deficit is projected to reach £2.3bn by April, by which time around 90% of acute hospitals are forecasted to be in the red, according to recent figures published by the King’s Fund think-tank.

In addition, NHS England’s five-year plan for the health service launched at the end of 2014, called for £22bn savings to be made by the NHS over five years – in combination with an additional £8bn in government funding – to plug an estimated £30bn hole in the budget by 2020.

King's Fund chief economist on health policy John Appleby

King’s Fund chief economist on health policy John Appleby

John Appleby

When asked how the NHS would make £22bn savings by that time, all of the experts raised concerns, suggesting previous tactics to cut costs could not be repeated again.

John Appleby, chief economist at the King’s Fund, noted that the NHS had achieved savings in the past few years partly by holding down staff pay, but he said he doubted this could continue up until 2020.

“There are groups in the NHS now who have had a pay freeze for five or six years. That may carry on and you be able to cut costs in that way, I just have my doubts you could do that for another four or five years,” he said.

Nigel Edwards, chief executive of think-tank the Nuffield Trust echoed his comments, saying a pay freeze for the next four years “doesn’t seem plausible”.

“There are groups in the NHS now who have had a pay freeze for five or six years. I have my doubts you could do that for another four or five years”

John Appleby

Meanwhile, Ms Charlesworth called for a “co-ordinated plan to address the workforce problem” in a bid to achieve some of the required savings.

It should include a “concerted” return to practice scheme for nurses, training more nurses and improving retention by understanding why so many leave before the age of retirement, she said.

“Critical to being able to hold down the pay problem – hold down the agency cost problem – is being able to recruit and retain, and the nursing workforce is the big part of that,” said Ms Charlesworth.

Anita Charlesworth

Anita Charlesworth

Anita Charlesworth

She noted that in 2014 just 800 former nurses returned to work for the NHS, while around 16,000 came back to practice over five years at the beginning of 2000.

This was against a backdrop of around 18,000 nurses a year leaving the NHS before retirement age, she told the MPs.

“I am perplexed by why we don’t have – 16 months after the Five Year Forward View – a really good co-ordinated plan to address the workforce problem and we know the workforce is at the heart of many of our cost issues,” she said.


Readers' comments (24)

  • The basis of cause for many leaving before their time:

    1. Badly written care legislation not allowing common sense and error, which demands excessive paperwork and processes causing more legislative problems for nurses resulting in senior management blaming the frontline and thus leaving. Cure the causes and the numbers will heal.

    2. Fear of tyrannical professional regulator not based on sense of objective understanding nursing as human task and implementation of inappropriate professional regulation.

    3. Neo-liberal economic disregard of nurses as simply replaceable numbers - not working now is it!

    4. Blairite preoccupation with nurses entering management and thus perpetuating hierarchies based on social class, which fits nicely with Tory regard for keeping frontline nurses down. Created disparity in understanding empathetic care away from direct nursing. Many nursing managers don't get employee responsibility by thinking they can make a difference further up just causes more to leave.

    5. H and S replaced with behavioural assessment of staff not doing processes properly rather than cause of setting, numbers and environment.

    You want to fix the problem then free nurses to care and employ more administrators actually on ward.

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  • michael stone

    'The NHS was really planning on needing fewer workers'

    I wonder - does anybody think that was 'an evidence-based plan' ? Or just 'a convenient 'political wish' [like 'nice weather tomorrow, for the cricket'].

    These things (flawed plans) - which are often very dubious to start with, if you cast 'a neutral eye' over them - just keep happening, in the NHS.

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  • Why do nurses leave before retirement age?
    1 escalating work and responsibility in terms of risk
    2 reducing salary in line with actual cost of living
    3 not paying staff for the actual skills they are using i.e. keeping staff at lower grades / down banding when A4C would suggest minimum of band 7 staff are kept at 6 or lower.
    4 constantly changing ways of working to less and less efficient/ effective increasing stress
    5 more burn out
    6 less investment in training for nurses
    Will I also retire early if I can .. Yes yes yes

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  • The evident questions which has to be asked in these conditions are:

    1.'Why NHS is paying big salaries for their top managers if they are not doing the job properly (i.e. workforce planning)?'
    2.'Who will be find responsible and pay with their jobs for the mess without being re-employed again by NHS through their magnificent revolving doors?'

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  • And yet with all these failures Nurse Leaders at strategic level get Awards when they leave. Lots and lots of navel gazing and patting backs and who cares about the public? The nursing profession has failed the public. Education content is not fit for purpose and neither is the direction or management of care provided.

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  • Again and again I say the disparity of pay levels comes from percentage pay rises which leads to a bigger and bigger pay gap between the lower and higher grades.

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  • Mismanagement is a huge problem and drain on monies. But some mismanagement appears to adhere closely to putting nazi principles into practice by deliberately causing the demise of vulnerable people.

    One side effect of this being that registered nurses who care but who are themselves receiving poor treatment, leave the profession; they are then replaced by nurses not registered here who sometimes culturally feel the need to put the demands of their profiteering employers ahead of lawful care for their patients. This can result in profiteering providers deliberately selecting staff who can be relied on to cut corners.

    The immoral NHS managers may knowingly (Brithdir) select providers who keep costs down in any way they can (and they also debilitate any whistleblowers who challenge). The police and court systems are acting as though politics not our laws are their main priority.

    I cannot see that this situation can have arrived over the years without central government approving or at very least turning a blind eye to situations that may originally have arrived as unintended consequences but are then used to deliver reduced costs on a short term basis.

    On a long term basis it is well known that decent care keeps decent staff thereby keeping all costs incurred -patients, staff, carers- well below the costs of care controlled by short term policies with unbelievably stupid amounts of money totally wasted on presentation (convincing lies) and litigation (false allegations against whistleblowers etc).


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  • H as anyone out there heard of " Adult Safeguarding " departments run by the County Councils, any up and coming whistle-blowers among you should contact them when it comes to taking on the NHS.

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  • Adult Safeguarding run by the Local Authority? In some areas they are just a bad joke. Contacting them just leads to a more solid cover up and false allegations against complainants. Even when something is proven they do nothing to actually improve the situation for the vulnerable people, just more activity without outcome and inappropriate hostility to valid complaints..

    It is unhelpful that the LA deal only with issues relating to individuals in care homes etc and the CQC deal only with issues relating to general care but not individuals. This is complicated and exhausting.

    When the Local Authority Adult "Safeguarding" (including the ineffective and colluding Deprivation of Liberties Safeguarding Team) and the NHS Supervisory body, the Providing body and the CQC all are unable or unwilling to deal in an appropriate and timely way with issues causing harm to patients in state care, it is also possible to go to one of approximately 70 organisations who deal with complaints against the NHS but according to debate last year in the House of Lords, the outcome is usually, as it was in my personal experience, harmful to the complainants well as the patient, and still lacking in satisfactory outcome for the patient.

    Anyone hear Lord Turnberg speaking in House of Lords debate on NHS Sustainability (on iPlayer bbc)? Greater Manchester is due to have devolved NHS budget shortly. Lord T related how joined-up the care in Salford had become; on paper or electronically it may be but not in reality. He also said words to the effect that he was unsure about the use of devolved NHS budgets because if things went wrong it meant that the government got off the hook. Short term thinking rules then and more cost ineffective methods dig us deeper into this political mess that is so harmful to the country's health.

    I would recommend anonymously alerting bodies to bad care and (maybe?) using the nurses Whistleblower Champion. Experience has taught me that the "proper" route is not only ineffective at preventing harm but it causes more. I still say that bad management and bad government is the root cause of the NHS's ills.

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  • michael stone

    ANONYMOUS28 FEBRUARY, 2016 9:41 AM

    Although my own experience was only of complaining to a PCT and then to the PHSO, it is in line with yours - the 'official complaints channels' are fairly hopeless, and very frustrating: also, if you are 'a first-time complainant', the cards are stacked against you in that you 'do not understand how the system works'. As well as ending up dissatisfied with the outcome, you tend to think 'if I doing this again, I would do it differently' with respect to how you complained/raised your concern.

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