In November 2018 the Royal College of Nursing (RCN) published Fund our Future Nurses: Cost effective options to support nursing students and grow the nursing workforce in England (RCN, 2018a). This argued that there are credible alternatives to the current tuition fee arrangements for higher education funding in England, which could be adopted to encourage more people to study nursing. As part of its campaign to raise awareness the RCN commissioned a poll from YouGov and more than 50% of those surveyed in England agreed that the Government should increase funding for nurse education to address the current shortfall in the numbers of people opting to go to university to study nursing (RCN, 2018b). It is important to stress that the situation in England is much worse than in the other countries of the UK because NHS Wales, NHS Scotland and Health and Social Care Northern Ireland have continued to fund student nurse training.
Background
Shortages of trained nurses can be traced back to the introduction of nurse registration. When the first elections to the General Nursing Council (GNC) (the forerunner to today's Nursing and Midwifery Council (NMC)) were held in 1923 only 12 100 registered nurses were actually eligible to vote. However, this was only a tiny proportion of the overall nursing workforce (Glasper and Charles Edwards, 2002). Applications for admission to the Register of Nurses could only be accepted from properly qualified nurses who had completed a 3-year training course. There were large numbers of second grade or assistant nurses with fewer years of training who were ineligible for registration. In reality the majority of care was delivered by these non-registered nurses. Such was and is the public concern about the shortage of trained registered nurses that successive commissions and working parties have been implemented to address the problem. For example, in the Lancet Commission on Nursing, it was noted that only 90% of hospitals had full establishments of staff, but this was only achieved by substituting trained nurses with untrained auxiliaries (Lancet, 1932).
In 1937 the Government asked the Earl of Athlone to chair a committee to examine the recruitment, training and registration of nurses. It published an interim report (Athlone Committee, 1939), which recommended that assistant nurses should be given a recognised status and placed on a roll under the jurisdiction of the GNC. The recommendation was subsequently ratified by Lord Horder's Nursing Reconstruction Committee, established by the RCN in 1941 to consider ways of implementing the Athlone recommendations (RCN, 1943). This eventually resulted in the Nurses Act of 1943 by which the GNC was to regulate what became the enrolled nurse.
The combination of pupil and student nurse training, facilitated through 2-year and 3-year apprenticeships, still did not fully address the problems of nurse recruitment and the employment of untrained nursing auxiliaries continued. The apprenticeship system of nurse training was abandoned with the introduction of Project 2000, which also saw the demise of enrolled nurse training. Student nurses became supernumerary to the workforce and to fill the labour gap many more unqualified nurses were employed, who became known as healthcare assistants. Although undergraduate-degree nurse preparation had been introduced in some universities from the 1960s, it was not until the NHS schools of nursing were incorporated into local universities in the mid-1990s that the numbers of student nurses undertaking degrees in nursing began to accelerate (Carpenter et al, 2012). In 2012 the NMC rolled out its national plan to make nursing an all-graduate profession and initially this was funded by the NHS across the whole of the UK. However, in 2016 in England the living support bursary for nursing students was abolished and course fees introduced.
Problems with nurse recruitment
Newspaper headlines frequently feature alarming stories about the state of the NHS—for example, The Telegraph citing that a total of 133 660 vacant posts were advertised in 2017, showing that the service was becoming increasingly desperate to recruit new staff (Wilson, 2018). Although NHS hospitals are trying to attract more trained nurses, where this has not been possible they are substituting them with healthcare assistants. During the period December 2015–December 2017, for every nurse recruited in England, four healthcare assistants were employed (Donnelly, 2018).
In November 2018 the Nuffield Trust in collaboration with the Health Foundation and The King's Fund published a position paper entitled The Health Care Workforce in England: Make or break?. This highlights the scale of workforce challenges impacting on the NHS and the threat posed to the delivery and quality of patient care over the next decade (Health Foundation et al, 2018). This is partly because the nursing workforce is an ageing one, with nearly a third of qualified nursing, midwifery and health visiting staff over 50 years of age and with one in three expected to retire in the next 10 years. In light of this and other pressures, the three bodies believe that the workforce challenges throughout the NHS in England are now a bigger danger to the delivery and quality of health services than funding shortfalls—they estimate that the current workforce shortage of 100 000 may rise to 250 000 by 2030, or even as high as 350 000.
NHS statistics reveal that the total number of nurses and midwives in England has not kept pace with demand or the changing demographics of the NHS and has only risen from 338 976 in September 2009 to 345 482 at the end of March 2018 (NHS Digital, 2018). Data supplied by NHS Improvement, for the period April–June 2018, showed that 11.8% of nurse posts had not been filled, resulting in a shortfall of nearly 42 000 registered nurses. Given the winter pressures of 2019 the situation regarding nurse recruitment is becoming a ‘national NHS emergency’ (Triggle, 2018). Furthermore the newspapers are already speculating that Brexit will also have a major impact on NHS nursing vacancies (Matthews-King, 2018).
The RCN perspective
The RCN is highlighting that since the living support bursary for nursing students was abolished in England in 2016, applications to undertake nursing degrees in English universities have fallen by 32%, leading to an 8% drop in the number of students accepted for entry to nursing programmes (RCN, 2018a: 8). Ironically at the time of the abolition of the bursary and the introduction of full course tuition fees the Government was confident that the policy would increase the number of people undertaking a nursing degree.
This RCN report underscores the difference between a student undertaking a non-vocational degree and a student undertaking a vocational nursing degree. Student nurses must undertake 50% of their 3-year degree in clinical placement, which curtails their ability to undertake part-time employment to boost their incomes. I have met many healthcare assistants in clinical practice who are actually student nurses employed through hospital nursing banks who are working shifts on their days off to try to make financial ends meet.
The RCN wants the Government to take immediate action to stem the tide of falling nurse recruitment. The college believes that NHS England needs a sustainable workforce strategy for nurses and that efforts to improve workforce retention should commence as soon as the students are enrolled on to their programmes. Crucial to this aspiration is to make the current nursing degrees financially viable. The RCN is adamant that the January 2019 NHS Long Term Plan (https://www.longtermplan.nhs.uk) cannot succeed without a sustainable nursing workforce.
It is asking the Government to take steps to increase the number of nursing students by 50% for the next 5 years, which would, if fulfilled, create an additional 24 000 registrants. This would tackle the gaps in the workforce in the short and medium term and would ensure parity with the other countries of the UK.
The RCN is urging the Government to take action to ensure that there is sufficient funding for clinical placements, which need to be commensurate with the various other routes, in addition to the standard 3-year undergraduate courses, that lead to entry to the nursing profession. These include postgraduate entry and entry via the nursing associate route. Furthermore the RCN is advising that the Government must initiate a new large-scale national advertising campaign to promote recruitment into nursing education.
The RCN has developed two options to help the Government to solve the problems of student nurse recruitment, the first of which is to offer potential students a universal tuition grant with a means-tested maintenance grant, which will ensure that they will graduate debt-free. The second option is the introduction of a forgivable tuition loan for public service and a universal maintenance grant. The Government has previously used such a loan forgiveness scheme to encourage entry to the teaching profession. This scheme is configured to avoid students paying their tuition fees up front and instead they take out a loan similar to the way undergraduates currently do. The difference with this scheme is that on graduation as a registered nurse the individual will be guaranteed a job and the Government commits that it will pay off the debt the longer they stay in their career.
Conclusion
Both of the RCN options are feasible and if adopted by Government will address many of the nursing workforce issues. Undoubtedly the reform of nurse education funding was disastrous for the profession and whatever option the Government takes to restore order to the crisis it must lead to greater numbers of registered nurses entering the NHS workforce. The NHS may only ever be as good as the nurses who deliver much of the service and ensuring a steady supply of nurses is vital to ensuring its continued success.