On 16 June, the House of Lords is scheduled to debate the following topical question for short debate:

Baroness Tyler of Enfield to ask Her Majesty’s Government what assessment they have made of the report by the Royal College of Nursing ‘Nursing under unsustainable pressure: Staffing for safe and effective care’, published on 6 June.

1. The Royal College of Nursing’s report

1.1 The ‘last shift’ survey

In June 2022, the Royal College of Nursing (RCN) published its report ‘Nursing under unsustainable pressure: Staffing for safe and effective care in the UK’. It reported on the results of the RCN’s March 2022 survey which asked staff about their ‘last shift’ (ie the last time they were at work) and compared the results to earlier surveys from 2017 and 2020.

The last shift survey invited all nursing and midwifery staff working in different settings across the UK to answer questions on a variety of issues. These included: adherence to the RCN’s nursing workforce standards; planned and actual staffing levels; and how staffing levels affected patient care and the wellbeing of staff. It also allowed staff to describe the impact that staffing levels have had upon themselves and those they care for. The RCN reported that it received 20,325 responses to the survey.

The RCN published its nursing workforce standards in 2021, setting out what it believed is required for planning staffing levels for safe and effective care across all settings in the UK. It explained that it had presented its findings from the last shift survey “through the lens of the importance of these standards”.

1.2 Key findings

The RCN said that recent events, including the UK’s exit from the EU and the Covid-19 pandemic, had both highlighted and worsened long-term problems with workforce supply in health and social care. It argued that for many years nursing staff have been “shouting about” the impact of growing staff shortages and rising demand on their ability to deliver care that is safe and effective. The RCN argued that the impact of these pressures is now “beyond concerning”, with patient safety, care outcomes, staff retention and staff wellbeing affected.

Summarising its findings, the RCN found an increase in staff reporting that, in their professional judgement, staffing levels were compromising care and that there were not enough registered nurses on shift. It also reported that staff were seeing increased patient acuity, where a greater intensity of nursing care was required by patients. In addition, staff said there was an increase in care they would describe as ‘poor’ or ‘very poor’, with more staff also saying that they did not have enough time to provide the level of care they would have liked.

The report highlighted that going into the Covid-19 pandemic in January 2020 73% of nursing staff surveyed said that staffing levels on their last shift were not sufficient to meet all the needs of the patients safely and effectively. In 2022, it said this had risen to 83%.

Other key findings included:

  • 25% of shifts had the full number of planned registered nurses on shift.
  • Around one in five (18%) respondents agreed they had enough time to provide the level of care they would like.
  • 69% of respondents said that the nursing skills mix (the number and education experience of nurses working in clinical settings) was not appropriate.
  • Around half (52%) of respondents said that students held supernumerary status (which means that education standards require that they are not to be counted in workforce numbers while learning), while 39% said they did not.
  • 62% reported that patient care was compromised on their last shift, compared to 57% in 2020 and 53% in 2017.
  • 81% felt that patient care was being compromised due to not having enough registered nurses on shift.
  • 43% said that they had to leave necessary care undone due to a lack of time, an increase from 38% in 2020, and 26% in 2017. On shifts where 100% of planned registered nurses were present, around one in three (31%) reported that necessary care was still left undone due to a lack of time.
  • One in five (21%) said they felt unable to raise their concerns.
  • Half of respondents (51%) felt “demoralised”.
  • 16% of respondents felt “fulfilled”.
  • Almost two-thirds (61%) were unable to take the breaks they were supposed to have.
  • 63% of respondents worked additional time. Of these, 77% were unpaid for these additional hours.
  • 87% of Black respondents who worked within the NHS reported working unpaid additional time compared to 77% of respondents from a White British background.

Reflecting on these findings, the RCN said that they presented “a clear picture of unsustainable staffing levels in health and care services in the UK, in which it is not possible for patient safety to be protected”.

In the report, the RCN made a number of recommendations for addressing these challenges. For example, it called for the UK to have government accountability for the health and care workforce enshrined in legislation. Other recommendations included the call for a government-funded health and care workforce plan and for the government to adopt and apply the RCN’s nursing workforce standards.

1.3 Nursing and Midwifery Council register

As part of its report, the RCN also set out data from the Nursing and Midwifery Council’s (NMC) register, which shows who can practise as a nurse or midwife in the UK, or as a nursing associate in England. The RCN found that in 2021/22 the register had grown by around 26,000, with most of the growth generated by registered nurses. It also reported that there were over 48,000 first-time joiners in the last year, almost 14,000 more than the previous year. Almost half of these new joiners (47%) were from outside the European Economic Area (EEA). The RCN said this “demonstrates a heavy reliance on international recruitment to fill domestic workforce gaps”. An increase in recruitment from countries on the World Health Organisation’s (WHO) support and safeguards list (2020), including Ghana and Nigeria, was also highlighted.

Although the numbers of staff on the register grew in this period, the RCN noted that the number leaving also increased to over 27,000, “having fallen steadily over recent years”. It reported that leavers’ survey data for January 2021 to December 2021 showed that the most common factors for leaving included: retirement; change of circumstances; too much pressure; and negative workplace culture. The RCN also highlighted that the number of professionals on the register aged 56 and above had increased by 4.2% to a total of 161,055. As a result, one in five of those on the register are aged 56 or over, and almost one in ten are over 60 and approaching retirement age.

2. Government plans to increase the number of nurses

2.1 2019 manifesto pledge

In May 2022, the government was asked what steps it is taking to tackle nursing shortages. In response it referred to the pledge in the 2019 Conservative manifesto to deliver 50,000 more nurses. Since the general election, the government has announced several measures aimed at increasing the number of nurses. For example, in December 2019 the government announced the introduction of a £5,000 per year maintenance grant for all nursing and midwifery students, with additional funds available for specialist disciplines which have struggled to recruit, such as mental health. Help with childcare is also available.

In addition, the government has announced plans for further international recruitment. In July 2020, the government launched a new health and care visa. It said this would “make it cheaper, quicker and easier” for healthcare professionals to come to the UK to work in the NHS, for NHS commissioned service providers, and in eligible occupations in the social care sector. More recently, in February 2022 the Health Secretary Sajid Javid wrote in the Telegraph that the government would aim to recruit 10,000 more nurses from overseas by the end of March 2022 to help tackle the backlog created by the pandemic.

The NHS People Plan for 2020/21 also said it would address workloads and wellbeing in the organisation. The key elements to this plan included: recruiting more people; adopting news ways of working; and creating a compassionate and inclusive culture to encourage fewer people to leave the organisation.

2.2 Progress made on the manifesto pledge

In March 2022, the government said it was on track to deliver its manifesto commitment of 50,000 more nurses by 2024. It said that overall total nurse numbers stood at 327,907 in December 2021, compared to 300,904 in September 2019. By March 2024, it argued that there are set to be around 351,000 full-time equivalent nurses. The government published a progress report which contained this data and set out its plans for reaching its target.

However, concerns have been raised that despite the likelihood of this target being met, there will still be a shortage of nurses. In a recent speech, the chief nursing officer for England, Ruth May, said that while she welcomed the pledge of 50,000 more nurses, it fell short of what was actually needed. She also argued that international recruitment would continue to be needed to fill a gap caused by the decision to remove bursaries for nursing students in 2017 (these have since been reinstated).

The King’s Fund has produced analysis which supports Ms May’s concern that the target will not be enough. It found that headline data suggests that the government’s approach was increasing the number of nurses working in the NHS. However, a focus on the impact of this increase on the number of vacancies showed that “recruitment is having no clear impact on actual vacancy numbers or on the shortfall of nurses in the NHS”. Although the King’s Fund did note that there was regional variation in this area, with the north-west and south-west making progress in addressing their workforce shortages and seeing vacancies decrease.

At a national level, the King’s Fund said that the trend of too few nurses was not explained by worsening retention rates. Instead, it said that demand for nurses was increasing more quickly than supply. It said that the factors behind this were “complex, longstanding and varied”, adding that:

The Covid-19 pandemic and new targets to increase diagnostic and elective activity have created new demands and exacerbated the workforce shortages that long pre-date Covid-19.

It recommended that a regular assessment of demand for and supply of nurses in the NHS would help in addressing these challenges. Without this, the King’s Fund argued that “long-term workforce shortages will continue and demands on the NHS will grow ever more severe, long waits will persist and the recovery from Covid-19 may well falter”.

3. Read more

Cover image by Vladimir Fedotov on Unsplash.