On 3 June, NHS Improvement launched the Interim NHS People Plan to address staff shortages in the health service. (NHS Improvement, 2019). This aspires to ensure that the NHS Long Term Plan (NHS England, NHS Improvement, 2019), which sets out the Government's 10-year vision for health care in England, does not get derailed by staff shortages. The interim plan aims to address many of the concerns that have been aired about the current staffing crisis, but principally the shortage of nursing staff.
Historical background
Ever since the creation of the General Nursing Council (GNC) in December 1919 the nursing profession has been beleaguered by staff shortages. The passing of the Nurses Bill, which paved the way for a register of nurses, was controversial because many nurses who had undergone a variety of training courses were not actually eligible to join the register. In fact, the register did not officially open until 27 July 1921 and the process was slow; Ethel Bedford Fenwick, the chair of the registration committee, insisted on personally scrutinising the qualifications of all applicants. Hence, by 1923, there were only 12 097 nurses on the register (Glasper and Charles Edwards, 2002).
In the aftermath of the passing of the 1919 Nurses Bill, successive governments recognised that hospitals simply did not have enough nurses to ensure optimal patient care. In 1937, for example, the Government asked Lord Athlone to chair an interdepartmental committee on nursing to help resolve the crisis.
However, as the Second World War loomed, the committee was disbanded but not before making some preliminary recommendations, the most significant being the recognition of the ‘assistant nurse’ who was to be annotated on an official roll held by the GNC. This was predicated on the reality that throughout the 1930s hospitals had large numbers of auxiliary staff with a wide range of titles who undertook many nursing duties. In 1943, and to alleviate some of the nurse staffing crisis, the Government passed the Nurses Act, enabling ‘assistant nurses’ to join a roll held by the GNC and thus the enrolled nurse (EN) entered the nursing workforce (Baly, 1995).
In 1988, the successor to the GNC, the UK Central Council for Nursing, Midwifery and Health Visiting (UKCC), introduced Project 2000, a new type of nurse training, which replaced the old apprenticeship style of training and elevated the academic status of most newly registered nurses to that of a higher education diploma. This was a prelude to the introduction of the all-graduate curriculum in 2010. It should be stressed that the decision to improve the academic standing of registered nurses was at the expense of EN training, which was subsequently discontinued despite its popularity (Glasper, 2018).
Following the demise of the 2-year EN courses many senior nurses recognised that the clinical acumen gap between a registered nurse and a healthcare assistant was too great and skill mix configurations became more difficult to formulate. It was subsequently the dissatisfaction of ambitious healthcare assistants with their career paths that led to the development of ‘nursing associate’ courses at foundation degree level, with clear progression points for those wanting to undertake further training to attain full nurse registration. As with the old EN, today's nursing associates are registered with the Nursing and Midwifery Council (NMC), the successor to the UKCC.
The current crisis
Much like its predecessors, the present Government has developed a plan to tackle nursing shortages (NHS Improvement, 2019). This latest initiative postdates the damning report (Health Foundation et al, 2018) into NHS staffing that estimated that the shortfall of 100 000 could rise to a quarter of a million by end of next decade.
The role of nurse staffing in maintaining patient safety has been recognised in the safe staffing guidelines for adult hospital wards produced by the National Institute for Health and Care Excellence (2019). Underpinning this is research by Rafferty et al (2007) that showed that hospitals with the highest patient to nurse ratios had a 26% higher mortality. Similarly, Griffiths et al (2018) showed that low registered nurse staffing is associated with reports of missed nursing care.
Prevailing concerns about staffing is indicative of the quest by the healthcare regulator, the Care Quality Commission (CQC), to ensure that another scandal such as that surrounding the failings in care at Mid Staffordshire NHS Trust never happens again (Francis, 2013). The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 12 has been formulated to prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm. To achieve this, the CQC insists that all healthcare providers must assess the risks to patients' health and safety during any episodes of care or treatment and make sure that staff have the qualifications, competence, skills and experience to keep people safe.
A CQC report into acute care in the NHS showed that, for many hospitals, staff recruitment was one of their greatest challenges, and this was leading to an over-reliance on temporary and agency staff (CQC, 2017).
Although it is not the role of the NMC to set or assure standards related to appropriate staffing, it acknowledges that staffing plays a key role in delivering safe and effective health care (NMC, 2016).
In Wales and Scotland, there is specific legislation to ensure safe staffing for health care, but there is none in England and Northern Ireland. In response to this, the Royal College of Nursing (RCN) (2019a) is campaigning for laws to guarantee safe staffing in England. The RCN considers that mandatory standards for nurse staffing levels and skill mix standards will help prevent ratios being set too low. Currently, nurse staffing levels are set locally by individual healthcare providers and there is no compulsion to follow these when planning services, although the CQC will take action in the face of significant breaches. The RCN (2013; 2019b) has developed staffing guidance for a variety of clinical domains, including that of children and young people's services. Similarly, the British Association of Perinatal Medicine (2018) has developed staffing standards for the care of neonates.
Interim plan to address shortages
The interim plan addresses all aspects of NHS staffing. However, the most urgent challenge to the successful implementation of the NHS Long Term Plan is the current nurse shortage. The Government recognises that it must act now to support and retain the existing cadre of nurses and to significantly increase the number of newly qualified nurses joining the NHS. Additionally, it recognises that enhancing recruitment of nurses from abroad is vital. Furthermore, it acknowledges the need to take urgent steps to tackle nursing vacancies, especially in primary care and community, mental health and learning disability settings. The Government therefore intends to:
The Government hopes these actions will enable the NHS to grow its nursing workforce by over 40 000 by 2024 and reduce vacancy levels to 5% by 2028.
Discussion
The Government knows that it needs to tackle retention as a matter of priority and wants to encourage trusts to take steps to do so. This strategy will help slow down staff losses, and efforts to increase the supply of nurses from universities will also help. However, it takes 3 years to educate a nurse and for that reason the Government is supportive of the 2-year postgraduate route to nursing. However, the interim plan recognises that since the education funding reforms applications to nursing courses have fallen dramatically, with a 31% drop between 2016 and 2018. Applications from mature students and men have also been affected, with a 39% and 40% recruitment fall respectively. Discussions within Government to cap tuition fees at £7500 rather than the current £9250 may help (Turner, 2019).
The nursing associate and apprenticeship route into nursing is popular, not least because trainees pay no tuition fees and receive an annual salary on band 3, starting at £18 813 with superannuation contributions. There are now over 1000 nursing associates annotated on the NMC register and Health Education England is aiming to fund the training of 7500 nursing associates a year, with the hope that significant numbers will go on to complete full nursing degrees (NHS England, 2019).
Many local NHS trusts will take steps to futureproof themselves against nursing shortages. For example, the Isle of Wight NHS Trust has worked with the Open University (Grimmette, 2019) to develop an innovative 3-year apprenticeship programme funded through the Trust's apprenticeship levy to increase the number of registered nurses and nursing associates on the island.
Conclusion
Nursing staff are the most valuable asset the NHS has. How it invests in, and cares for them, will ultimately determine the future of the NHS.