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The future nursing crisis

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29% of nurses will retire in the next 10 years. This comes at a time when the Care Act encourages keeping people at home for longer but the availability of district nurses and community psychiatric nurses is reducing and the demand increasing. It is also increasingly difficult to recruit nurses to the care home sector together with registered nurse managers as a result of the national shortage and the increasing responsibilities being placed on them in this setting. How is the Department of Health planning to redress this major looming crisis?

Roger Wharton, Executive Officer, Registered Care Providers Association Ltd

Dr David Foster, Deputy Director of Nursing and Midwifery Advisor, Department of Health responds.

The demand for nursing, care and support is increasing. It’s really a great success story because we are living longer, remaining independent for longer and taking more responsibility for managing our health than ever before. It’s also a cause of great concern that those who are living longer and want to stay independent but need nursing, care and support should not have to worry about who is going to provide it. Whichever way you look at it, the demand is outstripping the supply.

Whatever the statistics we know the nursing and caring workforce is ageing, significant numbers will wish to retire in the next decade and the supply of newly-qualified nurses is skewed towards staffing NHS hospitals. The Francis inquiry1 into Mid Staffordshire NHS Foundation Trust shone a spotlight on the quality of nursing care in acute hospitals which undoubtedly has influenced the increase in supply of nurses to the NHS. This has left, unfortunately and unintentionally, the impact of Winterbourne View2 and the staffing of the independent sector in the shadows.

Given this context it is easy to become negative about nursing, its pressures and demands and nursing older people generally. My introduction to nursing was as a nursing auxiliary in, what was then called, a geriatric hospital. It was a fantastic experience and fired my love of nursing. My exposure to older people recovering, rehabilitating or having a respectful and dignified death kept me going through my student nurse training. Images of that superb care still live with me but that was an ‘illness’ model. Now I am exposed to nursing in settings where the care of older people is more person-centred, people are helped to stay as independent as possible, manage their health and wellbeing and avoid hospital admissions. The breadth, value and autonomy of nursing older people in this way is something that we should make more obvious and celebrate as an incredibly meaningful and worthwhile career choice.

Getting a clearer picture

Policy intentions suggest care should be closer to home and therefore, more care in the community where we have decreasing numbers of district nurses, community psychiatric nurses and learning disabilities nurses particularly. However, there remain a number of gaps in our data which currently impede our ability to understand the current picture clearly or to plan effectively for the future. We need to understand better health and social care vacancy rates, the movement of staff between organisations and sectors and how students make career choices about where to work when they qualify. All health and social care employers share the same supply of nurses: they are either trained by the NHS or are recruited from overseas. We recognise that, valuable and experienced though overseas recruits are, this source of nurses cannot be an enduring solution.

The diversity of where staff trained by the NHS work is vast with 1,000 different public, private and voluntary sector organisations. There are 676,547 nurses and midwives in the UK on the Nursing and Midwifery Council (NMC) register and Skills for Care estimates there are 50,000 registered nurses employed in care homes (about the same number as are in Wales and Northern Ireland combined) and there are 30,000 to 50,000 nurses in the private and independent sector. The NMC says that 60 per cent of its registrants work outside the NHS. This is a huge number spread across independent sector healthcare organisations, social care, education, research, the armed forces and others. This sheer scale and complexity makes workforce planning a real challenge. The Department is looking closely at the evidence base to see what the collected data tells us about the issues in nursing. The Skills for Care National Data Set for Social Care is invaluable and to improve future decision-making we have asked the Centre for Workforce Intelligence to look at the future supply and demand situation.

Workforce planning

In my early days of being a director of nursing, I was very diligent about workforce planning and getting the right number of students for my organisation so I would have a regular supply of the newly-qualified to replace those who left. My numbers were signed off to the nearest tenth of a whole time equivalent to be aggregated into the regional pot. As I grew to understand the system better I realised it’s not an exact science and the precision of my calculations was unwarranted when it emerged that to create a supply of nurses for the independent sector the planners just added 10 per cent to the sum total of the NHS requirement. At least it was there.

Now the workforce planning landscape is much changed. Health Education England (HEE) was created under the Health and Social Care Act 2012 which has responsibility for delivering a better health and healthcare workforce for England. They are responsible for the education, training and personal development of every member of NHS staff, and making sure staff are recruited for their values as well as their abilities. They are governed by a mandate3 given to them by the Department of Health.

The supply of nurses nationally is, therefore, from the health sector and there needs to be greater recognition and focus on a whole system approach to care including adult social care. The mandate from the Government to HEE recognises that health and social care will change over the coming years with increased focus on managing complex co-morbidities which will place greater emphasis on the skills of generalist staff as care moves closer to home. Over time, the boundaries between health and social care will become blurred. Although HEE does not have responsibility for the social care workforce, it will be expected to work closely with the social care sector at local and national level to support the transition to integrated care. HEE will need to work with partners across health and care to develop common standards and portable qualifications and skills.

The key issue for the independent and third sector is capturing their requirements for the large number of clinical professionals they need.

The mechanism for doing this is through HEE’s Local Education and Training Boards (LETB). Their core purpose is to lead planning and education commissioning; ensure security of supply of the local health and care workforce; and support national workforce priorities set by HEE.

Their functions include:

  • Ensuring security of supply of the local health and care workforce.
  • Workforce planning and prioritisation of local education and training.
  • Holding and allocating funding for education and training.
  • Commissioning education and training and securing quality and value from education and training providers.
  • Securing effective partnerships with clinicians, clinical commissioning groups, local authorities, health and wellbeing boards, universities and the other providers of education, research and innovation.

They are a significant development in the redesigned structures. As can be seen from their functions their local reach in forging partnerships will mean including social care providers in their discussions. These partnerships might already exist between social care and local authorities, health and wellbeing boards and clinical commissioning groups to a degree of maturity that influencing LETBs will be possible. Challenging though this might be, LETBs will need to capture the future needs and expectations of independent and third sector employers who are providing NHS commissioned care.

The key issue for the independent and third sector is capturing their requirements for the large number of clinical professionals they need. This has not been done systematically so far yet, but it is crucial to develop ways of doing this. As Andrea Sutcliffe identified in the Care Quality Commission’s State of Care4 report there is current shortage of nurses in adult social care. With one in five nursing homes not having enough staff on duty to ensure care is good and safe, the supply of registered nurses to this sector has to be understood and driven by the new HEE mechanisms. This also means the sector having a voice at the LETB tables in the same way they have a voice on the national HEE Nursing and Midwifery Advisory Board.

Shape of caring

Another development which will help this situation is the Shape of Caring review chaired by Lord Willis of Knaresborough which is a joint initiative by the NMC and HEE. Its objective is to ensure that nurses and care assistants receive high quality education and training, which supports high quality care. It will bring together findings and expertise from recent major reviews such as Francis, Cavendish5, Willis6 and Berwick7 and make recommendations for the reform of nursing and care assistant education and training in England. The review has sought evidence about the type of workforce required to meet the needs of the population as care patterns and delivery change over the next 15 years. Evidence to this review has very helpfully been provided from the independent sector to highlight that the supply of registered nurses needs to be addressed across the whole health and social care system. It is also clear from the discussions amongst the review’s steering group members that the integration of health and care is a crucial development in streamlining services in the future.

The nature of this transition is also clear from NHS England’s Five Year Forward View8. This important document sets the direction for NHS England as a commissioner of services and incorporates an intention to work more closely with social care providers. Similarly, the mandate9 between the Government and NHS England sets an objective about transforming care so that it is more joined up right across GP surgeries, district nurses and midwives, care homes and hospitals.

Department of Health’s actions

As can be seen, the situation is complex. There are a number of new national bodies who are turning some attention to this situation and there are initiatives which will help change the situation for the future, but immediacy is also needed in tackling this problem. For this reason, the Department of Health, in its reformed role of as ‘system steward’, is hosting a symposium to work out some quick solutions to the supply of registered nurses to the sector. In the reformed and dispersed healthcare system, the Department does not run or manage the system, but does have a function to stimulate national and local action to help solve this problem. For this reason the Department of Health:

  • is hosting a symposium on this subject in February 2015 so that we can understand from stakeholders what they propose as solutions and what they are adopting as good practice to improve the image, recruitment and retention of nurses;
  • will use its membership of the national HEE Advisory Group to influence the commissioning of student nurse numbers to reflect the demands of the sector; and
  • will keep this on the agenda of the Department’s Independent Sector Nursing Advisory Forum so that stakeholders and partners can sustain pressure and momentum to reach solutions.

There is no easy answer to the shortage of nurses in social care, or the supply of newly-registered nurses from NHS-funded education and training programmes, but this is high on the national agenda. It needs sector-led solutions and also needs to be high on local agendas so that those providing NHS care in the independent sector can be involved in working through solutions for their communities, service users and the vulnerable people who need nursing, care and support.

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Dr David Foster is Deputy Director of Nursing and Midwifery Advisor at the Department of Health.

Are you facing a nursing shortage? Do you have suggestions on how it could be tackled? What are your thoughts? Add to the debate in the comments below. Subscription required. Subscribers can also access references and links to the reports mentioned in this feature.

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